ESGUINCE DE TOBILLO

El tobillo se lesiona con frecuencia en actividades diarias laborales, deportivas y recreativas. El tobillo, una articulacin de tipo bisagra, recibe cargas enormes, especialmente en la carrera o en deportes con giro sobre la extremidad. Los esguinces del tobillo resultan del desplazamiento hacia dentro o hacia fuera del pie, distendiendo o rompiendo los ligamentos de la cara interna o externa del tobillo. El dolor de un esguince de tobillo es intenso y con frecuencia impide que el individuo pueda trabajar o practicar su deporte durante un periodo variable de tiempo. Sin embargo, con un tratamiento adecuado, los esguinces de tobillo en la mayor a de los casos curan r!pidamente y no se convierten en un problema crnico.

TIPOS DE ESGUINCES DE TOBILLO

Esguinces de primer grado" Son el resultado de la distensin de los ligamentos que unen los huesos del tobillo. La hinchazn es m nima y el paciente puede comenzar la actividad deportiva en dos o tres semanas. Esguinces de segundo grado" Los ligamentos se rompen parcialmente, con hinchazn inmediata. #eneralmente precisan de un periodo de reposo de tres a seis semanas antes de volver a la actividad

normal. Esguinces de tercer grado" Son los m!s graves y suponen la rotura completa de uno o m!s ligamentos pero rara vez precisan cirug a. Se precisan ocho semanas o m!s para que los ligamentos cicatricen.

TRATAMIENTO DE LOS ESGUINCES

El objetivo primario del tratamiento es evitar el edema que se produce tras la lesin. La aplicacin de hielo es b!sica en los dos o tres primeros d as, junto con la colocacin de un vendaje compresivo. Si hay dolor al caminar, debe evitarse el apoyo usando unas muletas para evitar aumentar la lesin. $ependiendo de la severidad de la lesin una f%rula o un yeso pueden ser efectivos para prevenir mayores da&os y acelerar la cicatrizacin del ligamento. La movilizacin del tobillo 'flexin y extensin( y trazar c rculos con el pie 'hacia fuera y hacia dentro(, pueden ayudar a reducir la inflamacin y previenen la rigidez. $ependiendo de la severidad de la lesin, su m%dico puede ayudarle con un programa de rehabilitacin apropiado para conseguir un retorno r!pido a la actividad deportiva. El tratamiento inicial puede resumirse en cuatro palabras" )eposo, hielo, compresin y elevacin.

Reposo" Es una parte esencial del proceso de recuperacin. Si es necesario 'h!blelo con su m%dico(, elimine toda carga sobre el tobillo lesionado. Si necesita bastones siga los consejos de su m%dico o fisioterap%uta sobre la forma de usarlos" puede necesitar un apoyo parcial o una descarga completa dependiendo de la lesin y el nivel de dolor. El reposo no impide la realizacin simult!nea de ejercicios en descarga, como la natacin o la bicicleta est!tica. ie!o" Llene una bolsa de pl!stico con hielo

triturado y colquela sobre la zona inflamada. *ara proteger la piel, ponga la bolsa de hielo sobre una capa de vendaje el!stico empapada en agua fr a. +antener el hielo durante periodos de aproximadamente treinta minutos. Compresi"n" ,omprimir la zona lesionada con un vendaje el!stico. -ste protege el ligamento lesionado y reduce la inflamacin. La tensin del vendaje debe ser firme y uniforme, pero nunca debe estar demasiado apretado. E!e#aci"n" +ientras se aplica hielo, eleve la zona lesionada por encima del nivel del corazn. ,ontin.e con este procedimiento en las horas siguientes, con el vendaje de compresin colocado.

RE ABILITACI$N
Los dos objetivos de la rehabilitacin son"

$isminuir la inflamacin /ortalecer los m.sculos que rodean el tobillo.

La inflamacin puede reducirse manteniendo el tobillo lo m!s elevado posible y con la utilizacin adecuada de la compresin. )ealizar ejercicios para fortalecer el tobillo.

REANUDACI$N DEL DEPORTE

*ara volver a practicar deportes, generalmente se recomienda que la inflamacin o el dolor no existan o sean m nimos y que puedan realizarse saltos hacia delante o hacia los lados sobre el tobillo lesionado sin sentir dolor ni inestabilidad. En los esguinces m!s graves es una buena idea proteger el tobillo con una tobillera o una ortesis para disminuir la probabilidad de nuevos episodios de esguince. Su m%dico y entrenador deben guiarle en su retorno a la pr!ctica deportiva.

