The role of ankle bracing for prevention of ankle sprain injuries

Lateral ankle sprains are one of the most common injuries incurred in recreational and competitive athletics. These injuries have a significant impact in terms of cost, athletic participation, and activities of daily living. Prophylactic ankle braces are often used to reduce the risk of injury recurrence when individuals return to athletic participation. The purpose of this clinical commentary is to review the literature and provide our own experience relative to the use of prophylactic ankle bracing. Relatively high incidence rates of ankle sprain injury have been reported for basketball and soccer athletes, military trainees, and individuals with a previous history of ankle sprain injury. Semirigid and laced ankle braces have significantly reduced the incidence of initial and recurrent ankle sprain injuries in athletic and military samples. With few exceptions, these braces do not appear to affect functional performance adversely. The prophylactic use of semirigid ankle braces appears warranted to reduce the incidence of initial and, in particular, recurrent ankle sprain injuries for individuals who participate in activities that have the highest risk for these injuries. Additional research is needed to evaluate the many new braces that are available and in use and their influence on the incidence of ankle sprain injury and functional performance.     

TEMPER: an acronym for ankle sprain rehabilitation

As has been previously discussed, the incidence and resultant associated disabilities of ankle sprains have been well documented in the literature. The staggering statistics on long-term disability show that there is no such thing as a simple ankle sprain. The degree of disability is related to the extent of the initial injury as well as the follow-up medical care provided. It is this fact that requires a complete understanding of the injury as well as a proper treatment and rehabilitation program. One of the reasons cited for the long-term disability or lack of consistently good results in treating ankle sprains is the lack of uniformity in treatment. One possible reason is the lack of agreement in diagnostic techniques as well as the end diagnosis of a particular grade of ankle sprain. If a sprain is managed correctly, resultant disability will be kept to a minimum. A proper rehabilitation program may be the most important factor in preventing chronic instability. The acronym RICE falls short of complete ankle management. RICE primarily addresses the ankle edema. Thus, the patient's ankle is only partially rehabilitated. A rational approach to the management of ankle sprains is given. Upon reviewing a complete protocol for ankle sprain rehabilitation, the acronym TEMPER can be used judiciously to remember the key steps in the treatment plan. Through the use of this acronym, one can institute a complete rehabilitation program.     

Traumatic false aneurysm of the ankle. A case report

A 27-year-old man incurred a false aneurysm of the peroneal artery secondary to an inversion injury to the ankle. A search of the literature disclosed no other cases of false aneurysms with ankle sprains. The false aneurysm of the peroneal artery appeared as a mass with a compressive neuropathy of the sural nerve. The diagnosis of false aneurysm of the peroneal artery following an inversion injury to the ankle should be suspected in cases of persistent localized swelling with inordinate pain that does not subside with elevation and immobilization and is associated with peroneal neuropathy.     

Early detection of peroneal neuropathy by ultrasound

A 12 year old boy presented with ankle sprain. The physical examination revealed mild weakness of ankle dorsiflexion. An ultrasound was done for the soft tissues of the ankle. In addition to relative atrophy of the peroneus longus muscle, a compressive common peroneal nerve (CPN) lesion with a synovial cyst at the level of the proximal tibiofibular joint (PTFJ) was accidently found. Since there were features of CPN compression by the synovial cyst, total excision of the cyst was performed. After the operation, muscle strength improved and the neurological deficit subsided. Therefore, the early diagnosis of PTFJ synovial cyst with nerve injury was crucial in order to achieve a better result. The obscure nature of clinical presentations can delay the diagnosis, which may potentially lead to a poor prognosis after treatment in such cases. This report highlights the fact that ankle sprain do need a thorough clinical work up in some cases.     

