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How to treat
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Examination and
classifications
Diagnosis
Treatment phases
Barriers to healing
Prevention
The author
DR MARK BLACKNEY,
specialist orthopaedic foot and
ankle surgeon, and member of
the Park Clinic orthopaedic
group at the Mercy Private
Hospital, East Melbourne,
Victoria.
ANKLE SPRAINS
Background
SOFT tissue ankle injuries (sprains)
are the most common injury sustained by athletes and make up
4.7-24.4% of all injuries incurred in
an individual sport.
An ankle sprain can result in an
athlete being unable to compete in
sport or train for a significant
amount of time.
It can also lead to long-term morbidity, preventing a full return to fitness and loss of competitiveness,
particularly for elite athletes.
Ankle injury is common in most
sports but occurs especially in those
that involve jumping, such as Australian Rules football, basketball and
netball.
Soft tissue ankle injuries also often
occur during day-to-day activities,
for example when walking on steps,
off curbs or on uneven pavement.
Although many simple sprains heal
spontaneously and require no treat-
ment, up to 40% of soft tissue ankle
injuries continue to cause symptoms.
Therefore it is important that
ankle sprains are fully assessed to
determine whether treatment is necessary and to prevent long-term
sequelae.
Anatomy
Ankle stability is complex and relies
on a combination of bony, ligamentous and dynamic factors.
The anterior talofibular ligament
(figure 1, see page 26) blends with
the anterior capsule of the ankle and
spans the anterior lateral ankle joint.
It originates from the anterior edge
of the fibula just lateral to the articular cartilage of the lateral malleolus,
and the insertion on the talus begins
directly distal to the articular surface
of the ankle joint. There is an additional inferior band in some people.
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How to treat – ankle sprains
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The posterior talofibular ligament arises from the medial
surface of the lateral malleolus
and courses medially in a horizontal fashion to the posterior aspect of the talus.
The calcaneofibular ligament does not originate
from the apex of the tip of
the lateral malleolus, as commonly believed, but is
attached on the anterior
edge of the distal fibula, just
below the origin of the anterior talofibular ligament.
It runs medially, posteriorly and inferiorly from its
fibular origin to the calcaneal
insertion. During plantar
flexion it runs horizontally
but in dorsiflexion the ligament is almost vertical and
acts as a true collateral ligament by preventing talar tilt.
It spans the ankle and subtalar joints.
Figure 1: Ankle ligaments.
Posterior
talofibular
ligament
Anterior
talofibular
ligament
Calcaneofibular ligament
The lateral talocalcaneal
ligament is variable — it
may combine with the calcaneofibular ligament, be
separate or be completely
absent. These variations
occur but do not affect
injury risk or recovery.
The deltoid ligament is a
short, thick structure that has
deep and superficial layers.
The superficial layer runs
from the medial malleolus to
the medial aspect of the calcaneus, where the deep layer
attaches it to the talus in three
separate bands.
The fibula is held firmly to
the tibia, only allowing a
small degree of movement.
The distal tibiofibular syndesmosis consists of the
interosseous membrane, the
anterior tibiofibular ligament,
the posterior tibiofibular ligament and the transverse
tibiofibular ligament.
The inferior extensor retinaculum is also thought to
be an important stabiliser of
the ankle and subtalar joint.
It has three bands retaining
the extensor digitorum
longus and brevis and the
peroneus tertius.
Dynamic stability of the
ankle is achieved through the
actions of the peroneus
longus and brevis and their
retinaculum. Proprioceptive
signals from stretching of the
lateral ligaments or capsule
induce contraction of these
muscles.
The sinus tarsi (also known
as the talocalcaneal sulcus) is
a conical-shaped anatomical
space between the inferior
neck of the talus and the
superior aspect of the distal
calcaneus.
It opens just anteriorly to
the lateral malleolus and terminates posteromedially,
directly behind the sustentaculum tali (part of the calcaneus).
The sinus tarsi, which is
supplied by the tarsal canal
artery (a branch of the posterior tibial artery), contains fat
and ligaments.
The ligamentous structures
include the extensor retinaculum of the foot, the interosseous talocalcaneal ligament
and the cervical ligament.
