7. Ankle Sprains

Ankle sprain grade 1

(Mild) •Stretching

Ankle sprain grade 2

(Moderate) •Partial Tear

Ottawa rules: ___% sensitivity with foot fractures

98

Most common mechanism encountered in ankle sprains

Plantarflexion inversion

In the physical exam of an ankle sprain, where do you palpate

away from areas of maximal tenderness to area of maximal tenderness

Symptoms of O'Donoghue grade 3

•Severe swelling - >4cm diameter about the fibular •Severe Ecchymosis •Loss of function/motion - Unable to bear weight/ambulate •Mechanical Instability - Moderate to severe positivity in stress exam

Ankle sprain grade 3

(Severe) •Complete Tear

***arthrography needs to be performed within _____ of injury or fibrin clots may seal any capsular tear

1 week

Follow up with Foot and Ankle Surgeon at _____ to evaluate progression

1-2 weeks

Total treatment duration in a grade 1 ankle sprain

1-3 weeks

Bracing Treatment in a grade 2 high ankle sprain

1-4 weeks

Bracing Treatment in a grade 3 high ankle sprain

1-6 months

RICE Treatment in a grade 3 high ankle sprain

1-7 dayse

Ottawa rules: ___% sensitivity with ankle fractures

100

The angle between the CFL and the ATFL is approximately _____ degrees, and this angle is an important detail during reconstructive procedures.

104

RICE Treatment in a grade 1 high ankle sprain

12-48 hours

RICE Treatment in a grade 2 high ankle sprain

12-72 hours

How many deep bands make up the medial collateral ligaments

2

Total treatment duration in a grade 3 ankle sprain

2-6 months

Immobilization Treatment in a grade 2 high ankle sprain

2-6 weeks

Physical Therapy Treatment in a grade 2 high ankle sprain

2-6 weeks

Total treatment duration in a grade 2 ankle sprain

3-12 weeks

Immobilization Treatment in a grade 3 high ankle sprain

3-6 weeks

Physical Therapy Treatment in a grade 3 high ankle sprain

3-6 weeks

How many superficial bands make up the medial collateral ligaments

4

After what time period in acute ankle sprains do you get an MRI after failed conservative treatment

4-6 weeks

What determines a positive talar tilt

5-6 degrees difference between contralateral limb

Deltoid ligament complex are made up of ___ distinct ligaments.

6

If you see a pucker at the anterior ankle, what 2 structures are boarding the pucker

AITFL and ATFL

If the ankle is plantarflexed, which lateral ligament will rupture

ATFL

Which lateral ligament: Fan shaped primary stabilizer of the ankle

ATFL

What are the ligaments of the lateral collateral complex

ATFL CFL PTFL

Order of ligament injury in lateral collateral inversion sprains

ATFL -> CFL -> PTFL

Plantarflexion-inversion ankle sprain will result in initial rupture of _____ and continued force will cause rupture of _____

ATFL; CFL

What joints does the superficial medial collateral ligaments cross

Ankle joint & STJ

At 20-40% of all injuries, what is the Most Frequent Injuries Sustained by Athletes

Ankle sprains

Where are most of the superficial deltoid ligaments located

Anteriorly

If the ankle is dorsiflexed, which lateral ligament will rupture

CFL

Which lateral ligament: Narrow or cordlike directly below peroneal tendon sheath

CFL

What does talar tilt determine

CFL injury

Dorsiflexion inversion will result in initial rupture of ____, but continued force can result in rupture of ____

CFL; ATFL

What is the extracapuslar lateral collateral ankle ligament

Calcaneofibular

Dias grade 4

Complete Rupture of all three lateral collateral ligaments and partial failure of the deloid ligament

Dias grade 2

Complete Rupture of the ATFL

Dias grade 3

Complete Rupture of the ATFL, CFL and/or PTFL

O'Donoghue grade 3

Complete Tear with Loss of Ligament Integrity

Which complex in the medial deltoid tends to rupture first

Deep, because it is posterior

Function of the Ottawa scale

Determine if someone with an ankle injury needs an XR

O'Donoghue grade 2

Incomplete Tear of Ligament with Moderate Functional Impairment

MOI causing lateral collateral ankle injury

Inversion/supination and plantarflexion of the foot

alternative to stress test in ankle sprains

MRI

If a patient is non-ambulatory since the injury, what WB status do you give them?

