Treatment of the ankle in the immediate post injury phase is focused on reducing swelling and stabilizing the joint to prevent re-injury and further injury. Ice and elevation should be used for immediate post injury treatment, if the injury is moderately severe then a boot or ankle brace may offer stabilization and support.
As the swelling decreases more weight bearing and motion of the ankle can be employed as tolerated, physical therapy may be helpful. We provide comprehensive and integrated non-surgical solutions to promote tissue repair and recovery of function for individuals with musculoskeletal pain, orthopedic injuries, and degenerative joint conditions.
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Facebook-f Instagram Youtube Linkedin-in. October 30, Share on facebook. Share on twitter. A patient who continues to be unstable at this stage, with giving-way episodes, they will often benefit at first from a course of physical therapy if they haven't had that already. That's really to focus on proprioception and strengthening of the surrounding musculature to see if that can be adequately Sorry, to see if that can adequately restore their sense of stability and allow them to return to activity.
These patients often need bracing for more strenuous sporting activity to give them the sense of stability that they need. If those things fail, then surgery to repair the ligament is often very helpful. This is a diagram of the classic Brostrom-type repair. This is the fibula right here. This is the calcaneofibular ligament, which has been cut and shortened and repaired. You don't always actually have to repair this.
The most important part is repairing what's called the anterior talofibular ligament. That ligament is actually underneath here. This is the extensor retinaculum, which holds down the tendons on the front of the ankle.
We incorporate that into the repair for some additional stability. Underneath that is the ligament repair. That's very successful surgery. People do very well with that and they're able to return to most sporting activities, but it does take about six months before they can go back to real strenuous activity. Scenario 4 is an year-old football player who twisted his ankle on the turf about a month ago.
They did rest, ice, compression, elevation, and told him he'd be better in a couple weeks because it didn't look like that bad a sprain but he continues to have significant pain, pointing to the anterolateral aspect of the ankle.
The pain travels up the leg from that point. X-rays are negative, but an MRI shows this fluid right here in the recess of the syndesmosis. This, as we talked about earlier, is a syndesmotic injury, or your classic high ankle sprain. This is the injury to the syndesmotic ligaments that connect the fibula to the tibia, and so, when the ankle externally rotates, that's what puts stress on these ligaments.
You can diagnose this with what's called a squeeze test where you squeeze the fibula against the tibia proximally in the leg, just below the knee. That should recreate pain at the ankle. People often complain of pain over the tibia where you put your hand or your thumb. That's not a positive test.
It has to be pain that they feel down in the ankle. The X-rays will be negative unless there's severe ligament disruption and instability. That's a different sort of injury. These take a long time to heal. They need a good bit of bracing for a while and rehab, and mostly time, but they will almost always settle down. Scenario 5 is a year-old female. She sprained her ankle about nine months ago. She got better for a while but has pain in the anterolateral ankle.
No instability. She did some therapy, which didn't help, but she did get a cortisone injection in the ankle and that seemed to give her excellent relief for a period of time. This scenario, this is really a diagnosis of exclusion until you get to this point.
This is an arthroscopic image of the ankle. Patients can develop what's called an anterolateral impingement lesion. What that is is essentially hypertrophic scarring of the lateral ankle ligaments or the capsule. That creates, essentially, an impingement lesion where, when the ankle dorsiflexes and comes up, this excess tissue that you see here in the ankle.
Here is the talus and up here is the tibia. When these two bones come together during activities, or even just walking, it pinches all this tissue here and causes pain. These patients respond very well to excision of this tissue, but oftentimes they'll get better with time or with a local cortisone injection.
MRIs are not very helpful. They often don't show this lesion. We're looking at some research to see if ultrasound may be more helpful in finding these lesions, but sometimes it's simply a diagnosis of exclusion. You've ruled out all the other things, their pain is appropriate and clinically appropriate to this sort of diagnosis, and you offer them an arthroscopy.
That will often solve the issue for them. Scenario 6 is a year-old female. She turned her ankle stepping off a curb about six weeks ago. They placed her in an air stirrup in the ED but that didn't really help. Her bruising and swelling has resolved but she continues to have a lot of pain over the lateral foot and ankle.
Here are her X-rays. What you'll notice here is some abnormality at the base of the fifth metatarsal. The point here is you always need to check the foot when people have an ankle sprain and turn it because you can sometimes end up with a fracture of the fifth metatarsal.
This is indeed a Jones fracture, and it is an area of the bone that sometimes doesn't heal very well, my point being here is that you just need to make sure you examine this as a possible source of their injury. Treatment is often casting or a CAM boot. Most avulsion-type fractures will heal very readily. The Jones fracture, like we see in this image here, often gives us trouble healing, and so, especially in athletic patients, we'll consider putting a screw down the pike here to get this to heal more quickly.
Here is an example of that where you see the screw crossing the fracture line. This, again, helps to get this to heal much more quickly. Scenario 7 is a year-old female. She suffered an inversion ankle sprain about six months ago.
She's done well except she has this nagging posteriolateral ankle pain and swelling and sometimes popping. Worse with activity. She uses a lace-up brace, which makes her feel better for activity, but this is still a significant problem for her. This is a scenario where we can have some injury to the peroneal tendons. This is an MRI image, axial image. This is the fibula here, tibia is here, and these are the peroneal tendons running behind there.
