Ankle sprain

Introduction

Ligamentous Anatomy of Ankle

Classification

Mechanism of Injury

Signs and Symptoms

Epidemiology

Diagnostic Tools

Differential Diagnosis

Management

Evidence Based Rehabilitation.

Recommendations.

Mr. Nasir is a 35-year-old computer programmer whoplays Basketball at the local recreation center. Hesustained a massive inversion sprain of his right anklewhen landing on foot of an opponent after jumpingto rebound the basketball. He wrapped the ankleand iced it for 2 days. On the 3rd day he went for aradiograph. No fracture was detected, But he doeshave a Grade 2 Instability of the Anterior talofibularligament. Observation revealed swelling anddiscoloration in the anterior and lateral ankle region.He experienced a marked increase in pain witinversion and Planterflexion tests, with anterior glidingof the talus, and with palpation over the involvedligament. Because of muscle guarding strength wasnot tested.

Ankle injuries are among the most

common injuries presenting to primary

care offices and emergency

departments.

Also known as twist ankle, rolled ankle

or ankle ligament injury.

Recurrent ankle sprains can lead to

functional instability and loss of normal

ankle kinematics and proprioception,

which can result in recurrent injury,

chronic instability, and early

degenerative bony changes.

That

has to

hurt!!!

Boruta PM, Bishop JO, Braly WG, Tullos HS. Acute lateral ankle

ligament injuries: a literature review. Foot Ankle 1990; 11:107.

Three ligaments make up the lateral

ankle ligament complex.

Anterior talofibular ligament (ATFL)

Calcaneofibular ligament (CFL)

Posterior talofibular ligament (PTFL)

Usually anterior Talofibular

Ligament (ATFL) is affected

Function of Ligaments

Ankle ligaments provide

mechanical stability,

Proprioceptive information, and

directed motion for the joint.

Attarian DE, McCrackin HJ, DeVito DP, McElhaney JH, Garrett

WE Jr. Biomechanical characteristics of human ankle

ligaments. Foot Ankle. Oct 1985;6(2):54-8

Grade I (First Degree)

The ligament damage has occurred without any significant instability developing.

Grade II (Second Degree)

The ligament has been more significantly damaged, but there is no significant instability.

Grade III (Third Degree)

The ligaments have been torn and instability has resulted.

Moreira V, Antunes F (2008). "[Ankle sprains: from diagnosis to

management. the physiatric view]". Acta Med Port (in

Portuguese) 21 (3): 285–92

Types of Ankle Sprain

Lateral (Inversion) Sprains

Approximately 70-85% of ankle

sprains are inversion injuries.

High (Syndesmotic) Sprain

A high ankle sprain is an injury to

the large ligaments above the

ankle that join together the

bones of the lower leg.

Medial (Eversion) Sprains

This affect the medial side of the

foot and deltoid ligament is

stretched

The foot is placed in forced inversion

and plantar flexion

It can be from an unstable/irregular surface

Also caused by forced trauma

Swelling*

Pain*

Discoloration*

Redness

Warmth

Inability to walk

Ankle Instability

*The most common symptoms

Sprained ankle. American Academy of Orthopaedic Surgeons.

http://www.orthoinfo.org/topic.cfm?topic=a00150. Accessed June 9,

2014

Sprained ankles have been estimated toconstitute up to 30% of injuries seen insports medicine clinics. More than 23,000people per day in the United States,including athletes and non-athletes,require medical care for ankle sprains.Stated another way, incident cases havebeen estimated at 1 case per 10,000persons per day.

Mahaffey D, Hilts M, Fields KB. Ankle and foot injuries in sports. Clin

Fam Pract; 1999:1(1):233-50

The Ottawa ankle

rules are a set of guidelines for

clinicians to help

decide if a patient

with foot or ankle pain

should be offered X-rays to diagnose a

possible bone

fracture.

Sensitivity: 98.5%

Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle

rules to exclude fractures of the ankle and mid-foot: systematic

review. BMJ 2003; 326:417.

