ORTHOPAEDIC

Ankle
sprain
FEBRUARY 06, 2022
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anatomy Mechanis
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Risk factors Types and grading History Physical

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Radiological Management Prevention Cases
02–35 evaluation
 Definition

• An ankle sprain o
strong ligaments
ankle stretch bey
tear.

• Ankle sprains ar
that occur among
 Epidemiology

An ankle sprain is a common injury.

Inversion-type, lateral ligament injuries represent

approximately 85% of all ankle sprains.

The incidence of ankle sprain is highest in sports populations.

Poor rehabilitation after an initial sprain increases the chances

of this injury recurrence.

The ankle joint is the body part that is the second most likely
to be injured in sport.

Recurrence rates amongst basketball players are reported to be

greater than 70%.
ANATOMY – NORMAL ANKLE
01
The ankle is made of three bones:
1. Tibia
2. Fibula
3. Talus

These bones form a relatively stable joint that is secured even more by a
number of strong, thick and flexible bands called ligaments.
 Ligaments
There are three ligaments on the outside of the ankle that m
ligament complex, as follows:

01 •
THE ANTERIOR TALOFIBULAR LIGAMEN

Mechanism is plantar flexion and inversion.

• Physical exam shows drawer laxity in plantar fl

02 •
THE CALCANEOFIBULAR LIGAMENT (CF

Mechanism is dorsiflexion and inversion.

• Physical exam shows drawer laxity in dorsiflex

06-35 03 THE POSTERIOR TALOFIBULAR LIGAMEN

less commonly involved

Anterior and posterior ankle ligaments
MECHANISM OF
INJURY/PATHOLOGICAL PROCESS

Lateral ankle sprains occur

during a rapid shift of
body center of mass over
the landing or weight-
bearing foot.

MECHANISM OF INJURY/PATHOLOG
PROCESS

When a ligament tears or is overstretched its

The ankle rolls outward,
elasticity and resilience rarely returns. Some
whilst the foot turns
have described situations where return to pla
inward causing the lateral
too early, compromising sufficient ligamento
ligament to stretch and
tear.
 Mechanism of Injury and classification

Aspect Mechanism of injury Ligaments

anterior talofibular lig

Lateral Inversion and plantarflexion calcaneo-fibular ligam
posterior talofibular li

posterior tibiotalar lig

Medial Eversion tibiocalcaneal ligamen
tibionavicular ligamen
anterior tibiotalar liga

anterior-inferior tibiof
High External rotation and dorsiflextion posterior-inferior tibio
transverse tibiofibular
interosseous membran
interosseous ligament
inferior transverse lig
Inversion Exversion

High ankle sprain

 Grading

GRADE 1 SPRAIN (MILD)

• Slight stretching and microscopic tearing of the ligament fibers
• Mild tenderness and swelling around the ankle

GRADE 2 SPRAIN (MODERATE)

• Partial tearing of the ligament
• Moderate tenderness and swelling around the ankle
• If the doctor moves the ankle in certain ways, there is an abnormal looseness of the ankle

GRADE 3 SPRAIN (SEVERE)

• Complete tear of the ligament
• Significant tenderness and swelling around the ankle
• If the doctor pulls or pushes on the ankle joint in certain movements, substantial instabilit

11-35
 Risk factors
INTRINSIC RISK FACTORS
01 PREVIOUS SPRAIN
When the ligament distrupts it compromises an important biome
creates partial deafferentation of the ankle.

02 HEIGHT AND WEIGHT

Studies showed that an increase in either height or weight contri
suffering an ankle injury

03 GENERALIZED JOINT LAXITY

measurement of ankle laxity with the anterior drawer test showe
increased laxity was associated with an increased risk of ankle in

04 POSTURAL SWAY
Studies showed that an elevated postural-sway value identified a
risk of suffering an ankle sprain.
12-35
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Risk factors
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EXTRINSIC RISK FACTORS
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Shoe Type uneven surfaces Not war

before a

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 Approach to patient with ankle sprain
History taking
• What is the patient's chief complaint?
• Pain?
• Where? When? How bad? What is it like? What makes it bet
• What makes it worse? - Acute Injury vs. Chronic
• Progression of Symptoms?

