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Lateral Ankle Sprain

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Other Names

  • Ankle sprain
  • Rolled ankle
  • Inversion Ankle Injury
  • Lateral Ankle Sprains (LALS or LAS)
  • Low Ankle Sprain

Background

History

  • Described by Garrick in 1977[1]

Epidemiology

  • General
    • LAS represents most common lower limb musculoskeletal injury in physically active persons[2]
    • Ankle ligament sprains are the most common injury in NCAA sports, accounting for 15% of all reported injuries [3]
    • Overall, ankle injuries represent up to 30% of all injuries in sports[4]
    • Lateral ankle sprains represent 70-90% of all ankle sprains[5]
  • Prevalence
    • 18% of all sports injuries in the Netherlands were ankle injuries between 2000-2004[6]
  • Incidence
    • Roughly 1 inversion ankle injury occurs per 10,000 people each day in the UK (need citation)
    • 2.15 per 1000 person years in the US[7]
    • Reported to be between 0.324 and 9 per 1000 h of activity[8]
  • Location/ Surface/ Sport
    • Indoor /court sports had the highest incidence rates estimated as 7 ankle sprains per 1000 exposures[9]

General

Illustration of lateral view of ankle joint with ligaments, bones and tendons labeled
  • Injury mechanism is characterized by a high velocity inversion and internal rotation of the ankle/foot complex
  • Particularly prevalent in field and court sports
  • Vast majority will self resolve in 4-6 weeks, although some may persist for years

Etiology

  • General
    • Occurs due exaggerated, high force inversion and plantarflexion
    • Leads to stretching, tearing or rupture of the lateral ankle ligaments
    • Typically in a sequential pattern depending on severity
    • Starts with anterior talofibular ligament (ATFL) followed by calaneofibular ligament (CFL) followed by posterior talofibular ligament (PTFL)[10]
  • First contact mechanism[11]
    • Due to player-to-player contact with impact by an opponent on the medial aspect of the leg
    • Occurs just before or at foot strike, resulting in a laterally directed force across the ankle
    • This causes the player to land with the ankle in a vulnerable, inverted position
  • Second contact mechanism
    • Forced plantar flexion where the injured player hit the opponent’s foot when attempting to shoot or clear the ball.

Associated Conditions

Pathoanatomy


Risk Factors

  • General
    • Female > Male[9]
    • Young athletes (under 12) > adolescents (12-18) > adults[9]
    • Height ?
    • Weight
  • Orthopedic
  • Occupation
  • Sports
    • Netball
    • Volleyball
    • Hockey
    • Football
    • Basketball
    • Soccer[15]
  • Type of foot wear
  • Type of supportive device

Differential Diagnosis

Differential Diagnosis Ankle Pain


Clinical Features

Clinical demonstration of anterior drawer test of the ankle[16]

History

  • Athletes typically report a sudden twisting of the ankle joint
  • They may have an inability to bear weight
  • They usually can identify the palpatory painful spot
  • Also endorse swelling, bruising (may be subacute)
  • Inability to return to sport
  • Sometimes endorse a snap or crack

Physical Exam: Physical Exam Ankle

  • Palpate all bony and soft tissue structures (see: Ottawa Ankle Rules)
  • If no pain along ATFL distribution, likely not a standard LAS

Special Tests


Evaluation

Diagnostic ultrasound of the anterior talofibular ligament demonstrating acute rupture with hypoechoic fluid collection. Case courtesy of Dr Maulik S Patel.[17]

Radiographs

Ultrasound

  • Van Dijk et al[18]
    • Early on they found sensitivity 92%, specificity 64%
    • Inconclusive physical exam they found sensitivity 100%, specificity 72%
  • Among ED physicians, accuracy was similar to MRI[19]

MRI

  • Useful when other soft tissue injuries are suspected
    • Tendinous and syndesmotic trauma
    • Osteochondral lesions
    • Occult fractures
  • Joshy et al: sensitivity 92-100%, specificity 100%[20]
  • In comparison with arthroscopy, MRI (93%) was superior to US (63%) in correctly locating the injured portion of the ATFL[21]

