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Ankle Sprain

Dr. Ahmed RashadPGY 2 Family Medicine

+Introduction

Ankle injuries are among the most common injuries presenting to primary care offices and emergency departments [1].

Ankle ligaments provide mechanical stability, proprioceptive information, and directed motion for the joint.

Recurrent ankle sprains can lead to functional instability and loss of normal ankle kinematics and proprioception, which can result in recurrent injury, chronic instability, and early degenerative bony changes.[2]

+Anatomy

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+Classification

Lateral ankle sprain

The most common mechanism of ankle injury is inversion of the plantar-flexed foot.

The anterior talofibular ligament is the first or only ligament to be injured in the majority of ankle sprains. Stronger forces lead to combined ruptures of the anterior talofibular ligament and the calcaneofibular ligament, which can result in significant ankle joint instability, usually accompanied with nerve injury. [3]

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Medial ankle sprain

The medial deltoid ligament complex is the strongest of the ankle ligaments and is infrequently injured.

Forced eversion of the ankle can cause damage to this structure but more commonly results in an avulsion fracture of the medial malleolus because of the strength of the deltoid ligament.

+Syndesmotic sprain

Dorsiflexion and/or eversion of the ankle may cause sprain of the syndesmotic structures, which include the anterior tibiofibular, posterior tibiofibular, and transverse tibiofibular ligaments, and the interosseous membrane.These structures are critical to ankle stability.

Syndesmotic ligament injuries contribute to chronic ankle instability and are more likely to result in recurrent ankle sprain and the formation of heterotopic ossification. [4]

+Grading

Grade I sprain:

a. It results from mild stretching of a ligament with microscopic tears.

b. Patients have mild swelling and tenderness.

c. There is no joint instability on examination, and the patient is able to bear weight and ambulate with minimal pain

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Grade II sprain

a. Is more severe injury involving an incomplete tear of a ligament.

b. Patients have moderate pain, swelling, tenderness, and ecchymosis.

c. There is mild to moderate joint instability on exam with some restriction of the range of motion and loss of function.

d. Weightbearing and ambulation are painful

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Grade III sprain

a. involves a complete tear of a ligament.

b. Patients have severe pain, swelling, tenderness, and ecchymosis.

c. There is significant mechanical instability on exam and significant loss of function and motion. Patients are unable to bear weight or ambulate

+Ottawa ankle rules

Clinicians should remember that multiple systematic reviews have found the Ottawa ankle rules to be highly sensitive. [5]

+ The rules are as follows :

i. An ankle series is only indicated for patients who have pain in the malleolar zone AND

ii. Have bone tenderness at the posterior edge or tip of the lateral or medial malleolus OR

iii. Are unable to bear weight both immediately after the injury and for four steps in the emergency department or doctor's office.

iv. A foot series is only indicated for patients who have pain in the midfoot zone AND

v. Have bone tenderness at the base of the fifth metatarsal or at the navicular OR

vi. Are unable to bear weight both immediately after the injury and for four steps in the emergency department or doctor's office.

+Examination ( Special tests)

Squeeze test

The squeeze test consists of compression of the fibula against the tibia at the mid-calf level. This maneuver elicits pain in the region of the anterior tibiofibular ligament (anterior to the lateral malleolus and proximal to the ankle joint) when a syndesmotic sprain has occurred.

+Talar tilt test

The talar tilt test detects excessive ankle inversion. If the ligamentous tear extends posteriorly into the calcaneofibular portion of the lateral ligament, the lateral ankle is unstable and talar tilt occurs.

With the ankle in the neutral position, gentle inversion force is applied to the affected ankle, and the degree of inversion is observed and compared with the uninjured side.

+External rotation stress test

The external rotation stress test can also help identify a syndesmotic sprain.

