Low Ankle Sprain

Author: John Badylak

Topic updated on 04/02/13 7:24am

Introduction

Ankle sprains can be conceptually broken down into
- high ankle sprain
  - syndesmosis injury
  - 1-10% of all ankle sprains
- low ankle sprain (this topic)
  - ATFL and CFL injury
  - >90% of all ankle sprains
Epidemiology
- ankle sprains are the most common reason for missed athletic participation
- most common injury in dancers
Associated injuries include
- osteochondral defects
- peroneal tendon injuries
- deltoid ligament injury (isolated deltoid ligament injuries are very rare)
- fractures
  - 5th metatarsal base
  - anterior process of calcaneus
  - lateral or posterior process of the talus

Anatomy

Ligamentous anatomy of the ankle
ATFL
- most commonly involved ligament in low ankle sprains
- mechanism is plantar flexion and inversion
- physical exam shows drawer laxity in plantar flexion
CFL
- 2nd most common ligament injury in lateral ankle sprains
- mechanism is dorsiflexion and inversion
- physical exam shows drawer laxity in dorsiflexion
- subtalar instability can be difficult to differentiate from posterior ankle instability because the CFL contributes to both
PTFL
- less commonly involved

Classification

Classification of Low Ankle Sprains

Ligament disruption

Ecchymosis and swelling

Pain with weight bearing

Grade I
none

minimal

normal

Grade II
stretch without tear

moderate

mild

Grade III
complete tear

severe

severe

Presentation

Symptoms
- pain with weight bearing
- recurrent instability
- catching or popping sensation may occur following recurrent sprains
Physical exam
- focal tenderness and swelling over involved ligament(s)
- anterior drawer test
  - possible laxity with anterior drawer and eversion/inversion stress testing

Imaging

Radiographs
- indications for radiographs with an ankle injury include (Ottawa ankle rules)
  - inability to bear weight
  - medial or lateral malleolus point tenderness
  - 5MT base tenderness
  - navicular tenderness
- radiographic views to obtain
  - standard ankle series (weight bearing)
    - AP
    - lateral
    - mortise
  - ER rotation stress view
    - useful to diagnosis syndesmosis injury in high ankle sprain
    - look for asymmetric mortise widening
    - medial clear space widening > 4mm
    - tibiofibular clear space widening of 6 mm
  - varus stress view
    - used to diagnose injury to ATFL or CFL
    - measures ankle instability by looking at talar tilt and anterior talar translation
MRI
- indications
  - consider MRI if pain persists for 8 weeks following sprain
- useful to evaluate
  - peroneal tendon pathology
  - osteochondral injury

Treatment

Nonoperative
- RICE, elastic wrap to minimize swelling, followed by therapy
  - indications
    - Grade I, II, and III injuries
  - technique
    - may require short period of weight-bearing immobilization in a walking boot or cast, but early mobilization facilitates a better recovery
  - therapy
    - once swelling and pain have subsided and patient has full range of motion begin neuromuscular training with a focus on peroneal muscles strength and proprioception training
    - a functional brace that controls inversion and eversion is typically used during the strengthening period and used as prophylactic treatment during high risk activities thereafter
    - early functional rehabilitation allows for quickest return to physical activity
Operative
- anatomic reconstruction vs. tendon transfer with tenodesis
  - indications
    - Grade I-III that continue to have pain and instability despite extensive nonoperative management
    - Grade I-III with a bony avulsion
  - technique (see below)
- arthroscopy
  - indications
    - recurrent ankle sprains and chronic pain caused by impingement lesions
      - anteriorinferior tibiofibular ligament impingement
      - posteromedial impingement lesion of ankle
  - procedure
    - debride impinging tissue

Surgical Techniques

Gould modification of Brostrom anatomic reconstruction
- procedure
  - an anatomic shortening and reinsertion of the ATFL and CFL
  - reinforced with inferior extensor retinaculum and distal fibular periosteum
- results
  - good to excellent results in 90%
Tendon transfer and tenodesis (Watson-Jones, Chrisman-Snook, Colville, Evans)
- procedure
  - a nonanatomic reconstruction using a tendon transfer
- technique
  - any malalignment must be corrected to achieve success during a lateral ligament reconstruction
  - Coleman block testing used to distinguish between fixed and flexible hindfoot varus
- results
  - subtalar stiffness is a common complication

