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Medial Ankle Sprain

From WikiSM

Other Names

  • Deltoid Sprain
  • Medial Ligament Sprain
  • Medial Ankle Complex Sprain
  • Deltoid Ligament Injury
  • Medial ankle sprain
  • Deltoid ligament tear
  • Deltoid ligament rupture
  • Deltoid ligament sprain
  • Deltoid ligament insufficiency
  • Medial collateral ligament injury of the ankle
  • Medial ankle ligament rupture
  • Eversion ankle sprain
  • Eversion injury of the ankle
  • Medial ankle instability
  • Ankle eversion sprain with deltoid involvement
  • Chronic deltoid ligament insufficiency
  • Isolated deltoid ligament lesion

Background

History

  • Needs to be updated

Epidemiology

  • Far less common than lateral ankle sprains
    • 5-33% of ankle sprains involve the deltoid ligament (need citation)

Introduction

Anatomic illustration of the deltoid ligament and other medial ligaments of the foot and ankle
The medial ligament of the ankle[1]

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[2]

Etiology

  • 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

Anatomy of the Deltoid Ligament

Risk Factors

General

  • Male Gender[5]
  • High competition levels
  • Younger athlete
  • Previous ankle sprain

Sports

  • Football
  • Basketball
  • Long Jumping
  • Rugby
  • Soccer

Biomechanical

Differential Diagnosis

Differential Diagnosis Ankle Pain

Clinical Features

Gravity dependendent ecchymosis of the medial ankle
Clinical demonstration of the external rotation stress test[6]

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

Evaluation

oronal T2-weighted fat-suppressed MR image shows midsubstance tear of deep deltoid ligament (arrow). Fibers are poorly defined and discontinuous. Edema is evident at origin of superficial deltoid ligament (arrowheads), but tear is not distinctly seen.[7]
A partial tear can be seen at the proximal attachment at the tibia. The TCL can be visualized as thickened and a hypoechogenicity appearance of both the TCL and the aDPTL (blue arrows). Calcium deposits can be visualized inside the thickened ligament (yellow arrow)[8]

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[9][10]

Ultrasound

  • Can be used to evaluate deltoid ligament
  • Chen et al: useful to distinguish isolated lateral malleolus fracture from bimal equivalent[11]

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

Stirrup Air Cast

Prevention

  • Especially for recurrent injuries, prevention is critical
  • Continue neuromuscular training and external ankle support for up to 1 year post-injury, especially in athletes with previous sprains
  • Educate on proper warm-up and injury prevention strategies

Nonoperative

Operative

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

Rehab and Return to Play

Ankle sprain exercises[12]

Rehabilitation

  • Initial (day 1-7)[13]
    • Compression, bracing
    • Eelvate limb, analgesia, cryotherapy
    • Weight bearing as tolerated
  • Early Rehab (weeks 1-2)[14]
    • Initial gentle ROM, progressive stretching, isometric strengthening as pain allows
    • Early proprioceptive and balance training (e.g. single leg stance, wobble board)
    • Manual therapy, joint mobilization can help restore dorsiflexion, function
  • Intermediate rehab (weeks 2-4)[15]
    • Progressive strengthening including isotonic and resistance training
    • Advanced neuromuscular and coordination training, dynamic balance, agility drills
    • Continue functional bracing or taping during activity
  • Advanced (week 4+)[16]
    • Sport specific drills, plyometric exercises as tolerated
    • Advanced balance and proprioceptive training
    • Monotor for signs of recurrent instability

Return to Play/ Work

  • Consider Cumberland Ankle Instability Tool to assess perception of function
  • Perform functional tests (single leg hop, star excurion balance)
    • Athlete should be at least 80% of uninjured limb before returning to sport specific tasks
  • Ensure pain free ROM, strength and stability compared to contralateral limb
  • Consider prophylactic ankle brace

Prognosis and Complications

Prognosis

  • General
    • Prognosis is favorable with appropriate rehabilitation
    • Recovery can be variable, especially with severe injury

Complications

  • Ankle Osteoarthritis
  • Chronic Ankle Instability
    • Up to 40% of patients may report ongoing instability[17]
  • Re-sprain
  • Inability to return to sport
  • Persistent pain, swelling, reductioned function
    • In one study, only 26% of patients had fully recovered at 2 years[18]
  • Neuromuscular and biomechnical deficits

See Also

Internal

External

References

  1. ↑ Al-Mohrej, Omar A., and Nader S. Al-Kenani. "Acute ankle sprain: conservative or surgical approach?." EFORT open reviews 1.2 (2016): 34-44.
  2. ↑ 2.0 2.1 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.
  3. ↑ 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.
  4. ↑ Grath G. Widening of the ankle mortise. A clinical and experimental study. Acta Orthop Scand 1960;263(Suppl):1–88.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ Crim, Julia, and Loren G. Longenecker. "MRI and surgical findings in deltoid ligament tears." American Journal of Roentgenology 204.1 (2015): W63-W69.
  8. ↑ Manske, Robert C., et al. "Diagnostic Musculoskeletal Ultrasound in the Evaluation of the Deltoid Ligament of the Ankle." International Journal of Sports Physical Therapy 20.4 (2025): 641.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ CHEN P, WANG T. Ultrasonographic examination of the deltoid ligament in bimalleolar equivalent fractures. Foot & ankle international. 2008;29(9):883-886.
  12. ↑ Halabchi, Farzin, and Mohammad Hassabi. "Acute ankle sprain in athletes: Clinical aspects and algorithmic approach." World journal of orthopedics 11.12 (2020): 534.
  13. ↑ Herring, Stanley A., et al. "Initial assessment and management of select musculoskeletal injuries: a team physician consensus statement." Current Sports Medicine Reports 23.3 (2024): 86-104.
  14. ↑ Kaminski, Thomas W., et al. "National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes." Journal of athletic training 48.4 (2013): 528-545.
  15. ↑ Tiemstra, Jeffrey D. "Update on acute ankle sprains." American family physician 85.12 (2012): 1170-1176.
  16. ↑ Mattacola, Carl G., and Maureen K. Dwyer. "Rehabilitation of the ankle after acute sprain or chronic instability." Journal of athletic training 37.4 (2002): 413.
  17. ↑ Herzog, Mackenzie M., et al. "Epidemiology of ankle sprains and chronic ankle instability." Journal of athletic training 54.6 (2019): 603-610.
  18. ↑ Anandacoomarasamy, A., and L. Barnsley. "Long term outcomes of inversion ankle injuries." British journal of sports medicine 39.3 (2005): e14-e14.
Created by:
John Kiel on 7 July 2019 08:15:09
Last edited:
23 October 2025 02:07:43
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