Epidemiology

• 25,000 ankle sprains each day in United States
• Up to 30% of outpatient sports medicine clinics
• Ankle injuries are the most common type of injury in high school athletes

Anatomy

• Lateral
  • Lateral Collateral Complex
    • Anterior talofibular ligament (most common)
    • Calcaneofibular ligament (2^nd most common)
    • Posterior talofibular ligament
  • Mechanism of Injury
    • Inversions with either dorsiflexion or plantarflexion

• Medial
  • Deltoid Complex
    • Posterior tibiotalar ligament
    • Tibiocalcaneal ligament
    • Tibionavicular ligament
    • Anterior tibiotalar ligament
  • Mechanism of Injury
    • Forced eversion

• Syndesmotic (high ankle sprain)
  • Distal Tibiofibular Syndesmosis
    • Anterior-inferior tibiofibular ligament
    • Posterior-inferior tibiofibular ligament
    • Transverse tibiofibular ligament
    • Interosseous membrane
    • Interosseous ligament
    • Inferior transverse ligament
  • Mechanism of Injury
    • External rotation with dorsiflexion

Important History Questions

• What was the mechanism of injury?
• Could you walk immediately after the injury?
• Can you walk now?
• Any previous history of ankle injuries?

Physical Exam

• Observation
  • Swelling or ecchymosis
  • Ambulation to exam room
• Palpation
  • Bony
    • Entire fibula (from lateral malleolus to fibular head)
    • Lateral malleolus
    • 5^th metatarsal
    • Navicular
  • Soft Tissue
    • Palpate each ligament based on mechanism
  • Special Maneuvers
    • Lateral Injuries
      • Anterior drawer
        • Stabilize proximal leg to the ankle and grasp calcaneous and apply anterior force
      • Talar tilt
        • Stabilize proximal leg to ankle and grasp calcaneous and apply inversion force
    • Syndesmotic Injuries
      • Squeeze test (Hopkin’s test)
        • Compression of tibia and fibula at mid calf
      • External rotation stress test (Kleiger’s test)
        • Stabilize proximal leg to the ankle and applying external rotation force to the forefoot

Grading and Classifications

Indications for Radiography

• Ottawa Rules of Foot and Ankle
  • Published in 1996 and showed reduction of ankle x-rays by 28% if none of the following are present:
    • Posterior lateral malleolar tenderness
    • Posterior medial malleolar tenderness
    • Base of 5^th metatarsal tenderness
    • Navicular tenderness
    • Inability to ambulate both immediately and in the ED

• Views
  • Standard three views (AP, Lateral, Mortise)

• Varus stress view

• MRI
  • Used for clinically suspicious of syndesmotic injury with normal radiographs

Management

• Orthopaedic Referral
  • Fracture
  • Dislocation/Subluxation
  • Syndesmotic injury
  • Tendon rupture
  • Uncertain diagnosis
• Non-operative
  • Low ankle
    • RICE
      • Cryotherapy 20 min every 2 hours for 48 hours
    • May use crutches and NWB up to 10 days (Grade II and III)
      • Early immobilization = better recovery
      • Cast vs CAM Boot vs Aircast
    • NSAIDs for pain control
    • Refer to physical therapy for grade II and III for rehabilitation exercises
  • Syndesmotic
    • CAM Boot vs short leg cast for 2-3 weeks
• Operative
  • Indications
    • Low Ankle
      • Any grade with continued pain and instability despite extensive non-operative management
      • Any grade with bony avulsion
    • Syndesmotic
      • Instability on radiographs
      • Continued pain despite conservative pain
      • Associated ankle fracture
  • Procedures
    • Low Ankle
      • Modified Brostrum
        • Anatomic shortening and reinsertion of the ATFL and CFL
      • Tendon transfer and tenodesis
    • Syndesmotic
      • Screw fixation
      • Suture button

Athlete Return to Play

Cottage Physician

References

1. American College of Sports Medicine. Fact Sheets: Ankle Sprains. http://www.acsm.org/public-information/brochures-fact-sheets/fact-sheets.  Accessed May 23, 2016.
2. Wheeless’ Textbook of Orthopaedics. Ankle Sprain. http://www.wheelessonline.com/ortho/ankle_sprain.  Accessed May 23, 2016.
3. Low Ankle Sprain.  http://www.orthobullets.com/foot-and-ankle/7028/low-ankle-sprain.  Accessed May 23, 2016.
4. High Ankle Sprain.  http://www.orthobullets.com/foot-and-ankle/7029/high-ankle-sprain.  Accessed May 23, 2016.
5. Stiell I. Ottawa ankle rules. Can Fam Physician. 1996;42:478-80.
6. Tiemstra JD. Update on Acute Ankle Sprains.  Am Fam Physician.  2012;85(12):1170-1176.
7. De Brucker Y, Jager T, Devos H, Boulet CG, Kichouh M, De Maeseneer M, Shahabpour M, de May J. Trauma mechanism in ankle fracture: Let’s do the twist.  http://posterng.netkey.at/esr/viewing/index.php?module=viewing_poster&task=viewsection&pi=121495&ti=402298&searchkey=.  Accessed May 24, 2016.
8. Stress view of ankle – with deltoid ligament tear.  http://radiopaedia.org/cases/stress-view-of-ankle-with-deltoid-ligament-tear.  Accessed May 24, 2016.
9. Hocutt JE, Jaffe R, Rylander CR, Beebe JK. Cryotherapy in ankle sprains. Am J Sports Med. 1982;10(5):316-9.
10. Seah R, Mani-babu S. Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97:105-35.
11. Bleakley CM, O’connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964.
12. Tsao LY.  Radsource.  High Ankle Sprain. http://radsource.us/high-ankle-sprains/.  Accessed May 24, 2016.