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Medial Ankle Sprain
From WikiSM
Contents
Other Names
- Deltoid Sprain
- Medial Ligament Sprain
- Medial Ankle Complex Sprain
- Deltoid Ligament Injury
Background
- This page refers to sprains of the medial Ankle Joint
- Lateral Ankle Sprain are discussed separately
History
Epidemiology
- Far less common than lateral ankle sprains
- 5-33% of ankle sprains involve the deltoid ligament (need citation)
Pathophysiology
- General
- Medial ankle sprains are poorly described in the literature
- Isolated injury is unusual but does happen
- Involves excessive pronation, external rotation and/or abduction[1]
Etiology
- General
- Mechanism typically involves eversion (pronation) of the ankle
- Occurs while running and jumping
- Can also occur when someone steps on outside of a planted foot or ankle giving a medially directed force
- Other causes include landing on uneven surfaces, misstep on stairs
Associated Conditions
- Distal Fibula Fracture[1]
- Bimalleolar Fracture[2]
- Maisonneuve Fracture
- Ankle Osteoarthritis
- Syndesmotic Sprain
- Osteochondral Defect
- Lateral Ankle Sprain
Pathoanatomy
- Ankle Joint
- Deltoid Ligament
- Stabilizes the medial ankle
Risk Factors
- General
- Male Gender[3]
- High competition levels
- Younger athlete
- Orthopedic history
- Previous ankle sprain
- Sports
- Football
- Basketball
- Long Jumping
- Rugby
- Soccer
- Biomechanical
- Pes Planus
- Dysfunction of the spring ligament
- Posterior Tibialis Tendon Dysfunction
- Extreme fatigue of peroneus longs muscle
Differential Diagnosis
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Bursopathies
- Nerve Injuries
- Arthropathies
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Triplane Fracture
- Other
Clinical Features

Clinical demonstration of the external rotation stress test[4]
- History
- Pain over medial ankle following an acute injury (eversion or pronation)
- Worse with ambulation, running, jumping
- Sensation of instability
- Physical Exam: Physical Exam Ankle
- Useful to follow Ottawa Ankle Rules
- There may be bruising, swelling
- Exaggerated valgus hindfoot with or without weight bearing
- Tender to palpation over medial malleolus
- Special Tests
- External Rotation Stress Test: With the foot at 90°, apply external rotation to the joint
- Abduction Stress Test:
- Eversion Test:
- Anterior Drawer Test Ankle: translate distal tibia posteriorly to evaluate for laxity
Evaluation
Radiographs
- Standard Radiographs Ankle
- Findings (stable)
- Typically normal
- Findings (unstable)
- If complete, avulsion injury off of medial malleolus
- Widening on the medial clear space
- Lateral shift of talus
- Ottawa Ankle Rules
- Decision making rule can help determine if xray is necessary
- They are close to 100% sensitive (need citation)
- Consider Stress Radiographs Ankle
Ultrasound
- Can be used to evaluate deltoid ligament
- Chen et al: useful to distinguish isolated lateral malleolus fracture from bimal equivalent[7]
MRI
- Can be used to distinguish partial vs complete tear
- Evaluate for other soft tissue injuries
Arthroscopy
- Not considered part of a diagnostic workup
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
Prognosis
Nonoperative
- Indications
- Most cases
- In general, management mirrors Lateral Ankle Sprain
- Cessation of physical activity
- PRICE Therapy
- Tall Walking Boot
- Advance weight bearing as tolerated
- Physical Therapy
Operative
- Indications
- Complete deltoid tear (grade III, possibly grade II)
- Bimalleolar equivalent
- Technique
- Primary repair
Rehab and Return to Play
- In general, rehab and RTP mirrors Lateral Ankle Sprain
Rehabilitation
- Needs to be updated
Return to Play/ Work
- Needs to be updated
Complications
- Ankle Osteoarthritis
- Chronic Ankle Instability
- Re-sprain
- Inability to return to sport
See Also
- Internal
- External
- Sports Medicine Review Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/
References
- ↑ 1.0 1.1 Hintermann B, Regazzoni P, Lampert C, et al. Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br 2000;82:345–51.
- ↑ Tornetta P III. Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg Am 2000;82:843–8.
- ↑ Waterman BR, Belmont PJ Jr, Cameron KL, Svoboda SJ, Alitz CJ, Owens BD. Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med. 2011 May;39(5):992-8. doi: 10.1177/0363546510391462. Epub 2011 Feb 2. PMID: 21289274.
- ↑ Molinari, A., M. Stolley, and A. Amendola. "High ankle sprains (syndesmotic) in athletes: diagnostic challenges and review of the literature." The Iowa orthopaedic journal 29 (2009): 130.
- ↑ Bekerom MPJ van den, Mutsaerts EL a R, Dijk CN van. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Archives of orthopaedic and trauma surgery. 2009;129(2):227-35.
- ↑ Gill JB, Risko T, Raducan V, Grimes JS, Schutt RC. Comparison of manual and gravity stress radiographs for the evaluation of supination-external rotation fibular fractures. The Journal of bone and joint surgery. American volume. 2007;89(5):994-9.
- ↑ CHEN P, WANG T. Ultrasonographic examination of the deltoid ligament in bimalleolar equivalent fractures. Foot & ankle international. 2008;29(9):883-886.
Created by:
John Kiel on 7 July 2019 08:15:09
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Last edited:
3 October 2022 23:50:58
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