Ankle Sprains and Treatment

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Ankle Sprains and Treatment

• Baylor College of Medicine
• Anoop Agrawal, M.D.

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Quick Review

• Name the ligaments on the lateral aspect of the
  ankle.
• ant talofibular (ATFL), calcaneofibular (CFL),
  and post talofibular (PTFL)

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Quick Review

• Name the ligaments on the medial aspect of the
  ankle.
• deltoid ligament

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Quick Review

• What is the most common mechanism of injury that
  results in an ankle sprain?
• inversion with plantarflexion
• What is the name of the guidelines designed to
  assess need for radiographs?
• Ottawa ankle rules

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Ankle Sprains

• Classification based on location and grade
• Location
• Lateral
• Medial
• Syndesmostic (high ankle sprain)

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Lateral Ankle Sprain

• Most common type
• Which ligament is always involved in this type of
  sprain?
• ant talofibular ligament (ATFL)
• Stronger forces of injury may also involve the
  CFL. The CFL rarely is injured in isolation.

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Medial Ankle Sprain

• Uncommon injury due to the strength of the
  deltoid ligament
• Forced eversion can damage the deltoid, but more
  commonly results in an avulsion fracture of the
  medial malleolus because of the deltoids
  strength.

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Syndesmotic Sprain(High Ankle Sprain)

• One more ligament to KNOW...actually two more
• ant and post tibiofibular ligaments (syndesmosis
  ligaments)
• Occurs with dorsiflexsion and/or eversion, often
  times with concomitant lateral force to the knee
• What exam maneuver is performed to assess for
  this sprain?

Squeeze Test
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Syndesmotic Sprain

• Anterior tibiofibular ligament
• Posterior tibiofibular not pictured
• Positive Squeeze test on exam

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May see widened space between fibula and tibia.
Normally, less than 5 mm wide.
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Ankle Sprains Grade

• Three Classifications of Grades
• Grade I partial tear of ligament, no functional
  impairment, not frequently seen in the office
• Grade II incomplete tear of ligament with mild
  to moderate functional impairment, pain with
  weight bearing
• Grade III complete tear and loss of integrity of
  ligament, usually unable to bear weight
• Time for healing is not always proportional to
  grade.

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Treatment

• RICE - rest, ice, compression, elevation
• NSAIDS
• Functional Rehabilitation vs. Immobilization - In
  grade I and II, all studies have found rehab to
  be superior to immobilization in every aspect.
• For grade III - controversial, but a few studies
  support early functional rehab
• Splints and braces - semi-rigid device allowing
  for plantar and dorsiflexion with
  stabilization/prevention of inversion/eversion

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Rehab Program

• Functional Rehab begins on the day of the injury.
• There are four progressive phases
• Range of Motion - start immediately
• Achilles Tendon stretch
• Write upper case alphabet with great toe
• Perform each three to five times a day

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Rehab Program

• Muscle Strengthening - phase two, begin as
  swelling and pain are controlled.
• Isometric (using walls) and isotonic (using
  resistance bands/towels) exercises -
  dorsiflexion, plantarflexion, inversion, eversion
• Toe curls - two sets of 10, twice a day
• Toe raises - two sets of 10, twice a day
• Emphasis on strengthening peroneal and anterior
  tibialis muscles (dorsiflexion, eversion)

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Achilles Tendon stretch
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Rehab Program

• Proprioceptive training
• Activity-specific training
• Walk-jog
• Jog-run

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Orthopedics Referral

• Reasons for referral
• Fracture
• Dislocation or subluxation
• Syndesmosis injury
• Tendon rupture
• Wound penetrating into the joint
• Uncertain diagnosis
• Neurovascular compromise requires emergent care

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References

• Chorley, J, Powers, C. Clinical Features and
  Management of Ankle Pain in the Young Athlete.
  Up To Date, 2006
• Maughan, KL. Ankle Sprain. Up To Date, 2006.
• Pfeffer, GB. Foot and Ankle. Essentials of
  Musculoskeletal Care, Greene, WB (2nd Ed).
  American Academy of Orthopaedic Surgeons,
  Rosemont, IL, 2001.
• Wolfe, MW, et al. Management of Ankle Sprains.
  American Family Physician 631 Jan 1, 2001.

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Questions?