Acute Ankle Sprain


Article Author:
Scott Melanson


Article Editor:
Victoria Shuman


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
4/13/2019 5:20:19 PM

Introduction

Acute ankle sprains are commonly seen in both primary care practices and emergency departments and can result in significant short-term morbidity, recurrent injuries, and functional instability. Appropriate initial evaluation and treatment can decrease the likelihood of these complications.[1][2][3]

Etiology

Ankle sprains occur when there are stretching or microscopic tears of the ankle ligaments due to overstressing those ligaments. This mechanism may also lead to complete tendon disruptions and fractures of the ankle and foot.

Epidemiology

Females and individuals who participate in court and team sports are more prone to ankle sprains. Ankle sprains may also increase the risk of subsequent ankle injuries.[4]

Pathophysiology

The ankle joint is composed of the articulation of the tibia, fibula, and talus. The joint is stabilized by three ligamentous systems: the lateral ligament complex, the medial deltoid ligament, and the syndesmotic ligaments. The most common ankle injury occurs with inversion of the ankle and stressing the lateral ligament complex. The three ligaments that compose this complex are the anterior talofibular (ATFL), the calcaneofibular (CFL), and posterior talofibular (PTFL) and they tend to be injured in this order with the anterior talofibular ligament being injured most commonly. The ATFL is the weakest ligament of the lateral ligament complex, and approximately 70% of lateral ankle sprains involve only this ligament. The posterior talofibular ligament is injured uncommonly.

The medial deltoid ligament is the strongest of the ankle ligaments and tends to be injured with eversion injuries. The distal tibiofibular syndesmotic ligaments bind the tibia and fibula together, and injuries to this complex have been referred to as “high ankle sprains” and are much less common than other sprains. Given the amount of force required to injure this ligamentous complex, these injuries are distinctly uncommon in the general population and tend to occur primarily in competitive athletes. The most common mechanism of high ankle injuries is external rotation and/or ankle dorsiflexion.

History and Physical

In the evaluation of an ankle injury, a practitioner should elicit a history of the mechanism of injury. The practitioner should also investigate whether the injury involved inversion, eversion, rotational stressing, or direct contact, and take into account a history of previous ankle injuries and the patient's ability to bear weight after the injury.

Physical examination should include inspection, palpation, and functional testing. Each of the three lateral ligaments should be palpated at the anterior (ATFL), inferior (CFL), and posterior (PTFL) aspects of the lateral malleoli. The medial ankle should also be palpated along with the entire fibula. A severe ankle injury, typically involving eversion of the ankle, which disrupts the syndesmosis and fracture of the proximal fibula (Maisonneuve fracture). The foot should also be palpated for associated injuries, particularly over the base of the fifth metatarsal and over the navicular bone (proximal medial foot).

Evidence of a syndesmotic sprain can be elicited with the squeeze test and the external rotation stress test. A positive squeeze test results in pain in the area of the tibiofibular syndesmosis when the mid-calf is compressed and released. To perform the external rotation stress test, externally rotate the dorsiflexed foot. Pain with this maneuver is a positive result and suggests a syndesmotic sprain.

Stability of the ATFL can be assessed with the anterior drawer test. This is performed by stabilizing the distal leg with one hand while the other hands grasp the calcaneus. With the foot in 20 degrees of plantar flexion, the examiner pulls forward on the calcaneus. Greater than 1 cm of translation of the foot compared with the uninjured leg suggests ligamentous laxity.

The talar tilt test also assesses the lateral ankle ligaments for laxity, specifically calcaneofibular ligamentous laxity. The test is performed by stabilizing the distal leg in a neutral position while the examiner inverts the ankle. The degree of inversion is compared with the uninjured ankle. Both the talar tilt test and anterior drawer test can be falsely negative soon after the injury due to pain and muscle spasm.

Evaluation

The Ottawa ankle rules have been demonstrated to be accurate in predicting which patients with ankle injuries require x-rays to exclude fractures in both adult and children older than five years.[5]

The Ottawa ankle rules suggest ankle radiographs should be obtained in the setting of pain in the malleolar region and any of the following:

  • Tenderness over the posterior edge of the distal 6 cm or tip of the lateral malleolus
  • Tenderness over the posterior edge of the distal 6 cm or tip of the medial malleolus
  •  Inability to bear weight immediately after the injury and for four steps at the time of evaluation.

