Talocrural dislocations are not uncommon, especially with an associated fibular fracture.1–6 Many fracture-dislocation injuries of the ankle are the result of a fall4,7–11 or motor vehicle accident.12–15 Most ankle fracture and dislocation injuries have less than favorable outcomes for the patient.1,2,4,6,13,15–18 The literature presents numerous factors associated with these poorer outcomes, the main factors being the patient's age, fracture location, fracture pattern, and the presence of one or more associated dislocations.3,5,6,18–20

Few of the published case studies of ankle dislocation and fibula fracture are sport related.7–12,14,20–24 Of those cases, few authors25 discuss the occurrence in high-level football athletes.

External rotation of the ankle, paired with either pronation or supination, can place the ankle joint in a vulnerable position for dislocation or fracture (or both).1,4,13,16,18,20,22 Many injury classification methods use the mechanism of injury to determine the extent of damage.5,17,18 The Weber classification method uses the level of fibular fracture to classify the injury. A Weber type A injury refers to a fibular fracture below the tibiofibular joint line, whereas a Weber type B injury occurs at the level of the joint line, and a Weber type C injury occurs above the joint line.5 The Weber classification system has substantial interobserver reliability and intraobserver reproducibility.26 A Maisonneuve fracture (a Weber type C fracture) occurs in the proximal fibula when the distal tibiofibular syndesmosis ruptures and either the deltoid ligament fails or the medial malleolus fractures.20,22 This injury is caused by excessive ankle external rotation.20,22,27

Open reduction and internal fixation techniques help to restore fibular integrity and ankle mortise stability in a relatively low, Weber type C fracture pattern. A Maisonneuve fracture occurs relatively proximally in the fibula and, therefore, tends to be fairly stable compared with a lower Weber type C fracture. For that reason, the team physician will make a recommendation as to whether an open reduction and internal fixation procedure should be performed. Surgeons commonly use syndesmosis screws to help restore the stability of the ankle mortise between the tibia and fibula.1,2,18,20 Outcomes for ankle fracture-dislocation injuries typically depend on the fracture pattern associated with the injury.2–4,6,16,20

Internal fixation techniques tend to enhance outcomes for all patients with ankle fractures.1 The insertion of syndesmosis screws usually improves outcomes with a Weber type C injury.1,2,4,16,20 However, Kennedy et al18 showed that when a Weber type C fracture occurred within 5 cm of the joint line, syndesmosis screws did not affect the outcome radiographically, objectively, or subjectively. Regardless of the treatment, the most important outcome for patients is pain due to arthritic changes within the joint.1,4,16,18,20

Our purpose for this case study is to present a common injury in an uncommon setting. We present the case of a National Collegiate Athletic Association Division I football player who sustained a talocrural dislocation and subsequent Weber type C fibular fracture. The mechanism of injury was external rotation with pronation and did not involve a fall of any kind. We also present an aggressive physical rehabilitation protocol that allowed this player to return to full activity at a highly competitive level. With little literature available on this injury in a highly competitive athlete, the sports medicine staff developed an aggressive rehabilitation protocol based on the athlete's specific needs.

Case Report

In September 2005, a 20-year-old male football player was injured while attempting to tackle an opponent. The mechanism of injury was ankle pronation and external rotation. When he planted his leg to make a tackle, the opponent stepped on the lateral aspect of his ankle, causing excessive motion. Upon reaching the athlete, the sports medicine staff saw that the player's ankle was grossly deformed and made an on-field assessment of a talocrural dislocation. With the lateral dislocation, the skin on the medial aspect of the ankle was taut over the medial malleolus, thus compromising the vascular integrity of the skin. However, the orthopaedic physician decided not to reduce the dislocation on the field to decrease the potential for complications. He wanted to attempt to reduce the injury in a relatively calm, controlled atmosphere, where more supplies were available if needed. The athletic trainers applied a vacuum splint to immobilize the injury in the position found and transported the player to the athletic training room. In the athletic training room, the team physicians further evaluated the athlete and confirmed the initial diagnosis of talocrural dislocation.

The orthopaedic physician performed immediate (within 10 minutes of injury) reduction of the talocrural joint in an effort to decrease the risk of skin necrosis. Upon a more thorough evaluation after reduction, the physicians suspected a distal fibular fracture as well. The sports medicine team applied a posterior fiberglass splint with medial and lateral supports on the athlete's ankle and obtained radiographs. The radiographs confirmed the fibular fracture, as well as increased medial clear space in the ankle (Figure 1). The sports medicine staff applied ice and elevated the athlete's injured ankle for the remainder of the game.