The rules are as follows :

An ankle series (Ankle Radiograph) is only indicated for

patients who have pain in the malleolar zone AND

i. Have bone tenderness at the posterior edge or tip of

the lateral or medial malleolus OR

ii. Are unable to bear weight both immediately after

the injury and for four steps in the emergency

department or doctor's office.

A foot series (Foot Radiograph) is only indicated for

patients who have pain in the midfoot zone AND

i. Have bone tenderness at the base of the fifth

metatarsal or at the navicular OR

ii. Are unable to bear weight both immediately after

the injury and for four steps in the emergency

department or doctor's office.

Anterior Draw Test

Purpose:

To test for ligamentous laxity or instability in the ankle. This test primarily assesses the strength of the Anterior Talofibular Ligament.

Diagnostic Accuracy:

Sensitivity: .71 Specificity: .33

Docherty, Carrie. "Reliability of the Anterior Drawer and Anterior

Tilt Tests using the Ligmaster Joint Arthometer." 2009

External Rotation Test

Purpose:

To help identify a tibiofibular Syndesmotic injury (high ankle sprain). The term "high ankle sprain" refers to an isolated injury to the tibiofibularsyndesmosis


Sensitivity: 20

Specificity: 84.5

Cesar, Paulo. "Comparison of Magnetic Resonance Imaging

to Physical Examination for Syndesmotic Injury After Lateral

Ankle Sprain ." American Orthopaedic Foot and Ankle

Society. 32.2 (2011): n. page. Web. 23 Sep. 2012

Talar Tilt test

Purpose:

The talar tilt test detects excessive ankle inversion. If the ligamentous tear extends posteriorly into the calcaneofibularportion of the lateral ligament, the lateral ankle is unstable and talar tilt occurs.


Sensitivity: 67

Specificity: 75

Extracted from Orthopedic Physical Examination Tests:

An Evidence-Based Approach: "Medial Talar Tilt Stress Test": Hertel

et al. Sensitivity 67, Specificity 75, LR+ 2.7, LR- 0.44

Lateral malleolus fracture

Osteochondral injury to talus

Posterior-lateral talar process fracture

Anterior process of calcaneus (beak) fracture

Achilles tendon injury

Fifth metatarsal fracture (styloid process or base)

Subtalar joint injury

Calcaneo-fibular Ligament sprain

Posterior talo-fibular ligament sprain

Calcaneo-cuboid ligament sprain

Young CC et al, Ankle sprain, Medscape, Sep 2011

surgical

Conservative

Max. protection

phase

Mod. Protection

phase

Min. protection

phase

Return to activity

1-3 Days 4-10 Days 11-21 Days 3-8 weeks

• PRICE formula• Protection with a

splint• Icing every

2hours during 1st

48hours• Elevation to

reduce swelling• Gentle

mobilization to inhibit pain

• Partial WB with crutches

• Muscle-setting Techniques

• Non weight bearing AROM

• Cross-fiber massage

• Grade 2 joint mobilization

• Toa curls• Seated calf

stretches• Endurance

training• strengthening

exercises of

intrinsic foot muscles

• Weight bearing as tolerated

• Initiate Eccentric ex.

• Toe walks• Subtalar

mobilization• Tape or Brace for

sports or other strenuous activities

• Proprioception/ balance board ex

• ↑ Weight bearing as tolerated

• Agility drills.• Adv. Exercises

Static→dynamic• Isokinetic resistance

training• Specific sport training• Protective bracing for

participation into a sports

Caroline, Kysner, and Colby Lyn Allen. "Therapeutic Exercise Foundation and

Techniques." FA. Davis, Philadelphia (1988).

Surgical repair of ruptured ankle ligaments is sometimes considered in patients with ankle sprains.

It is Usually indicated for Grade III ankle sprain

A meta-analysis that looked at controlled trials of surgery for acute ruptures of lateral ankle ligaments found that compared with functional treatment, patients treated with surgery were significantly less likely to experience giving-way of the ankle (relative risk 0.23, 95% CI 0.17-0.31).

Pijnenburg AC, Van Dijk CN, Bossuyt PM, Marti RK. Treatment of

ruptures of the lateral ankle ligaments: a meta-analysis. J Bone

Joint Surg Am 2000; 82:761

Reference Study Design Study method Results

Bleakley, C. M.