Excursion and strain of the superficial peroneal nerve during inversion ankle sprain

BACKGROUND: Traction is presumed to be the mechanism of injury to the superficial peroneal nerve in an inversion ankle sprain, but it is not known whether the amount of strain caused by nerve traction is sufficient to cause nerve injury. We hypothesized that the superficial peroneal nerve would experience significant excursion and strain during a simulated inversion sprain, that sectioning of the anterior talofibular ligament would increase excursion and strain, and that an impact force would produce strain in a range that can structurally alter the nerve. METHODS: Differential reluctance transducers were placed in the superficial peroneal nerve in sixteen lower-extremity cadaver specimens to measure excursion and strain in situ. Static weight was applied to the foot in increments starting at 0.454 kg and ending at 4.54 kg. The anterior talofibular ligament was sectioned, and the measurements were repeated. A final impact force of 4.54 kg was applied to each specimen. Two-way repeated-measures analysis of variance was used to evaluate differences in excursion and strain. RESULTS: The mean excursion and strain of the superficial peroneal nerve increased with increases in the applied weight in both the group with the intact anterior talofibular ligament and the group in which it had been sectioned. Nerve excursion was greater in the sectioned-ligament group than in the intact-ligament group with all applied weights (p < 0.05). The mean nerve strain was greater in the sectioned-ligament group (range, 5.5% to 12.9%) than in the intact-ligament group (range, 3.0% to 11.6%) with application of the 0.454, 0.908, 1.362, and 1.816-kg weights (p < 0.05). With the ligament sectioned, the 4.54-kg impact force produced significantly higher mean nerve excursion and strain than did the 4.54-kg static weight (p < 0.05). CONCLUSIONS: The magnitude of strain with the impact force was in the lower range of values that have been shown to structurally alter peripheral nerves. The superficial peroneal nerve is at risk for traction injury during an ankle inversion sprain and is at additional risk with more severe sprains or with an insufficient anterior talofibular ligament.     

Evaluation and management of high ankle sprains

Owing to the variability of injury, a mechanism of injury other than external rotation of the foot should not rule out a high ankle sprain. One must consider syndesmotic injury in the differential diagnosis of common ankle sprains and trauma. A high index of suspicion must lead the physician through clinical and radiographic examinations. Early and appropriate treatment of a high ankle sprain can greatly decrease a prolonged return to activity. Patients, especially competitive atheletes, must be educated regarding the morbidity of the condition.     

Acute and chronic lateral ankle instability in the athlete

Ankle sprain injuries are the most common injury sustained during sporting activities. Three-quarters of ankle injuries involve the lateral ligamentous complex, comprised of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The most common mechanism of injury in lateral ankle sprains occurs with forced plantar flexion and inversion of the ankle as the body's center of gravity rolls over the ankle. The ATFL followed by the CFL are the most commonly injured ligaments. Eighty percent of acute ankle sprains make a full recovery with conservative management, while 20% of acute ankle sprains develop mechanical or functional instability, resulting in chronic ankle instability. Treatment of acute ankle sprains generally can be successfully managed with a short period of immobilization that is followed by functional rehabilitation. Patients with chronic ankle instability who fail functional rehabilitation are best treated with a Brostrom-Gould anatomic repair or, in those patients with poor tissue quality or undergoing revision surgery, an anatomic reconstruction.     

Successful management of foot drop by nerve transfers to the deep peroneal nerve

Traumatic damage to the common peroneal nerve due to sharp injury, gunshot wound, sciatic nerve tumor, radiculopathy, or hip replacement surgery may result in foot drop. We present an alternative strategy for reanimation of foot drop following deep peroneal nerve palsy, successfully restoring voluntary movement. Fourteen consecutive patients with deep peroneal nerve injuries resulting in foot drop underwent nerve transfer of functional fascicles of either the superficial peroneal nerve or of the tibial nerve as donor for deep peroneal-innervated muscle groups. Eleven cases had successful restoration of British motor grade 3+ to 4+/5 ankle dorsiflexion, one case had restoration of grade 3 ankle dorsiflexion, and two cases had no restoration of dorsiflexion. Nerve transfer to the deep peroneal nerve is a feasible and effective method of treating deep peroneal nerve injuries of less than 1-year duration.     

Tension neuropathy of the superficial peroneal nerve: associated conditions and results of release.

