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Positive squeeze test, injury identifies stable, unstable grade II syndesmosis injuries
Athletes with stable injuries tended to return to sport sooner than those with unstable injuries.
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A positive squeeze test and injury to the anterior tibiofibular ligament and deltoid ligament differentiated stable from dynamically unstable grade II syndesmosis injuries and may help identify patients who may benefit from early arthroscopic assessment and stabilization, according to results of a recently published study.
“Basically not all grade IIs [syndesmosis injuries] are the same, and we need to find a way of picking out those athletes who have a higher likelihood of developing long-term pain without surgery, and which ones would benefit from early stabilization and enable them to get back to an early return to play without pain,” James D. Calder, MD, FRCS(Tr&Orth), of Fortius Clinic and Imperial College in London, told Orthopedics Today.
Clinical markers
Calder and his colleagues assessed 64 athletes with an isolated syndesmosis injury without fracture. Researchers treated athletes with a stable grade IIA injury conservatively with a boot and rehabilitation, while athletes with clinically unstable grade IIB injuries underwent arthroscopy and stabilization of the syndesmosis. Clinical and MRI assessments of injury to individual ligaments were recorded, as well as time to return to play.
Although all athletes returned to the same level of professional sport, results showed patients with grade IIA injuries returned sooner than patients with grade IIB injuries (45 days vs. 64 days). Researchers found clinical and MRI assessments of ligament injury had a highly significant relationship. Athletes with a positive squeeze test were 9.5-times as likely to have instability, and patients with a deltoid injury were 11-times as likely. A delay in return to sports was associated with combined injury to the anterior-inferior tibiofibular ligament and deltoid ligament. The syndesmosis was less likely to be unstable and was associated with an earlier return to sports among athletes with purely an isolated injury to the anterior tibiofibular ligament, according to the study results.
“This is the first paper to look at identifying the ‘losers’ following a grade II syndesmosis injury — this injury is more common in athletes than previously thought,” Calder said. “We are getting better at identifying the problem, but until now we have had difficulty picking out which ones will have a delayed return to sport.”
Conservative treatment
“What I would have liked to have done was randomize the type IIB injuries into a conservative and operative group,” Calder said. “The problem is we were dealing with some high-level national and international athletes. In that group, it is impossible to randomize them. If you get it wrong, and they cannot get back to play for however many weeks, there is a big financial burden to the club.”
He noted the next step is to identify a conservative management control group and to look at biomechanical studies to “understand the difference and the nature of the two types of grades of injury.” – by Casey Tingle
- Reference:
- Calder JD, et al. Arthroscopy. 2016;doi:10.1016/j.arthro.2015.10.003.
- For more information:
- James D. Calder, MD, FCRS(TR&Orth), can be reached at Fortius Clinic, 17 Fitzhardinge St., London W1H 6EQ; email: james.calder@fortiusclinic.com.
Disclosure: Calder reports his institution receives sponsorship from DJO Global, Smith & Nephew and Arthrex.