Diagnosis
History
AS in most medical problems, the
history-taking is a very important
step in reaching a firm diagnosis in
patients with ankle sprains.
For example, the more common
inversion injury usually causes lateral ligament damage, while eversion
injuries cause medial ligament strains
or ruptures.
Injuries that involve jumping or
compression may cause osteochondral damage and those sustained at
speed usually cause more significant
damage. An audible ‘pop’ or a tearing sensation may be reported, indicating a partial or complete tear in
the lateral ligament.
It is important to ask if the patient
was able to bear weight afterwards
or, for an athlete, if they were able to
continue competing: inability to bear
weight indicates a more severe injury
of the ligament or possibly a fracture.
Generally the patient will be able
to describe the location of the pain,
which is most often over the anterolateral aspect of the ankle. Deep pain
may indicate chondral damage.
A history of ankle injuries and
episodes of instability is important, as
patients with previous ankle injuries
have a higher risk of secondary problems such as chondral lesions or peroneal tendon injury.
Examination
Examination of the acutely injured
ankle can be difficult because of
swelling and pain. If this is marked,
firm bandaging should be applied
(not plaster) and the foot strictly elevated.
An X-ray may be helpful to
exclude fracture in cases where bruising is marked and weight-bearing is
difficult. In those without fracture
reassessment in 48 hours should
follow.
The initial assessment should be
directed toward a few key factors,
including bone and ligament tenderness, presence of instability and signs
of peroneal subluxation or syndesmotic injury (see table 1).
Examination should follow the
standard pattern — look, feel and
move, then perform special tests.
Inspection is particularly directed
toward soft tissue swelling and bruis-
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| Australian Doctor | 17 March 2006
Table 1: Acute assessment
■
Bone tenderness
■
Assess for medial and lateral
ligament tenderness
■
Check for instability
■
Peroneal subluxation?
■
Syndesmotic injury?
Stability testing is
best carried out with
the knee bent and
foot hanging over the
side of the
examination table.
Table 2: Classification of lateral ankle ligament injury
Ligament injured
Examination findings
Grade I
Anterior talofibular ligament only
Pain, no laxity
Grade II
Anterior talofibular ligament with
partial calcaneofibular ligament
Painful, some laxity, firm
endpoint
Grade III
Complete anterior talofibular ligament Gross laxity, no endpoint
and calcaneofibular ligament
ing. The degree of swelling generally
correlates with soft tissue damage
but the distribution may also indicate the site of maximal trauma.
Any anatomical factors that could
predispose to injury, such as hind
foot varus or a cavovarus foot,
should be noted.
Palpation is an essential part of the
examination. Although this may be
carried out in any order, in the anxious patient it is usually wise to start
at the area where least pain is
expected.
On the lateral side palpate the:
■ Fibula (pain may suggest fracture).
■ Anterior talofibular ligament.
■ Calcaneofibular ligament.
■ Posterior talofibular ligament.
■ Lateral talocalcaneal ligament.
■ Peroneal tendons.
■ Sinus tarsi.
■ Distal syndesmotic ligament.
■ Base of the fifth metatarsal.
■ Anterior calcaneal process.
On the medial side palpate the:
■ Malleolus (for tenderness indicating possible fracture).
■ Deltoid ligament.
■ Sustentaculum tali.
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Finally, the examiner should palpate the anterior joint line, the
dome of the talus and the Achilles
tendon.
Direct tenderness is an important
clinical sign in ankle injury. Initially
tenderness may be less localised, but
after the first few days finely localising a specific area of tenderness correlates closely with damage to the
specific underlying structure.
As a general guide, grade I sprains
have tenderness just on the lateral
side, grade II sprains also have medial
tenderness, due to impact contusion,
and grade III sprains are associated
with bruising and swelling (see table
2).
The range of passive and active
movement at the ankle and subtalar
joints should be examined in both
feet and compared with the noninjured side.
Assessing the degree of instability
allows classification of lateral ligament damage (see table 2).
Grade II and III ankle sprains often
have coexistent injury to other structures about the ankle mortise, the
most common being deltoid ligament
contusions and sinus tarsi injuries.
The anterior drawer test is really
an assessment of the integrity of the
anterior talofibular ligament. It is
performed with the ankle held in the
neutral position.
