Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 41-07: Ankle Injuries + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis +++ Inversion ++ Localized pain and swelling Most ankle injuries involve inversion injuries affecting the lateral ligaments Consider chronic ankle instability or associated injuries if pain persists for > 3 months following an ankle sprain +++ Eversion ++ Severe and prolonged pain Limited range of motion Mild swelling Difficulty with weight bearing +++ General Considerations +++ Inversion ++ Ankle sprains are the most common sports injuries seen in outpatient clinics Patients usually report "turning the ankle" during a fall or after landing on an irregular surface The most common mechanism of injury is an inversion and plantarflexion sprain, which injures the anterior talofibular ligament rather than the calcaneofibular ligament Women appear to sustain an inversion injury more frequently than men Chronic ankle instability Defined as persistent complaints of pain, swelling and/or giving way in combination with recurrent sprains for at least 12 months after the initial ankle sprain Can occur in up to 43% of ankle sprains even with physical therapy, which makes appropriate attention to acute ankle sprains important See Table 41–8 for other injuries that can occur with inversion ankle injuries ++Table Graphic Jump LocationTable 41–8.Injuries associated with ankle sprains.View Table||Download (.pdf) Table 41–8. Injuries associated with ankle sprains. Ligaments Subtalar joint sprain Sinus tarsi syndrome (ongoing anterolateral post-traumatic ankle pain) Syndesmotic (distal tibiofibular ligamentous) sprain Deltoid sprain Lisfranc (tarsometatarsal bony or ligamentous) injury Tendons Posterior tibial tendon strain Peroneal tendon subluxation Bones Osteochondral talus injury Lateral talar process fracture Posterior impingement (os trigonum) Fracture at the base of the fifth metatarsal Jones fracture (between base and middle of fifth metatarsal) Salter (growth plate) fracture (fibula) Ankle fractures +++ Eversion ++ A syndesmotic injury or "high ankle" sprain involves the anterior tibiofibular ligament in the anterolateral aspect of the ankle, superior to the anterior talofibular ligament The injury mechanism often involves the foot being turned out or externally rotated and everted (eg, when being tackled) This injury is commonly missed or misdiagnosed as an anterior talofibular ligament sprain on initial visit + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs +++ Inversion ++ Localized pain, swelling, and bruising over the lateral aspect of the ankle Difficulty weight bearing Limping The patient's ankle may feel unstable The anterior, inferior aspect below the lateral malleolus is most often the point of maximal tenderness consistent with anterior talofibular and calcaneofibular ligament injuries +++ Eversion ++ Severe and prolonged pain over the anterior ankle at the anterior tibiofibular ligament, worse with weight bearing The point of maximal tenderness involves the anterior tibiofibular ligament, which is higher than the anterior talofibular ligament It is also important to palpate the proximal fibula to rule out any proximal syndesmotic ligament injury and associated fracture known as a "maisonneuve fracture" There is often some mild swelling in this area, and the patient may or may not have an ankle effusion The patient usually has limited range of motion in all directions + Diagnosis Download Section PDF Listen +++ +++ Imaging ++ Routine radiographic views include the anteroposterior, lateral, and oblique (mortise) views Less common views requested include the calcaneal view and subtalar view MRI is the best method to visualize injury to the tibiofibular ligament and to assess status of the other ligaments and the articular cartilage +++ Diagnostic Procedures +++ Inversion ++ Special stress tests include the anterior drawer test and subtalar tilt test (eTable 41–4) ++Table Graphic Jump LocationeTable 41–4.Ankle examination.View Table||Download (.pdf)eTable 41–4. Ankle examination. Maneuver Description Inspection Examine for the alignment of the ankle (SEADS). Palpation Include important landmarks: Ottawa Ankle Rules (medial and lateral malleolus, base of fifth metatarsal and navicular area), anterior tibiofibular ligament, posterior talus; tendons (Achilles, peroneals, posterior tibialis, flexor hallucis longus). Range of motion testing Check range of motion actively (patient performs) and passively (clinician performs), especially with flexion and extension of the spine. Rotation and lateral bending are also helpful to assess symmetric motion or any restrictions. Ankle strength testing Test resisted ankle dorsiflexion, plantarflexion, inversion and eversion strength manually. Ankle anterior drawer The clinician keeps the foot and ankle in the neutral position with the patient sitting, then uses one hand to fix the tibia and the other to hold the patient's heel and draw the ankle