Classification

  • Grade I (mild)
    • Injury: ligament fiber stretch without macroscopic rupture
    • Clinically minor swelling, palpatory tenderness
    • Hardly any functional loss
    • No increased instability
  • Grade II (moderate)
    • Injury: partial ligament tear
    • Moderate pain, swelling and palpatory tenderness
    • Mild to moderate instability
    • Moderate functional disability
  • Grade III (severe)
    • Injury: complete tear of the ligament and joint capsule rupture
    • Severe bruising, swelling, and pain
    • Significant loss of function and an increased instability
    • Unable to bear weight and walk normal

Management

Nonoperative

  • Indications
    • Vast majority of cases
  • PRICE Therapy
    • Typically for the first 3-5 days[22]
  • NSAIDS
    • Oral or topical appear to help[23]
  • External Support
    • Doherty et al: MA, SR found external support (taping, bracing and orthoses) is effective for improving function[24]
    • Duration of total immobilization should be brief and early mobilization should be encouraged
    • By 1-2 weeks transition to External Ankle Brace
    • No difference between tape, semi rigid brace or lace up brace at 6 months[25]
  • Physical Therapy
    • Doherty et al: MA, SR found PT improves self reported function[24]
    • Early PT combined with progressive weight bearing[26]
  • Manual Therapy
    • Unclear whether manual therapy helps with function[24]
  • Ice Therapy
    • Appears to help as a component of RICE management when combined with physical therapy[24]
  • Acupuncture
    • May have some benefit in SR/MA but overall evidence is lacking due to low methodological quality[27]
  • Unknown benefit[24]

Operative

  • Indications
    • Unknown
  • Technique
    • Primary reconstruction

Rehab and Return to Play

Rehabilitation

  • General
    • Progressive weight bearing
    • Early active range of motion (ROM) exercises
    • Followed by strengthening exercises, proprioceptive training, and functional exercises
  • Final phase of rehab
    • Progressively simulate the physical demands of the respective sport modality
    • Often includes jumping, turning, and twisting
  • Several rehab programs have been suggested
    • National Athletic Trainers Association[28]
    • Renstrom et al protocol[29]
    • Zoch et al protocol[30]
  • Postoperative[31]
    • 1-2 weeks: lower leg cast
    • 2-4 weeks: walking boot, active rehab

Return to Play

  • General
    • Difficult to predict when an athlete can RTP
    • No formal consensus guidelines or criteria
    • Consider use of the Foot And Ankle Outcome Score (FAOS), which is not currently validated[32]
    • Time for RTP depends on several factors including severity of the injury, ability of the athlete, available resources
  • Performance based
    • Athlete should be able to progress from simple tasks to complex tasks
    • Perform 90% of of function compared to unaffected ankle
    • Progress through sport specific tasks
  • Modalities
    • Proprioception
    • Balance (wobble board)

Prognosis and Complications

Prognosis

  • Nonoperative vs Operative
    • Surgical intervention associated with increased cost, risk of complications (wound infection, nerve injury, dystrophy, poor wound healing)[24]
    • Nonoperative vs operative management of grade III have failed to demonstrate a superior modality, thus nonoperative management is often the preferred approach[33]
  • Prevention of recurrence
    • PT helps with prevention of recurrence[24]
  • Missed time
    • Mean lay off per ankle sprain in soccer is reported between 7 and 18 days[34]
    • 83–89% of the ankle sprains require athletes less than 4 weeks of loss of activities[35]
    • RTP after surgical management ranged from 77 to 105 days in one study by Pearce[31]
  • Return to play
    • The vast majority of athletes will return to full pre-injury level of play
    • Important to distinguish the complex injuries from the simple single ligament injuries