HISTORY TAKING: Background Information

• Any Previous Injuries
• Past Surgical History
• Past Medical History
• Medications
• Allergies
• Social History
• Work situation (laboring type job?)
14-35
• Home situation
 Approach to patient with ankle sprain
History taking

• How did it happen?

• Was there any pain at the time? Was the pain sudden onset or gradual?
• Was there any swelling and was it sudden onset or gradual? - a sudden
swelling often indicates bleeding into the joint rather than a gradual
increase in synovial fluid within the joint.
• Did you hear any noises? - this could indicate ligaments tearing or bone
breaking. Did you apply any emergency procedures such as RICE?
• Is there anything you do that makes it worse / better?
• is this the first time you have injured your ankle?
 01 GENERAL EXAMINATIO
Physical Examination

02 LOOK

03 FEEL

05 MOVE

06 SPECIAL TESTS
1
GENERAL EXAMINATION
General state of the patient ,severe Distress and pain.
General look.
vital signs

2•
LOOK
Proper exposure (until mid legs).
• Compare right and left foot and ankle.
• Look from anterior,posterior, medial and lateral aspe
• Look for any deformity, swelling , ecchymosis, hem
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3 FEEL

Palpate the bony prominence.

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• Palpate the Achilles tendon( Thompson test should be

performed if any tenderness or a tissue deficit is
detected )
• Palpate plantar fascia.
• Palpate hind foot collateral ligaments(deltoid
,CFL,ATFL,PTFL)
• Feel skin temperature of both sides.

18-35
4 MOVE

• inversion: In lateral ankle sprains, pain is increased with forced ank

• eversion: pain of a medial (deltoid) ligament sprain is accentuated b
the ankle.
5 SPECIAL TEST

SQUEEZE TEST
• Consists of compression of the fibula against the tibia.
• This maneuver elicits pain in the region of the anterior tibiofib

EXTERNAL ROTATION STRESS TEST

• Can help identify a syndesmotic sprain
• The test is positive if pain is elicited in the region of the anterior tibiofibular
ligament
 5 SPECIAL TEST

ANTERIOR DRAWER TEST

• Detects excessive anterior displacement of the talus on the tibia.
• If the anterior talofibular ligament is torn by inversion stress, the talus
will sublux anteriorly and laterally out of the mortise.

TALAR TILT TEST

• Detects excessive ankle inversion.
• If the ligamentous tear extends posteriorly into the calcaneofibular
portion of the lateral ligament, the lateral ankle is unstable and
talartilt occurs.
 Imaging of ankle sprain
When to order x ray?
Based on Ottawa ankle rules ankle and foot x-ray should be order
conditions:

01 •
ANKLE SERIES:

point tenderness at the posterior edge of distal 6 cm, or

• point tenderness at the posterior edge of distal 6 cm, or
• inability to weight bear (four steps) immediately after t
emergency department

02 FOOT SERIES:
• point tenderness at the base of the fifth metatarsal

• point tenderness at the navicular

• inability to weight bear (four steps) immediately after t

22-35 emergency department
 Ankle X-ray

Views: weight bearing AP, lateral, and mortise view

(15°-20° internal rotation) to rule out ankle fracture

If high ankle sprain is suspected the following should be

considered:
• Stress view by applying external rotation and lateral
displacement of injured ankle to evaluate syndesmosis
and deep deltoid ligaments
• Radiographs of upper leg to assess bony injuries

NB: don’t forget to compare both sides

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X ray findings

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Tibiofibular overlap

Normally should be more than 10 mm, if less it’s

considered abnormal which implies syndesmotic
injury.

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X ray findings

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Tibiofibular clear space 4>

Normally it’s 4mm or less, if more than

4mm it’s abnormal and implies
syndesmotic injury

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X ray findings

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Talar tilt

If difference between medial and lateral

talarin greater than 2mm it’s considered
abnormal

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 Treatment
Nonoperative management
• RICE (Rest, Ice, Compression, and Elevation).

• NSAIDS.

• Elastic wrap to minimize swelling.

• Functional support:ankle brace recommended

for 4-6 weeks.