E%ERCICIOS
E&ercicio de rango de mo#imiento' (Escri)ir con e! pie( 0plicar una bolsa de hielo al tobillo durante 12 minutos. $espu%s trazar las letras del alfabeto en el aire con el dedo gordo. )ealizar este ejercicio tres veces al d a y hacerlo hasta que se consiga el movimiento completo del tobillo.

Resistencia $ebe iniciar los ejercicios de resistencia una vez recuperada la movilidad completa. 3tilizar una banda el!stica de un metro o una c!mara de rueda de bicicleta. 4acer 52 repeticiones de cada uno de los siguientes ejercicios tres veces al d a.

a* +!e,i"n p!antar' Sujetar ambos extremos de la banda el!stica con las manos y pasarla por debajo del pie. 0l mismo tiempo que se tracciona de la banda empujar con el pie lejos del cuerpo. ,ontar hasta tres y repetir el ejercicio.

)* Dorsi-!e,i"n' 0tar la banda alrededor de la pata de una mesa y pasar el otro extremo alrededor del dorso del pie. 6irar del pie en direccin al tronco. ,ontar hasta tres y repetir el ejercicio.

c* In#ersi"n' ,on la goma fija a un objeto est!tico, si%ntese en una silla. 0poyando el taln en el suelo llevar el pie hacia dentro contando hasta tres en cada ejercicio.

d* E#ersi"n' ,omenzando en la misma posicin que en el ejercicio de inversin pero con la banda el!stica en direccin inversa, realizar movimientos del pie hacia fuera contando hasta tres.

+orta!ecimiento' ,uando pueda realizar los ejercicios de resistencia descritos f!cilmente y sin molestias, doble la banda el!stica 'haciendo dos lazos( y haga 72 repeticiones de los mismos ejercicios tres veces al d a. 0lternativamente, haga los ejercicios con una bota pesada o colocando un peso en la suela de una zapatilla deportiva. 0&ada ejercicios en posicin 8de puntillas8" *ngase de puntillas y cuente hasta tres, primero con el pie apuntando hacia delante y despu%s hacia dentro y hacia fuera. $ as despu%s, repetir este ejercicio apoy!ndose en un slo pie.

E.ui!i)rio' *osicin de 8cig9e&a8" Elevar la extremidad no lesionada manteni%ndose sobre la lesionada durante un minuto. )epetir hasta un total de : minutos, tres veces al d a. *rogresar hasta mantenerse sobre una pierna con los ojos cerrados.

ACTI/IDADES +UNCIONALES ,uando pueda caminar sin dolor o cojera, iniciar la carrera por llano. Seguir con carrera realizando giros 8en forma de ocho8, y finalmente carrera en zigzag.

Causas' normalmente el esguince de tobillo es una lesin que se produce de manera fortuita por un mal movimiento o un accidente a la hora de hacer la pisada en el suelo. La esencia del esguince de tobillo es el estiramiento de! !igamento por encima de su !0mite de e!asticidad, lo que provoca su distensin, desgarro o rotura, seg.n la violencia con la que se sobrepase ese l mite. /actores como un ca!1ado inadecuado con suela alta o poco ajustado, terreno irregu!ar, debilidad de los grupos musculares protectores de la articulacin o -atiga pueden propiciar la aparicin del esguince de tobillo.
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S0ntomas' suelen ser inconfundibles, el propio movimiento de torcedura de tobillo al lesionarnos y la posterior posicin de dolor y proteccin son los primeros s ntomas. 0 nivel de diagnstico los s ntomas son"

Do!or intenso de la articulacin con la consecuente limitacin funcional, no poder apoyar el pie, andar o no poder hacer ligeros movimientos. 0 m!s grave la lesin m!s dolor e imposibilidad funcional conllevar!. In-!amaci"n de la zona afectada" suele ser lo m!s llamativo de esta lesin. 6al hinchazn no conlleva deformidad o desplazamiento de partes seas de la articulacin, es lo que diferencia el esguince de una luxacin o fractura. Aparici"n de 2ematomas" es menos frecuente pero se suele dar en los casos en los que se rompe alg.n vaso sangu neo. Este hematoma puede desplazarse y extenderse a otras zonas del pie a causa del movimiento de los efluidos de la lesin por el tejido conectivo. *or eso es normal que el primer d a el hematoma ocupe slo la zona lesionada y a los 1;< d as se haya extendido por parte del pie. 6ambi%n el color ir! cambiando de morado a tonos m!s amarillos y verdosos conforme el hematoma vaya desapareciendo. Ca!or !oca!" la zona lesionada est! caliente como consecuencia de la inflamacin y la mayor afluencia de sangre a la zona. 0lteracin de la sensibilidad localizada en la zona del ligamento lesionado.