Complications

  • Persistent ankle laxity, pain, weakness
    • Up to 30% of patients show objective mechanical laxity, subjective instability up to 1 year after an initial ankle sprain[36]
    • Up to 40% of the patients in the general population report residual symptoms despite appropriate treatment[37]
  • Re-injury/ sprain
    • Risk of re-sprain within a period of 3 years after the initial ankle sprain ranges from 3% to 34%[38]
    • External bracing can reduce risk of reinjury by up to 70%[39][40]
  • If untreated, patients can develop
  • Chronic disability
  • Decreased physical activity
  • Increased Fall Risk in geriatric patients[42]

See Also

Internal

External


References

  1. Garrick JG. The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. Am J Sports Med 5: 241–242, 1977.
  2. Waterman B, Owens B, Davey S, et al. The epidemiology of ankle sprains in the United States
  3. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train 2007;42:311–19.
  4. Fong DT, Hong Y, Chan LK, et al. A systematic review on ankle injury and ankle sprain in sports. Sports Med 2007; 37 (1): 73–94
  5. Hawkins RD, Hulse MA, Wilkinson C, Hodson A, Gibson M. The association football medical research programme: an audit of injuries in professional football. Br J Sports Med. 2001;35(1):43–7.
  6. Schmikli SL, Kemler HJ, Backx FJG. Blessureleed in de sport 2000–2004. In: Hildebrandt VH, Ooijendijk WTM, Hopman-Rock M, editors. Trendrapport Bewegen en Gezondheid 2000/2005. Leiden: TNOKwaliteit van Leven, 2007
  7. O’Connor SR, Bleakley CM, Tully MA, Suzanne M. McDonough: Predicting functional recovery after acute ankle sprain. PLoS One 8(8): e72124, 2013.
  8. Cloke DJ, Ansell P, Avery P, Deehan D. Ankle injuries in football academies: a three-centre prospective study. Br J Sports Med. 2011;45(9):702–8.
  9. 9.0 9.1 9.2 Doherty C, Delahunt E, Caulfield B, Hertel J, Ryan J, Bleakley C. The incidence and prevalence of ankle sprain injury a systematic review and meta-analysis of prospective epidemiological studies. Sports Med, 2013
  10. St Pierre RK, Rosen J, Whitesides TE, Szczukowski M, Fleming LL, Hutton WC. The tensile strength of the anterior talofibular ligament. Foot Ankle. 1983;4(2):83–5.
  11. Andersen TE, Floerenes TW, Arnason A, et al. Video analysis of the mechanisms for ankle injuries in football. Am J Sports Med 2004;32(1 Suppl):69s–79s.
  12. Vereijken AJ (2012) Risk factors for ankle sprain injury in male amateur soccer players: a prospective cohort study. http://dspace.library.uu.nl/handle/1874/252485.
  13. Cameron KL, Owens BD, DeBerardino TM. Incidence of ankle sprains among active-duty members of the United States armed services from 1998 through 2006. J Athl Train. 2010;45:29–38.
  14. Bronner S, Brownstein B. Profile of dance injuries in a Broadway show: a discussion of issues in dance medicine epidemiology. J Orthop Sports Phys Ther. 1997;26:87–94.
  15. Woods, Carol, et al. "The Football Association Medical Research Programme: an audit of injuries in professional football: an analysis of ankle sprains." British journal of sports medicine 37.3 (2003): 233-238.
  16. McGovern, Ryan P., and RobRoy L. Martin. "Managing ankle ligament sprains and tears: current opinion." Open access journal of sports medicine 7 (2016): 33.
  17. https://radiopaedia.org/cases/86361
  18. Van Dijk CN, Mol BW, Lim LS, Marti RK, Bossuyt PM. Diagnosis of ligament rupture of the ankle joint. Physical examination, arthrography, stress radiography, and sonography compared in 160 patients after inversion trauma. Acta Orthop Scand. 1996;67(6):566–70.
  19. Gün C, Unlüer EE, Vandenberk N, Karagöz A, Sentürk GO, Oyar O. Bedside ultrasonography by emergency physicians for anterior talofibular ligament injury. J Emerg Trauma Shock. 2013;6(3):195–8.
