Background: The risk of anterior cruciate ligament (ACL) injury is among the highest in female athletes and most likely multifactorial. Laboratory-controlled studies suggested that individuals with history of ankle sprains and individuals with ACL injury have similar biomechanical alterations. However, there are few clinical case studies illustrating the potential association that an ankle sprain may have on subsequent ACL injury. Therefore, the purpose of this case study is to discuss the occurrence of an ACL rupture following a syndesmotic ankle sprain in a female soccer player. Patient: A 16-year-old female soccer athlete sustained a left syndesmotic ankle sprain during a match when the left ankle was planted on the ground while rotating into ankle inversion. The patient reported feeling a "pop", pain on the distal lateral malleolus, and inability to bear weight on the affected ankle. The Ottawa Ankle Rules were employed and warranted confirmatory diagnostic imaging. A physician ruled out a fracture and provided a diagnosis of a grade II syndesmotic left ankle sprain. The patient was cleared for return to sport by the athletic trainer after participating in three weeks of rehabilitation with an athletic trainer. In the first full soccer match back, she sustained an ACL rupture in the right knee. She reported feeling and hearing a pop during a cutting motion in which she felt the right knee go into an excessive valgus position. The patient exhibited positive Lachman's and anterior drawer tests. All additional components of the evaluation were unremarkable. The patient was referred to an orthopedic clinic, where MRI confirmed a complete ACL rupture in the right knee. Intervention or Treatment: The patient's rehabilitation for her ankle sprain focused on restoring range of motion (ROM), strength, and neuromuscular control. The patient was held from sport activities for 16 days. A return to play (RTP) assessment was implemented which required: ROM equal and painfree bilaterally, manual muscle testing of strength to be 5/5, and functional and agility testing (T-test, 5-10-5 Shuffle, and zig zag test) without limitation. After successful demonstration of these milestones, the patient was progressed back to play with two days of non-contact practice, and game/ competition re-integration of 5 minutes per half, 10 minutes per half and then fully released with no play time restriction. Only soreness reported during the first partial competition. The patient underwent patellar tendon graft ACL reconstruction for her injured right knee and is currently completing a prescribed ACL rehabilitation protocol. Outcomes or Other Comparisons: There is limited documentation on the association of previous ankle injury to ACL ruptures. The suggested potential biomechanical relationship between individuals with ankle sprain and ACL injury raises awareness of the importance of thorough ankle rehabilitation protocols. Rehabilitation and RTP for this case followed traditional protocol and a common RTP progression. However, this raises question if the ankle rehabilitation dosage was large enough and if some ACL rehabilitation protocol aspects should be incorporated into ankle rehabilitation. Additionally, perhaps clinicians should evaluate for deficiencies that could indicate risk for subsequent injuries when returning from an ankle sprain. Conclusions: Many factors predispose athletes to ACL injury. In this case, a female adolescent athlete may have had potential gender-based risk factors amplified by a recent ankle injury. The close proximity of time in which the two injuries occurred brings question to if there needs to be a more conservative return to play or a different protocol for individuals that sustain a syndesmotic ankle sprain that may have additional injury risk factors. Clinical Bottom Line: More thorough rehabilitation and RTP protocols may be needed for ankle sprain patients as the link to additional injury risk becomes documented.
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