Everything You Ever Wanted to Know About Ankle Sprains

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Everything You Ever Wanted to Know About Ankle
Sprains

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

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Objectives

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

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Incidence of Ankle Sprains

• Estimated 1 million present to physicians with
  acute ankle injuries each year
• Sprains account for 25 of all sports-related
  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

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Military SpecificGerber 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
Oct19(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

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Military SpecificMiser 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

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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

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Physical Exam

• Inspection
• Obvious deformity?
• Ecchymosis?
• Swelling?

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Physical Exam

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

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Range of Motion

• Plantarflexion
• 50
• Dorsiflexion
• 20
• Inversion
• 5
• Eversion
• 5

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Special Tests

• Anterior drawer
• Talar tilt
• Squeeze test
• External rotation

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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

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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

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Squeeze Test

• Tests integrity of syndesmosis distal tib-fib
  joint
• Pain at anterior-inferior aspect of ankle
  suggests anterior inferior tibiofibular ligament
  injury

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External Rotation Test

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

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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

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Ottawa Ankle Rules
OR INABILITY TO BEAR WEIGHT AFTER INJURY OR IN
OFFICE/ED
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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
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Radiographs
Lateral View of Ankle
Mortise View of Ankle
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Mortise View Normals

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

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Classification of Lateral Ankle Sprainsby
Anatomic Findings

• A. Grade I sprain
• 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

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Classification of Lateral Ankle Sprainsby
Special Testing
Grade I Grade II Grade III
Anterior Drawer Negative
Talar Tilt Negative Negative
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Classification of Lateral Ankle Sprains by
History/Exam
Grade I Grade II Grade III
Edema, ecchymosis Localized, slight Localized, moderate Diffuse, significant
Weight bearing Full or partial without significant pain Difficult without crutches Impossible
Ligament pathology Ligament stretch Partial tear Complete tear
Instability testing None None or slight Definite
Time to return to sport 11 days 2-6 weeks 4-26 weeks
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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

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Other Foot/Ankle Injuriesand Associated Problems

• 5th Metatarsal Fractures
• Avulsion Fracture
• Jones Fracture
• Weber or Lauge-Hansen Fractures
• Weber A
• Weber B
• Weber C
• Masonneuve Fracture
• Ankle Dislocation
• Lisfranc Injury

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Treatment Phase IAcute

• 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

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Treatment Phase IISubacute

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

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Treatment Phase III-IVRehabilitative/Functional

• Proprioceptive training
• Standing on single leg
• Biomechanical ankle platform system (BAPS)
• Monitored plyometrics
• Strength training with gradual progression of
  resistance from stress-free position to stressful
  position (i.e. neutral/DF to inversion/PF)
• Sport-specific exercises

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Treatment Phase VProphylactic

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

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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

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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

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Main problem is instability
Stress tests positive
Stress tests negative
Treatment of functional instability.
Proprioception exercises, peroneal strengthening
Surgical reconstruction of lateral ligaments
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Main problem is pain
Generalized foot/ankle pain
Localized ankle pain
Bone scan

MRI
Diffuse uptake ? treat RSD
Localized uptake ? spot x-rays or CT to further define lesion
negative
for tendon tear
for talar dome OCD, fracture, or loose body
Consider diagnostic ankle injection
negative
for fracture, OCD, OA, tarsal coalition, loose body ? cast or surgery
surgical repair
positive
Cast or surgery, consider CT to further define bone lesion
Probable soft tissue impingement or chondromalacia
negative
Ankle arthroscopy
Treat symptoms
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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

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Questions?