Lateral Ankle Sprains
Normal Anatomy
· Lateral ankle ligament complex consists of
o Anterior talofibular ligament (ATFL)
o Calcaneofibular ligament (CFL)
o Posterior talofibular ligament (PTFL)
· ATFL blends with the ankle capsule, from anteroinferior margin of fibula to lateral margin of talus
· CFL is from the inferior margin of the fibular, distal to the ATFL and runs underneath the peroneal tendons to the lateral tubercle of the calcaneus
· PTFL is a thickening of the capsule from the posterior fibula to the lateral tubercle of the posterior process of the talus
· ATFL stress in plantarflexion
Pathology
· An episode of acute inversion/supination injury of the ankle associated with swelling, lateral ankle pain and difficulty weight bearing
Mechanism of Injury
Traumatic
· Foot and ankle inversion of a plantar-flexed or internally rotated foot
· External rotation of the lower leg with respect of the ankle
Risk Factors
Intrinsic
· Reduced invertors and evertors strength
· Reduced proprioception
· Reduced balance
· Reduced dorsiflexion range of movement
· Lower limb mal alignment
Extrinsic
· Previous lateral ligament sprain
· Twisting, pivoting sports
· Contact sport
· Playing on artificial grass
Classification
Grade 1
· Mild
· Painful
· Minimal ligament tearing
Grade 2
· Moderate
· Painful
· Significant ligament tearing
Grade 3
· Severe
· Sometimes not painful
· Complete ligament rupture
Examination
Subjective
· History of:
o Foot and ankle inversion of a plantar-flexed foot
o External rotation of the lower leg with respect of the ankle
· Swelling (immediate suggests rupture more likely)
· Maybe unable to continue to play
Objective
· Haematoma
· Pain on palpation lateral ligaments
· Abnormal anterior drawer test
· Pain on palpation of the medial malleolus is not unlikely
· Delayed physical exam (4-5 days) gives better diagnosis
· Reduced proprioception
Ottawa Ankle Rules
· Helps identify those that require an X-ray following lateral ankle sprains
· Sensitivity of 97.6%
A. Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus
B. Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus
C. Bony tenderness at the base of the 5th metatarsal
D. Bony tenderness at the navicular
E. Inability to weight bear both immediately after injury and for 4 steps during initial evaluation
· Ankle X–ray = Pain around the malleolus + A OR B OR E
· Foot X-ray =Pain around the midfoot + C OR D OR E
Special Tests
· Anterior drawer test
Further Investigations
· X-ray (rule out fracture)
· Ultrasound
· MRI
Management
· Conservative management always explored
· Reduce swelling initially although swelling may never go completely
· Emphasis on prevention of future injury
· Emphasis on proprioception and dynamic stability
Conservative
· Reduce pain and inflammation
o Immobilisation
o NSAID’s
o Ice
o Massage
· Restore Normal Range of Movement
o Ankle
§ Massage
§ Joint mobilisation
§ Joint manipulation
· Restore Normal Muscle Activation
o Evertors
o Invertors
o Plantarflexors
o Dorsiflexors
o Intrinsic Foot Muscles
· Restore Dynamic Stability
o Proprioceptive Training
· Sport Specific Training
Plan B
· Soft tissue repair
· Ligament Reconstruction
Chronic Ankle Instability
Normal Anatomy
· Lateral ankle ligament complex consists of
o Anterior talofibular ligament (ATFL)
o Calcaneofibular ligament (CFL)
o Posterior talofibular ligament (PTFL)
· ATFL blends with the ankle capsule, from anteroinferior margin of fibula to lateral margin of talus
· CFL is from the inferior margin of the fibular, distal to the ATFL and runs underneath the peroneal tendons to the lateral tubercle of the calcaneus
· PTFL is a thickening of the capsule from the posterior fibula to the lateral tubercle of the posterior process of the talus
· ATFL stress in plantarflexion
Pathology
· The perception by the patient of an abnormal ankle with a combination of symptoms including recurrent sprains, pain and swelling or avoidance of activities
Mechanism of Injury
Insidious
Intrinsic
· Reduced invertor and evertor strength
· Reduced proprioception
· Reduced balance
· Ligament laxity
· Lower limb mal alignment
Extrinsic
· Previous or repeated lateral ligament sprain
Classification
Functional Ankle Instability
· Instability due to proprioceptive deficits, neuromuscular deficits, postural control deficits and muscle weakness
Mechanical Ankle Instability
· Instability due to ligament laxity
Examination
Subjective
· History of multiple sprains
· Feeling of unstable ankle
· Regular giving way
Objective
· Reduced proprioception
· Weakness ankle evertors
· Tenderness palpation lateral ligaments
· Instability on anterior drawer test
Special Tests
· Anterior drawer test
Further Investigations
· X-ray (rule out fracture)
· Ultrasound
· MRI
Management
· Conservative management useful but not always successful
· Large emphasis on restoring neuromuscular control and strength
· Manual therapy can be used if acute sprain is present but general manual therapy is not useful
Conservative
· Restore Normal Muscle Activation
o Evertors
o Invertors
o Plantarflexors
o Dorsiflexors
o Intrinsic Foot Muscles
· Restore Strength
o Entire kinetic chain
· Restore Dynamic Stability
o Proprioceptive Training
· Sport Specific Training
Plan B
· Soft tissue repair
· Ligament Reconstruction
References
(Kerkhoffs, van den Bekerom et al. 2012, Guillo, Bauer et al. 2013, van den Bekerom, Kerkhoffs et al. 2013, Knupp, Lang et al. 2015, McGovern and Martin 2016)
Guillo, S., T. Bauer, J. W. Lee, M. Takao, S. W. Kong, J. W. Stone, P. G. Mangone, A. Molloy, A. Perera, C. J. Pearce, F. Michels, Y. Tourne, A. Ghorbani and J. Calder (2013). "Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy." Orthop Traumatol Surg Res 99(8 Suppl): S411-419.
Kerkhoffs, G. M., M. van den Bekerom, L. A. Elders, P. A. van Beek, W. A. Hullegie, G. M. Bloemers, E. M. de Heus, M. C. Loogman, K. C. Rosenbrand, T. Kuipers, J. W. Hoogstraten, R. Dekker, H. J. Ten Duis, C. N. van Dijk, M. W. van Tulder, P. J. van der Wees and R. A. de Bie (2012). "Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline." Br J Sports Med 46(12): 854-860.
Knupp, M., T. H. Lang, L. Zwicky, P. Lötscher and B. Hintermann (2015). "Chronic Ankle Instability (Medial and Lateral)." Clinics in Sports Medicine 34(4): 679-688.
McGovern, R. P. and R. L. Martin (2016). "Managing ankle ligament sprains and tears: current opinion." Open Access J Sports Med 7: 33-42.
van den Bekerom, M. P., G. M. Kerkhoffs, G. A. McCollum, J. D. Calder and C. N. van Dijk (2013). "Management of acute lateral ankle ligament injury in the athlete." Knee Surg Sports Traumatol Arthrosc 21(6): 1390-1395.
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