Ankle anatomy
Deltoid ligament limits eversion, dorsiflexion and plantarflexion - rarely injured (strongest ligament), isolated sprains are rare
Most commonly sprained = Anterior talofibular ligament (ATFL) - due to it being the weakest ligament
and Calcaneofibular ligament (CFL)
Complications
- Chronic pain/disability |
- Recurrent Ankle instability |
- Osteochrondral defects of the talus |
- Peroneal tendon injuries |
- Neurovascular injuries |
- Tibiotalar OA |
- Pantalar OA |
Classification
- Grade I: Stretch with no macroscopic fibre disruption |
- Grade II: Partial Fibre disruption |
- Grade III: Rupture (Usually associated with another injury, usually f#) + syndesmotic structures + tendon rupture |
Demographics/Causes
- Physically active people (basketball, football,soccer, soldiers)- most common |
- Males and females affected equally |
- Highest in 15-19 yo |
- Limited ankle dorsiflexion |
- Previous Hx of ankle sprain |
- Lateral ankle = inversion sprain |
- Medial ankle = eversion sprain (rare due to limited eversion of the ankle)
Usually occurs due to eversion/pronation and abduction/external rotation
Foot planted in pronation, upper body falls laterally -unexpected misstep/landing on uneven surface |
Presentation
- Sudden onset of pain from "rolling the ankle"/landing from a jump/stepping into a hole |
- Pts may recall a pop at the time |
- Pain from mild aching to intense (worse at the end of the day |
- Aggravated by weight bearing |
- Swelling (worse at the end of the day) |
- Rapid bruising and swelling could indicate rupture |
- Bruising and discolouration gradually gravitates towards foot |
- Cold foot and or paraesthesia = neurovascular compromise/compartment syndrome |
- Tenderness over affected ligament |
- ROM may be painful on passive inversion/dorsiflexion (lateral) or passive eversion (medial) |
- +ve Talar tilt, +ve Anterior draw test, +ve ankle eversion stress test +ve external rot test |
- Syndesmotic sprains can be differentiated with the fibular squeeze test (rare in the general population, ankle in high forced ext rot and/ankle dorsiflexion) |
- Palpation dorsalis pedis and posterior tibia pulses + sensation over foot for neurovascular compromise |
- Suspect instability = recurrent sprains, difficulty running on uneven surfaces, cutting and jumping, giving way |
- Palpation of ATFL, CFL and PTFL and medial ankle and entire fibula to assess for f# (pain and crepitus) |
- Assess foot : especially navicular, midfoot and 5th metatarsal |
- FADI, FAAM, LEFS and sports ankle rating system
Red Flags
- Significant Instability |
- Significant Crepitus |
- Catching |
- No response to conservative care after 4-6 weeks |
- MRI/US considered |
Imaging
- Ottawa Ankle rules:
- Ankle X-ray = bone tenderness at A
- Bone Tenderness at B
- Inability to weight bear both immediately and on physical exam
- AP, Lat, Mortise views
- Foot X-ray = Bony tenderness at C and D
- Inability to weight bear both immediately and on physical exam
- AP, lateral, oblique
- Moderate spec, high sens
- Should not be used:
- A distracting injury
- Intoxication
- Diminished lower extremity sensation
- Head injury/cooperation disorders
DDx
- Syndesmotic sprain |
- F# (Lisfranc) |
- Dislocation |
- Intraaritcular meniscoid |
- Subtalar sprain |
- Achilles tendinopathy |
- CRPS |
- Inflammatory Arthropathy |
Management
- Usually heal quickly, but some report pain, instability, crepitus, weakness, stiffness, swelling |
- PRICE for 72 hours after injury |
- Ice/ice massage for 15 minutes each hour |
- NSAID advice |
- All sprains may require complete immobilisation |
- Prevention = taping/using devices (air splint/velcro brace) |
- Then manual therapy |
- Joint mobilisation |
- Transverse friction massage of affected ligament |
- Myofascial release and stretching of gastrosoleus |
- Ankle Alphabet |
- When ROM, pain and swelling improves, move onto strengthening |
- Strengthening includes isometric contractions against immobile object then to dynamic resistance with weights, tubing, bands |
- Strenghtening of dorsiflexion, plantar flexion, inversion and eversion |
- Strengthening of Peroneals (resisted eversion) |
- If ankle is instable = hip abductor strengthening |
-Wobbleboard to gain proprioception |
- Return to activity starts with straight line then progress to forwards/backwards, side to side,pivoting cutting motions |
- Return to play = full pain free ROM and ankle strength >80-90% |
- Grade III/ syndesmosis involvement = surgical consult (younger patients with occupation/activities that places them at higher risk of re-injury) |
- If ligamentous laxity - immobilise and crutches should be given, refer to orthopaedic surgeon (could be osteochondral defects of the talus, peroneal tendon, intra-articular loose bodies and fractures) |
Whitman's CPR
- Symptom's worse when standing |
- Symptoms worse in the evening |
- Navicular drop >5mm |
- Distal tibiofibular joint hypomobility |
- Predicts the sucess of manipulation and exercise
- 3 out of the 4 variables above = >95% sucess rate
Prognosis
- Mild- Moderate sprains usually recover within 7-15 days |
- Instability and defects occur in 25-40% of patients |
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