Updated: 11/4/2021

Ankle Sprain

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  • summary
    • Ankle Sprains are very common twisting injuries to the ankle that are the most common reason for missed athletic participation.
    • Diagnosis can be made clinically with swelling and ecchymosis of the ankle and pain with range of motion. Radiographs are only indicated when clinical examination meets criteria (Ottawa ankle rules).
    • Treatment usually includes a brief period of immobilization followed by early functional physical therapy. Rarely, operative management is indicated in the setting of syndesmosis injury with tibiofibular diastasis or chronic ankle instability with recurrent sprains. 
  • Epidemiology
    • Incidence
      • ankle sprains are the most common reason for missed athletic participation
    • Demographics
      • most common injury in dancers
    • Risk factors
      • patient-related
        • limited dorsiflexion, decreased proprioception, balance deficiency
      • environmental-related
        • indoor-court sports have the highest risk (basketball, volleyball)
  • Etiology
    • Pathophysiology
      • Mechanism of injury
        • Inversion type ankle injury on a plantarflexed foot
        • Recurrent ankle sprains can lead to functional instability
    • Ankle sprains consist of
      • 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
    • Associated injuries/conditions include
      • osteochondral defects
      • peroneal tendon injuries
      • deltoid ligament injury (isolated deltoid ligament injuries are very rare)
        • superficial deltoid: limits talar abduction
        • deep deltoid: limits external rotation
          • initally treated conservatively, but may require reconstruction if patient continues to have instability
      • complex regional pain syndrome
      • 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 (may or may not be able to bear weight)
      • swelling and ecchymosis
      • recurrent instability
      • catching or popping sensation may occur following recurrent sprains
    • Physical exam
      • focal tenderness and swelling over-involved ligament(s)
      • anterior drawer test
        • looks for excessive anterior displacement of talus relative to tibia
        • limited usefulness in acute setting
        • ATFL best tested in plantarflexion, CFL in dorsiflexion
      • Talar tilt test
        • excessive ankle inversion (> 15 degrees) compared to contralateral side indicated injury to ATFL and CFL
  • 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
        • 96-99% sensitive in ruling out ankle fracture
      • radiographic views to obtain
        • standard ankle series (weight bearing)
          • AP
          • lateral
            • ATFL injury suggested with anterior talar translation
          • 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 (talar tilt) view
          • used to diagnose injury to CFL
          • measures ankle instability by looking at talar tilt
    • MRI
      • indications
        • consider MRI if pain persists for 6-8 weeks following sprain
      • useful to evaluate
        • peroneal tendon pathology
        • osteochondral injury
        • syndesmotic injury
  • Treatment
    • Nonoperative
      • RICE, elastic wrap to minimize swelling, followed by therapy
        • indications
          • Grade I, II, and III injuries
        • technique
          • initial immobilization
            • may require short period (approx. 1 week) of weight-bearing immobilization in a walking boot, aircast or walking cast, but early mobilization facilitates a better recovery
            • grade III sprains may benefit from 10 days of casting and nonweightbearing
          • therapy
            • early phase
              • early functional rehabilitation begins with motion exercises and progresses to strengthening, proprioception, and activity-specific exercises
            • strengthening phase
              • 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
        • outcomes
          • early functional rehabilitation allows for the quickest return to physical activity
          • supervised physical therapy has shown a benefit in early follow-up but no difference in the long term
    • 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
            • often used prior to reconstruction to evaluate for intra-articular pathology
        • procedure
          • debride impinging tissue
  • 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 (Gould modification)
      • results
        • good to excellent results in 90%
        • consider arthroscopic evaluation prior to reconstruction for intra-articular evaluation
    • 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
      • Return to play 
        Grade I
        1-2 weeks
        Grade II
        1-2 weeks
        Grade III
        3-4 weeks
        High ankle (immobilization)
        5-6 weeks
        High ankle (screw fixation)
        Season
    • Prevention
      • prevention techniques in athletes with prior sprains includes
        • semirigid orthosis
          • patients who demonstrate cavovarus alignment benefit from a brace with lateral hindfoot/forefoot wedging and first metatarsal recess
        • evertor muscle (peroneals) strengthening
        • proprioception exercises
        • season long prevention program
  • Complications
    • Pain and instability
      • Incidence
        • up to 30% continue to experience symptoms following and acute ankle sprain
      • Risk factors
        • most common cause of chronic pain is a missed injury, including
          • missed fractures (anterior process of calcaneus, lateral or posterior process of the talus, 5th metatarsal)
          • osteochondral lesion
          • injuries to the peroneal tendons
          • injury to the syndesmosis
          • tarsal coalition
          • impingement syndromes
    • Stretch neurapraxia
      • Neuropathic pain in the distribution of the affected nerve
  • Prognosis
    • Natural history
      • pain decreases rapidly during the first 2 weeks after injury
      • 5-33% reports some pain at 1 year
      • increased risk of a sprain to ipsilateral and contralateral ankle
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(OBQ13.145) A 30-year-old high level athlete sustained a low ankle sprain 1 week ago. The treatment options of immobilization and functional management are discussed. Which of the following statements is FALSE?

QID: 4780
1

Functional management is associated with higher rate of return to sports than immobilization.

5%

(247/4936)

2

Functional management is associated with greater range of motion than immobilization.

3%

(147/4936)

3

Functional management is associated with less persistent swelling than immobilization.

7%

(323/4936)

4

Functional management is associated with a greater risk of increased ankle joint laxity than immobilization.

79%

(3908/4936)

5

Functional management is associated with higher rate of satisfaction than immobilization.

