慢性踝關(guān)節(jié)不穩(wěn)Chronic

Ankle

Instability

(CAI)1

定義DefinitionChronicankleinstability

isdefinedastheperceptionbythepatientofanabnormalanklewithacombinationofsymptomsincludingrecurrentsprains,painandswellingoravoidanceofactivities.

(Guillo

et

al.,

2013)2

分級(jí)Classification機(jī)構(gòu)性

MechanicalinstabilityInvolvespathologicjointlaxity.Thisistypicallydelineatedbyatalartiltdiscrepancygreaterthanto10degreesorananteriordrawerdifferenceof10mmcomparedtothecontralateralankle.

(AOFAS,

2015)Mechanicalinstabilityisduetothelaxitycausedbyligamentstears.

(Bosien

et

al.,

1955)

功能性

FunctionalinstabilityIsascribedtosensorimotorandneuromusculardeficitsthataccompanyligamentousinjury,butmechanicalinstabilityisnotnecessarilypresent.(AOFAS,

2015)Functionalinstabilityisduetoproprioceptiveandmusculardeficitsafteranklesprain.

(Hiller

et

al.,

2011)BothmechanicalandfunctionalinstabilitiesmaybedifficulttoassessordistinguishandtheymostoftenoccurasacombinationinthedevelopmentofCAI.

(Guillo

et

al.,

2013)3

既往扭傷史Previous

lateral

ankle

sprain

(Konradsen

et

al.,

2002)運(yùn)動(dòng)水平Level

of

activity

(Van

den

Bekerom

et

al.,

2013)下肢對(duì)線＊Lower

limb

varus

mal-alignment

(Bonnel

et

al.,

2010)病理因素*Pathological

conditions

(Choi

et

al.,

2008)解剖學(xué)差異*Anatomical

variations病因AetiologyKonradsenL,BechL,EhrenbjergM,NickelsenT.Sevenyearsfollow-upafterankleinversiontrauma.ScandJMedSciSports2002;12:129—35.vandenBekeromMP,KerkhoffsGM,McCollumGA,CalderJD,vanDijkCN.Managementofacutelateralankleligamentinjuryintheathlete.KneeSurgSportsTraumatolArthrosc2013;21(6):1390—5.

BonnelF,ToullecE,MabitC,Tourne?Y.Chronicankleinstability:biomechanicsandpathomechanicsofligamentsinjuryandassociatedlesions.OrthopTraumatolSurgRes2010;96:424—32.ChoiWJ,LeeJW,HanSH,KimBS,LeeSK.Chroniclat-eralankleinstability.Theeffectofintra-articularlesionsonclinicaloutcome.AmJSportsMed2008;36:2167—72,/10.1177/03635465083190504

機(jī)制Motor

control病因Aetiology5

流行病學(xué)Epidemiology73%持續(xù)18個(gè)月(Braun,

1999)40%中等以上癥狀，74%持續(xù)癥狀(Anandacoomarasamy

and

Barnsley,

2005)損傷后3年仍持續(xù)癥狀(Van

Rijn

et

al.,

2008)55%未接受正規(guī)治療(McKay

et

al.,

2001)6

評(píng)定Evaluation

Subjective首次扭傷史Clinical

history

of

the

1st

sprain曾接受的治療Treatment

received運(yùn)動(dòng)項(xiàng)目及水平Types

of

sports

and

the

level就診原因Reasons

for

consulting不穩(wěn)所持續(xù)時(shí)間How

long

instability

has

existed

功能狀態(tài)Functional

effects7

評(píng)定Evaluation

Subjective評(píng)分量表8

評(píng)定Evaluation

Objective關(guān)節(jié)活動(dòng)度Range

of

motion觸痛Tenderness韌帶Ligament

Testing

形態(tài)Morphology功能檢查Functional

testing9

評(píng)定Evaluation

Objective關(guān)節(jié)活動(dòng)度Range

of

motiona.

AROM

&

PROMb.

Hind

foot

(figure

1)10

評(píng)定Evaluation

Objective關(guān)節(jié)活動(dòng)度Range

of

motiona.

AROM

&

PROM11

評(píng)定Evaluation

Objective關(guān)節(jié)活動(dòng)度Range

of

motionb.