*revencin" sin duda el mejor tratamiento para una lesin es la prevencin, y en el caso del esguince de tobillo hay dos factores fundamentales para la prevencin"

Un )uen ca!entamiento" que incluya movilizacin de la zona y ligeros estiramientos para dar algo de laxitud al ligamento y desentumecerlo antes de realizar pr!ctica deportiva. )ecuerda que el calentamiento debe ser progresivo en intensidad y dificultad. Propiocepci"n" los propioceptores son receptores sensoriales situados en las articulaciones que nos dan informacin sobre la posicin y velocidad de movimiento de dicha articulacin. El entrenamiento propioceptivo permite dotar a nuestro organismo de informacin sobre cambios de posicin y cambios

bioqu micos a nivel muscular, lo que desarrolla mecanismos de defensa frente a lesiones 'reflejos musculares que protegen la elongacin excesiva de los ligamentos(.

Si ya has sufrido el esguince otros m%todos para prevenir y evitar que se reproduzca la lesin son el uso de una ortesis adecuada por el tobillo 'esto es cuestin de tu m%dico o fisioterapeuta(, un buen taping o #enda&e -unciona!.

0n=le Sprains Sprains are the most common an=le injury presenting to the E$, and perhaps the most commonly mistreated injury confronting the emergency physician. >t is ironic that many physicians have a limited understanding of the 8simple sprain,8 yet this disorder confronts them more commonly than any other single entity involving the extremities. Sprains account for ?:@ of all injuries to the an=le.7 0n=le sprains occur most often in athletes betAeen 7: and 5: years of age involved in bas=etball, football, and running.B1,B5 Sprains of the lateral ligaments account for the vast majority, folloAed by the tibiofibular syndesmotic and medial ligaments. +echanism of >njury Sprains are due to forced inversion or eversion of the an=le, usually Ahile the an=le is plantar;flexed. >nversion stresses account for C:@ of all an=le sprains and result in lateral ligamentous injury. 0s force increases, a predictable sequence of structures are injuredB< '6able 7?D 7(. 6he lateral joint capsule and the anterior talofibular ligament '06/L( are the first structures to be injured folloAing an inversion stress. >solated injury to the 06/L is present in B2@ to ?2@ of all an=le sprains.: Eith greater forces, a tear of the calcaneofibular ligament ',/L( occurs, and finally the posterior talofibular ligament '*6/L( is injured. >njury to all three structures is seen in up to F@ of cases.: 6able 7?D7. Sequence of Structures >njured Aith >nversion and Eversion 0n=le Sprains

In#ersion Stress 0nterior talofibular ligament

E#ersion Stress +edial malleolus avulses 'deltoid ligament rupture(

,alcaneofibular ligament

0nterior;inferior tibiofibular ligament

In#ersion Stress

E#ersion Stress

*osterior talofibular ligament

>nterosseous 'syndesmotic( ligament

Eversion injuries to the an=le are much less li=ely to result in an=le sprains. >n addition to the structures listed in 6able 7?D7, a lateral malleolus fracture is seen much more commonly folloAing an eversion injury 'see /ig. 7?DF(.B: Ehen the medial structures are injured, avulsion of the medial malleolus occurs more frequently than rupture of the strong and elastic deltoid ligament. 0s the force continues, the 06/L 'anterior;inferior tibiofibular ligament( and the interosseous 'syndesmotic( ligament Aill tear 'see 6able 7?D7(. +edial an=le sprains account for approximately :D72@ of all an=le sprains.: Eversion of the an=le, internal rotation of the tibia, and excessive dorsiflexion may result in a tibiofibular syndesmotic ligament injury. 6his injury is termed the 8high an=le sprain.8 >n a series of an=le ligament ruptures, in 5@ of cases, an isolated syndesmosis rupture Aas identified.BB ,linical *resentation 0n=le sprains are categorized as first;, second;, or third;degree injuries according to the clinical presentation and the instability demonstrated by stress testing '6able 7?D1(. /irst;degree injuries are easy to diagnose, Ahile difficulty exists in distinguishing betAeen second; and third;degree injuries. 6able 7?D1. ,lassification of Sprains