6%

(286/4936)

L 2 B

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(OBQ13.69) An 18-year-old male college student presents with a right ankle injury two weeks after slipping on a soccer ball. The skin is grossly intact and there is no evidence of neurovascular compromise. The provocative test demonstrated in Figure A is positive. Which of the following nonoperative treatment modalities have been shown to minimize recurrence of his injury?

QID: 4704
FIGURES:
1

Immobilization in a non weight-bearing cast

3%

(133/4779)

2

Immobilization in a weight-bearing boot

3%

(154/4779)

3

Immobilization in a splint

1%

(24/4779)

4

Functional bracing with early proprioceptive training

90%

(4291/4779)

5

Neuromuscular training alone

3%

(155/4779)

L 1 A

Select Answer to see Preferred Response

(SBQ12FA.98) A 25-year-old military service member presents four weeks after sustaining an inversion ankle injury with continued severe pain despite conservative treatment. Anterior drawer testing and MRI obtained at initial presentation demonstrated a tear of the anterior talofibular ligament (ATFL). Exam reveals improved swelling but significant pain with light touch about the dorsal foot and anterolateral distal leg. Management should include prescription of a medication that acts by which of the following mechanisms?

QID: 3905
1

Interferes with nerve conduction through binding of intracellular sodium channels

7%

(141/1911)

2

Reduces hyper-excitability of voltage dependent presynaptic calcium channels

30%

(572/1911)

3

Binds and activates the mu receptor

3%

(56/1911)

4

Directly activates the gamma-amino-butyric acid (GABA) receptor

35%

(677/1911)

5

Selectively binds and inhibits cyclooxygenase type 1 (COX-1) enzymes

23%

(444/1911)

L 5 C

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(OBQ12.121) A 20-year-old male sustains a right ankle injury after landing awkwardly catching a rebound in a basketball game. The next day he has swelling and ecchymosis present about the lateral ankle. There is no effusion in the knee. His area of maximal tenderness is represented by the area at the white arrow in Figure A. The examination demonstrated in Figure B reveals 2mm of ankle translation. The examination demonstrated in Figure C is not provocative for pain. A 3-view radiograph of the ankle is normal. What is the next most appropriate step in management?

QID: 4481
FIGURES:
1

Short leg cast for 4 weeks followed by physical therapy

7%

(309/4203)

2

Magnetic resonance imaging (MRI) of the ankle

5%

(221/4203)

3

Brostrom reconstruction with Gould modification

1%

(46/4203)

4

Functional bracing as needed and physical therapy

84%

(3524/4203)

5

Magnetic resonance imaging (MRI) of the ankle with intra-articular contrast

2%

(69/4203)

L 2 B

Select Answer to see Preferred Response

(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?

QID: 3491
FIGURES:
1

A

3%

(85/2830)

2

B

85%

(2399/2830)

3

C

3%

(76/2830)

4

D

0%

(13/2830)

5

E

9%

(243/2830)

L 1 C

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(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?

QID: 3185
1

Anterior talofibular ligament

19%

(638/3317)

2

Calcaneofibular ligament

69%

(2302/3317)

3

Anterior tibiofibular ligament

5%

(176/3317)

4

Posterior tibiofibular ligament

4%

(144/3317)

5

Deltoid ligament

1%

(40/3317)

L 2 C

Select Answer to see Preferred Response

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(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?

QID: 30
FIGURES:
1

Steroid injection of the sinus tarsi and taping of the ankles before activity

1%

(16/2096)

2

Lateral ligament repair and augmentation with inferior extensor retinaculum

9%

(196/2096)

3

Lateral ligament reconstruction with peroneus brevis tendon grafting

19%

(397/2096)

4

First metatarsal osteotomy and lateral ligament reconstruction with peroneus brevis tendon grafting

67%

(1399/2096)

5

Triple arthrodesis and split peroneus brevis tendon graft reconstruction of the lateral ligaments

3%

(70/2096)

L 2 C

Select Answer to see Preferred Response

(OBQ05.94) An 18-year-old presents with complaints of ankle pain after a fall 10 days ago. He has kept his ankle wrapped and elevated as recommended by his primary care doctor. He is neurovascularly intact on physical exam. The provocative maneuver shown in Figure A is positive. What neuromuscular pathway needs to be rehabilitated to reduce recurrence of the injury?

QID: 980
FIGURES:
1

Tactile sensory

1%

(13/1369)

2

Pressure sensory

2%

(33/1369)

3

Proprioception

93%

(1271/1369)

4

Pain

0%

(6/1369)

5

Motor

3%

(38/1369)

L 1 B

Select Answer to see Preferred Response

(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?

QID: 1083
1

Evans tenodesis (peroneus brevis tenodesis)

6%

(72/1287)

2

Modified Broström procedure

80%

(1033/1287)

3

Allograft reconstruction with a tendon graft from the fibula to the 5th metatarsal base

7%

(89/1287)

4

Primary ligament repair with lateralizing calcaneal osteotomy

5%

(67/1287)

5

Primary ligament repair with a dorsiflexion osteotomy of the 1st metatarsal

2%

(20/1287)

L 1 C

Select Answer to see Preferred Response

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

QID: 89
1

Ankle sprain

83%

(1843/2224)

2

Fibular fracture

1%

(26/2224)

3

Acute cuboid subluxation

3%

(65/2224)

4

Achilles rupture

1%

(13/2224)

5

Midfoot sprain

12%

(270/2224)

L 2 D

Select Answer to see Preferred Response

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