Hind

foot

12

評(píng)定Evaluation

Objective觸痛Tenderness（韌帶肌腱等）13

評(píng)定Evaluation

Objective韌帶Ligament

Testing

(Anterior

Drawer

&

Talar

tilt

in

Varus)14

評(píng)定Evaluation

Objective韌帶Ligament

Testing

(Anterior

Drawer

&

Talar

tilt

in

Varus)15

評(píng)定Evaluation

Objective功能檢查Functional

Testing

16

評(píng)定Evaluation

Radiological

tools負(fù)重位影像Weight-bearing

X-rays動(dòng)態(tài)影像Stress

views/Dynaminc

X-rays輔助檢查Complementary

tests17

評(píng)定Evaluation

Radiological

tools負(fù)重位影像Weight-bearing

X-rays18

評(píng)定Evaluation

Radiological

tools動(dòng)態(tài)影像Stress

views/Dynaminc

X-rays19

評(píng)定Evaluation

Radiological

tools輔助檢查Complementary

tests超聲波UltrasoundCT掃描CT核磁共振MRI20

評(píng)定Evaluation

Radiological

tools輔助檢查Complementary

tests超聲波Ultrasound21

評(píng)定Evaluation

Radiological

tools輔助檢查Complementary

testsCT掃描CT22

評(píng)定Evaluation

Radiological

tools輔助檢查Complementary

tests核磁共振MRI23

治療Treatment康復(fù)訓(xùn)練Rehabilitation手術(shù)治療Surgical

treatment24

治療Treatment康復(fù)訓(xùn)練Rehabilitation關(guān)節(jié)活動(dòng)度ROM跟腱攣縮Short

Achilles

Tendon

(Aiis

and

Maffuli,

2006;

Mattacola,

2002)牽伸與離心練習(xí)Stretching

exercises

&

Eccentric

exercises神經(jīng)肌肉控制練習(xí)Neuromuscular

reprogrammingAjisA,MaffuliN.Conservativemanagementofchronicankleinstability.FootAnkleClin2006;11:531—7.MattacolaCarlG,DwyerMaureenK.Rehabilitationoftheankleafteracutesprainorchronicinstability.JAthlTrain2002;27:413—29.25

治療Treatment26

治療Treatment27

治療Treatment28

治療Treatment29

治療Treatment手術(shù)治療Surgical

treatment第二選擇Second

pillarLCL重建ColvilleR.Reconstructionofthelateralankleligaments.JBoneJointSurgAm1997;76:1092—102.HollisJP,BlasierRD,FlahiffC.Biomechanicalcomparisonofreconstructiontechniquesinsimulatedlateralankleligamentinjury.

AmJSportsMed1995;23:678—82.KripsR,DijkNV,LehtonenH,HalasiT,MoyenB,KarlssonJ.Sportsactivitylevelaftersurgicaltreatmentforchronicanterolateralankleinstability.Amulticenterstudy.AmJSportsMed2002;30:13—9.SaintPierreR,AlimanF,BassettFH,GoldnerJL,FlemmingLL.Areviewoflateralankleligamentousreconstructions.FootAnkle1982;3:114—23.30

參考文獻(xiàn)ReferencesAmerican

Orthopaedic

Foot

and

Ankle

Society,

2015,https:///education/OrthopaedicArticlesBosienWR,StaplesOS,RusselSW.Residualdisabilityfollowingacuteanklesprains.JBoneJointSurgAm1955;37:1237—43.HillerCE,KilbreathSL,RefshaugeKM.Chronicankleinstability:evolutionofthemodel.JAthlTrain2011;46:133—41.Guillo.S,Bauer.T,Lee.J.W,Takao.M,Kong.S.W,Stone.J.W,Mangone.P.G,Molloy.A,Perera.A,Pearce.C.J,Michels.F,Tourné.Y,Ghorbani.A,Calder.J,2013,Consensusinchronicankleinstability:Aetiology,assessment,surgicalindicationsandplaceforarthroscopy,Orthopaedics&Traumatology:Surgery&Research99S,S411—S419

KonradsenL,BechL,EhrenbjergM,NickelsenT.Sevenyearsfollow-upafterankleinversiontrauma.ScandJMedSciSports2002;12:129—35.vandenBekeromMP,KerkhoffsGM,McCollumGA,CalderJD,vanDijkCN.Managementofacutelateralankleligamentinjuryintheathlete.KneeSurgSportsTraumatolArthrosc2013;21(6):1390—5.

BonnelF,ToullecE,MabitC,Tourne?Y.Chronicankleinstability:biomechanicsandpathomechanicsofligamentsinjuryandassociatedlesions.OrthopTraumatolSurgRes2010;96:424—32.ChoiWJ,LeeJW,HanSH,KimBS,LeeSK.Chroniclat-eralankleinstability.Theeffectofintra-articularlesionsonclinicaloutcome.AmJSportsMed2008;36:2167—72,http:///10.1177/0363546508319050ColvilleR.Reconstructionofthelateralankleli