Persistent ankle pain following a sprain: a review of imaging

The initial diagnosis of an “ankle sprain” is not always correct. Prolonged pain, swelling and disability sufficient to limit the activity and refractory to treatment following an ankle injury are not typical of an ankle sprain and should alert the clinician of the possibility of an alternative or an associated diagnosis. There are several conditions that can be misdiagnosed as an ankle sprain and those include ankle syndesmosis injuries, sinus tarsi syndrome, ankle and hind foot fractures, osteochondral lesions, posterior tibialis and peroneal tendons abnormalities, spring ligament damage, impingement syndromes and reflex sympathetic dystrophy. In this review, we discuss the imaging features of these conditions that can clinically mimic an ankle sprain. It is crucial to remember that unresolved ankle pain following an injury is not always just due to a “sprain”.     

Anterior instability in the ankle joint following acute lateral sprain.

The relation between anterior instability in the ankle joint and rupture of the anterior talofibular ligament was investigated in patients with acute ankle sprains. Various techniques were used to provoke anterior displacement of the talus. The actual condition of the anterior talofibular ligament was assessed at operation. The appropriate radiographic method was defined, and its valve in diagnosing an acute rupture of the anterior talofibular ligament was assessed.     

Intra-articular fibrous band of the ankle: an uncommon cause of post-traumatic ankle pain

A case of an intra-articular fibrous band of the ankle is presented with emphasis on the MR imaging appearances. This entity is an important but uncommon cause of post-traumatic ankle pain and is well recognized within the arthroscopy literature, but there is little if any documentation of this condition in the imaging literature.     

Plantar vein thrombosis: a rare cause of plantar foot pain

Plantar vein thrombosis is a rare condition, with only a handful of cases reported in the literature. The cause is unknown; however, the disease has been attributed to prior surgery, trauma, and paraneoplastic conditions. We present a case of a 32-year-old female runner with plantar vein thrombosis diagnosed on contrast-enhanced MRI and confirmed on ultrasound. The symptoms resolved with conservative treatment and evaluation revealed the presence of a prothrombin gene mutation and use of oral contraceptive pills. To our knowledge, this is the first case of plantar vein thrombosis diagnosed initially by MRI. Moreover, this case suggests that plantar vein thrombosis should be considered in patients with hypercoagulable states and plantar foot pain.     

Mechanical output about the ankle joint in isokinetic plantar flexion and jumping

The purpose of this study was to compare for a group of ten subjects the mechanical output about the ankle during isokinetic plantar flexion with that during one-legged vertical jumps. For evaluation of the mechanical output the plantar flexion moment of force was related to the angular velocity of plantar flexion. The relationship for isokinetic plantar flexion was obtained using an isokinetic dynamometer; that for plantar flexion in jumping was obtained by combining kinematics and ground reaction forces. It was found that, at any given angular velocity of plantar flexion above 1 rad.s-1, the subjects produced much larger moments during jumping than during isokinetic plantar flexion. In order to explain the observed differences in mechanical output about the ankle, a model was used to simulate isokinetic plantar flexion and plantar flexion during jumping. The model represented both m. soleus and m. gastrocnemius as a complex composed of elastic tissue in series with muscle fibers. The force of the muscle fibers depended on fiber length, shortening velocity (Vfibers), and active state. The input variables of the model were histories of shortening velocities of the complexes, determined from kinematics, and active state. Among the output variables were Vfibers and plantar flexion moment. The simulation results were very similar to the experimental findings. According to the simulation results there are two reasons why at the same angular velocity of plantar flexion larger moments were produced during jumping than during isokinetic plantar flexion.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of the 6-minute walk test on plantar loading and capability to produce ankle plantar flexion forces

The six-minute walk test (6MWT) is used to evaluate the ambulatory capacity of patients suffering from respiratory disorders, obesity or neuromuscular diseases. Our primary aim was to evaluate the effects of the 6MWT on the postural sway and the ankle plantar flexion forces in healthy subjects.We measured the ankle plantar flexion forces and the plantar contact area before and after a 6MWT in normal weight and overweight subjects with no history of respiratory, cardiac, and neuromuscular disorders. A post-6MWT sensation of bodily fatigue was evaluated by Multidimensional Fatigue Inventory (MFI) and Pichot fatigue scales. A computerized pedobarographic platform was used to collect the mean plantar contact area, the changes of the center of pressure (CoP) surface and its medial and lateral deviations. In a limited number of subjects, the reproducibility of all the measurements was explored.In both groups, the 6MWT elicited a sensation of bodily fatigue. It also significantly reduced the ankle plantar flexion forces, and increased both the mean plantar contact area and the CoP surface, the changes being not apparent after 10 min. The post-6MWT lateral CoP deviations were accentuated in normal weight subjects, while an increase in medial CoP deviations occurred in overweight ones. The 6MWT-induced changes in the plantar flexion force and pedobarographic variables were reproducible.Because this study clearly showed some post-6MWT alterations of the subjects’ posture sway of our subjects, we questioned the possible mechanisms occurring that could explain the altered muscle force and the transient destabilization of posture after the 6MWT.     

