Ankle sprain: Difference between revisions
 
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==Background==
==Background==
stress tests-best done several days after injury.
===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


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.
==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


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


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.
===Syndesmotic Sprain ("High-ankle sprain")===
*Associated with with hyperdorsiflexion when talus moves superiorly and separates tibia/fibula
*Pain just above talus


Thompson's tests- prone with knee flexed squeeze gastroc and soleus in midcalf. if no plantarflexion-torn achilles tendon.
==Differential Diagnosis==
{{Other ankle injuries DDX}}


==Classification==
{{Distal leg fractures DDX}}
#Class I
## mild pain,swelling can bear weight, negative stress test-
##Treatment = RICE and f/u in 7 days.
#Class II
##mod pain, swelling, difficulty bearing weight, pos ant drawer (4-14 mm), pos talar tilt (5-15 degrees)
##Treatment: rigid splint, crutches, <7 day f/u.
#Class 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).
{{Foot and toe fractures DDX}}


eversion injuries- deltoid ligament rarely isolated tear-usually avulsion Fx of medial malleolus. syndesmotic sprains more common than deltoid injuries (and more easily missed).
==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


grade 2 and 3 eversion injuries are often placed in a short leg walking cast for 6-8 weeks.
===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


==Causes of Chronic Pain after Healing==
==Management==
#soft tissue problems
*Stable joint and ability to bear weight: (Likely Grade I)
##synovial impingement syndromes
**[[NSAIDs]], RICE (rest, ice, compression, elevation)
##loose bodies in the joint
**1 week follow up if no improvement
##proneal tendon subluxation
*Stable joint but unable to bear weight or unstable joint (Grades II and III) :
#bony problems
**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>
##osteochondral Fx of talar dome
**[[Splinting#Lower Extremity|Posterior mold splint]] and ortho consult/referral
##lateral or posterior fx of talus
##anterior fx of calcaneus


==Syndesmotic Sprain==
==Disposition==
(High Ankle)
*Discharge
 
===Diagnosis===
#Positive squeeze test
#TTP distal tibiofibular joint
 
===Treatment===
#Treat as sprain, f/u ortho/sports
#possible surgical repair if refractory to conservative management


==See Also==
==See Also==
*[[Ankle (Main)]]
*[[Ankle Fracture]]
*[[Ankle Fracture]]
*[[Ankle Fracture (Peds)]]
*[[Ottawa Ankle Rules]]
*[[Maisonneuve]]
 
*[[Ottowa Ankle Rules]]
==References==
*[[Pilon Fx]]
<references/>


[[Category:Ortho]]
[[Category:Orthopedics]]
[[Category:Sports Medicine]]

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
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