In the acute setting the examination is often more comfortable for
the patient if their foot is placed with
the plantar surface firmly on the
examination table and the tibia
drawn gently forward and backward.
The talar tilt test examines the
integrity of the calcaneofibular ligament. However, the stability of the
lateral ligamentous complex depends
on the other lateral ligaments and the
subtalar joint, so joint stability is not
completely assessed by the anterior
drawer test or the talar tilt test alone.
Stability testing is best carried
out with the knee bent and foot
hanging over the side of the examination table. One hand holds the
foot by the heel while the other
hand holds the medial leg. Inversion is then assessed, with comparison to the other side.
Syndesmotic injuries form a particular subset of ankle sprains. Being
an eversion-type injury, they have the
reverse mechanism to the most
common injuries, and are usually
associated with fractures.
Non-fracture related syndesmosis
injuries can occur but are rare.
Rugby is perhaps the most common
sport in which this non-fracturerelated ligament injury occurs.
The syndesmosis is assessed by
the squeeze test: the test is positive
when pain is reproduced at the
ankle by compressing the tibia and
fibula together at the mid-calf.
In this type of injury, pain may
also be reproduced by ankle dorsiflexion or external rotation and
usually there is also tenderness over
the deltoid ligament.
Proprioception can be assessed
when the injury is not acute by
asking the patient to carry out a
single leg stance with the eyes
closed, and comparing performance with the patient standing on
the non-injured leg.
Proprioception can be lost after
injury, due either to direct nerve
traction or prolonged protective
muscle spasm.
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Treatment
Phase 3
TO return function to an
injured ankle as quickly as
possible:
■ Reduce all swelling (and
therefore most pain).
■ Restore range of movement.
■ Arrange a graduated return
to sport, with muscle
strengthening and proprioception exercises.
Treatment can be divided
into three phases (table 3).
This begins when ankle
motion is pain free and
strength approaches 80-90%
of the unaffected side. It
incorporates return to
desired athletic activity with
the concurrent aim of preventing recurrent injury.
Activity is gradually
increased in a stepwise fashion, for example, walking
progressing to jogging, then
running, and finally changing direction at speed.
Proprioceptive exercises
are continued during this
phase and the patient gradually returns to their normal
sporting activities.
Phase 1
The injury should be treated
with the rest-ice-compression-elevation (RICE) regimen to reduce the amount
of soft tissue swelling and
therefore pain.
In grade II and III sprains
(see table 2, page 26), when
the patient is unable to bear
weight comfortably, it is
helpful to limit weight-bearing for a few days.
Crutches with a belowknee cast or a controlled
ankle motion (CAM) walker
may be used and can help
limit further injury.
Pain and swelling can be
further reduced with electrotherapeutic modalities such
as ultrasound and interferential stimulation, and with
analgesia.
Although there is ongoing
debate in the literature about
the use of NSAIDs, it is the
author’s usual practice to
prescribe them if there are
no contraindications. A
combination of paracetamol
and an anti-inflammatory
such as ibuprofen is quite
effective.
The physiotherapist becomes a key member of the
team at this stage. Gentle soft
tissue therapy and mobilisation can help reduce pain and
swelling further, preventing
muscle inhibition and wasting
and allowing exercise through
a full range of movement.
Sprains that do not
get better
Above: ankle lateral ligament rupture.
Sinus tarsi
syndrome, caused
by inflammation
of the structures
in the sinus tarsi
secondary to
injury, is a
frequent
complication of
severe ankle
sprain.
Table 3: Treatment phases for ankle injuries
Phase 1 – RICE
Limit the extent of injury
■
Rest till pain subsides (including not bearing weight, if necessary)
■
Ice
■
Compression with an elastic bandage to reduce swelling
■
Elevation
Phase 2 –
Restore strength and range of movement
physiotherapy
■
Begin when pain settles
■
Continue ice and compression bandaging
■
Range-of-movement and resistance exercises
■
Exercises to improve proprioception
Phase 3 –
return to sport
Restore agility and endurance
■ Graduated return to sporting activities
■
Athletes should continue ankle bracing or taping for six months after the
sprain, because they are at increased risk of further injury
Phase 2
The second phase is aimed
largely at restoring strength
and range of motion and
begins when acute oedema
and pain have resolved. This
may be as early as 3-4 days
after injury in simple grade I
sprains, but may take more
than a week in more severe
injuries.
