Background: A 22-year-old, Division I male football defensive back, with no previous history of ankle injury, sustained a left ankle injury during competition. The mechanism of injury was direct contact to the lateral lower leg from an opponent forcing the ankle toward eversion. Initial on-field evaluation revealed palpable pain over the medial ankle with no sign of fracture or obvious deformity; and the athlete was assisted off the field NWB. Sideline evaluation revealed pain and point tenderness over the medial and anterior ankle, decrease dorsiflexion flexion and eversion active range of motion, and pain with eversion ligamentous stress testing with increased laxity. The athlete was able to fully weight-bear but was not able to perform functional movements, removing him for continuing with the competition. On-site radiographs were negative for fracture or dislocation. The athlete was fitted with a walking boot, instructed to weight-bear as tolerated, and follow-up the following day with the sports medicine team.
Differential Diagnosis: Based on the initial signs, symptoms, and radiographs, differential diagnoses included: deltoid ligament sprain, anterior inferior tibiofibular ligament sprain, syndesmosis sprain.
Intervention & Treatment: Follow-up evaluation revealed gross swelling around the ankle and discoloration over the medial ankle. Standard-of-care treatment was initiated which included cryotherapy, pain-free PROM exercises, isometric strengthening, and NSAIDs. The athlete was referred to the team physician for repeat radiographs and MRI. Diagnostic testing noted a complete rupture of the deltoid ligament, grade II anterior inferior tibiofibular ligament sprain and bone contusions of the medial malleolus and talus. The athlete was referred to a physician with specialization in foot and ankle injuries for further evaluation. The evaluation concluded that the athlete suffered a complete rupture of the deltoid ligament and syndesmosis. There was also gross instability in the ankle and surgical intervention was indicated. The athlete underwent surgery that included a primary repair of the deltoid ligament combined with a syndesmotic Tight Rope fixation. Following post-surgical recovery, the athlete completed an aggressive intervention and return to sport program that included: progressive strengthening and proprioceptive ankle exercises with blood flow restriction, early initiation of a weight-supported gait/running program, progressive functional and sport specific agility drills, and gradual return to sport activities. The athlete was able to return to sport in 5 weeks with no restrictions and returned to the starting line-up at week 6 from the date of surgery. The athlete continued full participation with the use of an external ankle brace, modified spartan taping, and custom fitted orthotics.
Uniqueness: Ankle injuries that include a deltoid ligament rupture, combined with syndesmotic disruption are not commonly reported in the athletic population. This traumatic injury requires surgical fixation to stabilize the ankle and the typical time to return to sport varies, on average, from 4-6 months. We present a unique case where early access and frequency of an aggressive rehabilitative program, integrating a multi-disciplinary healthcare team, resulted in positive outcomes where the athlete was able to safely and successfully return to high level sport in 5 weeks.
Conclusions: Ankle injuries that result in rupture of the deltoid ligament and syndesmosis result in gross ankle instability. This injury is rare in sports and requires an extensive surgery that combines multiple surgical procedures. A 22-year-old football player sustained this traumatic ankle injury that commonly requires 4-6 months of recovery. Through an integrated healthcare team approach, an aggressive intervention program was successful in positive outcomes with the athlete returning to sport in 5 weeks. This unique case challenged the conventional recovery times as a result of early access and frequency of an aggressive rehabilitative program, while taking into account the physiological and patient response to the injury and rehabilitation.
Source: Blankenship VT, Foster SZ, Kessler KG, McDonough EB, Waldrop NE, Nguyen A. Return-to-Sport Following Deltoid Ligament and Syndesmosis Repair in a Division 1 Football Defensive Back: Type 4 CASE Study. J Athl Train. 2023;58(6S):267.
