Ankle sprain: Difference between revisions

(Created page with "==Background== stress tests-best done several days after injury. anterior drawer- tests the anterior talar fibular ligament (ATFL). knee at 90 degrees, foot in relaxed positio...")
 
 
(33 intermediate revisions by 9 users not shown)
Line 1: Line 1:
==Background==
==Background==
===Ankle stabilization anatomy===
[[File:919 Ankle Feet Joints.jpg|thumb|Ligaments of ankle and feet.]]
*Syndesmosis
*Ligaments
**Medial: Medial collateral (deltoid) ligament (tibia to talus and calcaneus)
**Lateral: Anterior/posterior talofibular, calcaneofibular ligaments


==Clinical Features==
[[File:Schwellung am Fußknloechel und Blutergussl.jpg|thumb|Right foot with acute lateral ankle sprain.]]
===Lateral Ankle Sprain===
*Most common
*Due to inversion of plantarflexed ankle
*Anterior talofibular ligament (ATFL) is most commonly injured ligament


stress tests-best done several days after injury.
===Medial Ankle Sprain===
*Isolated sprain is unusual; often associated with fibular fracture or syndesmosis injury
*Always rule-out [[Maisonneuve]] fracture by evaluating proximal fibula


anterior drawer- tests the anterior talar fibular ligament (ATFL). knee at 90 degrees, foot in relaxed position. cup heel with one hand and push on tibia posteriorly-positive is 2mm of subluxation relative to the other foot or visible dimpling of the anterior skin.
===Syndesmotic Sprain ("High-ankle sprain")===
*Associated with with hyperdorsiflexion when talus moves superiorly and separates tibia/fibula
*Pain just above talus


Talar tilt- tests ATFL and calcaneofibular ligament (CFL)-in same position as above-forced inversion of foot is applied- positive if there is obvious joint laxity relative to the other side or no passive resistance to forced motion-indicates rupture of ATFL and CFL. can do with forced eversion which tests the stability of the deltiod ligament.
==Differential Diagnosis==
{{Other ankle injuries DDX}}


Fibular compression: tests the tiobiofibular syndesmotic ligament. Same position as before but dorsiflex foot. squeeze tibia and fibula together 6-8 inches below knee. Positive tests if there is pain in the ankle.
{{Distal leg fractures DDX}}


Thompson's tests- prone with knee flexed squeeze gastroc and soleus in midcalf. if no plantarflexion-torn achilles tendon.
{{Foot and toe fractures DDX}}


==Evaluation==
*Anterior drawer test
**Tests anterior talofibular ligament
**Cup heel with one hand and and pull anteriorly while pushing tibia posteriorly
*Talar tilt test
**Tests for combined injury of anterior talofibular and calcaneofibular ligaments
**Inversion at the ankle causes tilting/lifting of the mortise joint
===Imaging===
{{Ottawa Ankle Rules}}
{{Ottawa Foot Rules}}
====Exceptions====
*Age <6 or >55
*Only for blunt trauma mechanism
*Does not apply to subacute/chronic injuries
*Does not apply to injuries of the hindfoot or forefoot


==Classification==
===Classification===
*Grade I
**No tearing of ligaments
**Minimal pain, swelling, ecchymosis; weightbearing is tolerable
**No splinting/casting; weight bearing as tolerated, isometric exercises, full ROM and stretching/strengthening exercises
*Grade II
**Partial ligament tear; possible instability
**Increased pain, swelling, ecchymosis; difficulty bearing weight
**Immobilize with air splint; PT with ROM/stretching/strengthening exercises
*Grade III
**Complete ligament tear; significant instability
**Severe pain, swelling, ecchymosis; inability to bear weight
**Immobilization and possible surgery; PT same as grade 2 but longer time period


==Management==
*Stable joint and ability to bear weight: (Likely Grade I)
**[[NSAIDs]], RICE (rest, ice, compression, elevation)
**1 week follow up if no improvement
*Stable joint but unable to bear weight or unstable joint (Grades II and III) :
**Ankle cast immobilization or a removable walking boot for 7-10 days for grades II and III. Follow up at 5 days with ortho/podiatry. <ref>[https://www.podiatrytoday.com/guide-conservative-care-ankle-sprains Douglas Richie, A Guide To Conservative Care For Ankle Sprains. Podiatry Today Volume 29 - Issue 7 - July 2016]</ref>
**[[Splinting#Lower Extremity|Posterior mold splint]] and ortho consult/referral


I- mild pain,swelling can bear weight, negative stress test-
==Disposition==
*Discharge


    -Treatment = RICE and f/u in 7 days.
==See Also==
*[[Ankle (Main)]]
*[[Ankle Fracture]]
*[[Ottawa Ankle Rules]]


II-mod pain, swelling, difficulty bearing weight, pos ant drawer (4-14 mm), pos talar tilt (5-15 degrees)
==References==
<references/>


    -Treatment: rigid splint, crutches, <7 day f/u.
[[Category:Orthopedics]]
 
[[Category:Sports Medicine]]
III- severe pain, unable to bear weight, lot of swelling. ant drawer >15 mm, talar tilt >15 degrees
 
    -Treatment: rigid splint, crutches, f/u in <7 days.
 