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The next day, the orthopaedic physician performed an open reduction and internal fixation procedure. Intraoperative examination under anesthesia demonstrated syndesmosis disruption, so 2 syndesmosis screws were inserted to restore ankle mortise stability (Figure 2). A below-the-knee, fiberglass cast was applied with instructions to bear no weight for 4 to 6 weeks.

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Rehabilitation

Three weeks after the initial injury, the below-the-knee cast was removed and replaced with a removable DonJoy walking boot (DJO Inc, Vista, CA). This enabled the athletic training staff to begin passive dorsiflexion and plantar-flexion range of motion (ROM) exercises early in the rehabilitation process. These passive motions progressed to active assistive and then to active ROM exercises as soon as the athlete was able to tolerate them. During the first month of rehabilitation, the athletic training staff applied ice and compression by means of a Game-Ready (CoolSystems Inc, Berkeley, CA) machine paired with electric stimulation before and after the session. Table 1 presents the flow sheet of therapeutic modalities. (The first month of modality use is not included in Table 1 because only electric stimulation with ice and compression were used. The athlete then returned home for semester break and was not under our direct supervision for rehabilitation until the 3½-month mark.) In the first week of rehabilitation (3½ weeks postinjury), the athletic trainers performed an aggressive milking massage before the Game-Ready application to promote the movement of residual edema. At 1 month postinjury, electric stimulation helped to strengthen both the vastus medialis oblique and gastrocnemius muscles without weight bearing. Incorporating upper body cardiovascular fitness exercises fatigued the patient too much to permit him to walk around campus on crutches all morning and, so, the athletic trainers decided to discontinue this activity immediately.

Table 1 Therapeutic Modality Applications^a

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The sports medicine staff educated the patient on many ROM exercises (plantar flexion, dorsiflexion, eversion, and inversion) he could perform on his own while at home during the semester break. In addition, the athletic trainers supplied the patient with Thera-Bands (Hygenic Corp, Akron, OH) of various resistances (red  =  medium, green  =  heavy, blue  =  extra heavy). The athletic training staff instructed the patient on strengthening exercises using the Thera-Bands, including how to progress through sets and repetitions with each resistance of the exercise band. He was instructed to perform the exercises periodically throughout the day. The patient applied ice as needed while he was at home. Table 2 shows the first phase of the rehabilitation from the time the cast was removed and rehabilitation sessions began (3 weeks postinjury) to the home exercise program the patient performed over the semester break.

Table 2 Initial Rehabilitation Protocol^a

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Tables 3 and 4 outline the remaining rehabilitation protocol after his return from the semester break. At this point, the patient started closed kinetic chain exercises that emphasized multijoint movements as well as cardiovascular exercises to help restore his fitness level (ie, bicycle with low resistance or upper body ergometer, or both). As the volume of the rehabilitation exercises progressed, the patient began complaining of localized pain around the healed incision. Because surgery for screw removal was already scheduled, the sports medicine staff decided to wait until after the surgery to address this pain if it did not resolve with the second surgery. At approximately 4 months postinjury, the second surgery was performed to remove the syndesmosis screws.

Table 3 Rehabilitation Protocol After Return From Semester Break^a

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Table 4 Last 3 Months of Rehabilitation Protocol Before Returning to Regular Team Summer Conditioning

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After surgical removal of the screws, the patient's rehabilitation underwent a slight setback as he recovered from the procedure. Fortunately, the patient was able to tolerate active ROM exercises almost immediately. When the incisions healed from the screw removal, the athletic training staff began laser and ultrasound applications on the anterior-medial, anterior, and anterior-lateral aspects of the talocrural joint. Gait training also began at this time in a HydroWorx (Middletown, PA) pool. A treadmill is mounted on the bottom of this small pool, along with a video monitor to aid in gait training. Hydrotherapy was not initiated after the initial surgery for several reasons. First, the patient wore a non-removable splint for a period of time. Second, the team physician wanted to wait until the incisions were completely healed. And third, the athlete was not on campus for semester break. The patient progressed from running in water to running on a track or treadmill by the 5-month mark, when he was able to tolerate full weight bearing. At this point, the patient was lacking the final few degrees of ankle plantar flexion and dorsiflexion. The athletic trainers started ultrasound treatments to the anterior-medial, anterior, and anterior-lateral aspects of the ankle. After approval was obtained from the orthopaedic physician, joint traction and joint mobilizations were added following the ultrasound treatments in an effort to regain the remaining ROM.28 The joint traction and mobilizations also helped to restore the arthokinematics of the talocrural joint.