Factors influencing return to play following conservatively treated ankle sprain: a systematic review

Background: Ankle sprain is a very common injury, yet uncertainty exists in what is appropriate time to return to play (RTP). Such guidance may inform treatment pathways and effective practice.

Objectives: To determine if consensus exist about potential influencing factors for time to RTP in conservatively treated ankle sprain.

Methods: We searched AMED, CINAHL Plus, Cochrane library, EMBASE, MEDLINE (EBSCO), SPOERDiscus, PsycINFO, PEDro, Scopus, unpublished literature and ongoing trials and Google Scholar from inception until April 2017. The quality of the eligible papers was assessed using the Downs and Black tool for randomized controlled trials (RCTs) and Critical Appraisal Skills Program (CASP) for observational studies.

Results: The initial search identified 1885 articles. After screening, 14 articles were included. Of these, 11 were RCTs and 3 were prospective observational studies. Individual treatment methods that resulted in a shorter time to RTP were functional treatment, compression stockings, anteroposterior joint mobilization, hyaluronic acid injection (HA), Jump Stretch Flex Band programme (JSFB) and diclofenac medication. Prognostic factors for determining time to RTP in the included prospective observational studies were measures of Global function, SF 36PF, athlete’s ambulation status, weight-bearing activity scores and self-reported athletic ability.

Conclusion: To our knowledge, this is the first review to report influencing factors for time to RTP following conservatively treated ankle sprain. Findings from this review identified factors that influence time to RTP. However, caution should be taken in generalizing these results due to the heterogeneity of studies and inability to clearly define and list the criteria for safe RTP. The inclusion of factors such as age, sex, BMI, level of sport, injury related factors in future studies might help to understand the course of injury and therefore assist in constructing safer criteria.     

Time-to-boundary analysis of postural control following acute lateral ankle sprain

BackgroundAcute lateral ankle sprain (ALAS) impairs unipedal balance both with the injured and uninjured limb, suggesting that balance during bipedal stance may also be compromised. However, a previous study failed to find such impairment because of poorly sensitive balance outcomes. Time-to-boundary (TTB) analysis may be sensitive enough for detecting latent deficits in bipedal balance following ALAS.Research questionWe aimed to examine postural stability during bipedal stance in patients with ALAS using TTB outcomes, and to determine bilateral deficits in unipedal balance.MethodsTwenty-seven patients with ALAS and 26 persons without a history of ALAS participated. ALAS was operationally defined as a traumatic injury to the lateral ligaments of the ankle joint occurring within 24–72 h. Both limbs of the control group were side-matched to those of the patients as either injured or uninjured limbs. All participants performed 3 trials of bipedal stance with eyes open and closed. Next, they completed 3 trials of unipedal stance on both the injured and uninjured limbs in both visual conditions. Order of limb and visual condition for each limb was randomly selected. Means and standard deviations of TTB minima in the anteroposterior and mediolateral directions were computed to assess balance, with lower values indicating poorer balance.ResultsIndependent t-tests revealed significant group differences for almost all measures (p=<0.001 to 0.021), indicating that the ALAS group presented poorer bipedal balance. For unipedal balance, there were no significant group-by-limb interactions for all measures (p > 0.05), indicating no side-to-side differences in the ALAS group. However, group main effects were found for all measures (p=<0.001 to 0.048), showing poorer unipedal balance in the ALAS group.SignificanceTTB analysis revealed impaired balance during both unipedal and bipedal stance conditions following ALAS. These results support the emerging hypothesis that centrally mediated changes in postural control may occur following ALAS.     