We reviewed eight patients who sustained superficial peroneal nerve neuralgia after an inversion ankle sprain. Surgical exploration found anatomic abnormalities that tethered the nerve from movement during plantarflexion and inversion of the ankle. Most patients' pain improved dramatically after release and anterior transposition of the nerve. Seven joints also underwent arthroscopy, which showed intra-articular disease that was consistent with the original trauma. Five patients had reflex sympathetic dystrophy, three of which resolved after nerve release. Nerve conduction studies were not helpful. Careful physical examination and local nerve blocks were most important in making the diagnosis and prescribing treatment. All conservative measures should be exhausted before surgery is considered.     

Radiologic case study. Fractures of the foot masquerading as ankle injuries

An ankle radiographic series frequently is obtained when a patient presents with an acute ankle and foot injury. Although many fractures are confined to the ankle and are readily apparent, fractures of the foot can mimic ankle injuries. It is important to differentiate these fractures of the foot from the more common ankle sprain. Most ankle sprains are treated with ice, compression, and elevation, followed by range-of-motion exercises and progressive weight bearing as tolerated. When foot fractures are not identified, however, lack of appropriate treatment can result in late complications. Concentration on key areas as described here will reduce the incidence of missed fractures of the foot in these patients.     

Neuromuscular control and rehabilitation of the unstable ankle

Lateral ankle sprain is a common orthopedic injury with a very high recurrence rate in athletes. After decades of research, it is still unclear what contributes to the high recurrence rate of ankle sprain, and what is the most effective intervention to reduce the incident of initial and recurrent injuries. In addition, clinicians often implement balance training as part of the rehabilitation protocol in hopes of enhancing the neuromuscular control and proprioception of the ankle joint. However, there is no consensus on whether the neuromuscular control and proprioception are compromised in unstable ankles. To reduce the prevalence of ankle sprains, the effectiveness of engaging balance training to enhance the neuromuscular control and proprioception of the ankle joint is also questionable.     

Incidence and variance of foot and ankle injuries in elite college football players

We conducted a study on the risk for foot and ankle injuries in college football players on the basis of injury type and player position. In February 2006, we evaluated 320 intercollegiate football players at the National Football League Combine. All pathologic conditions and surgical procedures of the foot and ankle were recorded, and data were analyzed by player position to detect any trends. Seventy-two percent (n = 231) of the players had a history of foot and ankle injuries, with a total of 287 foot and ankle injuries (1.24 injuries/player injured). The most common injuries were lateral ankle sprain (n = 115), syndesmotic sprain (50), metatarsophalangeal dislocation/turf toe (36), and fibular fracture (25). Foot and ankle injuries were most common in kickers/punters (100% incidence), special teams (100%), running backs (83%), wide receivers (83%), and offensive linemen (80%). Lateral ankle sprains, the most common injuries, were treated surgically only 2.6% of the time. Offensive linemen were most likely to have had syndesmotic sprains (32%), and quarterbacks had the highest incidence of fibular fractures (16%). Foot and ankle injuries are common in collegiate football players, affecting 72% of players. Thirteen percent underwent surgical treatment. Trends are seen in the types of injuries for the different player positions.     

Is lateral ankle sprain of the child and adolescent a myth or a reality? A systematic review of the literature

BackgroundAnkle trauma in children and adolescents is the most common orthopedic injury encountered in pediatric trauma. It has long been recognized that a lateral ankle injury in this population is often a Salter and Harris type I fracture of the distal fibula (SH1). The purpose of this study is to confirm the existence of a lateral ankle sprain and to report the incidence of each pathology of the lateral ankle compartment: SH1 fracture, ATFL injury, and osteochondral avulsions.MethodsA systematic review of the literature is done using the database provided by PubMed and Embase. All articles reporting the incidence of imaging modality-confirmed lateral ankle injury (SH1, ATFL injury, osteochondral avulsion) in children and adolescents were included. Exclusion criteria were the following: case reports or articles with less than ten subjects, unspecified imaging modality and articles unrelated to lateral ankle lesions. Thus, 237 titles and abstracts were selected, 25 were analyzed thoroughly, and 11 articles were included for final analysis.ResultsSH1 fractures were found in 0–57.5% of the cases in all series and 0–3% in the most recent series. A diagnosis of an ATFL injury was found in 3.2–80% and an osteochondral avulsion of the distal fibula in 6–28.1%. The most recent series report 76–80% and 62% for ATFL injury and osteochondral avulsion respectively.ConclusionsThere is a non-negligible incidence of ATFL sprains and fibular tip avulsions in patients with a suspected SH1 fracture of the distal fibula. According to recent evidence and MRI examinations, the most common injuries of the pediatric ankle are ATFL sprain and osteochondral avulsions. This should be taken into consideration in daily practice when ordering radiological examination and deciding on treatment modalities     

