Ankle Sprain - Foot & Ankle (2024)

• ankle sprains are the most common reason for missed athletic participation

• most common injury in dancers

• patient-related

  • limited dorsiflexion, decreased proprioception, balance deficiency

• environmental-related

  • indoor-court sports have the highest risk (basketball, volleyball)

• Mechanism of injury

  • Inversion type ankle injury on a plantarflexed foot

  • Recurrent ankle sprains can lead to functional instability

• high ankle sprain

  • syndesmosis injury

  • 1-10% of all ankle sprains

• low ankle sprain(this topic)

  • ATFL and CFL injury

  • >90% of all ankle sprains

Associated conditions

• osteochondral defects

• peroneal tendon injuries

  See Also

  Overcoming Inversion of Foot: Insights into Ankle Inversion and Sprain Recovery Strategies | Modern Foot & AnkleAnkle Strengthening Exercises to Help You Recover From an Ankle InjuryRecovering from an ankle sprain - Harvard HealthAnkle injuries and sprains

• subtle cavovarus foot

• intraarticular pathology

  • anterior/anterolateral synovitis (most common)

  • osteochondral defects of the talus

  • anterior ankle impingement

• deltoid ligament injury (isolated deltoid ligament injuries are very rare)

  • superficial deltoid: limits talar abduction

  • deep deltoid: limits external rotation

    • initally treated conservatively, but may require reconstruction if patient continues to have instability

• complex regional pain syndrome

• fractures

  • 5th metatarsal base

  • anterior process of calcaneus

  • lateral or posterior process of the talus

Ligamentous anatomy of the ankle

• most commonly involved ligament in low ankle sprains

• mechanism is plantar flexion and inversion

• physical exam shows drawer laxity in plantar flexion

• 2nd most common ligament injury in lateral ankle sprains

• mechanism is dorsiflexion and inversion

• physical exam shows drawer laxity in dorsiflexion

• subtalar instability can be difficult to differentiate from posterior ankle instability because the CFL contributes to both

• less commonly involved

• pain with weight bearing (may or may not be able to bear weight)

• swelling and ecchymosis

• recurrent instability

• catching or popping sensation may occur following recurrent sprains

• focal tenderness and swelling over-involved ligament(s)

• anterior drawer test

  • looks for excessive anterior displacement of talus relative to tibia

  • limited usefulness in acute setting

  • ATFL best tested in plantarflexion, CFL in dorsiflexion

• Talar tilt test

  • excessive ankle inversion (> 15 degrees) compared to contralateral side indicated injury to ATFL and CFL

• indications for radiographs with an ankle injury include (Ottawa ankle rules)

  • inability to bear weight

  • medial or lateral malleolus point tenderness

  • 5MT base tenderness

  • navicular tenderness

  • 96-99% sensitive in ruling out ankle fracture

• radiographic views to obtain

  • standard ankle series (weight bearing)

    • AP

    • lateral

      • ATFL injury suggested with anterior talar translation

    • mortise

  • ER rotation stress view

    • useful to diagnosis syndesmosis injury in high ankle sprain

    • look for asymmetric mortise widening

    • medial clear space widening > 4mm

    • tibiofibular clear space widening of 6 mm

  • varus stress (talar tilt) view

    • used to diagnose injury to CFL

    • measures ankle instability by looking at talar tilt

    See Also

    Ankle Sprains - Ankle Sprains - MSD Manual Professional Edition

• indications

  • consider MRI if pain persists for 6-8 weeks following sprain

• useful to evaluate

  • peroneal tendon pathology

  • osteochondral injury

  • syndesmotic injury

• RICE, elastic wrap to minimize swelling, followed by therapy

  • indications

    • Grade I, II, and III injuries

  • technique

    • initial immobilization

      • may require short period (approx. 1 week) of weight-bearing immobilization in a walking boot, aircast or walking cast, but early mobilization facilitates a better recovery

      • grade III sprains may benefit from 10 days of casting and nonweightbearing

    • therapy

      • early phase

        • early functional rehabilitation begins with motion exercises and progresses to strengthening, proprioception, and activity-specific exercises

      • strengthening phase

        • once swelling and pain have subsided and patient has full range of motion begin neuromuscular training with a focus on peroneal muscles strength and proprioception training

        • a functional brace that controls inversion and eversion is typically used during the strengthening period and used as prophylactic treatment during high-risk activities thereafter

  • outcomes

    • early functional rehabilitation allows for the quickest return to physical activity

    • supervised physical therapy has shown a benefit in early follow-up but no difference in the long term

• anatomic reconstruction vs. tendon transfer with tenodesis

  • indications

    • Grade I-III that continue to have pain and instability despite extensive nonoperative management

    • Grade I-III with a bony avulsion

  • technique (see below)

• arthroscopy

  • indications

    • recurrent ankle sprains and chronic pain caused by impingement lesions

      • anteriorinferior tibiofibular ligament impingement

      • posteromedial impingement lesion of ankle

      • often used prior to reconstruction to evaluate for intra-articular pathology

  • procedure

    • debride impinging tissue

Gould modification of Brostrom anatomic reconstruction

• procedure

  • an anatomic shortening and reinsertion of the ATFL and CFL

  • reinforced with inferior extensor retinaculum and distal fibular periosteum (Gould modification)

• results

  • good to excellent results in 90%

  • consider arthroscopic evaluation prior to reconstruction for intra-articular evaluation

• procedure

  • a nonanatomic reconstruction using a tendon transfer

• technique

  • any malalignment must be corrected to achieve success during a lateral ligament reconstruction

  • Coleman block testing used to distinguish between fixed and flexible hindfoot varus

• results

  • subtalar stiffness is a common complication

• Improved functional scores with early mobilization

• Increased ankle laxity with early mobilization

• Increased wound healing complications with early mobilization

• depends on, grade of sprain, syndesmosis injury, associated injuries, and compliance with rehab

• Return to play
  Grade I	1-2 weeks
  Grade II	1-2 weeks
  Grade III	3-4 weeks
  High ankle (immobilization)	5-6 weeks
  High ankle (screw fixation)	Season

• prevention techniques in athletes with prior sprains includes

  • semirigid orthosis

    • patients who demonstrate cavovarus alignment benefit from a brace with lateral hindfoot/forefoot wedging and first metatarsal recess

  • evertor muscle (peroneals) strengthening

  • proprioception exercises

  • season long prevention program

• Incidence

  • up to 30% continue to experience symptoms following and acute ankle sprain

• Risk factors

  • most common cause of chronic pain is a missed injury, including

    • missed fractures (anterior process of calcaneus, lateral or posterior process of the talus, 5th metatarsal)

    • osteochondral lesion

    • injuries to the peroneal tendons

    • injury to the syndesmosis

    • tarsal coalition

    • impingement syndromes

    • hindfoot varus

Stretch neurapraxia

• Neuropathic pain in the distribution of the affected nerve

• pain decreases rapidly during the first 2 weeks after injury

• 5-33% reports some pain at 1 year

• increased risk of a sprain to ipsilateral and contralateral ankle