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gold medal Bouncing Back from an Injury Like Strug's


The ankle sprain sustained by United States gymnast Kerri Strug Tuesday night (July 23) was the most dramatic injury so far of the 1996 Olympic Summer Games.

Strug had injured her ankle during the first of two vaults and needed to score well on the second to lead her team to its first-ever gymnastics team gold medal. On the second vault, she landed on both legs for an instant, just long enough to qualify her jump as a two-foot landing. She turned on one leg to salute the judges, then collapsed in pain. At the hospital afterward, her injury was diagnosed as a grade 3 lateral ankle sprain, according to a report in USA Today.

The result of her efforts was bittersweet: the 9.712 score she got from the judges was enough to ensure the US team's gold medal, but the injury threatens Strug's chance to compete in individual Olympic events. She pulled out of Thursday's all-around competition, but said she may attempt to compete Sunday in the vault finals and Monday in the floor exercise finals.

How do physicians manage grade 3 ankle sprains when an athlete is eager to return to play? Our Olympic consultants James G. Garrick, MD, and John G. Aronen, MD, give readers some background about these injuries and share some treatment strategies. Garrick is an orthopedic surgeon and director of the Center for Sports Medicine at Saint Francis Memorial Hospital in San Francisco. Aronen is a sports medicine physician and educational director of the Sports Medicine Store in San Diego. Garrick and Aronen are fellows of the American College of Sports Medicine and editorial board members of The Physician and Sportsmedicine.

Evaluation

The patient's mechanism of injury provides the best diagnostic clues. Lateral sprains usually stem from an inversion injury. On her first vault, Strug appeared to slip backward upon landing. Three ligaments can be sprained, usually in sequence: the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament. Garrick says a grade 3 sprain is simply a sprain that involves a complete tear of the ligament, and not necessarily a single ligament or a combination of ligaments.

In an injury like Strug's, it's important to consider the possibility of an occult or frank stress fracture of the ankle or foot, says Aronen, because from what he saw, the mechanism of injury was not typical for a lateral ankle sprain. "She impact loaded both ankles upon landing, then took weight-bearing off of her left one immediately," he said. "Athletes who have sprains usually fall." He says the amount of disability is the most important key to determining how serious the injury is. "It's important to ask the athlete how they got off the mat or field," Aronen says. "Strug walked off after the first vault, but was totally disabled after her second vault."

Aronen says he treated several people who had asymptomatic stress fractures of the distal leg or foot that became symptomatic on landing during his years as a physician with the training program for US Navy SEALs. "A good percentage of stress fractures show up on x-ray, but some do not," he says. Media reports have said that no fracture was seen on x-ray. "Only time will tell what the accurate diagnosis is," he says. Aronen says a bone scan would provide more information about the possible presence of a stress fracture. "However, a stress fracture that becomes an overt fracture would almost always result in the inability to bear weight-something Strug was able to do as evidenced by her second vault," Garrick says.

Treatment

When an athlete with a grade 3 injury needs a quick return to sport, preventing swelling is the top priority, says Garrick. "It's the swelling that will decrease range of motion and compromise performance, and getting rid of it is much more difficult than preventing it," he says. "A good focal compression wrap and elevation for the first 12 hours after the injury are most likely to accomplish this."

A local anesthetic is commonly injected into area of the injured ligaments to allow participation after an injury like this; however, the down side is that athletes may lose their ability to "feel" the ankle and foot. They might even lose the ability to contract some of the small muscles. Use of anesthetics also removes any protective influence of pain. Precision of muscle use and superior kinesthetic sense are essential for a gymnast and might be compreomised with local anesthetics, Garrick says.

Activity Outlook

The term "severe ankle sprain" doesn't mean much, so it's difficult to project how it might influence performance in 24 to 48 hours, Garrick says. "After a true grade 3 ankle sprain, the likelihood of being able to compete at a world class level in a sport that requires the sophisticated moves of gymnastics is not very good," he says. Garrick says it can be difficult to judge the severity of an ankle sprain: Instability found on the postinjury exam may have been there from a previous injury, and instability is difficult to judge in a patient who has an acutely injured ankle.

Says Aronen: "She may be able to compete, but she knows she has to land on that ankle."


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