  20. Joshy S, Abdulkadir U, Chaganti S, Sullivan B, Hariharan K. Accuracy of MRI scan in the diagnosis of ligamentous and chondral pathology in the ankle. Foot Ankle Surg. 2010;16(2):78–80.
  21. Oae K, Takao M, Uchio Y, Ochi M. Evaluation of anterior talofibular ligament injury with stress radiography, ultrasonography, and MR imaging. Skelet Radiol. 2010;39(1):41–7.
  22. Bleakley CM, Glasgow P, MacAulley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med 2012. 2011;46:220–1. https://doi.org/10.1136/bjsports-2011-090297.
  23. van den Bekerom MP, Sjer A, Somford MP, Bulstra GH, Struijs PA, Kerkhoffs GM. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating acute ankle sprains in adults: benefits outweigh adverse events. Knee Surg Sports Traumatol Arthrosc. 2015;23(8):2390–9.
  24. 24.0 24.1 24.2 24.3 24.4 24.5 24.6 Doherty, Cailbhe, et al. "Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis." British journal of sports medicine 51.2 (2017): 113-125.
  25. van den Bekerom MP, van Kimmenade R, Sierevelt IN, Eggink K, Kerkhoffs GM, van Dijk CN, et al. Randomized comparison of tape versus semi-rigid and versus lace-up ankle support in the treatment of acute lateral ankle ligament injury. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):978–84.
  26. Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. 2007;2:CD000380.
  27. Park J, Hahn S, Park J-Y, et al. Acupuncture for ankle sprain: systematic review and meta-analysis. BMC Complement Altern Med 2013;13:55.
  28. Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, et al. National Athletic Trainers’ association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013;48(4):528–45.
  29. Renström PA, Konradsen L. Ankle ligament injuries. Br J Sports Med. 1997;31(1):11–20.
  30. Zöch C, Fialka-Moser V, Quittan M. Rehabilitation of ligamentous ankle injuries: a review of recent studies. Br J Sports Med. 2003;37(4):291–5.
  31. 31.0 31.1 Pearce CJ, Tourné Y, Zellers J, Terrier R, Toschi P, Silbernagel KG, et al. Rehabilitation after anatomical ankle ligament repair or reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1130–9.
  32. Roos EM, Brandsson S, Karlsson J. Validation of the foot and ankle outcome score for ankle ligament reconstruction. Foot Ankle Int. 2001;22(10):788–94.
  33. Petersen W, Rembitzki IV, Koppenburg AG, Ellermann A, Liebau C, Brüggemann GP, et al. Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg. 2013;133(8):1129–41.
  34. Waldén M, Hägglund M, Ekstrand J. Time-trends and circumstances surrounding ankle injuries in men’s professional football: an 11-year follow-up of the UEFA champions league injury study. Br J Sports Med. 2013;47(12):748–53.
  35. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports. 2011;45(7):553–8.
  36. Hubbard TJ, Hicks-Little CA. Ankle ligament healing after an acute ankle sprain: an evidence-based approach. J Athl Train 2008 Sep-Oct; 43 (5): 523–9
  37. Ferran NA, Maffulli N. Epidemiology of sprains of the lateral ankle ligament complex. Foot Ankle Clin. 2006;11(3):659–62.
  38. van Rijn RM, van Os AG, Bernsen RM, et al. What is the clinical course of acute ankle sprains? A systematic literaturereview. Am J Med 2008 Apr; 121 (4): 324–31
  39. Dizon JM, Reyes JJ. A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players. J Sci Med Sport. 2010;13(3):309–17.
  40. Sharpe SR, Knapik J, Jones B. Ankle braces effectively reduce recurrence of ankle sprains in female soccer players. J Athl Train. 1997;32(1):21–4.
  41. Harrington KD. Degenerative arthritis of the ankle secondary to long-standing lateral ligament instability. J Bone Joint Surg Am 1979; 61 (3): 354–61
  42. Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: a prospective study. The Journals of Gerontology: Series A. 2006;61:866–70.
Created by:
John Kiel on 7 July 2019 08:16:21
Last edited:
30 November 2023 16:24:49
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