Rehabilitation

Return to play
- depends on, grade of sprain, syndesmosis injury, associated injuries, and compliance with rehab
  
  Classification
  
  Time to RTP
  
  Grade I
  1-2 weeks
  
  Grade II
  1-2 weeks
  
  Grade III
  few weeks
  
  High ankle (immobilization)
  several weeks
  
  High ankle (screw fixation)
  season
Prevention
- prevention techniques in athletes with prior sprains includes
  - semirigid orthosis
  - evertor muscle (peroneals) strengthening
  - proprioception exercises
  - season long prevention program

Complications

Pain and instability
- up to 50% continue to experience symptoms following and acute ankle sprain
- most common cause of chronic pain is a missed injury, including
  - injury to the anterior process of calcaneus
  - injury to the lateral or posterior process of the talus
  - injury to the base of the 5th metatarsal
  - osteochondral lesion
  - injuries to the peroneal tendons
  - injury to the syndesmosis
  - tarsal coalition
  - impingement syndromes

Please Rate Educational Value!

4.0

Average 4.0 of 15 Ratings

Qbank (8 Questions)

TAG

(OBQ11.68) The anterior drawer test with the ankle in 20 degrees of plantarflexion most effectively tests for injury or laxity or which of the following ligaments shown in Figure A? Topic

Review Topic

FIGURES: A

1. A
2. B
3. C
4. D
5. E

PREFERRED RESPONSE ▶

DISCUSSION: Answer choice B points to the anterior talofibular ligament (ATFL). The ATFL is the most common ligament injured with ankle sprains and occurs most often with the foot in slight plantar flexion. Plantar flexion of the foot causes the ATFL to become parallel with the axis of the foot and become taut.

Maffulli et al, in his study on the on the management of acute and chronic ankle instability, concluded that acute lateral ankle ligament injuries are very common and can result in chronic instability if left untreated. Conservative measures includes functional rehabilitation which is the management of choice for acute and chronic injuries. Surgical intervention is best reserved for high-demand athletes.

Illustration A shows the orientation of the ATFL, along with the other foot and ankle ligaments. Illustration B shows the ankle anterior drawer test can show injury of the ATFL and is performed by doing an anterior drawer of the talus with the foot in slight plantar flexion. Illustration C, shows a radiographic example of anterior translation of the talus during an anterior drawer exam. The video V is a link to a video demonstrating this exam maneuver.

Illustrations: A

REFERENCES:

1. Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008 Oct;16(10):608-15. PMID:18832604 (Link to Abstract)

2. Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. 2nd ed. Philadelphia, PA: JB Lippincott; 1983:488-489.

Question Authors:

David Abbasi MD, Patrick McCulloch MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 7 Ratings

TAG

(OBQ10.134) A 21-year-old collegiate basketball player comes down with a rebound and rolls his ankle. He is able to finish the game, but complains of ankle pain and swelling afterwards. Physical exam is notable for moderate inversion laxity with the ankle held in dorsiflexion. With placement of the ankle in plantarflexion, no inversion laxity is appreciated. Which of the following ligaments has been attenuated? Topic

Review Topic

1. Anterior talofibular ligament
2. Calcaneofibular ligament
3. Anterior tibiofibular ligament
4. Posterior tibiofibular ligament
5. Deltoid ligament

PREFERRED RESPONSE ▶

DISCUSSION: The primary static stabilizers of the lateral ankle are the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. The calcaneofibular ligament becomes most taut with the ankle dorsiflexed and inverted. Conversely, the anterior talofibular ligament is most tensioned with the ankle plantarflexed and inverted. The anterior and posterior tibiofibular ligaments contribute stability to the tibiofibular articulation and syndesmosis. The deltoid ligament is the primary stabilizer medially and is stressed with ankle eversion testing. Illustration A is a depiction of the lateral ligaments of the ankle. Mafulli et al reviews the evaluation and treatment of chronic ankle instability.

Illustrations: A

REFERENCES:

1. Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008 Oct;16(10):608-15. PMID:18832604 (Link to Abstract)

2. Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. 2nd ed. Philadelphia, PA: JB Lippincott; 1983:488-489.

Question Authors:

John Badylak MD,

Please Rate Educational Value!

