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Medial Ankle Sprain

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Other Names

  • Deltoid Sprain
  • Medial Ligament Sprain
  • Medial Ankle Complex Sprain
  • Deltoid Ligament Injury

Background

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

Anatomic illustration of the deltoid ligament and other medial ligaments of the foot and ankle

Pathoanatomy

Risk Factors

  • General
    • Male Gender[3]
    • High competition levels
    • Younger athlete
  • Orthopedic history
    • Previous ankle sprain
  • Sports
    • Football
    • Basketball
    • Long Jumping
    • Rugby
    • Soccer
  • Biomechanical

Differential Diagnosis

Clinical Features

Clinical demonstration of the external rotation stress test[4]

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
    • Useful in acute injuries, not chronic
    • Manual stress
    • Gravity stress views may be just as good as manual[5][6]

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

Operative

  • Indications
    • Complete deltoid tear (grade III, possibly grade II)
    • Bimalleolar equivalent
  • Technique
    • Primary repair

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications

See Also

References

  1. ↑ 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.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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
Last edited:
3 October 2022 23:50:58
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