Performing knee flexion and extension while on a physio ball helped to strengthen the muscle being worked (ie, flexion for hamstrings, extension for quadriceps) as well as the patient's core muscles (eg, abdominal muscles, erector spinae). Once the patient was able to perform this exercise with increased weight and minimal difficulty, he was progressed to using a DynaDisc (Exertools, Novato, CA) under the foot that was not performing the extensions. Once the patient advanced though this exercise for knee flexion and extension, he started a lower extremity workout in the weight room. This leg workout was a progressive strength training protocol that addressed movements in the frontal, sagittal, and transverse planes of motion.29

At approximately 5 months, functional electric stimulation was incorporated for the ankle plantar-flexor muscles. To facilitate contraction of both heads of the gastrocnemius muscle, the athletic trainer placed the electric stimulation pads on both heads. The patient stood on the edge of the box, just as he would be for a regular toe raise. The athletic trainer instructed him to contract when he felt the stimulation ramp up and to relax when he felt it ramp down.

Once the patient was able to tolerate normal running with minimal pain (5½ months), he began basic agility drills, including straight-ahead jogging, lateral shuffles, backward lunges, and backward shuffles. These agility drills slowly progressed to modified, sport-specific drills, such as the “W” drill, zigzag running, and box drills. All of these drills require forward and backward running as well as lateral movements and lateral cutting. During winter conditioning practices, the patient added regular, position-specific drills to the regular conditioning drills. After the rehabilitation sessions and conditioning practices, the patient received ice as needed.

At 6 months, the patient returned to participation in practice to a limited extent. By 6½ months, he was participating in full-length practices with full pads and minimal restrictions (no contact). By the end of the spring season (7 months postinjury), the patient had no restrictions and was 100% functional. The athletic trainers applied tape for prophylactic purposes for practices and games. The patient continued with a maintenance rehabilitation program in order to preserve his strength and proprioception in addition to the regular team summer conditioning program. He participated with no restrictions in the summer conditioning program. At the beginning of the following season, the patient started in his usual position of defensive back.

Discussion

Ankle injuries are common in athletic settings.30 Numerous types of injuries can occur at the ankle, including fractures to the tibia and fibula and sprains to any of the syndesmosis ligaments that can compromise the integrity of the ankle mortise.31 Ankle dislocation at the talocrural joint coupled with a fracture of the fibula is commonly reported in the literature.6,7,11,12,14,22 Lin et al32 showed that external rotation with excessive dorsiflexion was the most common mechanism of injury for ankle injuries in athletes playing on artificial turf (as the current case demonstrated). However, most of the reported injuries are the result of a fall4,7–11 or motor vehicle accident.12–15 Although similar injuries have likely occurred in the sport setting, ours is the first case report to present this injury at this level of participation.

As with any injury, prompt and accurate evaluation is vital. In the current case, the sports medicine team made an on-field assessment, had the athlete in a “stable” condition, and made a more accurate diagnosis (with the help of radiographs), all within 20 to 30 minutes of injury. Knowledge of anatomy and possible conditions associated with a talocrural dislocation is vital to a swift and accurate assessment. Knowing that this type of injury can occur in the sport population and being able to recognize it, as well as any associated injuries, are essential.

The generally accepted treatment for a Weber type C fracture is to immobilize the extremity below the knee and insert syndesmosis screws. With a Weber type C fibular fracture, the syndesmosis ruptures distally from the fracture site.1,18 This disruption can affect the stability of the ankle joint and require syndesmosis screws.18 Kennedy et al18 studied outcomes in low Weber C fractures, both with and without syndesmosis screws, and found no difference between the groups. However, Kennedy et al18 did not describe their study population. Intraoperative examination under anesthesia performed on our patient demonstrated disruption of the syndesmosis. Therefore, the physician who performed the surgery inserted 2 screws to stabilize the syndesmosis and allow the ankle mortise to heal anatomically. This approach gave the athlete the best chance for an early and full return to sport and has been suggested by other authors as well.32 The athlete began weight bearing as tolerated in an effort to ensure an early and full return to activity. Patients who incorporated weight bearing as early as tolerated with a Weber type C fracture tended to return to sport more quickly than those who waited for complete healing before beginning weight bearing.27

