Ankle injuries fall into the same basic categories as do all athletic injuries:

• Contusions• Sprains• Strains• Fractures

Lateral ankle sprains (85%)› Plantar flexion and inversion

Syndesmotic sprains (10%)› Dorsi-flexion and/or eversion

Medial ankle sprains (5%)› Eversion

Ankle Ecchymosis

Lateral complex› Ant. talofibular› calcaneofibular› Post. talofibular

Syndesmosis› Ant. Inf. tibiofibular› Post.Inf. tibiofibular

Syndesmosis:› Ant. Inf. Tibiofibular

ligament› Post. Inf.

Tibiofibular ligament

› Transverse tibiofibular ligament

› Interosseous membrane

Major Ligament complex is called the Deltoid Ligament.

It is the strongest of the ankle ligaments

Navicular bone› post. Tibial tendon

attaches

Provide proprioceptive information for joint function

Provide static stability to the joint and prevent excessive motion

Act as guides to direct motion

Peroneus brevis Peroneus longus

› Both serve as the major everters of the ankle

› Also serve as plantar flexors

Major tendons› Anterior tibialis

(dorsi-flexor)› Achilles tendon

(plantar flexor)› Medial tendons

Posterior tibialis (inverter and plantar flexor)

Flexor digitorum longus

Flexor hallucis longus

Osseous Structures (bones)› Tibia, fibula, talus

Ligaments (static stabilizers)› Lateral, medial, syndesmotic

Muscles/Tendons (dynamic stabilizers)› Plantar & Dorsi-flexors› Everters (peroneals)› Inverters (post & ant tibialis)

History is always good!› What happened?› Which way did it bend?› Could you walk?› How much swelling/ecchymosis?› When did it happen?› What have you done for it?› Have you sprained it before?

› Past history› Mechanism of injury› When does it hurt?› Type of, quality of, duration of pain?› Sounds or feelings?› How long were you disabled?› Swelling?› Previous treatments?

› Postural deviations?› Is there difficulty with walking?› Deformities, asymmetries or swelling?› Color and texture of skin, heat, redness?› Patient in obvious pain?› Is range of motion normal?

› Most helpful during the acute phase› Remember your anatomy! › Palpate the structures you know

Boney prominences Ligaments Tendon insertions

› Check Range of Motion Plantar and Dorsi-flexion Inversion and Eversion

› Neurovascular status› Strength?

Not helpful in the acute setting

› Ligamentous testing May be very difficult to do in the acute

setting

Anterior Drawer Test tes utk mengetahui integritas ligamen talofibular anterior

Tes utk mengetahui integritas ligamen calcaneofibular

Untuk mengetahui adanya cedera syndesmotic

› Xrays are indicated to r/o fx if: Presents within 10 days of injury Unable to bear weight at time of injury or in

office Tenderness of distal 6cm of malleoli on the

post. Aspect. Tenderness over the base of the 5th met or

navicular bone

Several Classifications Exist based on:› Ligamentous injury and evidence of

instability› Classification based on functional

impairment› Number of ligaments involved

Combination of the above

Ligament status› partial tear of the ligament› mild tenderness and swelling› no instability on exam when stressing

ligament Functional status

› Slight or no functional loss› able to bear weight and ambulate with

minimal pain

- The anterior talofibular ligament affected

- stress: minimal change on inversion, normal anterior drawer

- treatment by encouraging early active movement:

a) stationary cycling b) walking with protective taping or

semi-rigid brace ( Aircast splint )

c) NSAIDS (anti-inflammatory medication)

d) physiotherapy: electrotherapy, strengthening exercises, proprioception.

e) functional progression to running, jumping, hopping, swerving, recovery into 6 weeks

• Ligament Status– Incomplete tear of the ligament– Moderate pain swelling and tenderness– Mild to mod. ecchymosis– Mild to moderate instability of the ligament

• Functional status– Some loss of motion and function– patient has pain with weight-bearing and

ambulation

- Complete tear of anterior talofibular ligament with some damage of the calcaneofibular ligament

- laxity when inversion, anterior drawer present

- treatment: a) 1 week crutches, joint taped or in aircast splint

b) follow grade 1 rehabilitation

• Ligament Status– Complete tear and loss of integrity of a

ligament.– Severe swelling (more than 4cm around the

fibula) – Severe ecchymosis– Significant mechanical instability with

ligament stressing• Functional Status

– Significant loss of function and motion– patient is unable to bear weight or ambulate.

- Uncommon severe injuries, associated with fractures

- treatment: 10 days NWB in aircast brace, then PWB with the brace up to 6 weeks. Aggressive rehabilitation follows

- surgical reconstruction must be considered

–PRICEM– Protection: (orthosis or brace)– Rest: limit wt. Bearing until non-painful– Ice, Compression, and Elevation• Most important component acutely• Limiting inflammation and swelling has been

shown to speed recovery– Mobilize • early range of motion has also been shown

to speed recovery

ACUTE Major goals in the acute

phase are to reduce swelling and pain

RICE AROM as long as it is pain

free. U/S, Laser, Acupuncture A brace can be used to

prevent inversion of the foot

Research shows that early limited stress following the inflammation phase might promote faster, stronger healing as it helps to align the collagen fibers.

SUBACUTE U/S, laser, Acupuncture AROM without brace

starting with dorsiflexion and plantarflexion

Progressive isometric exercises

Cross fiber massage to the ligament in late rehab

Taping or tensor bandage Build up to functional

skillsCHRONIC Resisted exercise

strengthening Balance and agility Proprioception training Functional training

- Ice- Ultrasound- Rest/Activity Modification- Fix training errors

- Fix biomechanical problems- Stretching- Strengthening - Taping

• Phase one—ImmobilizationPhase one—Immobilization

• Phase two-Early motionPhase two-Early motion

• Phase three-StrengtheningPhase three-Strengthening

• Phase four-Functional activityPhase four-Functional activity

• Phase five-Return to full activityPhase five-Return to full activity

Neuromuscular Control Training› Can be enhanced

by training in controlled activities

› Uneven surfaces, BAPS boards, rocker boards, or Dynadiscs can also be utilized to challenge athlete

Stretching of the Achilles tendon Strengthening of the surrounding

muscles Proprioceptive training: balance

exercises and agility Wearing proper footwear and or tape

when appropriate

Reviewed anatomy and clinical exam Ankle injuries are extremely common

with high potential for long term sequele.

A through exam and early aggressive treatment including a rehabilitation program will lead to optimal results.