Grade +irst4degree" Ligament injury Aithout tear

Signs and S3mptoms +inimal functional loss 'patient ambulates Aith minimal pain( +inimal sAelling +ildly tender over involved ligament Go abnormal motion or pain on stress testing

Second4degree" >ncomplete tear +oderate functional loss 'patient has pain Aith of a ligament Aeight bearing and ambulation( +oderate sAelling, ecchymosis, and tenderness *ain on normal motion +ild instability and moderate to severe pain on stress testing T2ird4degree" ,omplete tear of Significant functional loss 'patient is unable to bear a ligament Aeight or ambulate( Egg;shaped sAelling Aithin 1 hours of injury +ay be painless Aith complete rupture

Grade

Signs and S3mptoms *ositive stress test

>n a first-degree sprain, there is stretching of the fibers of the ligament Aithout tear. 6he patient presents Aith no functional loss in the an=le and many of these patients often do not see= care, usually treating themselves at home. *atients Aith first;degree sprains demonstrate little or no sAelling of the an=le, no pain on normal motion of the an=le, and only mild pain on stressing the joint in the direction of the insulting force, usually inversion. *atients Aith a second-degree sprain are more difficult to diagnose because second; degree sprains mean that the ligament is partially torn. 6his can run the gamut of anything from just a feA fibers being torn to tears involving almost the entire ligament Aith only a feA fibers remaining intact. 6he patient presents Aith moderate sAelling and complains of immediate pain upon injuring the an=le. 6his is in contrast to patients Aith a first;degree injury Aho may not =noA they had a sprain until the next day or after a period of rest. 6he second;degree sprain is fraught Aith complications, including the possibility of ligamentous laxity Aith recurrent sprains due to instability. 0 third-degree sprain exists Ahen there is a complete tear of the ligament. 0n 8egg; shaped8 sAelling over the lateral ligaments of the an=le occurring Aithin 1 hours of injury, in most cases, indicates a third;degree injury of the an=le. >t is often difficult to differentiate a severe second;degree sprain from a third;degree injury Aithout adequate stress testing.B?D?2 Hecause the ligaments are completely torn, there may be little or no pain, but there is usually sAelling and tenderness of the an=le. Examination ,areful examination of the an=le Aill give the emergency physician better insight into the ligamentous structures injured folloAing an an=le sprain. >f the lateral malleolus sAelling increases the an=le circumference by < cm, then the probability of ligament rupture Aithin the an=le is ?2@. 6enderness over the ,/L suggests rupture of this ligament in ?1@ of cases. Li=eAise, tenderness over the 06/L means that in :1@ of cases, the ligament is ruptured. >f all three symptoms are present, then there is a F7@ chance of major ligament damage.B5 Stress testing aids in differentiating second; and third;degree an=le sprains.?7,?1 >f pain and sAelling secondary to the acute injury does not alloA stress testing, the an=le should be immobilized and the patient =ept from Aeight bearing. )eferral for serial examinations improves diagnostic accuracy.1,?5 >njection of the an=le may alloA performance of stress tests of the acutely injured an=le. 6his is done by injecting the joint opposite to the side of the injury 'usually medially( and infiltrating : to 72 mL of lidocaine. 4oAever, diagnostic accuracy is diminished folloAing injection. 6he inversion stress test, for example, is only BC@ accurate Aith anesthesia compared to F1@ Aithout anesthesia.?< 6he anterior drawer test is the first test to be performed because it examines for rupture of the 06/L. >f this test is negative then there is no need to go to the inversion stress

test because it requires both the anterior talofibular and the calcaneofibular ligament to be ruptured to be positive. 6he anterior draAer test of the an=le can be done Aith the patient either sitting or supine '/ig. 7?D1B(. 6he muscles surrounding the an=le should be relaxed. 6he =nee should be flexed to relax the gastrocnemius muscle, and the an=le should be held in a neutral position. >f the an=le is plantar;flexed, a positive anterior draAer test Aill be impossible to demonstrate, even if the ligaments are completely disrupted.?1 6he examiner places the base of the hand over the anterior aspect of the tibia and applies a posterior directed force. 0t the same time, the other hand cups the heel and displaces the foot anteriorly. ?1 )upture of 06/L is indicated by mild anterior displacement of the talus. >ncreasing laxity indicates additional injury to the calcaneofibular and posterior talofibular ligaments. 6he degree of laxity should alAays be compared Aith the normal side. /igure 7?D1B.