Acute lateral ankle sprain to chronic ankle instability: a pathway of dysfunction

Lateral ankle sprains (LAS) have been reported as one of the most common musculoskeletal injuries observed in sports and in individuals who are recreationally active. Approximately 40% of individuals who sustain a LAS develop a condition known as chronic ankle instability (CAI). Years of research has identified numerous impairments associated with CAI such as decreases in range of motion (ROM), strength, postural control, and altered movement patterns during functional activities when compared to individuals with no LAS history. As a result, an impairment-based rehabilitation model was developed to treat the common impairments associated with CAI. The impairment-based rehabilitation model has been shown to be an effective rehabilitation strategy at improving both clinical and patient-oriented outcomes in patients with CAI. To date, the efficacy of an impairment-based rehabilitation model has not been evaluated in patients with an acute LAS. Prior to implementing an impairment-based model for the treatment of an acute LAS, similarities between impairments associated with acute LAS and CAI across the spectrum of the healing process is warranted. Therefore, the purpose of this review paper is to compare and contrast impairments and treatment techniques in individuals with an acute LAS, sub-acute LAS, and CAI. A secondary purpose of this review is to provide clinical commentary on the management of acute LAS and speculate how the implementation of an impairment-based rehabilitation strategy for the treatment of acute LAS could minimize the development of CAI. The main findings of this review were that similar impairments (decreased ROM, strength, postural control, and functional activities) are observed in patients with acute LAS, sub-acute LAS, and CAI, suggesting that the impairments associated with CAI are a continuation from the original impairments developed during the initial LAS. Therefore, the use of an impairment-based model may be advantageous when treating patients with an acute LAS.     

Osteochondroma leading to proximal tibiofibular synostosis as a cause of persistent ankle pain and lateral knee pain: a case report

This paper presents a case report of persistent ankle pain and lateral knee pain due to existing proximal tibiofibular synostosis.     

Prevention and treatment of ankle sprain in athletes

The frequent nature of ankle sprains and persistent disability that often ensues has lead to considerable medical costs. As prevention of disease and injury becomes an increasingly important part of the practice of medicine today, we strive to understand and identify interventions that optimally reduce the frequency of ankle sprain and re-injury. In doing so, considerable morbidity and unnecessary medical expenditures may potentially be averted. The prophylactic use of ankle braces is fairly common. Recent critical evaluation of their effectiveness supports their use for at least 6 months following injury in athletes who have sustained a moderate or severe sprain; however, their role in primary prevention of ankle sprain is less evident. Functional ankle rehabilitation is the mainstay of acute ankle sprain treatment and in recent reviews has been deemed preferable to immobilisation or early surgery for initial treatment of acutely injured ankles. Furthermore, certain components of ankle rehabilitation, such as proprioceptive exercises, have been found to protect the joint from re-injury. Multifaceted ankle sprain prevention programmes that incorporate a variety of strategies for injury reduction are also effective in sprain prevention, although the relative importance of each component of such programmes warrants further investigation. Surgery for ankle sprain is principally reserved for patients who fail a comprehensive non-operative treatment programme and can be highly successful in treating chronic functional instability. This paper examines the current literature regarding common ankle sprain prevention strategies and provides a review of appropriate treatment schemes.     

The role of a posteriorly positioned fibula in ankle sprain

BACKGROUND: Specific anatomic variations of the ankle mortise may predispose people to ankle sprains. HYPOTHESIS: There is a correlation between a higher malleolar index (posteriorly positioned fibula) and incidence of ankle sprain. STUDY DESIGN: Prospective case control study. METHODS: We compared the malleolar index (transverse plane of the talus) on computerized axial tomographic images of 61 patients with ankle sprain with that of 101 normal controls. A positive number for the malleolar index meant that the lateral malleolus was posterior to the plane of the medial malleolus. A negative number meant that the lateral malleolus was actually anterior to the plane of the medial malleolus. RESULTS: The average malleolar index of the patients with ankle sprain was +11.5 degrees with a standard deviation of 7 degrees. Malleolar relationships varied from -6 degrees to +39 degrees, a range of 45 degrees. The average malleolar index in the control group was +5.85 degrees with a standard deviation of 4.9 degrees, which varied from -8 degrees to +16 degrees. However, there was no correlation between recurrence of sprains and malleolar index values. CONCLUSION: Patients with an ankle sprain were more likely to have a posteriorly positioned fibula, possibly predisposing them to ankle sprain.     

Effects of reduced ankle dorsiflexion following lateral ligament sprain on temporal and spatial gait parameters

Partial rupture of the lateral ligament complex of the ankle is the commonest soft tissue injury affecting the lower limb. The effect of the limitation of motion at the ankle, particularly of dorsiflexion, on gait is unclear. In this study, 34 subjects were measured during their recovery from a partial rupture of the lateral ligament for both range of dorsiflexion and the temporal and spatial parameters of walking. Consistent relationships were identified between the range and the gait variables which were in concordance with the characteristics expected from an antalgic gait pattern.     

