Introduction:
- Ankle sprains are among the most common injuries, affecting both athletes and everyday pedestrians.
- The streets of New York City illustrate how treacherous surfaces can lead to ankle injuries.
- The ankle is the most commonly injured joint in sports; jogging is a frequent cause.
Anatomy of the Ankle:
- The ankle joint, or mortise, is formed by the talus bone fitting snugly between the distal fibula and tibia.
- Key ligaments securing the ankle include:
Medial deltoid ligament
Syndesmosis
Anterior talofibular ligament (ATFL)—the most commonly injured ligament.
- Types of Ankle Sprains:
Lateral Ankle Sprains (ATFL injuries):
Account for 85% of all ankle sprains.
Typically caused by inversion of the ankle.
The ATFL is the weakest ligament, making it more susceptible to injury.
Medial Ankle Sprains:
Much less common due to stronger ligaments.
Result from eversion and/or forced external rotation.
High Ankle Sprains (Syndesmosis injuries):
Occur in collision sports like football and soccer.
Notable athletes affected include Saquon Barkley and Steph Curry.
- Grading of Ankle Sprains:
Grade I:
Mild swelling and tenderness.
No instability; patients can bear weight.
No macroscopic tearing.
Grade II:
Moderate swelling and tenderness.
Some instability and loss of range of motion.
Difficulty with ambulation or bearing weight.
Represents a partial tear of the ligament.
Grade III:
Severe swelling and tenderness.
Mechanical instability.
Inability to bear weight.
Represents a complete rupture of the ligaments.
Examination and Diagnosis:
- Ottawa Ankle Rules guide the examination to distinguish between fractures and sprains:
Palpate for tenderness over specific areas:
Posterior edge of the lateral malleolus.
Posterior edge of the medial malleolus.
Base of the fifth metatarsal.
Navicular bone.
Assess the patient’s ability to bear weight and take four steps immediately after the injury and in the emergency department.
- Special Tests:
Squeeze Test: Checks for syndesmosis injury (Maisonneuve fracture).
Anterior Drawer Test: Suggests an acute rupture of the ATFL.
Thompson Test: Used if there is concern for an Achilles tendon injury.
Imaging:
X-rays are necessary if Ottawa Ankle Rules indicate potential fractures.
Imaging of the entire tibia and fibula is recommended if a Maisonneuve fracture is suspected.
Treatment:
- RICE Protocol:
Rest: Limit weight-bearing activities.
Ice: Apply ice packs to reduce swelling.
Compression: Use bandages or braces to provide support.
Elevation: Keep the ankle raised above heart level.
- Medications:
Non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief.
- Functional Rehabilitation Exercises:
Restore range of motion, strength, and proprioception.
Exercises include:
Dorsiflexion and Plantarflexion
Foot Circles
Toe Curls
Inversion and Eversion Movements
Balance Exercises (e.g., wobble board, drawing the alphabet with the big toe).
Immobilization:
Grade I Sprains: No immobilization needed.
Grade II Sprains:
Lateral sprains: Benefit from an aircast brace.
Medial sprains: Require immobilization and non-weight bearing for at least one week.
Grade III Sprains:
May require immobilization with a below-knee cast.
Consult orthopedic specialists for management.
Take-Home Points:
- Ankle sprains are common, with the ATFL being the most frequently injured ligament.
- Proper grading of the sprain is crucial for appropriate treatment.
- Utilize the Ottawa Ankle Rules to assess the need for imaging and rule out fractures.
- Be vigilant for Maisonneuve fractures and syndesmosis injuries.
- RICE, NSAIDs, and rehabilitation exercises are key components of treatment.
- Educate patients that recovery may be prolonged, and set realistic expectations.
- Not all patients need orthopedic follow-up, but severe cases (Grade III) and certain sprain types may require specialist care.