A foot series is indicated in patients with midfoot pain and any of the following: 

  • Tenderness of the base of the fifth metatarsal
  • Tenderness over the navicular bone
  • Inability to bear weight immediately after the injury and for four steps at the time of evaluation

These rules should not be used in the presence of a distracting injury, intoxication, conditions causing diminished lower extremity sensation, and those with head injury or other conditions that would make cooperation difficult. The Ottawa ankle rules have been found to have only moderate specificity but a high sensitivity for ankle fractures. Less than 2% of those in whom no imaging was recommended by these rules have been found to have a fracture.

A typical ankle x-ray series would include anteroposterior, lateral, and mortise views. Standard views with a foot series include anteroposterior, lateral, and oblique views.

Treatment / Management

Initial management of ankle sprains includes the PRICE protocol (protection, rest, ice, compression, and elevation). Resting the injured ankle for the first 72 hours followed by gradual resumption of activity as tolerated is a reasonable approach. Initially, crutches can be used, if needed for comfort. When compared with immobilization, early weight bearing with support (elastic bandage or another source of external support) has been found to improve return to sports, return to work, persistent swelling, the range of motion, and patient satisfaction.[6][7][8][3]

Compression can be achieved with an elastic bandage, any lace-up ankle support, or a semi-rigid or inflatable brace. Elevation of the injured ankle above the level of the heart as frequently as possible for the first 24 to 48 hours may lessen the swelling associated with the injury. The range of motion exercises can be initiated when pain and edema resolve. Nonsteroidal anti-inflammatory drugs or acetaminophen can be used for analgesia.

Patients with evidence of ligamentous laxity should be immobilized, given crutches to allow ambulation without weight-bearing of the injured ankle, and referred to a sports medicine specialist or orthopedic surgeon. Patients suspected of having syndesmotic complex strains should also be referred given that these injuries are often associated with a prolonged recovery.

Mild to moderate ankle sprains typically have a full recovery in 7 to 15 days. Symptoms persisting beyond this period should prompt reevaluation. All symptoms should be resolved before return to sports. For highly competitive athletes, reevaluation by a sports medicine physician for all but mild sprains is reasonable before returning to play to ensure full recovery to avoid recurrent injury and ankle instability.

Complications

  • Chronic pain
  • Ankle instability

Pearls and Other Issues

An important injury that can be mistaken for an ankle sprain is the Maisonneuve fracture. This injury typically occurs with an eversion injury that results in a tear of the deltoid ligament or medial malleolar fracture. The forced eversion causes a complete disruption of the tibiofibular syndesmosis and fracture of the proximal fibula. This injury, therefore, involves the complete disruption of the ligamentous stability of the ankle thus necessitating surgical fixation. In the absence of a medial malleolar fracture, the associated disruption of the ankle mortise may not be evident on the x-ray and ankle films may be completely normal. Weight-bearing views of the injured foot should demonstrate a widened ankle mortise but often are not obtained unless a high index of suspicion is maintained. Tenderness of the proximal calf should also raise suspicion of this injury. When suspected, x-rays of the tibia and fibula should be obtained.

Enhancing Healthcare Team Outcomes

Ankle sprains remain one of the most common musculoskeletal injuries that present to the emergency department. Ankle sprain is frequently seen in certain sports and is best managed by an interprofessional team approach. The key to ankle sprain is to prevent them in the first place and this requires patient education. Healthcare workers including nurses should emphasize the importance of stretching and conditioning to minimize the severity of ankle sprain. A brief period of warm is essential. In addition, the athlete should be encouraged to wear proper shoes and use braces or even taps to further protect the ankle. Finally, patients with ankle sprain should enter physical therapy before returning to their sporting activity.[9][10]


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Acute Ankle Sprain - Questions

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When is the ankle joint most unstable?



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Which is the most frequently injured joint in the body?



