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Updated: Jan 24 2024

Ankle Sprain

Images
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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
      • intraarticular pathology
        • anterior/anterolateral synovitis (most common) 
        • osteochondral defects of the talus
        • anterior ankle impingement
      • 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
    • Early (<3 weeks) vs. delayed (>3 weeks) post-operative mobilization protocols 
      • Improved functional scores with early mobilization
      • Increased ankle laxity with early mobilization
      • Increased wound healing complications with early mobilization
    • 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
          • hindfoot varus
    • 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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