Entorses do tornozelo: do diagnóstico ao tratamento perspectiva fisiátrica

Ankle injuries are the most frequently encountered injuries in clinical practice. They are often managed by general practicians, and not only by orthopaedic or physiatric physicians. This injury is usually non-complicated, but some care should be taken to assure an adequate management and to exclude severe lesions. The stability of the ankle is necessary for functional activity of lower extremity, allowing walking and participation in other high demanding activities like running or jumping. There is a constant concern in adopting the best diagnostic and treatment procedures to enhance the recovery and to prevent the chronic joint instability. According to this, there should be proposed comprehensive strategies focusing the rehabilitation view. The ankle is a complex articular structure with contributions from the talocrural, subtalar, and inferior tibiofibular joints. The full understanding of the functional anatomy and biomechanics is the first step for the evaluation of the etiologic factors. The recognition of the mechanism of injury, and the risk factors, should be carefully addressed to make an accurate diagnosis, proper management and to implement prophylactic measures, knowing that the lateral ligamentous complex is the most commonly injured. As always, diagnosis can be made taking an adequate history, performing a thorough physical examination, and when necessary, requesting complementary studies. The priority in initial assessment it's to clear out some severe complications, like fractures, that can mimic or that can be associated with ankle sprains. Although the conventional radiology is suitable for most cases, that has been greatly improved through the institution of the Ottawa Rules, in selected patients the severity of the damage is best evaluated with other imaging resources. Treatment of acute ankle sprains depends on the severity of the injury. Most acute lateral ligament injuries are best treated nonsurgically and will regain satisfactory ankle stability after functional treatment. The conservative approach has been found to be equally effective in treating grade I and II ankle sprains. Some controversy still exists regarding the appropriate treatment of grade III injuries. General belief is that the majority of these patients may also be treated well with conservative management. Surgical reconstruction may be necessary, in cases that develop chronic functional instability, and especially in athletes with high demands on ankle joint stability. The purpose of this article is to review the biomechanics, clinical examination, diagnosis, management and secondary prevention of ankle sprains. We discuss the use and benefit of different modalities and outline a three-phase intervention program of rehabilitation based on recent guidelines.

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