Contents

Search

ankle sprain

Etiology: 1) inversion & plantar flexion: injury to lateral ligaments a) anterior talofibular ligament injury (generally injured 1st) b) posterior talofibular ligament c) calcaneofibular ligament injury 2) eversion: injury to medial ligaments (most common) a) deltoid ligament b) anterior talofibular ligament c) interosseous membrane 3) high ankle sprain - tibiofibular syndesmosis ligament injury Classification: (ligament injuries) Grade 1 1) < 25 % tear 2) able to continue activity 3) swelling occurs hours later 4) no laxity when ligament stressed Grade 2 1) 25-75% tear 2) unable to continue activity 3) swelling within minutes 4) laxity mild when ligament stressed, firm end point Grade 3 1) 75%-complete tear 2) unable to continue activity 3) swelling within minutes 4) laxity when ligament stressed, soft end point 'clink' Clinical manifestations: 1) pain 2) swelling 3) inability to bear weight 4) decreased range of motion 5) ecchymosis suggests bleed in the region of a torn ligament [3] 6) point tenderness over ligament or insertion point 7) diffuse tenderness 8) laxity when ligaments stressed (grades II & III) 9) high ankle sprain - pain & swelling above ankle - pain reproduced by squeezing the leg at the mid calf & by having the patient cross the affect leg with the lateral malleolus resting on the opposite knee Laboratory: - arthrocentesis & joint fluid analysis if septic joint or inflammatory arthritis suspected Radiology: 1) ankle & foot radiographs as determined by Ottawa ankle rules 2) stress radiographs or arthrograms to differentiate grades II & III Differential diagnosis: 1) fracture a) lateral malleolus b) medial malleolus c) dome of talus d) tarsal navicular e) proximal 5th metatarsal 2) growth place injury - in children, the ligaments & joint capsules are 2-5X stronger than the physis, thus growth plate injuries are more common than sprains 3) syndesmosis sprains (sprains of the tibiofibular ligament) 4) arthritis a) gout b) septic joint c) onset may coincide with or be triggered by trauma 5) myositis ossificans 6) compartment syndrome 7) Achilles tendon rupture Management: - P: protection. - grade 1: Ace wrap - grade 2: aircast (air stirrup), soft brace, posterior splint, Unna boot - ref [5] (NEJM) does not grade sprain. - recommends RICED + air stirrup for what appears to be grade 1 sprain - grade 3: cast or referral - R: rest. crutches with grade 2 or 3, early rehabilitation - I: ice 1st 24-72 hours. Ice for 10-20 minutes every 1-2 hours - N: NSAIDs. NSAIDs round the clock not PRN for 1st few days - C: compression. - elastic bandage with or without compression pad around malleolus - snug around foot, looser towards the calf - objective is to reduce swelling - E: elevation. Elevate above the heart for 24-48 hours. 1) pharmacologic agents a) non-steroidal anti-inflammatory agents (NSAIDs) b) narcotic analgesics for grades 2 & 3 as needed 2) physical therapy a) passive range of motion exercises early - flexion/extension with towel under ball of foot, toe circles, heel walk toe walk, water exercises in pool b) wobble board, especially athletes, helps regain proprioception c) athletes: progress through stages & advance when activity no longer hurts. Stages: walk & run in straight line, run in wide circles, run in figure 8. Football player can practice when he can run 20 yard figure 8 with little or no pain d) physical therapy does not improve ankle function recovery [4] 3) chronic unstable ankles: 3 mm lateral heel & sole wedge to prevent inversion 4) if healing is delayed, repeat radiographs at 3-4 weeks 5) athletes tape ankle after 1st injury 6) braces for recurrent sprains (lace up, air splints) 7) consider underlying cause of recurrent sprain

Related

ankle Ottawa ankle rules

Specific

anterior talofibular ligament injury calcaneofibular ligament injury tibiofibular syndesmosis ligament injury (high ankle sprain)

General

ankle injury

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 671-72
  2. Lamb SE et al, Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial Lancet 2009 373:575-581 PMID: 19217992 - Hertel J. Immobilisation for acute severe ankle sprain. Lancet 2009 Feb 14; 373:524. PMID: 19217974
  3. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2018, 2021. - 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. PMID: 20710025
  4. Brison RJ et al Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial. BMJ 2016;355:i5650 PMID: 27852621 http://www.bmj.com/content/355/bmj.i5650 - Bleakley C Supervised physiotherapy for mild or moderate ankle sprain. BMJ 2016;355:i5984 PMID: 27852567 http://www.bmj.com/content/355/bmj.i5984
  5. NEJM Knowledge+