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
