March 21, 2017Sports Injuries
Ankle sprains are a common problem in most sports. However, in hockey, the common ankle sprain caused by plantar flexion, inversion and internal rotation is a relatively rare occurrence. This is due to the protection afforded by the modern stiff skating boot and because there is relatively little jumping and landing, which is a frequent cause of inversion injuries in other sports. More frequent and much more troublesome in skating is the dorsiflection-eversion-external rotation ankle sprain.
There are two principal etiologies for this sprain. The first and most common injury occurs when a player catches his or her support blade in an ice rut, causing the skate to follow the rut, forcefully rotating and everting the ankle. The second etiology is a fall over the front of the skates, with the foot being caught in an externally rotated, dorsiflexed position under the body. Both cases result in a strain of the deltoid ligament followed by progressive loading of the tibiofibular ligament and interosseous ligament.
This type of sprain results in immediate pain which is localized in two distinct areas, the medial aspect of the ankle over the deltoid ligament and the anterolateral aspect of the ankle over the anterior inferior tibiofibular ligament and distal interosseous ligament. The pain is increased with eversion-external rotation stress of the dorsiflexed ankle. Inversion-internal rotation of the plantar flexed ankle is relatively painless. When the mechanism of injury and clinical examination are consistent with an eversion sprain, you should perform stress X-rays to rule out a diastasis of the ankle syndesmosis. Be sure to include the entire tibia and fibula on the film in order to avoid missing a proximal fibular fracture.
Immediate treatment for these sprains should include prompt compression, ice and elevation since the amount of swelling predicts the amount of ankle pain and the length of recovery you can expect. When the radiograph demonstrates evidence of mortise widening or instability, consider performing open fixation with a syndesmodic screw in order to reduce and hold the ankle anatomically. If the stress X-rays are negative for diastasis, continue with crutches and a compression dressing until the initial injury pain subsides. At that point, you can allow weightbearing as tolerated and proceed to emphasize ankle rehabilitation.
The initial focus of the ankle rehabilitation program should concentrate on return of motion. An exercise bicycle and an ankle board are valuable in this early phase. As the tenderness over the anterior tib-fib ligament and interosseous space begins to subside, have the patient initiate inversion-eversion strengthening and heel cord stretching. Encourage proprioception training, using a tilt board or other balance device, in conjunction with the stretch and motion program.
Once the patient can tolerate full weightbearing, ankle strengthening, range of motion and proprioception well, you can allow the patient to proceed to straight ahead running. The final, most difficult phase of the rehabilitation is returning to skating because of the inherent external rotation, everson forces placed across the ankle with normal skating stride. To help protect the ankle against excessive stress in this period, apply immobilization taping. In non-operative cases, return to function occurs within three to six weeks after the injury while a surgical case will require 15 to 18 weeks for functional recovery.
Expert Pointers On Treating Foot And Toe Fractures
Although the foot is protected by a solid boot made of leather and plastic, foot injuries still occur frequently in hockey. Fractures and contusions account for most of the foot injuries. Fractures of the feet are almost invariably the result of impact by the puck or stick.
The most commonly fractured bones are the navicular and the base of the fifth metatarsal (styloid process). The first through fourth metatarsals are fractured much less frequently. These fractures are usually oblique but can appear comminuted or spiral. When these fractures are not displaced, players often “play through the pain.” Treatment for these fractures consists of four to eight weeks of immobilization, depending on the injury. If the fracture is displaced and cannot be closed or reduced, it may be necessary to perform ORIF.
Toe fractures are not very common in hockey due to the hard toe of the skate. However, these fractures do occur occasionally due to direct trauma from a puck or stick. You may see a subungual hematoma with these injuries and the fracture will usually be comminuted. The player will present with pain, edema and ecchymosis of the affected toe.
Treatment of nondisplaced toe fractures consists of immobilization splinting to the neighboring toe with tape, felt or prefabricated splints. With these cases, you can expect a return to action in a matter of days. If the fracture is displaced, depending on severity, you should perform a closed or ORIF. Return to play will then take a couple of weeks, depending on the degree of displacement and the amount of reduction and stabilization you perform on the area.
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