• Rehabilitation exercises : including range-of-

motion exercises, stretching, strengthing, and
balance exercises .
Ankle sprain rehabilitation exercises
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Treatment
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operative management
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ANATOMIC RECONSTRUCTION VS. TENDON TRANSFER WITH TENODESIS
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Indications:
• Grade I-III that continue to have pain and instability despite extensive nonoperati
• Grade I-III with a bony avulsion.

ARTHROSCOPY

Indications:
• recurrent ankle sprains and chronic pain caused by
impingement lesions.
• often used prior to reconstruction to evaluate for intra-
articular pathology.
29-35
procedure : debride impinging tissue.
 Prevention
Options for primary or secondary prevention of ankle injur

01 WARM UP PRIOR TO ANY SPORTS ACTIVI

02 PROPER FOOTWEAR.

03 EXTERNAL ANKLE SUPPORTS (EG, SEMI-

LACE-UP SUPPORT).

04 FUNCTIONAL SUPPORT (TAPING, BRACE)

30-35
05 ANKLE TRAINING (STRETCHING, STRENG
PROPRIOCEPTIVE).
 Complications
STRETCH NEURAPRAXIA

Neuropathic pain in the distribution of the affected nerve

PAIN AND INSTABILITY

Risk factors:
the most common cause of chronic pain is a missed injury, including
• missed fractures (anterior process of calcaneus, lateral or posterior
process of the talus, 5th metatarsal)
• osteochondral lesion
• injuries to the peroneal tendons
• injury to the syndesmosis
• tarsal coalition
• impingement syndromes
CASE
A 23-year-old female had a right ankle injury after landing
awkwardly catching a rebound in a basketball game. The next day
there was a swelling and ecchymosis in the lateral ankle. Anterior
drawer test showed 2 mm ankle translation. A radiograph was
performed but was normal. What is the next most appropriate step
in management?

A- Functional support ankle brace for 4-6 weeks followed by

physiotherapy.

B- Arthroscopy.

C- Reconstruction of the lateral ligament.

D- Steroid injection of the sinus tarsi and taping of the ankles before
activity.
CASE
In the AP of the ankle X- ray which one of the following is
considered a normal tibiofibular overlap:

A- A-< 10 mm

B- A-> 10 mm

C- A-< 4mm

D- A-> 4mm
 References
• HTTPS://WWW.TOWNCENTERORTHO.COM/BLOG/SPRAINED-ANKLE-
DEFINITION-ANATOMY-AND-CAUSES-VIDEO/

• https://www.orthobullets.com/foot-and-ankle/7028/ankle-sprain
• HTTPS://ORTHOINFO.AAOS.ORG/EN/DISEASES--
CONDITIONS/SPRAINED-ANKLE/
• BJ. MANASTER AND JULIA CRIM., IMAGING ANATOMY -
MUSCULOSKELETAL [20161, AND ED., BYELSEVIER, PRINTED IN
CANADA BY FRIESENS, ALTONA, MANITOBA, CANADA
• MARTIN ET AL. ANKLE STABILITY AND MOVEMENT
COORDINATIONIMPAIRMENTS: ANKLE LIGAMENT SPRAINS
CLINICAL PRACTICE GUIDELINESLINKED TO THE INTERNATIONAL
CLASSIFICATION OF FUNCTIONING, DISABILITY ANDHEALTH
FROM THE ORTHOPEDIC SECTION OF THE AMERICAN
PHYSICALTHERAPY ASSOCIATION. J ORTHOP SPORTS PHYSTHER.
2013:43(9):A1-A40. DOI:10.2519/JOSPT.2013.030
• JOHN M. FLYNN, (2011] AMERICAN ACADEMY OF ORTHOPAEDIC
SURGEONS, ORTHOPAEDICKNOWLEDGE UPDATE OKU 10. PRINTED
IN THE USA.
• SOLOMON L., WARWICK D. , NAYAGAM S.[20101 APLEY'S SYSTEM
OF ORTHOPAEDICS ANDFRACTURES, 9TH ED. HODDERAROLD
COMP.,LONDON, UK.
ANKLE SPRAIN

Thank you