forward. Normally, there may be approximately 3 mm of translation until an endpoint is felt. A positive test includes increased translation of one foot compared to the other with loss of the endpoint of the anterior talofibular ligament. Subtalar tilt test Performed with the foot in the neutral position with the patient sitting. The clinician uses one hand to fix the tibia and the other to hold and invert the calcaneus. Normal inversion at the subtalar joint is approximately 30 degrees. A positive test consists of increased subtalar joint inversion greater than 10 degrees on the affected side with loss of endpoint for the calcaneofibular ligament. External rotation stress test Performed when the clinician fixes the tibia with one hand and grasps the foot in the other with the ankle in the neutral position and then dorsiflexes and externally rotates the ankle, reproducing the patient's pain. SEADS, swelling, erythema, atrophy, deformity, and (surgical) scars. +++ Eversion ++ The external rotation stress test reproduces the mechanism of injury (eTable 41–4) Note: The patient's foot should have an intact neurovascular examination before undertaking this test + Treatment Download Section PDF Listen +++ +++ Therapeutic Procedures +++ Inversion ++ Immediate treatment follows the MICE mnemonic Modified activities Ice Compression Elevation NSAIDs are useful in reducing pain and swelling in the first 72 hours following the ankle sprain Subsequent treatment involves protected weight bearing with crutches and use of an ankle stabilizer brace +++ Eversion ++ A cast or walking boot should be worn for 4–6 weeks Thereafter, protected weight bearing with crutches is recommended until the patient can walk pain-free + Outcome Download Section PDF Listen +++ +++ Follow-Up +++ Inversion ++ Early motion is essential Patients should be encouraged to do an exercise program or physical therapy Proprioception and balance exercises (eg, "wobble board") are useful to restore function to the ankle and prevent future ankle sprains There was strong evidence for bracing and moderate evidence for neuromuscular training in preventing recurrence of an ankle sprain Chronic instability can develop in 10–20% of people after acute ankle sprain; may require surgical stabilization with ligament reconstruction surgery +++ Eversion ++ Physical therapy can start early to regain range of motion and maintain strength with limited weight-bearing initially +++ Prognosis ++ Difficulty jumping and landing within 2 weeks from the acute ankle sprain, abnormal postural or hip muscle control, or ligamentous laxity noted 8 weeks post injury are poor prognostic signs +++ When to Refer +++ Inversion ++ Ankle fractures Recurrent ankle sprains or signs of chronic ligamentous ankle instability No response after more than 3 months of conservative treatment Suspicion of associated injuries +++ Eversion ++ If there is widening of the joint space and asymmetry at the tibiotalar joint, the patient should be referred urgently to a foot and ankle surgeon Severe or prolonged persistent cases that do not heal may require internal fixation to avoid chronic instability at the tibiofibular joint + References Download Section PDF Listen +++ + +Chen ET et al. Ankle sprains: evaluation, rehabilitation, and prevention. Curr Sports Med Rep. 2019 Jun;18(6):217–23. [PubMed: 31385837] + +Delahunt E et al. Risk factors for lateral ankle sprains and chronic ankle instability. J Athl Train. 2019 Jun;54(6):611–6. [PubMed: 31161942] + +Doherty C et al. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. Br J Sports Med. 2017 Jan;51(2):113–25. [PubMed: 28053200] + +Fort NM et al. Management of acute injuries of the tibiofibular syndesmosis. Eur J Orthop Surg Traumatol. 2017 May;27(4):449–59. [PubMed: 28391516] + +Kaminski TW et al. Prevention of lateral ankle sprains. J Athl Train. 2019 Jun;54(6):650–61. [PubMed: 31116041] + +Kellett JJ et al. Diagnostic imaging of ankle syndesmosis injuries: a general review. J Med Imaging Radiat Oncol. 2018 Apr;62(2):159–68. [PubMed: 29399975] + +Mandegaran R et al. Beyond the bones and joints: a review of ligamentous injuries of the foot and ankle on (99m)Tc-MDP-SPECT/CT. Br J Radiol. 2019 Dec;92(1104):20190506. [PubMed: 31365277] + +Medina McKeon JM et al. The ankle-joint complex: a kinesiologic approach to lateral ankle sprains. J Athl Train. 2019 Jun;54(6):589–602. [PubMed: 31184957] + +Nickless JT et al. High ankle sprains: easy to miss, so follow these tips. J Fam Pract. 2019 Apr;68(3):E5–13. [PubMed: 31039220] + +Tassignon B et al. Criteria-based return to sport decision-making following lateral ankle sprain injury: a systematic review and narrative synthesis. Sports Med. 2019 Apr;49(4):601–19. [PubMed: 30747379] + +Vuurberg G et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018 Aug;52(15):956. [PubMed: 29514819] + +Yuen CP et al. Distal tibiofibular syndesmosis: anatomy, biomechanics, injury and management. Open Orthop J. 2017 Jul 31;11:670–77. [PubMed: 29081864]