Ankle Injuries:Sprains and More

Ankle Injuries:Sprains and More

John F. Meyers M.D.John F. Meyers M.D.

Bony AnatomyBony Anatomy

• Tibia

• Fibula

• Talus

• Tibia

• Fibula

• Talus

Mortice and Tenon JointMortice and Tenon Joint

Lateral LigamentsLateral Ligaments

• Anterior talofibular• Calcaneofibular• Posterior talofibular

• Anterior talofibular• Calcaneofibular• Posterior talofibular

Medial ligamentsMedial ligaments

• Deltoid• Deltoid

Mechanism of InjuryDefinitions

Mechanism of InjuryDefinitions

• Plantar flexion: toes down• Dorsiflexion: Toes up• Inversion: Heel in• Adduction: Heel in• Eversion: Heel out• Abduction: Heel out

• Plantar flexion: toes down• Dorsiflexion: Toes up• Inversion: Heel in• Adduction: Heel in• Eversion: Heel out• Abduction: Heel out

Inversion InjuryInversion Injury

Eversion InjuryEversion Injury

External Rotation InjuryExternal Rotation Injury

Ankle Sprain OccurrenceAnkle Sprain Occurrence

• 27,000 ankle ligament injuries per day in United States

• Ankle sprains are more than 25% of injuries in football, basketball, soccer and volleyball

• 27,000 ankle ligament injuries per day in United States

• Ankle sprains are more than 25% of injuries in football, basketball, soccer and volleyball

Making The DiagnosisHistory

Making The DiagnosisHistory

• Mechanism of injury– Plantar flexion and inversion– Uneven terrain-stepping in a hole– Landing on another player’s foot– Teammate on back of ankle while foot is externally

rotated

• Mechanism of injury– Plantar flexion and inversion– Uneven terrain-stepping in a hole– Landing on another player’s foot– Teammate on back of ankle while foot is externally

rotated

Making The DiagnosisHistory

Making The DiagnosisHistory

• Audible pop• Immediate swelling• Inability to bear weight• These are all signs of a more severe injury

• Audible pop• Immediate swelling• Inability to bear weight• These are all signs of a more severe injury

Physical ExaminationPhysical Examination

• Observe for:– Swelling– Deformiity

• Palpate for tenderness– Ligaments– Bones

• Observe for:– Swelling– Deformiity

• Palpate for tenderness– Ligaments– Bones

Physical ExamDrawer test

Physical ExamDrawer test

• ATFL

• >4mm difference

• ATFL

• >4mm difference

Physical ExamTalar Tilt TestPhysical ExamTalar Tilt Test

• CFL

• > 6° difference

• CFL

• > 6° difference

Physical ExamSqueeze TestPhysical ExamSqueeze Test

• Anterior tibiofibular ligament

• High ankle sprain

• Anterior tibiofibular ligament

• High ankle sprain

Physical ExamExternal Rotation Test

Physical ExamExternal Rotation Test

• Anterior tibiofibular ligament

• High ankle sprain

• Anterior tibiofibular ligament

• High ankle sprain

Physical ExamPalpation

Physical ExamPalpation

• Length of tenderness predicts severity

• One week for each cm above ankle joint

• Length of tenderness predicts severity

• One week for each cm above ankle joint

Classification and Return to SportClassification and Return to Sport

• Grade I 7-14 days

• Grade II 2-6 weeks

• Grade III 4-26 weeks

• High ankle sprain 1 week per cm

• Grade I 7-14 days

• Grade II 2-6 weeks

• Grade III 4-26 weeks

• High ankle sprain 1 week per cm

Differential DiagnosisPhyseal Fractures OCDDifferential Diagnosis

Physeal Fractures OCD

Differential DiagnosisDifferential Diagnosis

Jones FractureJones Fracture Peroneal Tendon SubluxationPeroneal Tendon Subluxation

Treatment RICETreatment RICE

• Rest

• Ice

• Compression

• Elevation

• Rest

• Ice

• Compression

• Elevation

Treatment Grade I and IIFunctional Bracing

Treatment Grade I and IIFunctional Bracing

Treatment Grade III and SyndesmosisTreatment Grade III and Syndesmosis

Surgery or cast – NO!Functional Bracing –YES!

Surgery or cast – NO!Functional Bracing –YES!

• Return to work 2 to 4 times sooner• No difference in long term stability• No surgical complications• 87% excellent and good results with bracing• 60% excellent and good results with surgery

• Return to work 2 to 4 times sooner• No difference in long term stability• No surgical complications• 87% excellent and good results with bracing• 60% excellent and good results with surgery

RehabilitationRehabilitation

• Decrease swelling• Regain range of motion• Strengthen muscles• Balance and proprioceptive training• Functional drills

• Decrease swelling• Regain range of motion• Strengthen muscles• Balance and proprioceptive training• Functional drills

Balance and ProprioceptionBalance and Proprioception

Return to PlayReturn to Play

• Run without pain or limitations

• Sport specific movements without pain or limitation

• 90% strength• Protective brace

• Run without pain or limitations

• Sport specific movements without pain or limitation

• 90% strength• Protective brace

Failure to RecoverGiving Way and Recurrent Sprains

Failure to RecoverGiving Way and Recurrent Sprains

Rehabilitation Bracing Surgical reconstruction

of ligaments

Rehabilitation Bracing Surgical reconstruction

of ligaments

Failure to RecoverIntra Articular Problems

Failure to RecoverIntra Articular Problems

• OCD• Loose bodies• Bone spurs• Arthritis• Soft tissue impingment

• OCD• Loose bodies• Bone spurs• Arthritis• Soft tissue impingment

PreventionPrevention

• High top shoes• Taping• Shoes and tape• Braces

• High top shoes• Taping• Shoes and tape• Braces

PreventionPrevention

• Conditioning– Agility– Flexability

• Proprioception• Strengthening• Stretching and warming up• Recognize effects of fatigue

• Conditioning– Agility– Flexability

• Proprioception• Strengthening• Stretching and warming up• Recognize effects of fatigue

Thank You

Orthopaedic Research of Virginia

Thank You

Orthopaedic Research of Virginia