In this phase the patient
starts resisted motion exercises using manual resistance
and isometric contractions
with, for example, elastic
bands. The level of resistance
is gradually increased within
the patient’s tolerance.
Different muscle groups
are targeted individually,
including the anterior compartment, gastrocnemiussoleus complex, posterior
tibialis, and the peroneals.
During this phase the
patient continues with ice
and compression bandaging.
As the patient progresses
with rehabilitation and
closed-chain exercises (performed with a fixed distal
segment, such as during lunge
stretches or leg presses), proprioception exercises are also
started. This may be simple
limb-balance exercises initially, building up to use of
wobble boards and minitrampolines.
Table 4: Sprains that do
not get better
Sinus tarsi syndrome
Osteochondral lesions
■ Peroneal tendon
pathology
■ Syndesmotic injury
■ Impingement
■ Complex regional pain,
nerve injury
■
■
In a minority of patients
recovery is slower than usual
or symptoms persist, so it is
important to monitor recovery closely to detect any
potential problems and to
intervene early. A list of the
common setbacks to recovery is shown in table 4.
The sinus tarsi is, as
described previously, a conical shaped anatomical space
that lies beneath the palpable
soft spot just anterior to the
lateral malleolus.
Sinus tarsi syndrome,
caused by inflammation of
the structures in the sinus tarsi
secondary to injury, is a frequent complication of a
severe ankle sprain and is also
seen in patients with pes
cavus, hypermobile pes
planus and chronic subtalar
joint instability.
Usually the patient has tenderness over the sinus tarsi
and complains of anterolateral pain, exacerbated by
weight-bearing activities, particularly on uneven surfaces.
There is often a subjective feeling of hind-foot instability.
Tenderness in the sinus
tarsi must be distinguished
from tenderness over the
anterior talofibular ligament
and from the ankle joint.
Although these conditions
can be slightly difficult to
separate without careful palpation, initial treatment is
generally similar.
Most patients respond well
to an injection of local anaesthetic and corticosteroid into
the sinus tarsi, directed to the
area of maximum tenderness.
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from page 27
This does not always completely relieve the symptoms
and the procedure may need
to be repeated at 2-3 weeks.
In the minority of patients
that do not respond it is wise
to order an MRI scan to
confirm the diagnosis and
rule out other injuries such
as occult subtalar or peroneal tendon pathology.
In patients who do not
respond to injection, subtalar
arthroscopy and excision of
scar tissue (see ‘Impingement
lesions’, page 30) should be
considered.
Peroneal tendon
pathology
The peroneal tendons run in
a common sheath contained
within a sulcus on the posterolateral aspect of the
fibula. The sulcus, supplemented by the superior peroneal retinaculum, prevents
subluxation.
When subluxation occurs
the patient usually describes
a ‘snapping’ sensation of the
tendons moving out of place
and usually they can easily
reproduce the sound.
Examination may show
tenderness over the peroneal
tendons, and subluxation
may be provoked by dorsiflexion of the foot.
Imaging with dynamic
ultrasound using provocation in dorsiflexion can be
used to confirm the diagnosis if necessary.
If subluxation is detected
early, immobilisation in a
walking cast at a neutral
position will correct the
problem in about 50% of
cases (in the author’s experience), but in active patients
surgical correction may be
needed.
Surgery has the added
advantage of allowing the
tendons to be checked for
tears, which are usually
obvious on ultrasound.
Delayed diagnosis is
common because in less
severe cases the subluxation
may not be apparent until
normal activity resumes.
Although peroneal longitudinal tears are common
they may be over-reported
in MRI scans because minor
tears are often asymptomatic.
Syndesmosis injury
Although most clinicians
understand that the syndesmosis can be disrupted in
Above: peroneal tendon tear.
Although peroneal
longitudinal tears
are common
they may be
over-reported in
MRI scans
because minor
tears are often
asymptomatic.
This pressure may be continued proximally up the
fibula, and gives an indication of the degree of proximal extension of the injury.