How the ankle joint angle alters the antagonist and agonist torques during maximal efforts in dorsi- and plantar flexion

The aim of this study was to assess, via an EMG bio-feedback method, the ankle joint angle effect on the agonist and antagonist torques in plantar- (PF) and dorsi-flexion (DF). The isometric PF and DF maximal voluntary contractions (MVCs) torques were measured simultaneously with surface EMG activity of triceps surae (TS) and tibialis anterior (TA) muscles in 12 young adults (mean age 27) at five different ankle joint angles. Our results showed that: (i) The coactivation level does not properly reflect the mechanical effect of the antagonist muscle, (ii) TS antagonist torque significantly altered the DF MVC-angle relationship, whereas TA antagonist torque did not influence this MVC-angle relationship in PF. The alteration of the MVC with angular position was due, in part, to the coactivation phenomenon in DF, but not in PF. Thenceforth, when investigating the torque at the ankle joint, it is necessary to take into account both agonist and antagonist torque modifications with ankle joint angle.     

Inversion and eversion strengths in the weightbearing ankle of young women. Effects of plantar flexion and basketball shoe height

Maximum isometric ankle inversion and eversion muscle strengths were measured under full unipedal weightbearing in 20 healthy young adult women. When the women wore a low-top shoe, the mean (standard deviation) maximum external eversion moments resisted with the foot in 0 degrees and 32 degrees of ankle plantar flexion were 24.1 (7.6) and 24.1 (8.1) N x m, respectively, while the corresponding values for maximum inversion moments resisted were 14.7 (6.8) and 17.4 (6.4) N x m, respectively. Both shoe height and ankle plantar flexion affected the overall inversion moment resisted by 17% (P = 0.03) at 0 degrees of ankle plantar flexion to 11.9% (P = 0.003) at 32 degrees of ankle plantar flexion. However, neither shoe height nor ankle plantar flexion significantly affected the maximum eversion moment resisted. Although eversion muscle strength of the young women averaged 39% less than the corresponding value found in young men, the sex difference was not significant when ankle strengths were normalized by body size (body weight x height). Thus, when data from healthy young men and women were averaged, eversion and inversion strengths averaged 1.6% and 2.7%, respectively, of body weight x height.     

The ankle meter: an instrument for evaluation of anterior talar drawer in ankle sprain

The aim of this study was to work out a clinical test which is possible to measure the anterior talar drawer (ATD) in patients after ankle sprain. The instrument for evaluation was called ankle meter. The instrument consists of two plastic scales (heal scale and tibia scale). The instrument allows quantifying the results of the anterior drawing test. A total of 38 persons (16 men, 22 women) were available as control group. The persons were 28.8±10.1 years old. No proband had any ankle problems in his history. A total of 45 patients (25 males, 20 females) suffering from ankle sprain were included in the study. In these patients stress radiography (147.1 N) was performed to measure the ATD. In control group the clinical measured ATD was 1.7±1.3 mm. Measurement for detect the interobserver validity did not detect significant differences. The ATD of the joint after ankle sprain was significantly higher (8.9±4.3 mm). The difference between healthy and injured ankle in case of an ankle sprain was 7.4±4.2 mm. There was a significant correlation between clinical and radiological measured ATD (R=0.91). The results suggest that it is possible to measure the ATD exactly. The values of the clinical ATD measurement showed a good correlation with the results of stress radiography. Diligent clinical examination in combination with this special test are after this experiences sufficient to classify the severity of injury after ankle sprain.     

The effectiveness of imagery on pain,edema, and range of motion in athletes with a grade II ankle sprain

ObjectivesTo examine the effectiveness of imagery on pain, edema, and range of motion in athletes who have sustained a grade II ankle sprain.ParticipantsThe sample consisted of 18 active male athletes, aged from 18 to 30 years, with a grade II ankle sprain, confirmed by ultrasound testing. The participants were randomly divided into two conditions: a relaxation and imagery condition (n=9) and a control condition (n=9). The participants in the relaxation and imagery condition received 12 individual sessions of imagery rehearsal in addition to a normal course of physiotherapy, while the participants in the control condition followed only the physiotherapy treatment.Main outcome measuresParticipants were administered a Visual Analogue Scale (VAS) in order to measure acute pain intensity. Edema was evaluated with the water volumetric displacement method. Ankle range of motion (ROM) was assessed using a goniometer.ResultsThe study did not show demonstrable effects on pain, edema, and ROM after the application of imagery treatment.ConclusionsFurther research could examine the relationship between different types of imagery and rehabilitation from sport injury using standardized imagery instruments.