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A patient slipped on a waxed floor yesterday and felt a pop and pain at the lateral aspect of the ankle. There was swelling within a few hours and the patient could not bear weight. Now she can walk with a marked limp. The patient has swelling and tenderness over the lateral ankle, some ecchymosis, but no laxity on inversion. Anterior drawer test is negative and there is no bony tenderness. What is the most likely injury?



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Which of the following ligaments is most commonly injured in a lateral ankle sprain?



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What is the best management of a lateral ankle sprain?



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A basketball player falls and twists his right ankle. It is believed that he has suffered an ankle sprain. Which of the following ligaments is most commonly damaged in an ankle sprain?

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A sprained ankle should be initially managed with which of the following?



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What is the best initial care for a minor ankle sprain?



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Which ligament is most commonly injured in ankle sprains?



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A patient sustains an ankle sprain playing soccer. The exam shows grade II anterior talofibular ligament laxity. After the acute pain and swelling subside which of the following would be most appropriate?



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A patient sprains her ankle and is referred for physical therapy. Marked edema is noted and cryotherapy is initiated. Intermittent compression would be of benefit. Which of the following would be an appropriate inflation pressure?



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A patient presents with right ankle pain after he took a jump shot during basketball coming down on his inverted ankle--exam reveals a swollen ankle with anterolateral tenderness, decreased range of motion, no foot tenderness and negative Thompson test-his diagnosis?



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Which of the following is not included in the rationale for applying cold compresses to an acutely sprained ankle?



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What is the most commonly injured ligament in the ankle joint?



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Which of the following should prompt the performance of ankle x-rays in a patient with an ankle injury associated with ankle pain?



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A "high ankle sprain" refers to an injury of which of the following?



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A patient walks into your office complaining of ankle pain after rolling it during a basketball game yesterday. What structures are most likely injured and what is the next best step?



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A 17-year-old boy comes into your office after hurting his ankle in a soccer game one hour ago. The ankle is swollen and tender to palpation on the posterior edge of the lateral malleolus, but he is still able to bear weight on the ankle. Which of the following is the most appropriate next step in management?



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Acute Ankle Sprain - References

References

Koutras C,Antoniou SA,Jäger M,Heep H, Acute Injuries Sustained By Racing Drivers: A Cross-Sectional Study. Acta orthopaedica Belgica. 2017 Dec     [PubMed]
Swords M,Brilhault J,Sands A, Acute and Chronic Syndesmotic Injury: The Authors' Approach to Treatment. Foot and ankle clinics. 2018 Dec     [PubMed]
Slater K, Acute Lateral Ankle Instability. Foot and ankle clinics. 2018 Dec     [PubMed]
Ponkilainen VT,Laine HJ,Mäenpää HM,Mattila VM,Haapasalo HH, Incidence and Characteristics of Midfoot Injuries. Foot     [PubMed]
Kerkhoffs GM,Rowe BH,Assendelft WJ,Kelly K,Struijs PA,van Dijk CN, Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. The Cochrane database of systematic reviews. 2002     [PubMed]
Vuurberg G,Hoorntje A,Wink LM,van der Doelen BFW,van den Bekerom MP,Dekker R,van Dijk CN,Krips R,Loogman MCM,Ridderikhof ML,Smithuis FF,Stufkens SAS,Verhagen EALM,de Bie RA,Kerkhoffs GMMJ, Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British journal of sports medicine. 2018 Aug     [PubMed]
Strudwick K,McPhee M,Bell A,Martin-Khan M,Russell T, Review article: Best practice management of common ankle and foot injuries in the emergency department (part 2 of the musculoskeletal injuries rapid review series). Emergency medicine Australasia : EMA. 2018 Apr     [PubMed]
Wight L,Owen D,Goldbloom D,Knupp M, Pure Ankle Dislocation: A systematic review of the literature and estimation of incidence. Injury. 2017 Oct     [PubMed]
Sprouse RA,McLaughlin AM,Harris GD, Braces and Splints for Common Musculoskeletal Conditions. American family physician. 2018 Nov 15     [PubMed]
Barelds I,van den Broek AG,Huisstede BMA, Ankle Bracing is Effective for Primary and Secondary Prevention of Acute Ankle Injuries in Athletes: A Systematic Review and Meta-Analyses. Sports medicine (Auckland, N.Z.). 2018 Dec     [PubMed]

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