Esguince de tobillo
El esguince de tobillo es la lesión más frecuente de las extremidades inferiores. Un 70% de la población reporta haber sufrido al menos uno a lo largo de su vida. Además, estas lesiones son las que tienen la tasa más alta de reincidencia; por lo que la correcta valoración del esguince de tobillo y su tratamiento son de gran importancia. Entonces, ¿cómo valorar un esguince de tobillo?
Recientemente fue publicado un artículo en el que se recogen las recomendaciones de un comité de expertos sobre cómo valorar un esguince de tobillo. Esta valoración no requiere material sofisticado por lo que puede ser empleada en consulta.
Valoración clínica básica
Cuando un paciente acude a consulta con esta lesión debemos realizar una valoración del esguince de tobillo que incluya los siguientes aspectos básicos:
Mecanismo de lesión
Debemos conocer las circunstancias en las que se ha producido la lesión pues esto nos aportará información sobre las estructuras afectadas. El mecanismo lesional del esguince lateral de tobillo es un movimiento de inversión, es decir «pie hacia dentro”, forzada en carga. Respecto al mecanismo de lesión de un esguince con lesión de la sindesmosis no hay tanto consenso, pero suele incluir rotación externa del pie, eversión del astrágalo y flexión dorsal forzada.
Historia de esguinces previos
En muchos casos es una lesión recurrente y puede convertirse en una inestabilidad crónica de tobillo. Por ello, debemos conocer los antecedentes de la lesión.
Tolerancia a la carga
La imposibilidad de caminar 4 pasos seguidos cargando el peso debe hacernos sospechar de la posible existencia de otras lesiones, como una fractura.
Evaluación clínica ósea
Empleando las Reglas de Otawwa, que detallamos a continuación en la siguiente imagen
Si ambas reglas son positivas (existe dolor en las zonas marcadas), se recomienda la utilización de pruebas de imagen del tobillo para descartar posibles fracturas en el tobillo
Evaluación clínica de los ligamentos
- Ligamento peroneo-astragalino anterior (El que más se lesiona). Emplearemos, sobre todo, los siguientes test:
- Palpación del ligamento (normalmente dolor conocido para el paciente)
- Estrés mecánico (inversión forzada)
- Test de cajón anterior
- Ligamento peroneo-calcáneo. Emplearemos, sobre todo, los siguientes test:
- Palpación (siendo reconocido por el paciente)
- Estrés mecánico: flexión dorsal de tobillo combinado con varo de retropié y aducción de pie
- Test de compresión
Valoración clínica de las deficiencias mecánicas y sensoriomotorias
Los expertos amplían la valoración con el objetivo de identificar deficiencias mecánicas o sensoriomotoras y, en consecuencia, poder desarrollar una correcta rehabilitación, para así evitar futuras inestabilidades crónicas de tobillo.
Dolor y edema
Siempre es necesario tener en cuenta el dolor del paciente. Además, nos ayudará para guiar la rehabilitación. Para ello podemos emplear la escala numérica del dolor y la Foot and Ankle Disability Index (FADI): Cuestionario para valorar limitaciones funcionales…
Rango de movimiento
Una de las secuelas de esta lesión es la disminución de la flexión dorsal. Por ello, valoraremos el rango de movimiento activo y pasivo. Para dicha valoración se puede emplear el “Test de Lunge”
Artrocinemática
Probablemente el déficit de flexión dorsal de la articulación esté relacionado con una alteración en la biomecánica de la articulación. Por tanto, podemos valorarlo a través de un deslizamiento posterior del astrágalo. Además este deslizamiento es una buena técnica de tratamiento cuando existe esta alteración tanto para la mejora del dolor como de la funcionalidad.
Fuerza muscular
Un déficit de fuerza puede alterar la estabilidad del tobillo. Por ello, para su valoración emplearemos dinamómetros.
Equilibrio postural estático y dinámico
Ante un esguince de tobillo, tanto el equilibrio estático como el dinámico se verán alterados. Para valorar el primero de ellos se emplean test como por ejemplo el “Balance Error Scoring System” y el «Test de elevación del pie». En cambio para la valoración del equilibrio dinámico empleamos el «Star Excursion Balance Test».
Marcha
También es un aspecto clave en la valoración. De forma visual valoraremos la marcha del paciente, teniendo en cuenta posibles compensaciones.
Nivel de actividad física
Además de lo anterior, debemos conocer al nivel de actividad del paciente previo a la lesión. A partir de esa información plantearemos los objetivos de la rehabilitación. El objetivo final será devolver al paciente a dicho nivel. Para ello, se emplean cuestionarios como por ejemplo el «Tegner activity-level scale”.
Autoinformes
Es decir, cuestionarios en los que el paciente refiere cómo se siente en relación a su lesión. Algunos ejemplos son «Foot and Ankle Disability Index” y el “Foot and Ankle Ability Measure”
Conclusión
Podemos concluir que es de gran importancia realizar una correcta valoración del esguince lateral de tobillo para detectar posibles complicaciones. Para ello contamos con diversas herramientas fiables y sencillas de realizar a nivel clínico.
Por otra parte, la cronificación de la inestabilidad del tobillo puede generar importantes problemas para el paciente, por lo que una detección precoz y una buena valoración puede prevenir muchas complicaciones.
En cualquier caso, si sufres un esguince de tobillo lo mejor es que acudas a un profesional que sepa cómo valorar un esguince tobillo. En Centro AMAYPE estaremos encantados de atenderte. Y si no, asegúrate siempre de que el profesional que te valora se encuentra colegiado en el Colegio Profesional de Fisioterapeutas . ¡Con la salud no se juega!
Bibliografía: Delahunt E, et al. Br J Sports Med 2018;52:1304–1310. doi:10.1136/bjsports-2017-098885
#fisioterapia #lesiones #esguince #tobillo #deporte #valoración #recuperación
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