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Ankle Sprain

Epidemiology of Ankle Sprain

  • 1/10,000 persons/day
  • 23,000 ankle sprains in the U.S. each day
  • 40-45% of sports injuries are ankle injuries. 85% of ankle injuries are sprains. 85% of sprains are due to inversion with injury to the lateral ligaments.
  • Basketball players account for 50% of ankle sprain

Anatomy

  • Ankle stability is an interplay between osseous constraints and ligamentous support
  • Osseous constraints: shape of the talus and its tight fit between the tibia and the fibula.
  • Ligamentous constraints: tibiofibular ligaments, deltoid ligament complex, and lateral ligament complex.

Lateral Ligaments

  • ATFL (anterior talofibular ligament)
  • CFL (calcaneofibular ligament)
  • PTFL (posterior talofibular ligament)


ATFL

  • Origin: fibula Insertion: talus
  • Runs parallel to the foot in ankle dorsiflexion
  • Runs palallel to the leg in ankle plantarflexion
  • Most commonly injured ligament in inversion ankle sprain since most sprains occur when the foot is in plantar flexion.

CFL (calcaneofibular ligament)

  • Origin: fibula Insertion: calcaneous
  • Runs almost parallel to tibia when the foot is in dorsi flexion
  • Forms the floor of the peroneal tendon sheet. Clinically relevant in diagnosing CFL rupture on ankle arthrography and peroneal tenography.

PTFL (posterior talofibular lig.)

  • Origin: fibula Insertion: posterior talus
  • Strongest ligament of the three lateral ligaments.
  • Rarely injured
  • PTFL tear occurs only in combination with ATFL or CFL tear

Deltoid Ligament

  • Triangular fan shaped attaching the medial malleolus to the navicular, the calcaneous, and the talus.
  • Injury occurs with foot pronation, external rotation, and abduction.
  • Only 3% of ankle sprains involve the deltoid ligament.
  • Complete tear is almost always associated with ankle fractures.

Tibiofibular syndesmosis

  • Consists of:
    • AITF (anterior inferior tibiofibular lig.)
    • PITF (posterior inferior tibiofibualr lig.)
    • Interosseous membrane
  • Function:
    • Prevent lateral displacement of the fibula resulting in a widened mortis.
    • Control external rotation and posterior displacement of the fibula with respect to the tibia


Classification of Injuries

Functional loss Instability
Grade I Minimum None
Grade II Moderate Moderate
Grade III Maximum Marked

Stability exam

  • Anterior Drawer test:
    • Test for the ATFL
    • Brostrom and Linstrand: negative drawer test under anesthesia excludes ATFL rupture
    • Halmilton: best predictor of instability and dysfunction.
  • Talar Tilt test:
    • Test for the CFL

Treatment

  • Early immobilization with active rehab
  • Long term disability for early immobization is no different than cast immobiliztion
  • Results of primary repair is contradictory.
  • Late repair yields excellent results.
  • Degree of instability does not change the management of ankle sprain or long term disability
  • For additional information on treating injured ankles. Visit theathlete.org.

Chronic Ankle Pain

  • Patient Profile
    • Previous injury of weeks to months
    • Activity limiting pain described as "soreness"
    • Generalized "weakness" with locking, giving way, and swelling
    • Frustrated and often hostile

Differential Diagnosis

  • Incomplete rehabiliation/Reflex Sympathetic Dystrophy (RSD)
  • Previously undetected trauma or anatomic disruption
  • Inflammatory disorder
  • Congenital abnormality
  • Unrecognized neoplasm

Differential Diagnosis

  • Persistently weak and/or easily fatigable muscles about the ankle joint
  • Capsulitis results in a restricted ROM
  • Pinching or inflamed tissue between the talus and fibula that results in a meniscoid tissue development in the ankle
  • Post traumatic arthritis

Shrier vs. Grana

  • Improper rehab may result in instability which can cause pain.
  • Post traumatic inflammation and resulting impingement. Both believe in postraumatic arthritis in ankle sprain.

Improper Rehab

  • Premature return activity may delay healing and perpetuate residual inflammation. Advocates "hop stress test" as indication to return to activity.
  • Inadequate rehab (stretching and strengthening) can provoke an abnormal sympathetic response
  • Weak muscles that are worked beyond point of fatigue can place excessive stress on ligaments which can create pain.
  • Improper Rehab theory --> urrrrgh!!
  • Jacobson: "inadequate immobilization and rehab lead to chronic inflammation resulting in scar tissue…then becomes trapped between the talus and lateral malleolus causing irriation and synovitis…end result is chronic ankle pain"
  • Not aware of any study that shows increase morbidity with repeated sprains or early return to activities.