6echnique for performing anterior draAer stress test of the an=le. Eithin the first <C hours after injury, the anterior draAer test Aas found to have a sensitivity of ?7@ Aith a specificity of 55@. /ive days postinjury, the sensitivity improved to FB@ Aith a specificity of C<@.?5 0n inversion stress test 'talar tilt test( can be performed to identify rupture of the ,/L, although this test is usually not necessary acutely and can be quite painful. For this reason, we do not recommend performing this test in the acute setting. 6his test measures the angle produced by the tibial plafond and the dome of the talus in response to forced inversion. 6o perform this test, the an=le is =ept in a neutral position and the examiner grasps the anterior tibia Aith one hand and the heel Aith the opposite hand. 6he an=le is inverted. 0 difference of :@ to 72@ or 15I tilt indicates tears to the 06/L and the ,/L.?5 Eversion, in the manner described above, detects injury to the deltoid ligaments. Examination for the detection of a syndesmotic ligament sprain should include the squeeze test. 6o perform this test, the tibia and fibula are 8squeezed8 together at the mid calf. $istal pain on compression in the absence of a fibula fracture indicates injury to the syndesmotic ligaments.7,: 6his injury should also be suspected Ahen tenderness is present at the distal tibiofibular joint or pain is produced upon forced external rotation of the an=le. >maging )adiographs of the an=le should be ta=en in most cases. 6he JttaAa 0n=le )ules, as described previously, Aill aid the clinician in avoiding unnecessary an=le radiographs. >n some patients Aith a second;degree sprain, one Aill note a small fla=e of bone off of

the lateral malleolus. 6his indicates an incomplete tear and is usually associated Aith a second;degree injury to the lateral ligaments. Eidening of the tibiofibular clear space to KB mm suggests a syndesmotic ligament sprain. 0rthrography may be used to define the extent of ligamentous rupture. 6he benefit of this technique is controversial, and it is rarely used in the E$.B?,BF,?2 6o perform an arthrogram, the an=le is thoroughly prepped and a 11;gauge needle, attached to a 72;mL syringe, is inserted into the side opposite the injury and about B mL of contrast material is injected. 0 7"7 mixture of 4ypaque ':2@ diatrizoate meglumine and diatrizoate sodium( and sterile Aater is used. )adiographs of the an=le are then obtained. Ehen ligamentous rupture is present, extravasation Aill be seen laterally outside of the an=le joint along the lateral malleolus. 0ssociated >njuries Jsteochondral lesions of the talar dome occur in B@ to 11@ of an=le sprains and are easily missed on the initial assessment.7,BB 6his lesion should be suspected Ahen tenderness is present along the anterior joint line Aith the an=le plantar;flexed. +agnetic resonance imaging '+)>( or ,6 scan of the an=le Aill detect these injuries and should be considered in patients Aith sprains that remain symptomatic for B Aee=s after injury. 6reatment 6he initial care of most lateral an=le sprains treated in the E$ is similar, but important differences exist. /irst;$egree Sprain /or the first;degree sprain, ice pac=s, elevation, and an elastic bandage Aith early mobilization is the most appropriate treatment. Gonsteroidal antiinflammatory medications provide analgesia and possible improved outcomes.: >ce should be crushed, placed in a plastic bag, and covered Aith a thin protective cloth to avoid cold;induced injury to the s=in. >ce application is recommended for 12 minutes < to B times a day for the first 1 days. 6he elastic bandage should extend just proximal to the toes to the level of the mid calf. Elevation of the injured extremity 7: to 1: cm above the level of the heart Aill facilitate venous and lymphatic drainage.7 Eeight bearing is encouraged as tolerated. /unctional rehabilitation is begun immediately '/ig. 7?D1?(.7 )eturn to full activity is usually achievable Aithin a Aee= and patients should be referred to their primary physician. /igure 7?D1?.