The clinician stabilizes the leg proximal to the ankle joint while grasping the plantar aspect of the foot and rotating the foot externally relative to the tibia. The test is positive if pain is elicited in the region of the anterior tibiofibular ligament (anterior to the lateral malleolus and proximal to the ankle joint

+Anterior drawer test

The anterior drawer test detects excessive anterior displacement of the talus on the tibia. The test is performed with the patient's foot in the neutral position (slightly plantar flexed and inverted).

The lower leg is stabilized by the examiner with one hand, and with the opposite hand, the examiner grasps the heel while the patient's foot rests on the anterior aspect of the examiner's arm.

An anterior force is gently but steadily applied to the heel while holding the distal anterior leg fixed.

+Management

Immediate therapy

Rest

Ice

Compression

Elevation

+ Exercises including plantar flexion, dorsiflexion, and

foot circles should be started early, once acute pain and swelling subside, to maintain range of motion.

The intensity of rehabilitation is increased gradually.

Ankle splints or braces can limit extremes of joint motion and allow early weightbearing while protecting against reinjury.

The treatment of severe (grade III) ankle sprains is controversial. A brief period of immobilization may be helpful in some instances.

+Rehabilitation

Functional rehabilitation is of great importance in aiding the return to activity and preventing chronic instability.

Early functional rehabilitation includes :

a. Range of motion exercises (Achilles tendon stretch, foot circles , alphabet exercises; have the patient trace letters in the air with his big toe)

b. Muscle strengthening exercises (isometric and isotonic plantar flexion, dorsiflexion, inversion, eversion, toe curls and marble pickups, heel walks and toe walks), and proceeds to

c. Proprioceptive training (circular wobble board and walking on different surfaces) and [6] [7]

d. activity-specific training (walk-jog, jog-run).

+Splints and braces

During functional rehabilitation, it may be of benefit to use splints, braces, elastic bandages, or taping to try to reduce instability, protect the ankle from further injury, and to limit swelling. Studies have shown that:

i. Lace-up ankle supports were superior to semi-rigid ankle supports, elastic bandages, and tape in preventing persistent swelling.

ii. Semi-rigid ankle supports resulted in a quicker return to work and to sports, and less instability at short-term follow-up, than elastic bandages.

iii. Tape caused more skin irritation than elastic bandages. [8]

+Surgery

Surgical repair of ruptured ankle ligaments is sometimes considered in patients with ankle sprains.

A meta-analysis that looked at controlled trials of surgery for acute ruptures of lateral ankle ligaments found that compared with functional treatment, patients treated with surgery were significantly less likely to experience giving-way of the ankle (relative risk 0.23, 95% CI 0.17-0.31). [9]

+Resources

[1] Boruta PM, Bishop JO, Braly WG, Tullos HS. Acute lateral ankle ligament injuries: a literature review. Foot Ankle 1990; 11:107.

[2]Anandacoomarasamy A, Barnsley L. Long term outcomes of inversion ankle injuries. Br J Sports Med 2005; 39:e14; discussion e14.

[3] Nitz AJ, Dobner JJ, Kersey D. Nerve injury and grades II and III ankle sprains. Am J Sports Med 1985; 13:177.

[4] Taylor, DC, Englehardt, DL, Bassett, FH III. Syndesmosis sprains of the ankle: The influence of heterotopic ossification. Am J Sports Med 1992; 20:146.

+Resources

[5] Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 2003; 326:417.

[6] Wester JU, Jespersen SM, Nielsen KD, Neumann L. Wobble board training after partial sprains of the lateral ligaments of the ankle: a prospective randomized study. J Orthop Sports Phys Ther 1996; 23:332.

[7] Verhagen E, van der Beek A, Twisk J, et al. The effect of a proprioceptive balance board training program for the prevention of ankle sprains: a prospective controlled trial. Am J Sports Med 2004; 32:1385.

+Resources

[8] 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

[9] Pijnenburg AC, Van Dijk CN, Bossuyt PM, Marti RK. Treatment of ruptures of the lateral ankle ligaments: a meta-analysis. J Bone Joint Surg Am 2000; 82:761

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