■ The squeeze test, which also
directly tests the syndesmosis. The fibula is compressed against the tibia,
and the test is positive if
this reproduces pain over
the anterior tibiofibular ligament. However, this test
does not indicate the severity of injury.
■ The external rotation test,
which reproduces pain over
the anterior syndesmosis.
This may be done under
anaesthetic, with image
intensifier for comparison
with the uninjured ankle.
If syndesmosis injury is
suspected, plain X-rays
should be taken to exclude
other bony injuries.
Weight-bearing films may
show disruption of the
normal mortise relations but
are often impossible to
obtain because of pain.
MRI is the most useful
examination and will clearly
show disruption of the ligaments, especially on the T2
sequences.
Treatment (table 5)
Osteochondral lesion at arthroscopy (above left); osteochondral lesion of the talus on MRI (above right).
Table 5: Grades and treatment of syndesmosis injuries
Grade
Type of injury
Treatment
Grade I
Incomplete tears of the anterior
tibiofibular ligament
No weight-bearing; in cast or CAM walker
for 2-4 weeks on average
Grade II
A complete disruption of one of
the ligaments
No weight-bearing; in cast or CAM walker
for 2-4 weeks on average
Grade III
All ligaments have been torn and
there is mortise instability
Surgical management
Grade I and II injuries
should be treated with a
weight-bearing-free period,
with the ankle in a cast or
CAM walker. The period of
time depends on the severity
of injury but is usually 2-4
weeks.
In the author’s experience
the patient can start to bear
weight using a CAM walker
when the area of tenderness
(in the point test) gets close
to the anterior tibiofibular
ligament.
Grade III injuries should
be stabilised surgically using
a trans-fibular syndesmotic
screw. Treatment requires a
prolonged recovery, with six
weeks on crutches and screw
removal at 12 weeks, before
a return to sport some weeks
later.
Osteochondral lesions
ankle fractures, isolated
injuries are often missed
because they are mistaken
for lateral ligament sprains
and may cause persistent disability in athletes.
Injuries may be graded IIII (table 5):
■ Grade I injuries are incomplete tears of the anterior
tibiofibular ligament.
Grade II injuries consist of
complete disruption of one
of the ligaments.
■ Grade III injuries are
injuries in which all the ligaments have been torn and
there is mortise instability.
Injury to the syndesmosis
can result from various
mechanisms but generally
involves a torsional force to
■
a fixed foot or direct contact. The injury often coexists with a lateral ankle ligament injury and can
therefore be easily missed if
not specifically looked for.
Clinically examination is
based on three tests:
■ The point test. Direct pressure over the anterior syndesmosis produces pain.
Damage to the cartilage of
the talus is generally caused
by trauma. In general, lateral lesions are caused by
injuries that occur with the
ankle inverted and dorsiflexed, while those on the
medial side are caused by
inversion with the ankle
plantar flexed.
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The more common medial
osteochondral lesions tend
to lie more posteriorly, be
undisplaced and deeper than
the more anterior, often displaced, lateral lesions.
The original classification
by Berndt and Hardy (table
6) was based on X-ray findings, and modifications have
been proposed with the
introduction of CT and MRI
(table 7).
Osteochondral injuries are
not often diagnosed at the
time of trauma but present
later with a continuing ache,
generally felt deep in the
ankle.
Swelling is common after
weight-bearing activity and
the patient may describe
catching or locking.
MRI is the imaging
modality of choice and may
show oedema or a cyst in
the T2 sequences, thought to
be a result of synovial fluid
being forced through the
articular defect.
There is much research
and discussion in the literature about osteochondral
grafts, allograft replacement
and autologous chondrocyte
implantation.
Most defects, especially
the smaller ones, can be successfully treated with simple
debridement and drilling,
which heals with fibrocartilage repair tissue.
Although this tissue is biomechanically inferior to hyaline cartilage it usually
allows the patient to return
to sport.
Long-term outcomes for
the newer methods are still
awaited, but at present these
should be reserved for
lesions that fail to respond
to simple treatment.
Table 7: Proposed CT and MRI classifications of
ankle injuries
CT classification
I.
Cystic lesion within dome, intact roof
IIa.
Cystic lesion in communication with surface
IIb.
Open articular surface lesion with overlying non-displaced
fragment
III.
