Stephanie M Chu, DO
Assistant Professor
University of Colorado SOM
Team Physician Colorado Buff aloes
Evaluation of Ankle Injuries in Primary Care
Anatomy of the Ankle Articular congruity
Between talus and tibia, talus and calcaneus Ligamentous stability
Tib-fib ligament (Syndesmotic ligament)Lateral ligament complexDeltoid ligamentSubtalar ligaments
Lateral Ligamentous Complex
ATFL Arises from anterior
border of tip of fibula and inserts on the neck of talus
Parallel to axis of foot in neutral position
Parallel to axis of tibia in plantarflexion
DeLee & Drez
Posterior Lateral Ligamentous Complex PTFL
Arises from posterior tip of fibula and inserts on posterior process of talus
ATFL & PTFL Resist AP motion of
the talus relative to the fibula
DeLee & Drez
Posterior Lateral Ligamentous Complex CFL
Arises from tip of fibula and inserts on lateral calcaneus
Forms the floor of the peroneal tendon sheath
Resists inversion
DeLee & Drez
Functional Anatomy Normal ROM
highly variable DF ranges from
10-50 degrees PF ranges from
15-60 degrees Functional ROM
from 10 deg DF to 50 deg PF
Functional Anatomy Subtalar motion
Supination – combination of inversion, adduction, internal rotation
Pronation – combination of eversion, abduction, external rotation
Functional Anatomy Lateral ligamentous
complex Anterior talofibular
ligament (ATFL) Calcaneofibular
ligament (CFL) Posterior talofibular
ligament (PTFL) Ligaments
continuous with capsular connective tissue
History Description of
injuryPosition of footDirection of force
Previous h/o ankle sprainResolution of
symptomsChronic laxity or
instability Use of tape/braces
Previous treatment Ability to bear
weight Symptoms
Onset of pain Location Duration of pain Feeling of “giving
way”
FactsMost common injury in sports – 25%Estimated 1 inversion injury/10,000
persons/dayMost frequent in basketball, volleyball,
soccer, footballMajority < 35yrsMost often between ages 15-19Certain populations (US military service
personnel) as high as 35%
Definition “Ankle injury that
occurs when a person stumbles and the supporting foot twists, resulting in
damage to the ligaments.”
Most common – “inversion sprain”Combination of inversion and adduction of foot
in plantar flexionDamage to lateral ligament complex of ankle
Eversion sprainsDamage to deltoid ligament
‘High’ ankle sprainDamage to ankle syndesmosis and tibiofibular
ligaments
Mechanism of Injury
Classification of InjuriesGrade I (mild)
Mild ligament stretching
No macroscopic tearing
StableMin tenderness or
swellingMin functional loss
Classification of InjuriesGrade II (moderate)
Partial macroscopic tearing
Moderate tenderness or swelling
Mild to moderate instability
Classification of InjuriesGrade III (severe)
Complete rupture of ligaments
Marked pain, swelling, ecchymosis
Abnormal joint motion (instability)
Decreased functionSoft or no “end
point”
Clinically, grading can be subjective, especially in acute
setting without radiologic modalities (diagnostic
ultrasound or MRI) to confirm.
Clinical EvaluationPhysical Examination
ObservationLocation of ecchymosis, swelling
PalpationPoint of maximal tendernessMedial pain – may be indicative of concussive
injury to deltoid ligamentTenderness over fibula or talus may indicate
fractureAssociated injuries to midfoot, 5th metatarsal, prox
fibula
Clinical EvaluationPhysical Examination (compare to uninjured
ankle)ROMStability testing
Anterior drawer (ATFL)Talar tilt (CFL, ATFL)Syndesmosis
External rotation testSqueeze test
Radiographic EvaluationPlain radiographs
Standard AP/lat/mortise viewsStress radiographs
Ant drawer & talar tilt thought to be inadequate predictors of functional stability
Can be useful for syndesmotic injuriesArthrography
Rarely used
When do we get
radiographs???
Ankle = Pain around the malleoli and ONE of the following:Inability to bear weight immediately following
injury AND in ED (four steps)Bone tenderness 6 centimeters up posterior
edge of the tibia and fibula
Palpation – Ottawa Ankle Rules
Radiographic EvaluationBone scan
May have a role in syndesmotic injuriesCT scan
Useful for evaluation of OCD lesions, loose bodies, syndesmotic widening
MRI Useful for determining soft tissue injury, OCD,
associated tendon injures
TreatmentAcute ankle sprains
Grade I and IIFunctional rehab
Includes brief period of immobilization (taping, functional braces statistically better than immobilization)
Lace-up supports more effective than tape
Early ROM, followed by strengthening and proprioceptive exercises
Seah, Richard, and Sivanadian Mani-Babu. "Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence." British medical bulletin 97.1 (2011): 105-135.
TreatmentGrade III
Somewhat controversialEvidence suggest semi-rigid orthoses
and pneumatic bracing provide beneficial ankle support to prevent recurrent sprains
Numerous studies have shown that functional rehab results similar to surgical outcomes
TreatmentChronic ankle sprains
Functional rehabilitationRole in recovery May attempt for as long as 6 monthsStudies have shown that delayed
functional rehab can still be successful
Risk FactorsPrevious history of
ankle sprainLigament hyperlaxityPoor sensorimotor
controlAxial/foot alignmentPlantar/dorsiflexion
strengthInversion/Eversion
strengthGender/sport
No significant difference
PreventionTaping
Shown to be effective for initial stabilizationAids in proprioception
BracesShown to be effective in athletes with h/o
previous sprainsProphylactic proprioceptive training
More effective in athletes with h/o previous sprains
Top Related