4.0

Average 4.0 of 14 Ratings

TAG

(OBQ07.118) In the majority of patients, which of the following definitive treatments leads to a good or excellent one-year prognosis in the care of grade-III sprains of the lateral ligaments of the ankle? Topic

Review Topic

1. Surgical repair of the ligament and casting
2. Casting alone
3. Early controlled mobilization
4. Application of a removable brace
5. Good or excellent outcomes can be expected regardless of which treatment above is provided

PREFERRED RESPONSE ▶

DISCUSSION: Grade 3 lateral ankle ligament injuries involve a complete rupture of the ligament with severe swelling, hemorrhage and tenderness as well as loss of function and abnormal motion and instability. Initial treatment consists of rest, ice, compression, and elevation (RICE). Early weight bearing and use of a protective brace during functional activities facilitates recovery better than non–weight bearing or immobilization. Surgery can be a reasonable option when an adequate trial of nonsurgical treatment fails to control symptoms.

Kannus et al, in their CCR, summarized the results of 12 randomized studies which attempted to identify the proper treatment of acute grade-III sprains of the lateral ligaments of the ankle. They concluded that in 75-100% of patients, the one-year prognosis was good or excellent irrespective of therapy (repair and cast, cast or brace alone, or early controlled mobilization). In terms of recovery time, however, they concluded that early controlled mobilization was superior. Their reasoning was that this treatment provided the quickest recovery to full ROM and return to work and physical activity, does not compromise the late mechanical stability of the ankle more than other treatments, nor does it produce more late symptoms (giving-way, pain, swelling, stiffness, muscular weakness) than operation and immobilization in a cast or cast alone.

REFERENCES:

1. Kannus P, Renström P. Treatment for acute tears of the lateral ligaments of the ankle. Operation, cast, or early controlled mobilization. J Bone Joint Surg Am. 1991 Feb;73(2):305-12. PMID:1993726 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Michael Hughes MD,

Please Rate Educational Value!

1.0

Average 1.0 of 41 Ratings

TAG

(OBQ06.19) A 38-year-old postal carrier complains of recurrent right ankle sprains and lateral ankle pain. A clinical photograph and radiograph are provided in Figures A and B. Coleman block testing demonstrates correction of the deformity. Custom orthotics, bracing, and NSAIDS have failed to provide pain relief or prevent recurrent sprains. Which of the following treatments should be pursued? Topic

Review Topic

FIGURES: A

1. Steroid injection of the sinus tarsi and taping of the ankles before activity
2. Lateral ligament repair and augmentation with inferior extensor retinaculum
3. Lateral ligament reconstruction with peroneus brevis tendon grafting
4. First metatarsal osteotomy and lateral ligament reconstruction with peroneus brevis tendon grafting
5. Triple arthrodesis and split peroneus brevis tendon graft reconstruction of the lateral ligaments

PREFERRED RESPONSE ▶

DISCUSSION: The photograph demonstrates bilateral cavovarus foot orientation. Cavovarus positioning of the foot leaves the ankle susceptible to inversion sprains and lateral ligament attenuation. The radiograph shows a calcaneal pitch consistent with cavovarus deformity and no evidence of degenerative change. Initial conservative treatment should include orthotics with a recessed first metatarsal, lateral forefoot wedge, reduced arch, and heel wedge. Failure of conservative treatment is an indication for surgery. The lateral ligament reconstruction must be augmented with an osteotomy to correct the cavovarus deformity or it will be very prone to failure. The flexible deformity (as demonstrated by Coleman block testing) suggests successful correction with a metatarsal osteotomy as opposed to a calcaneal osteotomy which would be reserved for a rigid deformity.

Fortin et al review 13 cases of chronic lateral ankle instability with cavovarus foot deformity. Ankles with significant degenerative changes were treated with arthrodesis. Ankles without degenerative changes were treated with lateral ligament reconstruction with calcaneal and/or first metatarsal osteotomies to correct the cavovarus deformity.