Undisplaced lesion with lucency
IV.
Displaced fragment
(Ferkel et al. Orthop Trans 1990; 14:172.)
MRI classification
Table 6: Berndt and Hardy classification of talus
osteochondral lesions
1.
Articular damage only
2a.
Cartilage injury with underlying fracture + oedema
2b.
Cartilage injury with underlying fracture, no oedema
I.
Small area of compression
3.
Detached and undisplaced
II.
Partially detached osteochondral lesion
4.
Detached and displaced
III.
Completely detached, non-displaced fragment
5.
Subchondral cysts
IV.
Detached and displaced fragment
(Hepple et al. Foot and Ankle International 1999; 20:789-93.)
Impingement lesions
Soft-tissue or bony impingement lesions cause persisting
pain at the extremes of
movement.
For example, fibrotic scar
tissue may develop in the lateral gutter after an inversion
injury, and the scar tissue
may become chronically
inflamed, causing a reactive
hyperplastic synovitis.
This synovitis then forms
a meniscoid lesion that can
become trapped between the
lateral malleolus and the
talus during dorsiflexion.
The patient generally
reports tenderness along the
anterior joint line and especially in the lateral gutter.
The ankle is stiff, and pain is
reproduced with full dorsiflexion.
Soft-tissue impingement
lesions generally respond to
one or two corticosteroid
injections and hydrodilatation, using a larger amount
of local anaesthetic than
usually used (5-10mL) and
double the dose of steroid.
The aim is to stretch the
thickened and inflamed capsule with the hydrodynamic
pressure of the injection.
If a combination of injection and restricted activities
does not improve symptoms
and function, arthroscopy is
usually indicated.
Similarly, if there are preexisting bony spurs and the
patient’s symptoms do not
settle, arthroscopy is the
next step.
Complex regional pain
Continuing pain associated
with paraesthesia, night pain
Author’s case studies
Synovitis and scarring after a grade III
lateral ligament sprain
MISS AB, a 24-year-old social basketball player,
landed awkwardly on another player’s foot
while coming down from a rebound. The ankle
inverted and she felt a pop and immediate pain.
She was unable to bear weight and spent the
next week on crutches, with extensive bruising
and swelling.
Early assessment confirmed a grade III lateral
ligament sprain and tenderness medially suggested a medial contusion as well. Miss AB was
treated with compression using a firm bandage,
and elevation.
Early on it was explained to her that the severity of the injury indicated at least a 12-week
recovery and possibility of a secondary injury.
She attended physiotherapy from the first
week and was able to walk after two weeks. At
four weeks she was making slow but steady
progress and the ankle was stabilising, but she
had persistent swelling and lateral pain.
At six weeks the ankle was stiff and swollen,
with lateral and medial pain. An MRI did not
show any osteochondral damage but revealed
chronic synovitis and ligament scarring.
The injury was treated with injection of 1mL
of local anaesthetic and 1mL of celestone to the
sinus tarsi, as this was her most tender area.
When seen two weeks later, her lateral pain had
resolved and the swelling was reducing.
She eventually returned to sport four months
30
| Australian Doctor | 17 March 2006
after the injury and made a full recovery after
completing a full rehabilitation program.
Chronic ankle pain and stiffness after
repeated sprains
MR BC, a 34-year-old former high-level footballer, had sprained his ankle many times during
his career, often returning to sport early and
without appropriate treatment.
He presented because of chronic pain and
stiffness that interfered with his work as a
builder. He was also unable to run because of
pain.
Examination revealed low-grade instability
and tenderness over the anteromedial corner of
the ankle joint. X-rays showed osteophytes
along the anterior tibial margin but the joint
space was preserved.
Arthroscopy was recommended but reconstruction was not performed because instability was not a symptom. At surgery, significant
impinging osteophytes were seen along the anterior and medial parts of the joint and removed.
A 1cm osteochondral lesion was also noted on
the medial talus and was treated with debridement and curettage. The rest of the articular
surface was normal.
Mr BC recovered over an eight-week period
and at 12 weeks was free of pain. He could run
but was advised to keep this activity to a minimum to reduce the impact on the damaged
ankle.
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or pain of a magnitude
greater than would be
expected should raise suspicions of a pain disorder.
