Everything You Ever Wanted to Know About Ankle Sprains

Rodney S. Gonzalez, MD MAJ, MC, USA Adapted from: Sean T. Mullendore Maj, MC, USAF

Objectives
Describe incidence of ankle sprains Diagnosis and classification Acute, subacute, & prophylactic treatment Workup of persistent pain

Incidence of Ankle Sprains

Estimated 1 million present to physicians with acute ankle injuries each year Sprains account for 25% of all sportsrelated injuries and 75% of all ankle injuries Lateral ankle ligaments are the most commonly injured structures in young athletes More than 40% of ankle sprains have potential to cause chronic problems

Military Specific
Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998 Oct;19(10):653-60.

Over 2 month period, there were 104 ankle injuries accounting for 23% of all injuries 93% of all ankle injuries were sprains 40% of cadets had persistent pain &/or functional disability 6 months after injury

Military Specific
Miser WF, Lillegard WA, Doukas WC. Injuries and Illnesses Incurred by an Army Ranger Unit During Operation Just Cause. Mil Med. 1995 Aug; 160(8):373-80.

Retrospective interview of 471 U.S. Army Rangers returning from military action Injury rate = 35% 19.6% of all injuries = ankle injuries 80% of ankle injuries = sprains 66% of all ankle injuries led to limitations of mission completion Ankle injuries caused 3 times more Rangers to be out of duty than GSW and open fractures combined

Diagnosis
History Wheres the pain? Able to bear weight? Swelling? How soon? Prior injury to foot/ankle? History is often vague Usual mechanism is combination of plantarflexion and inversion of foot

Physical Exam
Inspection
Obvious deformity? Ecchymosis? Swelling?

Physical Exam
Palpation
Bones Lateral ligaments ATFL, CFL, PTFL Medial ligaments Syndesmosis Tendons achilles, peroneal Neurovascular status

Range of Motion
Plantarflexion
50

Dorsiflexion
20

Inversion
5

Eversion
5

Special Tests
Anterior drawer Talar tilt Squeeze test External rotation

Anterior Drawer Test

Tests integrity of ATFL Performed with foot in neutral and slightly plantarflexed positions A few millimeters of translation is normal Compare to contralateral side Suction Sign is positive if dimple in the anterolateral ankle with maneuver

Talar Tilt
Tests integrity of CFL and ATFL Performed with foot neutral and plantarflexed Neutral position tests CFL Plantarflexed position tests ATFL Compare to other side

Squeeze Test
Tests integrity of syndesmosis & distal tib-fib joint Pain at anteriorinferior aspect of ankle suggests anterior inferior tibiofibular ligament injury

External Rotation Test

Tests integrity of syndesmosis & distal tib-fib joint Pain over anterior or medial ankle suggests syndesmotic injury

Ottawa Ankle Rules

Purpose: to determine which patients with ankle trauma need radiographs Strengths:
Decrease unnecessary x-rays, patient waiting times, & diagnostic costs Sensitivity near 100% for detecting malleolar and midfoot fractures

Limitations:
Only for skeletally mature patients Only applies if seen within 10 days of injury

Ottawa Ankle Rules

OR INABILITY TO BEAR WEIGHT AFTER INJURY OR IN OFFICE/ED

Radiographs
A-P, lateral, mortise views WEIGHT BEARING Looking for fracture, dislocation, abnormal widening of clear space Dont forget to image the foot if clinically indicated
A-P View of Ankle

Radiographs View of Ankle Lateral View of Ankle Mortise

Mortise View Normals

E-F Tib-Talo clear space should be 5 mm A-B Tib-Fib clear space should be 5 mm

A. Grade I sprain

Classification of Lateral Ankle Sprains by Anatomic Findings

Stretching of ATFL & CFL B. Grade II sprain Partial tear of ATFL & stretching of CFL C. Grade III sprain Rupture of ATFL/CFL & partial tear of PTFL+/- partial tear of tibiofibular ligaments