Previously Undetected Trauma

  • Lateral talus, anterior calcaneous process, lateral cuboid, fifth metatarsal fractures.
  • Peroneal tendon dislocation and subluxation
  • Syndesmotic ligament injuries
  • Osteochondriitis dissecans

Inflammatory Disorders

  • Anterior tibia and talar neck osteophytes
  • Posterior synovial inflammation with impingement of hypertrophied synovium or pathologic labrum.
  • Anterolateral synovitis or impingement from adhesion in the talomalleolar joint, ie, "meniscoid" like lesion

Congenital Abnormalities

  • Tarsal Coalition
  • Accessory navicular

Tumor

  • Simple cysts
  • Osteoid osteomas

My Differential Diagnosis

  • Instability
  • Missed Fractures
  • Syndesmosis Diastasis and Synostosis
  • Osteochondritis Dissicans
  • Anterior and Posterior Tibiotalar Impingement
  • Sinus Tarsi Syndrome

Instability

  • Isolated medial instability does not exist
  • Must rule out peroneal weakness
  • Patients complain of recurrent ankle sprain, pain, swelling, giving way, and inability to attain pre-injury activity.
  • Diagnosed mainly by history, physcial exam, and exclusion of other causes

Instability

  • Mechanical instability
    • 120 patients with complaints of instability
    • Anterior talar translation of 10mm or more
    • Talar tilt of 9 degrees
    • Side to side difference of 3 mm and 3 degrees
  • Other authors have found no correlation between mechanical and functional instability

Mechanical Instability

  • Anatomic repair:
    • Brostrom: 90% good short and long term
  • Non-anatomic reconstruction:
    • Evans: 50% good long term result
    • Watson-Jones: 30-80% good long term result
    • Chrisman&Snook: 90% good long term result

Arthritis

  • Long standing lateral ligament instability may possibly cause degenerative arthritis
  • Of 36 patients with 10 year history of instability, 26 had degenerative changes on X Ray, 24 had chronic synovial thickening.
  • 12 arthoscopies showed extensive degenerative changes.

Functional Instability

  • Feeling of giving way without laxity on exam
  • Freeman 1965: motor incoodination due to capsular deafferentation, lack of proprioception that is treatable with coordination exercises and ankle tilt board.
  • Treatment: peroneal strengthening, taping, bracing, and proprioceptive training.

Missed fractures

  • Proximal fibula
  • Lateral or posterior process of the talus
  • Anterior process of the calcaneus (calcaneal attachment of the ligaments)
  • Fifth metatarsal (insertion of peroneus brevis)
  • Navicular and mid metatarsals
  • Epiphyseal separation in children

Syndesmotic Injury (DTFS)

  • 18% of ankle injuries in football players have DTFS sprain
  • DTFS is stabilized by four ligaments
  • Mechanism of injury is forced external rotation of the foot with simultaneous internal rotation of the leg.
  • Diagnosed by history and physical exam: point tenderness, squeeze test, Cotton test
  • Rule out fractures since isolated syndesmotic rupture is rare.

Syndesmotic Injury

  • Stiehl 1990: diagnostic criteria
  • Treatment:
    • Partial isolated sysdesmosis tears without fractures or tibiofibular/joint space widening should be treated consevatively
    • Complete tear requires surgery, suture repair of the ligaments and fixation of tibia and fibula with screw or wire.
  • Inadequate treatment of syndesmotic injury will result in instability, pain, and arthritis

Tibiofibular synostosis

  • Partial of complete ossification of the syndesmosis as the result of hematoma formation.
  • Pain during push off phase of running 3-12 months after ankle sprain.
  • Limited dorsiflexion on exam
  • Surgical excision recommended for symptomatic high level athletes

Osteochondritis Dissicans

"They wanted to interview me before signing me to endorse the product…I told them I had never eaten Wheaties and didn't know I'd even like Wheaties…eat some kind of wheat puffs when I was growing up."

Anterior impingement

  • Morris and McMurray described osseous exostoses of the anterior rim of the tibia and the sulcus of the talus.
  • Thought to be secondary to traction injury of the joint capsule occuring when the foot was in extreme plantar flexion
  • Others thought it was due to repetitive dorsiflexion trauma resulting in ossification.
  • These can be seen on plain X-Ray

Anterior Impingement

  • Ligamentous impingement caused by the distal fascicle of the normal anteroinferior tibiofibular ligament.
  • Seven patients with anterior ankle pain after inversion injuries. None had osseous exostoses.
  • Severe pain in anterior ankle especially in dorsiflexion
  • At surgery, all had thickened distal fascicle.
  • All had excellent to good result with resection at 2-6 year follow up.

Posterior Impingement

  • Chronic posterior ankle pain and swelling after repeated sprains with normal exam and Xray
  • On arthroscopy: soft tissue mass at posteriornedial capsule. Plantarflexion and inversion causes impingement of mass between posterior talus and tibia.
  • Symptom free one year after surgery
  • Reported cases of os trigonum in dancers

Sinus Tarsi Syndrome

  • Pain and tenderness ove the lateral opening of the sinus tarsi.
  • 70% cases involve severe inversion sprain. 
    30% other inflammtory disorders.
  • Pain in lateral side of foot over the opening of the sinus tarsi.
  • Pain is severe when standing, walking on uneven ground, supination--resolves with rest/pronation.
  • Pain is thought to be from low grade inflammatory synovitis from sprain of the interossus ligament within the sinus tarsi.

SST - Treatment

  • Komparda: 2/3 of patients will respond to repeated injections (once/week x 5-6). Also rec'd re-education of the peroneal and calf muscles through strengthening exercises.
  • Kuwada:
    • 22/88 patients responded with injections.
    • 66/88 were cured with sinus tarsectomy.
  • Others are not as successful. Arthrodosis as last resort

Summary

  • Instability
  • Missed Fractures
  • Syndesmosis Diastasis and Synostosis
  • Osteochondritis Dissicans
  • Anterior and Posterior Tibiotalar Impingement
  • Sinus Tarsi Syndrome
  • Congenital/tumor
  • Examine the foot!

 

 


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