Stephanie M Chu, DO

Assistant Professor

University of Colorado SOM

Team Physician Colorado Buff aloes

Evaluation of Ankle Injuries in Primary Care

Objectives

Review ankle anatomy

Clinical examinationAnkle sprainsTreatment options

Ankle AnatomyArticular

Ligamentous

Functional

Anatomy of the Ankle Articular congruity

Between talus and tibia, talus and calcaneus Ligamentous stability

Tib-fib ligament (Syndesmotic ligament)Lateral ligament complexDeltoid ligamentSubtalar ligaments

Bony Anatomy

TibiaFibulaTalusNavicularCalcaneusBase of 5th

Metatarsal

Lateral Ligaments

Lateral Ligamentous Complex

ATFL Arises from anterior

border of tip of fibula and inserts on the neck of talus

Parallel to axis of foot in neutral position

Parallel to axis of tibia in plantarflexion

DeLee & Drez

Medial Ligaments

Posterolateral Ligaments

Posterior Lateral Ligamentous Complex PTFL

Arises from posterior tip of fibula and inserts on posterior process of talus

ATFL & PTFL Resist AP motion of

the talus relative to the fibula

DeLee & Drez

Posterior Lateral Ligamentous Complex CFL

Arises from tip of fibula and inserts on lateral calcaneus

Forms the floor of the peroneal tendon sheath

Resists inversion

DeLee & Drez

Functional Anatomy Normal ROM

highly variable DF ranges from

10-50 degrees PF ranges from

15-60 degrees Functional ROM

from 10 deg DF to 50 deg PF

Functional Anatomy Subtalar motion

Supination – combination of inversion, adduction, internal rotation

Pronation – combination of eversion, abduction, external rotation

Functional Anatomy Lateral ligamentous

complex Anterior talofibular

ligament (ATFL) Calcaneofibular

ligament (CFL) Posterior talofibular

ligament (PTFL) Ligaments

continuous with capsular connective tissue

Clinical Evaluation

History Description of

injuryPosition of footDirection of force

Previous h/o ankle sprainResolution of

symptomsChronic laxity or

instability Use of tape/braces

Previous treatment Ability to bear

weight Symptoms

Onset of pain Location Duration of pain Feeling of “giving

way”

Ankle Sprains

FactsMost common injury in sports – 25%Estimated 1 inversion injury/10,000

persons/dayMost frequent in basketball, volleyball,

soccer, footballMajority < 35yrsMost often between ages 15-19Certain populations (US military service

personnel) as high as 35%

Definition “Ankle injury that

occurs when a person stumbles and the supporting foot twists, resulting in

damage to the ligaments.”

Injury Patterns

Most common – “inversion sprain”Combination of inversion and adduction of foot

in plantar flexionDamage to lateral ligament complex of ankle

Eversion sprainsDamage to deltoid ligament

‘High’ ankle sprainDamage to ankle syndesmosis and tibiofibular

ligaments

Mechanism of Injury

Classification of InjuriesGrade I (mild)

Mild ligament stretching

No macroscopic tearing

StableMin tenderness or

swellingMin functional loss

Classification of InjuriesGrade II (moderate)

Partial macroscopic tearing

Moderate tenderness or swelling

Mild to moderate instability

Classification of InjuriesGrade III (severe)

Complete rupture of ligaments

Marked pain, swelling, ecchymosis

Abnormal joint motion (instability)

Decreased functionSoft or no “end

point”

Clinically, grading can be subjective, especially in acute

setting without radiologic modalities (diagnostic

ultrasound or MRI) to confirm.

Clinical EvaluationPhysical Examination

ObservationLocation of ecchymosis, swelling

PalpationPoint of maximal tendernessMedial pain – may be indicative of concussive

injury to deltoid ligamentTenderness over fibula or talus may indicate

fractureAssociated injuries to midfoot, 5th metatarsal, prox

fibula

Clinical EvaluationPhysical Examination (compare to uninjured

ankle)ROMStability testing

Anterior drawer (ATFL)Talar tilt (CFL, ATFL)Syndesmosis

External rotation testSqueeze test

Radiographic EvaluationPlain radiographs

Standard AP/lat/mortise viewsStress radiographs

Ant drawer & talar tilt thought to be inadequate predictors of functional stability

Can be useful for syndesmotic injuriesArthrography

Rarely used

When do we get

radiographs???

Ottawa Ankle Rules

Ankle FracturesSensitivity = 98-

100%Specificity = 31%

Ankle = Pain around the malleoli and ONE of the following:Inability to bear weight immediately following

injury AND in ED (four steps)Bone tenderness 6 centimeters up posterior

edge of the tibia and fibula

Palpation – Ottawa Ankle Rules

Radiographic EvaluationBone scan

May have a role in syndesmotic injuriesCT scan

Useful for evaluation of OCD lesions, loose bodies, syndesmotic widening

MRI Useful for determining soft tissue injury, OCD,

associated tendon injures

Treatment

TreatmentAcute ankle sprains

Grade I and IIFunctional rehab

Includes brief period of immobilization (taping, functional braces statistically better than immobilization)

Lace-up supports more effective than tape

Early ROM, followed by strengthening and proprioceptive exercises

Seah, Richard, and Sivanadian Mani-Babu. "Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence." British medical bulletin 97.1 (2011): 105-135.

TreatmentGrade III

Somewhat controversialEvidence suggest semi-rigid orthoses

and pneumatic bracing provide beneficial ankle support to prevent recurrent sprains

Numerous studies have shown that functional rehab results similar to surgical outcomes

TreatmentChronic ankle sprains

Functional rehabilitationRole in recovery May attempt for as long as 6 monthsStudies have shown that delayed

functional rehab can still be successful

Functional Rehabilitation

Risk FactorsPrevious history of

ankle sprainLigament hyperlaxityPoor sensorimotor

controlAxial/foot alignmentPlantar/dorsiflexion

strengthInversion/Eversion

strengthGender/sport

No significant difference

PreventionTaping

Shown to be effective for initial stabilizationAids in proprioception

BracesShown to be effective in athletes with h/o

previous sprainsProphylactic proprioceptive training

More effective in athletes with h/o previous sprains

THANK YOU!