/unctional rehabilitation folloAing an an=le sprain consists of restoring range of motion, muscle strengthening exercises, proprioceptive training, and finally, gradual return to activity. A. 0chilles tendon stretching exercises should begin Aithin <C hours of injury. Jther range of motion exercises include =nee bends Aith the heel on the floor ': repetitions : timesLday( and alphabet exercises, in Ahich the patient 8draAs8 the letters of the alphabet Aith the toes. B, C. Strengthening exercises begin once sAelling and pain are controlled. >sometric exercises 'plantarflexion, dorsiflexion, inversion, and eversion( against a Aall are folloAed by isotonic exercises. D. *roprioceptive exercises begin once full Aeight bearing Aithout pain has been achieved. 0 8Aobble board8 is used for : to 72 minutes tAo timesLday, first Ahile seated, and then Ahile standing. 6he patient rotates the board cloc=Aise and countercloc=Aise. Second;$egree Sprain >n second;degree sprains, the initial treatment is similar to first;degree sprains except the patient is =ept from Aeight bearing for <C to ?1 hours. 0fter that period, touch;doAn Aeight bearing Aith crutches should progress to crutch Aal=ing as soon as possible.1 0n an=le support, Ahich provides much more stability than an elastic bandage is applied until healing is complete. 6hese supports include lace;up braces, semi;rigid bimalleolar orthotics, and air splints '0ppendix 0D7?(.1,?: *rolonged immobilization is a common error in the treatment of these injuries. Hecause second;degree sprains are stable injuries, functional rehabilitation should be started Aith range of motion exercises on day one.7 /unctional rehabilitation stimulates healing by promoting collagen replacement. Lac= of an appropriate rehabilitation program may delay return to activity by months.?B /olloA;up care Aith an orthopedist or sports medicine specialist is recommended. 6hird;$egree Sprain 6hese patients are treated initially Aith immobilization in a splint for ?1 hours Aith ice, elevation, and referral. Ehen applying a splint, it is vitally important to =eep the an=le out of equinus and in the neutral position. *hysical examination is notoriously difficult immediately folloAing an injury due to pain and sAelling. >n patients in Ahich the differentiation betAeen a second;degree or third;degree sprain cannot be certain, Ae recommend treating the injury as a third; degree sprain Aith reexamination after the sAelling and pain has subsided. $elayed physical examination : days postinjury has been shoAn to be more accurate than Ahen performed in the first 1 days.?5,?? 6he definitive treatment of patients Aith third;degree injury remains controversial. Ehen significant talar instability is present, surgical repair is recommended by some authors, particularly in the young athletic patient, Ahile others recommend early mobilization and physical therapy.1,BF,?CDC: Jrthopedic consultation for these injuries, as Aith any serious injury fraught Aith complications, is recommended.

,omplications 6he 8simple sprain8 can be associated Aith a high degree of morbidity. Ehile most patients return to normal activity Aithin < to C Aee=s, as many as 12@ to <2@ of patients after third;degree sprains Aill have pain that limits their activity for years after the injury.BB 6he most common complication, lateral talar instability, Aill develop in as many as 12@ of patients after an an=le sprain.CB 6hese patients complain of chronic instability of the an=le and 8giving Aay8 on running. 0 majority of patients can be successfully treated Aith a rehabilitative exercise program and bracing to improve stability. >n severe or refractory cases, surgical intervention using a tendon graft to stabilize the joint may be Aarranted.CB *eroneal nerve injury is another common complication folloAing an=le sprains. >n one series, 7?@ of patients Aith second;degree sprains had mild peroneal nerve injuries and CB@ of patients Aith third;degree sprains injured either the peroneal or the posterior tibial nerve.C? 6hus, impaired ability to Aal= : to B Aee=s after a sprain may be due to peroneal nerve injury. 6his injury is probably caused by mild nerve traction or a hematoma in the epineural sheath. *eroneal tendon dislocation or subluxation, syndesmotic injuries, tibiofibular exostosis, sinus tarsi syndrome 'subtalar sprain(, talar dome osteochondral injuries, and complex regional pain syndrome are infrequent complications of lateral ligament sprains. 6hese entities are all covered in the folloAing sections Aith the exception of complex regional pain syndrome, Ahich is described in ,hapter <.