REFERENCES:

1. Fortin PT, Guettler J, Manoli A 2nd. Idiopathic cavovarus and lateral ankleinstability: recognition and treatment implications relating to ankle arthritis.Foot Ankle Int. 2002 Nov;23(11):1031-7. PMID:12449409 (Link to Abstract)

Question Authors:

John Badylak MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 16 Ratings

TAG

(OBQ05.197) A 20-year-old female collegiate basketball player has had recurrent ankle sprains of her right ankle. Trials of immobilization and physical therapy have not prevented further injuries. Physical exam reveals significant laxity of the right ankle compared to the left ankle, but otherwise is normal. Radiographs are unremarkable. What is the best surgical treatment for this patient? Topic

Review Topic

1. Evans tenodesis (peroneus brevis tenodesis)
2. Modified Broström procedure
3. Allograft reconstruction with a tendon graft from the fibula to the 5th metatarsal base
4. Primary ligament repair with lateralizing calcaneal osteotomy
5. Primary ligament repair with a dorsiflexion osteotomy of the 1st metatarsal

PREFERRED RESPONSE ▶

DISCUSSION: When chronic lateral ligamentous instability remains despite conservative treatment, the surgeon must choose between a multitude of operative methods for surgical stabilization. For most cases of chronic ankle instability in the athletic population, the modified Brostrom technique (answer #1) is preferred. The modified Brostrom procedure is an anatomic reconstruction of the lateral ankle ligaments (ATFL and/or CFL) and augmentation with the inferior extensor retinaculum. Messmer at al showed at a mean follow-up of 34.5 months (minimum of 18 months), twenty patients (91%) reported a good or excellent functional outcome with the modified Brostrom procedure. Krips et al looked at anatomical reconstruction and tenodesis in the treatment of chronic anterolateral ankle instability in a retrospective multicenter study. They found superior results in anatomical reconstruction compared to tenodesis in regards to stability (anterior drawer test and talar tilt & anterior talar subluxation on stress XR) and degenerative changes. They concluded that when compared with anatomical reconstruction, a tenodesis leads to inferior results in terms of functional and mechanical stability, as well as overall satisfaction at long-term follow-up. The Evans procedure (answer #1) is a nonanatomic reconstruction as the tendon weave does not recreate the ATFL or CFL but lies somewhere in between. It involves harvesting either half or the entire peroneus brevis tendon proximally and leaving it attached to the fifth metatarsal base distally. The free proximal portion is then passed anterior to posterior through a drill hole in the distal fibula or placed over the anterior fibula and sutured to the periosteum.

Osteotomies are generally reserved when dealing with abnormal foot shapes. Hindfoot varus can be treated with a valgus producing calcaneal osteotomy. Hindfoot varus due to a plantar flexed 1st metatarsal (confirmed with the Coleman block test) can be treated with a dorsiflexion osteotomy of the 1st metatarsal.

REFERENCES:

1. Krips R, van Dijk CN, Halasi PT, Lehtonen H, Corradini C, Moyen B, Karlsson J. Long-term outcome of anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a multicenter study. Foot Ankle Int. 2001 May;22(5):415-21. PMID:11428761 (Link to Abstract)

2. Messer TM, Cummins CA, Ahn J, Kelikian AS. Outcome of the modified Broström procedure for chronic lateral ankle instability using suture anchors. Foot Ankle Int. 2000 Dec;21(12):996-1003. PMID:11139039 (Link to Abstract)

3. Li X, Killie H, Guerrero P, Busconi BD. Anatomical reconstruction for chronic lateral ankle instability in the high-demand athlete: functional outcomes after the modified Broström repair using suture anchors. Am J Sports Med. 2009 Mar;37(3):488-94. PMID:19251684 (Link to Abstract)

Question Authors:

Doug Nowak MD, Patrick McCulloch MD,

Please Rate Educational Value!

4.0

Average 4.0 of 4 Ratings

TAG

(OBQ04.28) In dancers, peroneal muscle weakness has been shown to be the cause of which of the following? Topic

Review Topic

1. Ankle sprain
2. Fibular fracture
3. Acute cuboid subluxation
4. Achilles rupture
5. Midfoot sprain

PREFERRED RESPONSE ▶

DISCUSSION: The most common acute skeletal injury in the dancer is the inversion sprain of the ankle and thought to be due to relative peroneal muscle weakness. Sprains may occur in any ligament in the foot or ankle, but most common ones involve the lateral ligament complex (anterior talofibular, calcaneal-fibular, and posterior talofibular ligaments); the anterior tibiofibular, the lateral talocalcaneal ligament; and, occasionally the medial (deltoid) ligament. Regardless of the method of treatment, adequate physical therapy and proper rehabilitation are necessary to restore normal use following injury. Restoration of full peroneal strength is essential to minimize risk of recurrent sprains.

