Combined Extracorporeal Shockwave Therapy And Platelet-Rich Plasma Injections Promote Healing After Anterior Talofibular Ligament Fixation

HISTORY: A 20-year-old college athlete sustained a right ankle sprain after landing on an opponent's foot in a supinated position. He reported hearing a snap, experiencing severe pain, and being unable to bear weight. After a month of conservative treatment, he continued to have pain, instability, and limited range of motion, prompting a visit to our hospital. PHYSICAL EXAMINATION: The anterior drawer test was positive, with clear pain avoidance and mild swelling compared to the healthy ankle. DIFFERENTIAL DIAGNOSIS: 1. ATFL sprain; 2. Talus cartilage injury; 3. Chronic ankle instability. TEST AND RESULTS: MRI of the right ankle: Detected bone marrow edema of the talus, injuries to the deltoid ligament, Anterior Talo-Fibular Ligament (ATFL), and Posterior Talo-Fibular Ligament (PTFL). CT (4D reconstruction): No fractures but identified an intact 7x7mm distal fibula fragment. Arthroscopy: ATFL rupture with talus avulsion fragments, and bony free bodies at the fibula’s distal end. FINAL/WORKING DIAGNOSIS: Avulsion fracture of the talus with Os subfibulare. TREATMENT AND OUTCOMES: 1. The ATFL was re-fixed to the talus using absorbable anchor, and the ankle was immobilized with an orthopedic air boot for 4 weeks. 2. Physical therapy was initiated after surgery, including limb elevation, ice application, proximal joint training and so on. Proprioception and balance training, peroneus longus and peroneus brevis training were added four weeks later. 3. Platelet-Rich Plasma (PRP) was injected at the second, third and fourth months after surgery, totaling 3 times. Each injection was given at the first week of the month. 4. Extracorporeal Shockwave Therapy (ESWT) commenced one week after each PRP injection, with sessions twice per week for three weeks, totaling 18 times. FOLLOW-UP AND RECOVERY: Great improvements were seen in VAS, FAAM, and AOFAS scores. At the third month, the patient resumed normal activities and training, and at the sixth month, he returned to competitive sports. Musculoskeletal ultrasound confirmed good ATFL healing and structural continuity after 6 months.