McDonough, S.

M. et al. Aug

2006. Cryotherapy for

acute ankle sprains:

a randomised

controlled study of

two different icing

protocols

Randomized

controlled trial

Group 1

n = 46 standard

ice application

Group 2

n = 43 intermittent

ice application.

Function, pain,

and swelling were

recorded at

baseline and

one, two, three,

four, and six

weeks after injury.

It was Assessed

from the study

that Intermittent

applications may

enhance the

therapeutic effect

of ice in pain

relief after acute

soft tissue injury


Michel P.J. van den

Bekerom, et al,

July/Aug. 2012,

What Is the

Evidence for Rest,

Ice, Compression,

and Elevation

Therapy in the

Treatment of Ankle

Sprains in Adults?

Randomized

controlled trial

After deduction of

the overlaps among

the different

databases,

evaluation of the

abstracts, and

contact with some

authors, 24

potentially eligible

trials remained. The

full texts of these

articles were

retrieved and

thoroughly assessed

as described. This

resulted in the

inclusion of 11 trials

involving 868

patients.

It was concluded

that Insufficient

evidence is

available from

randomized

controlled trials to

determine the

relative

effectiveness of

RICE therapy for

acute ankle

sprains in adults.


Axelsen, S. M.

Bjerno, T. 1993,

effect of Laser

therapy in

management of

ankle sprain

Randomized

controlled trial

40 patients were

randomly

selected from the

casualty ward

All pts. Received

the low-level

Laser treatment

unless ankle

sprain was

painless

After assessment

pain was

significantly

reduced. There

was no significant

effect on swelling

and

discoloration.


Green, T. et al. April

2001, Effectiveness

of passive

accessory joint

mobilization on

acute ankle

inversion sprains

Randomized

controlled trialN=41 subjects with acute ankle

inversion sprains

(<72 hours) & no

other injury in L.L

were Randomly

Assigned to 1 of 2

treatment groups

1. Control groupReceived only

RICE protocol

2. Treatment Group received

Antero-posterior

gliding of Talus

in addition to

RICE protocol

Study Revealed

that addition of a

talocrural

mobilization to

the RICE protocol

in the

management of

ankle inversion

injuries

necessitated

fewer treatments

to achieve pain-

free dorsiflexion

and to improve stride speed


Vicenzino, B.

Branjerdporn, M.

et al. july 2006,

Initial changes in

posterior talar

glide and

dorsiflexion of the

ankle after

mobilization with

movement in

individuals with

recurrent ankle sprain

A double-blind

randomized

crossover

experimental study

N=16

subjects with (mean +/- SD age,

19.8 +/- 2.3 years)

with a history of

recurrent lateral

ankle sprain and

deficits in posterior

talar glide (71%)

and weight-bearing

dorsiflexion (34%)

were studie

Treatment group:

weight-bearing

MWM, non-weight-

bearing MWM

Control group:No treatment

It was found that

Both the weight-

bearing and non-

weight-bearing

MWM treatment

techniques

significantly

improved

posterior talar

glide by 55% and 50% Respectively.


Verhagen, E. A.

van Tulder, M. et

al. Sep. 2005,

Effect of

Proprioceptive

balance board

training

programme for

the prevention of

ankle sprains in

volleyball Players

Prospective

Randomized controlled trial

n=116 male &

female Volleyball

teams followed prospectively during

the 2001-2002

season.

Teams were

Randomized into

Control and

Intervention Group

This study

highlights that

Significantly fewer

ankle sprains in

the intervention

group were found

compared to the

control group.


Refshauge, K. M.

Raymond, J. et al.

Feb. 2009,

The effect of ankle

taping on detection

of inversion-eversion

movements in

participants with

recurrent ankle

sprain.

Controlled laboratory study

16 participants with recurrent ankle

sprain under 2

conditions: with the

ankle taped or

untaped were

selected. The

threshold for

movement

detection was

examined at 3

velocities (0.1

deg/s, 0.5 deg/s,

and 2.5 deg/s) and

in 2 directions

(inversion and eversion).

It was found that

Taping the ankle

decreased the

ability to detect

movement in the

inversion-eversion

plane in

participants with

recurrent ankle sprain.

