Ankle Sprains Lat-Hi Sprains M Casillascme.uthscsa.edu/Presentations/Sports13/011813/14_Ankle...

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Ankle Sprains:Lateral and High Sprains

Financial Disclosure

• Dr. Mark Casillas has no relevant financial relationships with commercial interests to disclose.

Outline

• Ankle Anatomy• Ankle Biomechanics• Pathologic Anatomy • Classification• Differential Diagnosis• History • Physical Examination• Imaging• Treatment

Outline

Ankle Anatomy

• Bony Stability• Soft Tissue Stability

Malleolar Length

Talar Width

Soft Tissue Stability

• Ankle ligaments• Joint capsule

Ankle Ligaments

• Lateral • Medial • Syndesmosis

Ankle Ligaments

• Lateral• Medial • Syndesmosis

Ankle Ligaments

• Lateral • Medial • Syndesmosis

Lateral Ankle Ligaments

• ATFL (3)• CFL (4)• PTFL (5)

Alexander I J, The Foot: Examination and Diagnosis

ATFL• Origin

– anterior fibula

• Insertion– lateral talar neck

• Dimension• Orientation

• Origin– tip of the fibula

• Insertion– lateral calcaneus

• Dimension • Orientation

Medial Ankle Ligaments

• Deltoid – Superficial (3)– Deep (1,2,4)

Syndesmosis Ligaments

• AITFL (2)• PITFL (1)• IOL

Outline

Isolated Stress Testing

• ATFL first to fail • Deep deltoid last to fail

Neutral Dorsiflexion

• ATFL is perpendicular to the axis of the tibia

• CFL is oriented parallel to the tibia

• CFL provides resistance to varus tilt of the talus

Plantarflexion

• ATFL is oriented parallel to the tibia

• CFL is perpendicular to the axis of the tibia

• ATFL provides resistance to varus tilt of the talus

Putting It All Together…Neutral Dorsiflexion

• Best ligament stability• Best bony stability

Plantarflexion

• Weak ligament stability• Poor bony stability

Outline

Pathologic Anatomy of Lateral Ankle Ligament Injury

• Broström, Acta Chir Scand, 1964• Surgical exploration of 105 recent ankle sprains

• ATFL most commonly injured• CFL second most commonly injured

Pathologic Anatomy of Lateral Ankle Ligament Injury

• Disruption of capsular mechanoreceptors – loss of afferent nerve function– loss of ankle motor coordination

Syndesmosis Injury

• The syndesmosis – Stabilizes distal tibia and fibula– Keeps talus under the tibia

• The tibio‐talar surface – Must be perfectly matched– 1 mm lateral shift increases joint surface pressure by 42%

Syndesmosis Injury

• A failed syndesmosis – Leads to lateral translation– tibio‐talar pressure– Promotes ankle arthritis– Results in a loss of function

Outline

Classification

• AMA and O’Donoghue – Stretch– Partial tear– Complete rupture

• Additional information with regard to associated ligamentous injuries

Outline

Differential Diagnosis• ATFL sprain• CFL sprain• Syndesmosis sprain• Deltoid sprain• Subtalar sprain• Subtalar coalition• Bifurcate sprain• Peroneal instability• Peroneal tendon tear• Lateral malleolus fracture• Talar dome fracture• Anterior process fracture• Fifth metatarsal fracture

Ankle Sprain

Differential Diagnosis• ATFL sprain• CFL sprain• Syndesmosis sprain• Deltoid sprain• Subtalar sprain• Subtalar coalition• Bifurcate sprain• Peroneal instability• Peroneal tendon tear• Lateral malleolus fracture• Talar dome fracture• Anterior process fracture• Fifth metatarsal fracture

Ankle Sprain

Not an Ankle Sprain

When An Ankle Sprain Is Not An Ankle Sprain• Subtalar sprain• Subtalar coalition• Bifurcate sprain• Peroneal instability• Peroneal tendon tear• Lateral malleolus fracture• Talar dome fracture• Anterior process fracture• Fifth metatarsal fracture

Subtalar Sprain (Dislocation)

Subtalar Coalition

Bifurcate Ligament Sprain

Surgical Atlas of the Musculoskeletal System, AAOS, 2008

Peroneal Instability

Peroneal Tendon Tear

Lateral Malleolus Fracture

Talar Dome Fracture

Anterior Process Fracture

Fifth Metatarsal Fracture

Outline

• Ankle Anatomy• Ankle Biomechanics• Pathologic Anatomy • Classification• Differential Diagnosis• History• Physical Examination• Imaging• Treatment