This type of disorder occurs
to some degree in about 5%
of ankle sprains.
Early suspicion and management with treatment such
as sympathetic blockade
provides the best results.
Referral to a pain management physician is generally
recommended.
Prevention
Research into prevention of
ankle sprains suggests that
proprioceptive training and
prophylactic bracing are
useful in reducing the incidence of recurrent ankle
sprains. However, they have
not been proven to prevent
initial injury.
Further reading
Garrick JG. The frequency
of injury, mechanism of
injury, and epidemiology
of ankle sprains. American
Journal of Sports Medicine
1977; 5:241-42.
n Garrick JG. Characterization
of the patient population in
a sports medicine facility.
The Physician and
Sportsmedicine 1985;
13:73-76.
n Freeman M, et al. The
aetiology and prevention
of functional instability of
the ankle. The Journal of
Bone and Joint Surgery.
British Volume 1965;
47:678.
n Sammarco VJ. Principles
and techniques in
rehabilitation of the athlete’s
foot. Part III: Rehabilitation
of ankle sprains. Techniques
in Foot and Ankle Surgery
2003; 2:199-207.
n Hintermann B.
Biomechanics of the
unstable ankle joint and
clinical implications.
Medicine and Science in
Sports and Exercise 1999;
31[suppl]:S459-S469.
n
Online resources
Arthroscopy.com —
Treatment of upper and
lower extremity injuries
including arthroscopy of
the knee, ankle, shoulder,
elbow, and carpal tunnel.
www.arthroscopy.com
n Sports Injury Clinic —
The virtual sports injury
clinic.
www.sportsinjuryclinic.net
n The Park Clinic —
Specialised orthopaedics.
www.theparkclinic.com.au
n About Orthopedics —
www.orthopedics.about.
com/od/sprainsstrains/a/
syndesmosis
n
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Page 32
How to treat – ankle sprains
GP’s contribution
Case Study
DR FIONA ROBINSON
Balmain, NSW
undertake to prevent another
injury?
She should improve her
proprioception and strength
and wear a brace when playing sport.
EMMA is a physically active
12-year-old who enjoys most
sports, particularly tennis
and netball.
A year ago she sustained
an inversion injury to her
right ankle during a tennis
match. This was Emma’s
first ankle injury and the lateral ligament damage was
assessed as grade I.
Treatment included RICE,
followed by physiotherapy,
with increasing mobilisation
and a gradual return to sport.
Four months after the
injury she began a season of
representative netball and all
the members of her team
were advised to wear ankle
braces to prevent injury.
Emma continued to compete at a high level for six
months before she again
‘rolled’ her right ankle. She
was able to limp off the
court and there was minimal
swelling, bruising and no
point tenderness around the
ankle joint.
First aid again was RICE,
but within 24 hours the pain
around her ankle was worse
and bearing weight was a
problem. An X-ray was
taken that day and Emma
General questions for the
author
What is the evidence for
usefulness of ankle guards?
There is ample evidence that
bracing increases the stability
of the ankle. The problem is
braces are often cumbersome
and so not used. Strapping is
more common but loses its
effectiveness after 30 minutes.
In patients without previous
ankle injuries, bracing does not
reduce the risk of injury. It is
most useful in patients with
previous ankle sprains.
was found to have a spiral
fracture of the distal fifth
metatarsal.
She used crutches for several days and a CAM boot
for two weeks until the pain
settled and she started
mobilising again.
With the winter sports
season fast approaching,
Emma and her mother ask
for advice about participation
in netball this year.
How to Treat Quiz
Ankle sprains — 17 March 2006
1. Which TWO statements about the ankle
are correct?
❏ a) Most sporting ankle injuries occur in
jumping activities
❏ b) Anatomical variations in the ankle
ligaments increase the risk of injury
❏ c) Unlike ankle fractures, soft tissue ankle
injuries rarely cause ongoing symptoms
❏ d) The calcaneofibular ligament acts as a
true collateral ligament by preventing talar tilt
2. Santo, 22, injured his left ankle last night
while playing social sport. Which THREE
questions are most likely to give clues to the
type or extent of his injury?
❏ a) Did Santo hear a ‘pop’ or tearing sound?
❏ b) Which sport was he playing?