 
ATFL most common ligament (80% of inversion injuries).
 
eversion injuries- deltoid ligament rarely isolated tear-usually avulsion Fx of medial malleolus. syndesmotic sprains more common than deltoid injuries (and more easily missed).
 
grade 2 and 3 eversion injuries are often placed in a short leg walking cast for 6-8 weeks.
 
 
==Causes of Chronic Pain after Healing==
 
 
1)soft tissue problems
 
synovial impingement syndromes
 
loose bodies in the joint
 
proneal tendon subluxation
 
2)bony problems
 
osteochondral Fx of talar dome
 
lateral or posterior fx of talus
 
anterior fx of calcaneus
 
 
==Syndesmotic Sprain==
 
 
(High Ankle)
 
Diagnosis:
 
-Positive squeeze test
 
-TTP distal tibiofibular joint
 
Rx: Treat as sprain, f/u ortho/sports
 
    -possible surgical repair if refractory to conservative management
 
 
 
 
 
 
[[Category:Ortho]]

Latest revision as of 22:54, 5 March 2025

Background

Ankle stabilization anatomy

Ligaments of ankle and feet.
  • Syndesmosis
  • Ligaments
    • Medial: Medial collateral (deltoid) ligament (tibia to talus and calcaneus)
    • Lateral: Anterior/posterior talofibular, calcaneofibular ligaments

Clinical Features

Right foot with acute lateral ankle sprain.

Lateral Ankle Sprain

  • Most common
  • Due to inversion of plantarflexed ankle
  • Anterior talofibular ligament (ATFL) is most commonly injured ligament

Medial Ankle Sprain

  • Isolated sprain is unusual; often associated with fibular fracture or syndesmosis injury
  • Always rule-out Maisonneuve fracture by evaluating proximal fibula

Syndesmotic Sprain ("High-ankle sprain")

  • Associated with with hyperdorsiflexion when talus moves superiorly and separates tibia/fibula
  • Pain just above talus

Differential Diagnosis

Other Ankle Injuries

Distal Leg Fracture Types

Foot and Toe Fracture Types

Hindfoot

Midfoot

Forefoot

Evaluation

  • Anterior drawer test
    • Tests anterior talofibular ligament
    • Cup heel with one hand and and pull anteriorly while pushing tibia posteriorly
  • Talar tilt test
    • Tests for combined injury of anterior talofibular and calcaneofibular ligaments
    • Inversion at the ankle causes tilting/lifting of the mortise joint

Imaging

Ottawa ankle rule

Ottawa ankle rule

Ankle x-ray needed if:

  • Pain near the maleoli AND
  • Inability to bear weight immediately and in the ED (4 steps) OR
  • Tenderness at posterior edge or tip of lateral malleolus OR
  • Tenderness at posterior edge or tip of medial malleolus

Ottawa foot rules

Ottawa foot rules

Foot x-ray series needed if:

  • Pain in the midfoot AND
  • Inability to bear weight both immediately and in the ED (4 steps) OR
  • Tenderness at the navicular OR
  • Tenderness at the base of the 5th metatarsal

Exceptions

  • Age <6 or >55
  • Only for blunt trauma mechanism
  • Does not apply to subacute/chronic injuries
  • Does not apply to injuries of the hindfoot or forefoot

Classification

  • Grade I
    • No tearing of ligaments
    • Minimal pain, swelling, ecchymosis; weightbearing is tolerable
    • No splinting/casting; weight bearing as tolerated, isometric exercises, full ROM and stretching/strengthening exercises
  • Grade II
    • Partial ligament tear; possible instability
    • Increased pain, swelling, ecchymosis; difficulty bearing weight
    • Immobilize with air splint; PT with ROM/stretching/strengthening exercises
  • Grade III
    • Complete ligament tear; significant instability
    • Severe pain, swelling, ecchymosis; inability to bear weight
    • Immobilization and possible surgery; PT same as grade 2 but longer time period

Management

  • Stable joint and ability to bear weight: (Likely Grade I)
    • NSAIDs, RICE (rest, ice, compression, elevation)
    • 1 week follow up if no improvement
  • Stable joint but unable to bear weight or unstable joint (Grades II and III) :
    • Ankle cast immobilization or a removable walking boot for 7-10 days for grades II and III. Follow up at 5 days with ortho/podiatry. [1]
    • Posterior mold splint and ortho consult/referral

Disposition

  • Discharge

See Also

References

  1. ↑ Douglas Richie, A Guide To Conservative Care For Ankle Sprains. Podiatry Today Volume 29 - Issue 7 - July 2016
Retrieved from "https://www.wikem.org/w/index.php?title=Ankle_sprain&oldid=375925"