History

• Previous injury• Mechanism• Ability to continue play

• Current complaints

Outline

Physical Examination

• Systematic approach• Inspection • Palpation • Provocative

maneuvers

Provocative Maneuvers

• Resisted motor function • Squeeze test• Stress tests

– varus– valgus– external rotation

Resisted Motor Function

Squeeze Test

• Syndesmosis injury• Compress mid‐leg • Pain at syndesmosis • Must first rule‐out

– fracture– contusion– compartment syndrome

Stress Tests

• Clinical and radiographic tool

• Grading ankle sprains• Inadequate for

reproducible diagnosis of lateral ankle ligament injuries

Anterior Drawer

• ATFL disruption– Contralateral comparison – Normal translation– False negative results– Local anesthesia

Anterior Drawer

Talar Tilt

• ATFL/CFL disruption– Neutral and plantarflexion tests– Contralateral comparison – Normal tilt– False negative results– Local anesthesia

External Rotation Stress Test

• Syndesmosis injury• Knee forward facing• Examiner applies ER• Pain at syndesmosis

Outline

Radiographs

• AP, mortise, and lateral– malleolar fx– physeal fx– osteochondral fx– avulsion fx– alignment– translation

Radiographs

• Weight bearing– physiologic loading– not always obtainable

Bilateral Stress Radiograph

• Quantify – anterior translation – varus tilt

• Not routine• 3‐15º > contralateral• Absolute > 9º• No consensus

Magnetic Resonance Imaging

• ATFL

• Associated injuries– talar dome – subchondral bone– peroneal tendons– interosseous ligament

– cervical ligament– tarsal coalition

Syndesmosis Imaging

• X‐ray– Standing– ER stress test– Comparison view– Alignment– Associated injuries Non-WB ER Stress

Imaging

• X‐ray– Standing– ER stress test– Comparison view– Alignment– Associated injuries

Syndesmosis Imaging

CT– Axial – Comparision– Alignment– Associated injuries

Syndesmosis Imaging

MR– AITFL injury– Alignment– Associated injuries

Outline

Lateral Ankle Sprain Treatment

• Grade I and II• Grade III• Chronic Instability

Grade I and Grade II Sprains

• RICE method • Gentle ROM • Protected weightbearing• Non‐rigid functional ankle brace

Grade III Sprains

• Early mobilization• Cast immobilization• Surgical repair

Grade III‐ Early Mobilization

• Functional treatment– Early WB– Early rehabilitation – Semi‐rigid pneumatic

ankle brace

• Favored method• Avoids cast

immobilization

Grade III‐Cast Immobilization

• Short leg walking cast • Early return to work • Early discontinuation of crutch walking

• Improved compliance • Rehab delayed by 1‐2 weeks

Grade III‐Surgical Repair

• Anatomic repair• Predictable, good results

• No advantage over non‐surgical tx

Rehabilitation For All Ankle Injuries:Acute Phase

• Pain• Inflammation

Acute Phase

• Rest• Cold therapy• Whirlpool • Ankle and subtalar

flexibility • Isometrics • Weight bearing to

tolerance

Sub‐acute Phase

• Heat therapy • Flexibility • Strengthening • Closed chain• Cross‐training• Cold therapy

Sub‐acute Phase

Return to Sport Phase

• Protective bracing• Range of motion• Strength activities • Progressive activity• Avoid re‐injury

Chronic Instability

• Mechanical instability • Functional instability

– frequent sprains– difficulty running on uneven surfaces– difficulty jumping– difficulty cutting

Chronic Instability‐ Rehabilitation

• Non‐rigid functional ankle brace– Velcro– Lace‐up

• Acute Phase• Sub‐acute Phase• Return to Sport Phase

Chronic Instability‐ Surgical

• Failed supervised rehabilitation• Broström• Tenodesis• Arthroscopy

Broström

Anterior Drawer

Talar Tilt

Broström

Pre‐op Post‐op

Tenodesis

Arthroscopy

Ankle Arthroscopy

• General Anesthesia

• Supine, foot off the table

Portals

• Medial • Lateral

Ankle Arthroscopy

• Extra‐articular soft tissue approach first

• Blunt technique• Small and large scopes

• Gravity inflow

Syndesmosis Treatment

• Grade I and II• Grade III• Chronic Instability

Grade I and Grade II Sprains

• RICE method • Cast or cast boot• Gentle ROM • Tape or non‐rigid functional ankle brace for return to sport

Return to Sport Phase

• Protective taping to resist ER

• Bracing• Range of motion• Strength activities • Progressive activity• Avoid re‐injury

Grade III Sprains

• Surgical repair

Grade III Injury with Fracture

Screw Removal

• WB after screw removal• WB with screw

– Physiologic motion• Osteolysis• Screw failure• Pain• Prominent hardware

Complications

• Instability• Persistent pain• Ossification

Ankle Sprains Lat-Hi Sprains M Casillascme.uthscsa.edu/Presentations/Sports13/011813/14_Ankle...

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