❏ c) Was he able to continue playing after the
injury?
❏ d) Has he injured his ankle before?
3. Santo has significant swelling and cannot
bear weight, so your examination is limited.
Which TWO actions are you most likely to
take next?
❏ a) Encourage Santo to weight-bear and
review in four days
❏ b) Advise firm bandaging and elevation,
with review in two days
❏ c) Order an X-ray
❏ d) Refer to a physiotherapist to apply a
below-knee plaster
4. Santo returns for review. The swelling has
decreased considerably. Which THREE
examination techniques are most important
in assessing which structure(s) has been
injured?
❏ a) Eliciting localising tenderness
❏ b) Comparing passive and active movements
in both ankles
❏ c) Measuring proprioception
❏ d) Conducting tests for instability
5. When you examine Santo’s left ankle, he
has some lateral ligament laxity but a firm
endpoint on inversion. If he has a grade II
lateral ligament injury, which TWO other
structures are most at risk of injury?
❏ a) Fibula
❏ b) Deltoid ligament
❏ c) Sinus tarsi
❏ d) The anterior calcaneal process
6. The swelling and pain in Santo’s left ankle
have improved and he starts physiotherapy.
Questions for the author
Should Emma play netball
this season?
She would be able to play
if the fracture has healed, she
has regained proprioceptive
control and the ankle feels
stable. She should wear a
brace to play and seek specialist advice if the instability
symptoms continue.
What preparation should she
Does wearing an ankle
guard predispose the patient
to injuries in other parts of
the foot or lower leg?
This does not seem to be
the case.
When ankle ligamentous
injuries occur in childhood,
are they more common in
adulthood as a result?
Yes, and often compound
other problems.
INSTRUCTIONS
Complete this quiz to earn 2 CPD points and/or 1 PDP point by marking the correct answer(s)
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Which THREE treatments are most likely to
be included in his management at this stage?
❏ a) Ice and compression bandaging
❏ b) Resistance training
❏ c) Open chain exercises
❏ d) Proprioception exercises
7. Which TWO statements about tests used
in ankle examination are correct?
❏ a) The anterior drawer test assesses the
integrity of the anterior talofibular ligament
❏ b) The talar tilt test assesses the integrity of
the posterior talofibular ligament
❏ c) The squeeze test assesses the
syndesmosis
❏ d) Joint stability is fully tested using the
anterior drawer and talar tilt tests
8. Greta, 37, has played netball for many
years and often injured her right ankle. She
attends because of persistent deep ankle
pain accompanying weight-bearing since
her last injury, six weeks ago. If Greta has
had an injury to the lateral aspect of the talar
cartilage, which two statements are correct?
❏ a) Greta may describe a locking or catching
sensation
❏ b) The type of injury would have been easily
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diagnosed at the time of trauma
❏ c) Any osteochondral lesion or fragment is
likely to be displaced
❏ d) An X-ray would be the most appropriate
test
9. You think Greta has a grade III lateral
ligament injury but she is slow to respond to
treatment. Which TWO findings would make
you consider an injury to the syndesmosis
unlikely as the cause of her delayed
recovery?
❏ a) Having similar symptoms to those of an
injury to the lateral ligament
❏ b) A history of a torsional force to a fixed foot
❏ c) An MRI showing little disruption to the
ligaments making up the syndesmosis
❏ d) A negative point test
10. Which THREE findings would be
consistent with subluxation of, or injury to,
the peroneal tendons?
❏ a) A normal ultrasound
❏ b) A ‘snapping’ sensation reported by the
patient
❏ c) Delay in reporting symptoms until normal
activities are resumed
❏ d) Absence of symptoms
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HOW TO TREAT Editor: Dr Lynn Buglar
Co-ordinator: Julian McAllan
Quiz: Dr Lynn Buglar
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October.
NEXT WEEK Chronic heart failure is an epidemic that affects at least 300,000 Australians each year, including 30,000 new patients. Get the latest on diagnosis and treatment in next week’s How to Treat.
The authors are Professor Andrew Sindone, director, CHF unit and department of cardiac rehabilitation, Concord Hospital, Sydney, NSW; and Dr Tommy Chung, cardiology fellow, Concord Hospital.
32
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