Background: Syndesmotic injuries make up 12% of all ankle sprains, but 25% of ankle sprains in football. Historically, screw fixation has been the predominant type of surgery, which provides stabilization to the syndesmosis joint. However, the strong fixation procedure can cause a loss of movement in the early recovery phase, an inability to bear weight, and typically needs the screw to be removed. The tightrope procedure provides athletes with a faster recovery, as there is no need for removal and allows for early weight bearing. Typical recovery timeline for a screw fixation is 4-6 months, compared to the tightrope procedure taking 2-3 months. The use of blood flow restriction (BFR) could be an effective addition to rehabilitation intervention to decrease the time to return to sport (RTS).
Patient: A 21-year-old, Caucasian, male, Division I collegiate football athlete, defensive end, junior presented with left (L.) lower leg pain the day after a game. During the game, the athlete was rushing when he was forced into plantar flexion and inversion as another player fell on top of him. He continued to play the entirety of the game without reporting the injury. The evaluating athletic trainer (AT) performed the squeeze test and Kleiger, which was positive. Imaging revealed no fractures, but an MRI revealed a L. syndesmosis ankle sprain and a fracture of the fibula.
Intervention & Treatment: The team physician and the AT decided that a surgical treatment with the addition of BFR as part of the rehabilitation would afford the athlete an opportunity to return at an accelerated rate. Rehabilitation started by targeting edema with soft tissue mobilization, ankle exercises, as well as BFR to assist with the acute phase of healing. The athlete started his progression to weight bearing beginning with seated exercises, then assisted exercises, working his way to full weight bearing by the 12th day. BFR continued to be performed 4 days a week to strengthen the surrounding musculature. To further assist in the athlete’s recovery, a run progression was introduced by using the alter-G to increase strength and range of motion. During week 4, the athlete was introduced to tempo running, which is a gradual building of speed for a certain length of yards, as well as performing sport-specific functioning drills with the AT, and training fully with strength and conditioning staff. A week after physician clearance 9/17 injury 10-11-physician practice, the athlete was able to begin progression back to practice, and the subsequent week (10-18), was able to play as tolerated in the following game, while being braced and taped.
Outcomes or Other Comparisons: The athlete made excellent progress with tightrope surgery and BFR. The athlete recovered in 33 days compared to the average 64 days after a tightrope procedure, with the use of BFR during rehabilitation.
Conclusions: The main priority after an injury is to RTS in the shortest and safest amount of time as possible. Tightrope procedure facilitates recovery exponentially, when compared to screw fixation surgery. Incorporating the use of BFR during the recovery phase could potentially accelerate this process even further, as shown in this case. The recovery time was reduced by almost half when compared to the average of 64 days. In athletic populations, the tightrope procedure is the most favorable intervention for a syndesmotic ankle sprain.
Clinical Bottom Line: Tightrope procedure for a syndesmotic ankle injury can significantly reduce the return to play time in the athletic population, along with the assistance of BFR during rehabilitation. The use of BFR to aid in the healing process of a syndesmotic ankle injury is a practical application that can be used in a variety of patient populations because it can be personalized to the patient.
Source: Worley J, Pollard-McGrandy AM, Dufon S, Smith L, Homer M, Zita A, Molliter E, Belhomme T, Roskelly J, Rice L, Scott R, Nogle S, Covassin T. Syndesmosis Ankle Sprain in a 21-Year-Old Division 1 Collegiate Football Player. J Athl Train. 2023;58(6S):266.