Most outcome assessments after ankle injuries are taken at least 2 years postinjury.1–4,6,16,18,20 The main complaint of patients in those studies was persistent joint pain, which is due to arthritic joint changes. The majority of patients tend to have a fair outcome. Proper anatomic reduction and re-establishment of the ankle mortise was a positive prognostic predictor in all of the studies. Patients with reductions that did not restore the ankle mortise tended to have worse outcomes. Another predictor of outcome was patient age; the older the age at injury, the worse the outcome.16,18

With no published studies addressing outcomes in high-level athletes, the long-term outcome in the current case is difficult to estimate. The sports medicine staff believes that the athlete is doing very well and has had an excellent outcome. Many factors may have contributed to the athlete's successful rehabilitation. The prompt on-field assessment and reduction with immobilization stabilized the soft tissue and minimized swelling to allow early surgical intervention. The anatomic reduction permitted the aggressive rehabilitation protocol. Further, the athlete's relatively young age, combined with the presence of only an extra-articular fibular fracture (as opposed to a malleolar fracture) may have played a role in the successful outcome. At present, the athlete is not complaining of the joint pain that some authors believe reflects the early onset of arthritis or chondral defects of the talar dome or tibia.3,6,17–19

The athlete did not report excessive pain once he began weight-bearing exercises, so the sports medicine team assumed that there was no lateral gutter scarring of the ankle. (The incisional pain the athlete experienced before syndesmosis screw removal resolved after the screws were removed.) Ferkel et al33 showed that scar tissue can form in the space between the talus and fibula, also known as the lateral gutter, in patients similar to the current athlete. Their patients complained of general, chronic ankle pain when they started to return to their activities. Upon surgical removal of this tissue, the painful symptoms resolved. The authors recommended early removal of any type of immobilization device and beginning ROM exercises as early as possible to minimize the possibility of scarring.33 The potential for lateral gutter scarring is one reason the sports medicine team began early ROM exercises with the athlete in the present case.

Arthritis, chondral defects, lateral gutter scarring, or a combination of these conditions are all possible results of this injury.3,5,6,17–20,23,33 Only the lateral gutter scarring appears to be preventable with early mobilization and ROM exercises. Chondral defects and arthritis appear to be unavoidable. Authors of some case studies performed diagnostic imaging (eg, radiographs, magnetic resonance imaging, computer tomography) to diagnose these conditions. Performing these tests may be beneficial to athletes with persistent ankle pain. In an athlete having persistent pain after beginning full weight-bearing exercises, diagnostic imaging would help to distinguish among the 3 conditions and allow for an exact diagnosis. Diagnosing the cause of pain and treating the painful condition appropriately allows the athlete to further progress in rehabilitation.

The fact that many collegiate athletes have access to more resources than the general public must be addressed. Laser therapy is a modality that not every physical rehabilitation clinic may have due to its high price. We speculate that the biostimulation of the laser had positive effects in decreasing injury healing time by increasing local metabolism within the tissue.34 In the current case, the athlete attended 2 rehabilitation sessions per day, 5 days per week, for most of his rehabilitation. Because of insurance concerns and scheduling problems, many patients and athletes not in this setting have limited access to physical rehabilitation. With the athlete in the athletic training room so frequently, the sports medicine team was able to not only monitor his progression but also adjust his rehabilitation according to his subjective reports from session to session and week to week. The cumulative effect of multiple rehabilitation sessions using a variety of modalities may have played a role in the favorable outcome.

Conclusions

Talocrural dislocation with associated Weber type C fibular fracture has likely occurred before in the sport setting; however, we are the first to report it in the literature for a collegiate football player at the Division I level. It is important for the certified athletic trainer to recognize this injury and not overlook injuries associated with a talocrural dislocation. Sports medicine clinicians can use our treatment and rehabilitation progressions as an outline. Although short-term and long-term outcome measures for talocrural dislocations with Weber type C fibular fractures in competitive athletes are unknown, the athlete in the present case has had an excellent short-term outcome and has successfully returned to sport after injury.