Classification of Lateral Ankle Sprains by Special Testing

Grade I Grade II Grade III

Anterior Drawer
Talar Tilt

Negative
Negative

+
Negative

+++
+++

Classification of Lateral Ankle Sprains by History/Exam

Grade I Edema, ecchymosis Weight bearing Ligament pathology Instability testing Time to return to sport Grade II Grade III Diffuse, significant Impossible Localized, slight Localized, moderate Full or partial without significant pain Ligament stretch None 11 days Difficult without crutches Partial tear None or slight 2-6 weeks

Complete tear Definite 4-26 weeks

Other (than lateral) Ankle Sprains

Syndesmotic or high ankle sprain
Stretching/tearing of syndesmosis and/or inferior tibiofibular ligaments Common mechanism forced external rotation of foot or internal rotation of tibia on planted foot

Isolated deltoid ligament sprain

Rare, usually accompanied by lateral malleolar fx and/or syndesmotic injury

Rehabilitation similar to lateral sprains but more likely to require immobilization and have residual symptoms

Other Foot/Ankle Injuries and Associated Problems

5th Metatarsal Fractures
Avulsion Fracture Jones Fracture

Weber or LaugeHansen Fractures

Weber A Weber B Weber C

Masonneuve Fracture Ankle Dislocation Lisfranc Injury

Treatment Phase I Acute

PRICE
Protection stirrup splint, walking cast/boot, crutches if unable to bear weight due to pain Rest Ice 20 min every 2-3 hours for first 48-72 hours Compression Elevation

Treatment Phase II Subacute

Weight bearing as soon as tolerated Passive/active ROM Resistance exercises
Isometric Isotonic +/- Proprioceptive exercises

Treatment Phase III-IV Rehabilitative/Functional

Proprioceptive training
Standing on single leg Biomechanical ankle platform system (BAPS) Monitored plyometrics

Strength training with gradual progression of resistance from stressfree position to stressful position (i.e. neutral/DF to inversion/PF) Sport-specific exercises

Treatment Phase V Prophylactic

Emphasis on functional drills, prophylactic strengthening Protective taping/bracing
Non-rigid lace up brace Semi-rigid pneumatic brace Ankle taping?

Surgery?
Most patients respond to non-operative management Subjective and objective outcomes similar among operative and non-operative treatment Some recommend surgery for the high demand athlete with grade III sprain Delayed reconstruction produces results similar to repair of acute injury

Non-Healing Ankle Sprains

Symptoms not improving after 6 weeks Pain and/or recurrent instability Top 3 causes:
Inadequate rehabilitation Inadequate rehabilitation Inadequate rehabilitation

Other causes
Talar dome OCD, peroneal tendon injury, anterolateral impingement, loose body, OA, tarsal coalition, complex regional pain syndrome

Main problem is instability

Stress tests positive

Stress tests negative

Surgical reconstruction of lateral ligaments

Treatment of functional instability. Proprioception exercises, peroneal strengthening

Main problem is pain

Localized ankle pain

Generalized foot/ankle pain

Bone scan MRI

negative + for tendon tear + for talar dome OCD, fracture, or loose body

Diffuse uptake treat RSD

Consider diagnostic ankle injection positive

Localized uptake spot x-rays or CT to further define lesion

surgical repair

Cast or surgery, consider CT to further define bone lesion

Probable soft tissue impingement or chondromalacia

+ for fracture, OCD, OA, tarsal coalition, loose body cast or surgery

negative

negative Treat symptoms

Ankle arthroscopy

Conclusions
Lateral ankle sprains are very common Ottawa ankle rules dont apply to everyone Radiographs should be weight-bearing Degree of sprain better determined by exam findings than ligament pathology Rehabilitation is key to decrease sxs and return to play Workup of recurrent sprain dictated by predominant sx instability vs. pain

Questions?