Patient-reported comfortand satisfaction duringtreatment with a semi-rigidbrace was significantlyincreased. The rate of skincomplication in this groupwas significantly lowercompared to the tapegroup (14.6% versus 59.1%,P < 0.0001).

Lardenoye S, Theunissen E, Cleffken B, Brink PR, de Bie RA,

Poeze M. The effect of taping versus semi-rigid bracing on

patient outcome and satisfaction in ankle sprains: a

prospective, randomized controlled trial. BMC musculoskeletal

disorders. 2012; 13: 81


Boyce, S. H.

Quigley, M. A.

Campbell, S. Jan.

2005,

Management of

ankle sprains: a

randomized

controlled trial of

the treatment of

inversion injuries

using an elastic

support bandage

or an Aircastankle brace

Prospective

Randomized

controlled trial

N=50 pts.Randomized into 2

Groups

Group 1:Elastic support

bandage +

standard RICE

Group 2:Air cast brace +

standard RICE

It was analyzed that

the use of an

Aircast ankle brace

produces a

significant

improvement in

ankle joint function

compared with

standard

management with

an elastic support bandage.


Ismail, M. M.

Ibrahim, M. M.

et al. June, 2010,

Plyometric training

versus resistive

exercises after

acute lateral ankle

sprain

Randomized

controlled trialN=22 athletes (aged from 20 to 35

years) of both sexes

with grade I or II

unilateral inversion

ankle sprain (at

least 3 weeks after

acute injury) were

randomly allocated

Group 1:

Pylometric training

Group 2:

Resistive training for

6 weeks

Isokinetic peak

torque/body weight

for invertors and

evertors at 30 & 120

degree/s

This study reports

that Plyometrics

were more effective

than resistive

exercises in

improving

functional

performance of

athletes after lateral

ankle sprain.

A Metaanalysis suggests that

Subjects who were Braced

with Ankle-Stirrup has

significantly Reduced

Inversion Stress at ankle than

those who were not braced.

Kimura IF, Nawoczenski DA, Epler M, Owen MG. Effect of the AirStirrup

in Controlling Ankle Inversion Stress. The Journal of orthopedic and

sports physical therapy. 1987; 9(5): 190-3

There is a strong evidence that

Star Excursion Balance training is

more effective than the

conventional therapy program in

improving functional stability of

the sprained ankle.

Chaiwanichsiri D, Lorprayoon E, Noomanoch L. Star excursion balance

training: effects on ankle functional stability after ankle sprain. Journal of

the Medical Association of Thailand = Chotmaihet thangphaet. 2005; 88

Suppl 4: S90-4.

Mild sprain

Acute phase (0-3 days): reducing pain and swelling, partial load-bearing

Information/advice: rest, elevate foot, perhaps ice, load-bearing (perhaps with

crutches) determined by pain, actively moving foot and toes

Instruction: compression bandage

If necessary re-evaluation / check-up after 1 week.

Severe sprain

Acute phase: as in mild sprain

Proliferation phase: regaining functions and activities; increasing loads

tape or brace: depending on load-bearing capacity required and patient's preference

exercises for functions and activities: range of motion, active stability, coordination, and walking

Early remodeling phase: increasing muscular strength, active (functional) stability, walking

exercises for functions and activities: dynamic stability, balance, coordination

Late remodeling phase: regaining ADL activities

exercises for activities: progression to normal load-bearing, exercises at home

If recovery normal, treatment once a week, maximum duration of treatment 6 weeks.Wees P, Lenssen A, Feijts Y, Bloo H, van Morsel S, Ouderland R, et al. KNGF guideline for physical therapy in patients with acute ankle sprain-practice guidelines. Suppl Dutch J Phys Ther. 2006; 116: 1-30.

•PRICE

•Ankle Taping/Bracing/ splints

•Gentle Mobilization

•Strengthening ex for intrinsic foot Muscles

•Proprioception training

•Balance training

•Plyometric training to regain functional level of activity

Acute Injury/ Minor Tear

•Surgical RepairChronic or

recurrent Ankle Sprain

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Health & Medicine

Ankle sprain