You can see these tendons should be restricted back here. Successful prevention exercise programs emphasize a quick warm up, balance training and proprioceptive drills that will challenge ankle joint position. The warmup includes stretching, strength, agility and balance exercises. Physical therapists and sports trainers employ balance boards, wobble boards or ankle discs.
Single leg and double leg hopping exercise help strengthen the ankle and enhance proprioception, agility, and stability. Some athletes prefer to employ taping and bracing as a substitute to an effective exercise program. Athletes, particularly adolescents, find it easier to consistently tape or brace than to consistently do exercises over the course of weeks and months.
Many athletes prefer taping to bracing as they find ankle braces to be restrictive, uncomfortable and bulky resulting in underperformance. Nevertheless, evidence based practice supports combining taping and bracing with a recovery exercise programs in order to achieve the best long term outcomes. Kaminsky concluded that external prophylactic supports and preventive exercise programs are effective for reducing the risk of ankle sprains in both uninjured and previously injured populations.
Ankle bracing appears to offer the best outcomes in terms of cost and risk reduction [38]. However, there remains a need for well-designed, prospective randomized controlled trials relevant to the primary prevention of lateral ankle sprains [33,38]. Core strengthening exercises involving the hip, abdominals and back also aid in the prevention of LAS. The strength and function of the hips and trunk is important for movement and sports performance. Imagine running lightly and abruptly changing direction.
Improving flexibility of the lower extremity may also play a role in the prevention of initial and recurrent ankle injuries. A balance between strength and flexibility is important.
Simple stretching for seconds after a light warm-up can help relieve discomfort and promote adequate mobility of the lower leg. The amount of time spent on the activity should be increased gradually over a period of weeks to build both muscle strength and mobility. Cross training by participating in different activities can help build the muscles while avoiding activity adaptation. Podiatrists may educate and advise the athlete on their foot type and function through biomechanical exams and gait analysis.
Shoe selection and custom foot orthoses play a large role in prevention of ankle sprains as stabilizing faulty biomechanics and foot position is crucial in preventing recurrent LAS. Extensive patient education regarding the natural history of ankle injuries, risk of re injury, long term sequelae, healing timelines and return to activity guidelines must be conveyed to the athlete and coaching staff. Unfortunately, there is a lack of consensus among expert opinion and preferred practice guidelines on return to sports criteria following lateral ankle sprains.
Internal pressure from athletic programs to expedite a quick return to sports activity sometimes overrides appropriate medical advice []. LAS patients often receive care, but an emphasis on rapid return to sport RTS may sometimes override the best medical advice. Wikstrom and Mueller reported a RTS average of 12 days. Rapid RTS timelines neglect the biological processes required for adequate healing increasing injury risk and long-term sequelae. Quick Return to play may lead athletes to demonstrate ligamentous laxity, limitations in self-reported function, limited dorsiflexion range of motion, and impaired dynamic postural control.
According to Wikstrom RTS decisions for LAS, were derived from anecdotal evidence and practitioner experience and influenced by stakeholders patients, parents, and coaches pushing RTS expediency []. According to recent data from the National Collegiate Athletic Association NCAA , the lateral ankle sprain LAS is most prevalent in high impact sports like football, basketball, wrestling and ice hockey.
The direct and indirect costs related to ankle sprains approximates 4 billion per year and long term sequelae and disability often result when cases are mismanaged. Most LAS do not require surgical intervention, but a comprehensive evaluation, an accurate and timely diagnosis, and an evidence supported treatment plan will help achieve optimum outcomes, quicker return to activity, and a lower risk of recurrence and complications.
Ankle sprains in athletes may best be managed by an interprofessional team approach which include, sports trainers, podiatric and orthopedic specialists, nurse practitioners and physical therapists that focus on prevention. Patient education by the healthcare team emphasize the importance of stretching and conditioning to minimize the severity of ankle sprain.
Athletes should be encouraged to wear proper shoes and use braces or foot orthoses to further protect the ankle, prevent recurrence and enhance performance.
Guidelines Published. Research Article Navigation. More Information. The epidemiology, evaluation, and assessment of lateral ankle sprains in athletes G Javier Cavazos Jr.
Summary Navigation. Introduction Navigation. Epidemiology Navigation. Anatomy The ankle joint is a hinged synovial joint that is formed by the articulation of the talus, tibia, and fibula.
Ref: Anatomy Standard. Download Image Diagram 3: Shape of talus; Conelike structure wider anteriorly. Download Image Diagram 4: Lateral view of the ankle collateral ligaments. Download Image Diagram 6: Biomechanics of the Ankle. Conclusion Navigation.
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Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: Systematic Review. Effect of accelerated rehabilitation on function after ankle sprain: randomized controlled trial.
Effects of ankle sprain in a general clinic population 6 to 18 months after medical evaluation. Arch Fam Med. Long term outcomes of inversion ankle injuries. Br J Sports. Lynch S. Assessment of the Injured Ankle in the Athlete. Diagnosis of lateral ankle ligament injuries: comparison between talar tilt, MRI and operative findings in athletes.
Acta Orthop Scand. The efficacy of a semirigid ankle stabilizer to reduce acute ankle injuries in basketball: a randomized clinical study at West Point. J Orthopaedic Sports Physical Ther. Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World J Orthop. Curr Rev Musculoskelet Med.
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