NWB

Which lateral ligament: Thickest and strongest of the three

PTFL

Dias grade 1

Partial Rupture of the CFL

O'Donoghue grade 1

Partial Tear of Ligament

Where are most of the deep deltoid ligaments located

Posteriorly

Characteristic of CFL

Rope-like

Leach 1st degree sprain

Rupture of ATFL

Leach 2nd degree sprain

Rupture of ATFL and CFL

Leach 3rd degree sprain

Rupture of ATFL, CFL and PTFL

Differentiate between ankle sprain and a high angle sprain

Squeeze the tib and fib together at the distal aspect but proximal to the malleoli, pain with this = high ankle sprain

Most significant ligamentous complex of the ankle uniting the distal tibia and fibula

Syndesmosis

T/F: High ankle sprains can occur with any ankle motion

TRUE

T/F: In an inversion/supination injury, you can have isolated ligament rupture

TRUE

T/F: MRIs are not a great study for acute ankle injuries

TRUE

T/F: Non-weightbearing films cannot evaluate the tib-fib syndesmosis

TRUE

T/F: Ottawa rules is not a classification system

TRUE

T/F: The lateral collateral complex involves 3 distinct ligaments which do not reinforce each other as the deltoids do

TRUE

Bracing Treatment in a grade 1 high ankle sprain

Usually unnecessary

Immobilization Treatment in a grade 1 high ankle sprain

Usually unnecessary

Physical Therapy Treatment in a grade 1 high ankle sprain

Usually unnecessary

If a patient is ambulatory since the injury, what WB status do you give them?

WB

With the deltoid complex, because of ligamentous strength, more likely to get _____

an avulsion fracture than a ligamentous rupture

The dome of the Talus is wider in which direction

anterior

Most patients after an acute ankle injury have pain and will guard when trying to do the _____

anterior drawer test

Weak ligaments, more likely to rupture then cause an ____

avulsion fracture

After rupture of ligamentous structures, how does the patient present

edematous and painful ankle

85% of ankle sprains are caused by _____

excessive inversion

Orientation of the superficial deltoid ligaments

fan-shaped and originate on the anterior colliculus of the medial malleolus

What does the anterior drawer test evaluate

integrity of ATFL

In an arthrography, what does it mean when extension of contrast > 3.5 cm above joint

ligamentous injury

You can predict which ligament is more likely to rupture based on which is _____

perpendicular to the STJ axis

In an arthrography, what does it mean when extra articular dye is seen anterior to the lateral malleolus

rupture of ATFL

In an arthrography, what does it mean when dye is seen in peroneal sheath

rupture of CFL

When ankle rolls inward at high velocity, it may lead to _____

stretching or tearing of the lateral ligament complex

What indicates a positive anterior drawer test

talus translates forward

The lateral ligaments support _____

the lateral buttress of the ankle and when sprained or torn fail from anterior to posterior respectively

Ligaments that rupture are determined by _____

the type of force that is applied to the ankle

What joint does the deep deltoid ligaments cross

tibiotalar

What will you see on XR if the deltoid ligaments are shot

widening of the medial gutter

What are the Ottawa ankle rules

• Pain at tip or posterior 6cm of lateral malleoli • Pain at tip or posterior 6cm of medial malleoli • Pain at the base of the 5th metatarsal • Pain at the navicular • Inability to bear weight

Three distinct ligaments form the syndesmosis complex

•Anterior Inferior Tibiofibular Ligament: AITFL •Posterior Inferior Tibiofibular Ligament: PITFL •Interosseous Membrane

What are the deep bands of the medial ankle

•Deep Anterior Tibiotalar Ligament Deep Posterior Tibiotalar Ligament

In diagnostic radiographs of ankle sprains, what do you look at

•Diastasis •High tib-fib image •Contralateral limb

Forces applied to the foot that can cause a deltoid complex injury

•External rotation •Abduction •Eversion •Pronation

Most common ankle motions causing high ankle sprains

•Extreme external rotation •Dorsiflexion of the talus

XR views when evaluating ankle sprains

•Inversion stress view •Eversion stress view

Steps of arthrography

•Leakage of the dye thru a particular ligament or thru the distal tibiofibular syndesmosis will pin point structure torn •Insert 22 gauge needle into the medial side of joint

Diagnostic imaging for ankle sprains

•MRI •Arthrography •radiographs •Ultrasound

What are aspects of the patients history when evaluating for ankle sprain

•Mechanism ("foot fell underneath them") •Treatment since injury (bracing/taping) •Ambulatory status •History of prior injuries

What can be ruptured in an ankle sprain

•Medial collateral ligaments •Lateral collateral ligaments

Symptoms of O'Donoghue grade 1

•Mild Tenderness •Mild Swelling •Slight/No Functional Loss - Weight Bearing - Ambulates with minimal pain •No Mechanical Instability

Symptoms of O'Donoghue grade 2

•Moderate Pain •Moderate Swelling •Mild to Moderate Ecchymosis & Tenderness over Involved Structures •Some Loss of Motion/Function - Pain on WB & ambulation •Mild to Moderate Instability - Mild positivity in clinical stress exam

Ankle sprain diagnosis

•Pain on palpation to ligament complexes medially or laterally •Ecchymosis •Inability to bear weight •Edema • Anterior drawer test

How to perform the anterior drawer test

•Stabilizes the anterior distal leg with one hand & grasps the patient's calcaneus and rear foot with their second hand •Place the patient's foot into 10-15 degrees of plantar flexion and translate the rear foot anteriorly

What are the superficial bands of the medial ankle

•Superficial posterior tibiotalar ligaments •tibiocalcaneal •Tibiospring •tibionavicular

Deltoid complex injury usually accompanied by other ligament injuries or fractures such as

•Tib/fib ligaments •Fibular fractures