The reference by Hamilton is a review of foot and ankle injuries in the dancing population. He reviews the importance of early diagnosis and covers the different conservative and operative treatments available.

REFERENCES:

1. Hamilton WG. Foot and ankle injuries in dancers. Clin Sports Med. 1988 Jan;7(1):143-73 PMID:2900693 (Link to Abstract)

2. Ritter S, Moore M. The relationship between lateral ankle sprain and ankle tendinitis in ballet dancers. J Dance Med Sci. 2008;12(1):23-31 PMID:19618575 (Link to Abstract)

Question Authors:

Ben Taylor MD, John Badylak MD, Dave Marcu MD, Daniel Farber MD,

Please Rate Educational Value!

2.0

Average 2.0 of 11 Ratings

Videos

	Brostrom-Gould Ankle Reconstruction - Dr. Weatherby Foot & Ankle - Surgical Techniques - Low Ankle Sprain Dr. Brian Weatherby with the Steadman Hawkins Clinic of the Carolinas performs a...	7/21/2012 588 views 5
	Ankle Anterior Drawer Test Foot & Ankle - Physical Exam - Low Ankle Sprain The Anterior Drawer test is used to asssess the ligaments of the ankle after an...	1/23/2012 1656 views 3

See More Videos

Posts

Tested Article: Anatomical Reconstruction for Chronic Lateral Ankle Instability in the High-Demand Athlete: Functional Outcom...

Li X, Killie H, Guerrero P, Busconi BD. Am J Sports Med. 2009 Mar;37(3):48...

Foot & Ankle - Journal Club - Low Ankle Sprain

3/1/2013

42 responses

See More Posts

Groups

ABOS II: Low Ankle Sprain

General - Oral Boards Review

7/29/2011

0 responses

See More Groups

Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008 Oct;16(10):608-15. PMID:18832604 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. 2nd ed. Philadelphia, PA: JB Lippincott; 1983:488-489.

Undefined

Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008 Oct;16(10):608-15. PMID:18832604 (Link to Abstract)
Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. 2nd ed. Philadelphia, PA: JB Lippincott; 1983:488-489.
Kannus P, Renström P. Treatment for acute tears of the lateral ligaments of the ankle. Operation, cast, or early controlled mobilization. J Bone Joint Surg Am. 1991 Feb;73(2):305-12. PMID:1993726 (Link to Abstract)
Fortin PT, Guettler J, Manoli A 2nd. Idiopathic cavovarus and lateral ankleinstability: recognition and treatment implications relating to ankle arthritis.Foot Ankle Int. 2002 Nov;23(11):1031-7. PMID:12449409 (Link to Abstract)
Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med 1997; 25: 130-137. PMID:9006708 (Link to Abstract)
Funk DA, Clanton TO, Bonci CM: Leg, ankle, and foot injuries, in Schenck RC Jr (ed): Athletic Training and Sports Medicine, ed 3.
Krips R, van Dijk CN, Halasi PT, Lehtonen H, Corradini C, Moyen B, Karlsson J. Long-term outcome of anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a multicenter study. Foot Ankle Int. 2001 May;22(5):415-21. PMID:11428761 (Link to Abstract)
Messer TM, Cummins CA, Ahn J, Kelikian AS. Outcome of the modified Broström procedure for chronic lateral ankle instability using suture anchors. Foot Ankle Int. 2000 Dec;21(12):996-1003. PMID:11139039 (Link to Abstract)
Li X, Killie H, Guerrero P, Busconi BD. Anatomical reconstruction for chronic lateral ankle instability in the high-demand athlete: functional outcomes after the modified Broström repair using suture anchors. Am J Sports Med. 2009 Mar;37(3):488-94. PMID:19251684 (Link to Abstract)
Hamilton WG. Foot and ankle injuries in dancers. Clin Sports Med. 1988 Jan;7(1):143-73 PMID:2900693 (Link to Abstract)
Ritter S, Moore M. The relationship between lateral ankle sprain and ankle tendinitis in ballet dancers. J Dance Med Sci. 2008;12(1):23-31 PMID:19618575 (Link to Abstract)

Topic Comments

Subscribe status: On Off

Recent on Bottom | Recent on Top

Page:1

Low Ankle Sprain

Qbank (8 Questions)

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Videos

Posts

Groups

Evidence & References Show References

Topic Comments