Introduction Overview ankle sprains involve an injury to the ATFL and CFL and are the most common reason for missed athletic participation treatment usually includes a period of immobilization followed by physical therapy. Only when nonoperative treatment fails is surgical reconstruction indicated. 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 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) Pathophysiology Mechanism of injury Inversion type ankle injury on a plantarflexed foot Recurrent ankle sprains can lead to functional instability Associated injuries/conditions include osteochondral defects peroneal tendon injuries subtle cavovarus foot 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 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 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 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 (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 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 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
QUESTIONS 1 of 22 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 4780 Type & Select Correct Answer 1 Functional management is associated with higher rate of return to sports than immobilization. 5% (224/4477) 2 Functional management is associated with greater range of motion than immobilization. 3% (130/4477) 3 Functional management is associated with less persistent swelling than immobilization. 7% (292/4477) 4 Functional management is associated with a greater risk of increased ankle joint laxity than immobilization. 79% (3535/4477) 5 Functional management is associated with higher rate of satisfaction than immobilization. 6% (271/4477) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (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? Tested Concept QID: 4704 FIGURES: A Type & Select Correct Answer 1 Immobilization in a non weight-bearing cast 3% (124/4570) 2 Immobilization in a weight-bearing boot 3% (139/4570) 3 Immobilization in a splint 0% (19/4570) 4 Functional bracing with early proprioceptive training 90% (4115/4570) 5 Neuromuscular training alone 3% (150/4570) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 4481 FIGURES: A B C Type & Select Correct Answer 1 Short leg cast for 4 weeks followed by physical therapy 7% (300/4024) 2 Magnetic resonance imaging (MRI) of the ankle 5% (200/4024) 3 Brostrom reconstruction with Gould modification 1% (40/4024) 4 Functional bracing as needed and physical therapy 84% (3385/4024) 5 Magnetic resonance imaging (MRI) of the ankle with intra-articular contrast 2% (66/4024) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (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? Tested Concept QID: 3491 FIGURES: A Type & Select Correct Answer 1 A 3% (75/2661) 2 B 85% (2263/2661) 3 C 3% (70/2661) 4 D 0% (13/2661) 5 E 9% (227/2661) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (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? Tested Concept QID: 3185 Type & Select Correct Answer 1 Anterior talofibular ligament 19% (599/3134) 2 Calcaneofibular ligament 70% (2184/3134) 3 Anterior tibiofibular ligament 5% (163/3134) 4 Posterior tibiofibular ligament 4% (133/3134) 5 Deltoid ligament 1% (39/3134) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ07.118) In the majority of patients, which of the following treatments leads to a good or excellent one-year prognosis in the care of first time grade-III sprains of the lateral ligaments of the ankle? Tested Concept QID: 779 Type & Select Correct Answer 1 Ice, elevation, and early physical therapy 17% (458/2634) 2 Operative repair of the lateral ligaments 2% (46/2634) 3 Self-guided early controlled mobilization 25% (657/2634) 4 Application of a removable brace 2% (55/2634) 5 All of the above 53% (1408/2634) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (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? Tested Concept QID: 30 FIGURES: A B Type & Select Correct Answer 1 Steroid injection of the sinus tarsi and taping of the ankles before activity 1% (14/1889) 2 Lateral ligament repair and augmentation with inferior extensor retinaculum 9% (169/1889) 3 Lateral ligament reconstruction with peroneus brevis tendon grafting 19% (355/1889) 4 First metatarsal osteotomy and lateral ligament reconstruction with peroneus brevis tendon grafting 67% (1271/1889) 5 Triple arthrodesis and split peroneus brevis tendon graft reconstruction of the lateral ligaments 3% (63/1889) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (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? Tested Concept QID: 980 FIGURES: A Type & Select Correct Answer 1 Tactile sensory 1% (10/1162) 2 Pressure sensory 2% (29/1162) 3 Proprioception 93% (1079/1162) 4 Pain 0% (3/1162) 5 Motor 3% (32/1162) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (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? Tested Concept QID: 1083 Type & Select Correct Answer 1 Evans tenodesis (peroneus brevis tenodesis) 6% (64/1126) 2 Modified Broström procedure 80% (902/1126) 3 Allograft reconstruction with a tendon graft from the fibula to the 5th metatarsal base 7% (77/1126) 4 Primary ligament repair with lateralizing calcaneal osteotomy 5% (61/1126) 5 Primary ligament repair with a dorsiflexion osteotomy of the 1st metatarsal 1% (16/1126) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ04.28) In dancers, peroneal muscle weakness has been shown to be the cause of which of the following? Tested Concept QID: 89 Type & Select Correct Answer 1 Ankle sprain 83% (1643/1982) 2 Fibular fracture 1% (21/1982) 3 Acute cuboid subluxation 3% (56/1982) 4 Achilles rupture 1% (13/1982) 5 Midfoot sprain 12% (243/1982) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept
All Videos (3) Podcasts (1) Login to View Community Videos Login to View Community Videos 2017 Orthopaedic Summit Evolving Techniques Expediting Return to Play after Ankle Instability - Troy S. Watson, MD Troy Watson Foot & Ankle - Ankle Sprain B 4/24/2018 578 views (3) Login to View Community Videos Login to View Community Videos Brostrom-Gould Ankle Reconstruction - Dr. Weatherby Foot & Ankle - Ankle Sprain D 7/21/2012 8066 views (17) Login to View Community Videos Login to View Community Videos Ankle Anterior Drawer Test Foot & Ankle - Ankle Sprain C 1/23/2012 13137 views (16) Foot & Ankle | Ankle Sprain Team Orthobullets (J) Foot & Ankle - Ankle Sprain Listen Now 10:37 min 10/15/2019 300 plays (4)
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