ANKLE SPRAINS:
A Primary Care Update
Mark Leung, MD, MSc, CCFP(SEM), Dip Sport Med
Director, Enhanced Skills Program in Sport & Exercise Medicine
Faculty/Presenter disclosure
Faculty:
Dr. Mark Leung
Relationships with commercial interests:
None
2
Dr. Mark Leung, MD, MSc, CCFP, Dip Sport Med
Outline
• Acute lateral ankle sprains
• Classification of lateral ankle sprain, treatment, prevention
• Syndesmosis (“high ankle”) sprain
• Mechanism of injury, anatomy, diagnosis, imaging, grading, and
conservative treatment
• Deltoid ligament sprain
• Anatomy, diagnosis, treatment
• Return to play
Ankle Sprain = Ligament Injury
• High prevalence
• NCAA studies – of all injuries, basketball (25%), W Volleyball (20%)
• UEFA study – top 4 injuries, 40% of all
• High propensity for development of residual symptoms
• 40% develop chronic instability at 1 year (Gerber et al., 1998)
• Natural history
• Following sprain, 2 weeks of rapid improvement
• Followed by 2 weeks of slower improvement
• Most report residual pain at 1 year post-injury
Acute Ankle History
• Age
• Mechanism of injury
• Initial ability to weight bear
• Potential role for imaging
• Seriousness of injury
• Pop/snap
• Ligament or tendon rupture
• Avulsion fracture
• Previous injury
Lateral Ligament: Diagnosis
• 85% of ankle injuries are isolated lateral ligament injuries
• Among lateral ligament sprains (Bridgman et al, 2003, Holmer et al., 1994)
80% involve ATFL
20% further involve CFL
• Mechanism of injury plantar flexion with inversion:
• ATFL most vulnerable because:
• “Narrow” posterior talus
• ATFL length and inherent relative tensile strength
• Grading
• Several available, none superior
• Sport-specific grading – Hertel et al., 2004; Mallioparous et al., 2006
Ankle Sprain Classification
Several classification schemes, most useful in RTP prediction:
Limping?
Joint effusion?
Grade 1: Mild
Grade 2: Obvious limp, unable do functional test
Grade 3: Unable to weight bear, massive joint effusion
Dr. Mark Leung, MD, MSc, CCFP, Dip Sport Med
Functional testing?
Mallioparous et al., 2006
Ankle Sprain R.E.S. Classification
• Grade 1: AROM ≤5º reduced, EDE ≤ 0.5cm, AD and TT neg
• Grade 2: AROM 5-10º reduced, EDE 0.5-2cm, AD pos, TT neg
• Grade 3: AROM ≥10º reduced, EDE > 2cm, AD and TT positive
• RTP allowed when:
• AROM ≤ 5º + isokinetic strength TA, P, G are 85% of unaffected side + neg
advanced hop test
•
•
•
•
Grade 1: 7-10 days
Grade 2: 2-3 weeks
Grade 3a: 4 weeks
Grade 3b: 8 weeks
Mallioparous et al., 2006
Lateral Ligament: Treatment
• Acute management - Re-look at PRICE?
• P
Trial, 2009)
•
•
•
•
 Brace/Tape (Grade 1 and 2) (Fatoye & Haigh, 2016) OR Aircast boot (Grade 3)
(CAST
R  Earlier RTP with weightbearing (Cochrane Review 2007)
I  Analgesia – good for numbing, minimal harm, but anti-inflammatory effect unlikely
C  VERY important! Less joint effusion, more rapid return to normal function
E
 Same as ’C’
• What’s missing?
• Early active ROM
• Isometric strengthening! (Functional gains and reduced pain scores similar to NSAIDs)
• RCT of non-supervised home exercise program (BMJ) – balance/proprioception 3/week x 30 minutes after return
to sport (Hupperets et al., 2009)
• Reduced absolute recurrence rate significantly by 12%
• NNT = 9
• Peri-articular HA injections followed by standard care? (Petrella et al., 2007)
Lateral Ankle Sprain: Prevention?
• Good evidence for brace (semi-rigid or lace-up) and taping at preventing recurrent
ankle sprain, rather than for prophylaxis (Shawen et al., 2016; Kaminski et al., 2013)
• Multi-intervention injury-prevention program lasting at least 3 months that focuses on
balance and neuromuscular control to reduce the risk of ankle injury
• Addressing the strength of the leg muscles (evertors, invertors, dorsiflexors, and
plantar flexors) and hip extensors and abductors may be an ankle injury-prevention
strategy
• Clinicians should consider assessing dorsiflexion ROM in at-risk athletes. If
dorsiflexion ROM is limited, clinicians should incorporate techniques to enhance
arthrokinematic and osteokinematic motion for possible prevention of ankle injury
Kaminski et al., 2013 – NATA Position Statement
Lateral Ankle Sprain: Chronic Instability
• Persistent residual symptoms
• “Feeling” ankle joint unstable
• Fear incur repeat sprain with e.g., uneven surfaces or rapid lateral
movement in sport
• Instability
• Giving way ankle joint
• Regular occurrence of uncontrolled or unpredictable episodes
• Without excessive pain, swelling, or bruising
• Excellent candidates for surgical repair
Dr. Eamonn Delahunt, 2017
High Ankle Sprain
Represent 10% of all athletic ankle
injuries
High Ankle Sprain: Mechanism of Injury
https://docflynn.com/2016/10/11/the-high-ankle-sprain/
Forced external rotation
Image by Dr. J.C. Kennedy
Axial load with forced dorsiflexion
High Ankle Sprain: Anatomy
Images from http://ssorkc.com/wp-content/uploads/2016/01/syndes.jpg
Tenderness length (Nussbaum)
• Strongly correlates with degree of injury and time to return to
sport
A rotation injury
High Ankle Sprain: Diagnosis
Sman AD, et al. Br J Sports Med 2015;49:323–329
It is not possible to rely on a single test for diagnosis of ankle syndesmosis injury.
Clinicians are advised to start with sensitive tests:
1. Inability to hop
2. Inability to walk at injury
3. Tenderness of the syndesmosis ligament
4. Dorsiflexion-external rotation stress test
If sensitive test is positive, use specific tests:
1. Pain out of proportion to the apparent injury
2. Squeeze test