Common peroneal nerve palsy complicating ankle sprain: report of 5 cases and review of the literature

Abstract Common peroneal nerve palsy associated with inversion sprains of the ankle has been mentioned in the literature on a case presentation basis only and is consequently regarded to be a rare complication. The etiologic mechanisms responsible for the nerve impairment have not been clearly identified. The onset of the palsy may be delayed and recovery seems to occur mostly spontaneously. Yet, some of the cases reported in the literature eventually required a surgical treatment, which was always followed by complete recovery. In this paper we present 5 additional cases of this peculiar neuropathy: all the patients were surgically treated, but only in 2 cases we observed a neurological recovery. The relevant literature is also briefly reviewed.     

Ankle Arthroscopy: Is Preoperative Marking of the Superficial Peroneal Nerve Important?

The aim of this study was to see whether preoperative marking of the superficial peroneal nerve and its branches before anterior ankle arthroscopy reduced the incidence of nerve injury compared with the available evidence reported in the literature. We reviewed 100 consecutive cases of anterior ankle arthroscopy that had been performed between February 2005 and April 2009. The medical records for all of the patients were reviewed for any documented complications related to the arthroscopic procedure. The patients were interviewed by telephone to find out if they had experienced any temporary or long-term neurologic symptoms after the surgery, and any patient with symptoms suggestive of a neurologic complication was thereafter physically examined in the clinic. A total of 96 (96%) of the patients were followed up for a mean of 15.3 (range 1 to 39) months, and the incidence of post-arthroscopy injury to the superficial peroneal nerve or its branches was 1.04% (1 out of 96 cases). Based on our observations, we believe that marking the superficial peroneal nerve and its branches before anterior ankle arthroscopy is an important and effective way to decrease the risk of iatrogenic nerve injury.     

踝关节扭伤的生物力学与运动学研究进展

踝关节扭伤是骨科临床常见病,占关节韧带扭伤的首位,如治疗不及时或不恰当,常遗留疼痛及关节不稳,继而发生骨关节炎等。目前踝关节的损伤机制、解剖学基础等已经得到了充分的研究,其诊断问题已经很明确,随着科学技术日新月异的发展,生物建模与三维有限元、三维运动捕捉系统、数字化技术的研究、体表肌电研究等技术被用于踝关节扭伤的基础研究之中,使踝关节扭伤的生物力学与运动学研究得到发挥,现结合踝关节的损伤机制等,探讨踝关节扭伤的生物力学与运动学研究进展。     

Diagnostics in suspicion of ankle syndesmotic injury

Ankle sprains are among of the most common injuries seen in daily orthopaedic practice. Beside injuries of the lateral ligament, which is the most frequently injured single structure in the body of athletes, sprains can also affect the tibiofibular syndesmosis. These injuries are known as high ankle sprains. They can occur with or without a bony injury. In this report, we will discuss the high ankle sprain without any bony injury. These kinds of injuries are rare, but often associated with complications and are frequently misdiagnosed or undiagnosed. The purpose of this article is to provide a clear understanding of clinical tests described in the literature for testing of syndesmotic integrity.     

Dislocation of the calcaneocuboid joint presenting as lateral instability of the ankle

A 16-year-old professional female ballet student sustained a plantar flexion-inversion injury to her left ankle while dancing. Clinical examination and MRI suggested subluxation of the tibiotalar joint. However, accurate diagnosis was hampered by a transient palsy of the common peroneal nerve. It was subsequently established that she had also sustained a dislocation of her calcaneocuboid joint, a rare injury, which was successfully stabilised by using a hamstring graft. The presentation and management of this rare condition are discussed.     

Prognostic factors of acute ankle sprain: Need for ultrasonography to predict prognosis

BackgroundAnkle sprains are one of the most common musculoskeletal injuries. To guide management decisions, a clear insight into the relevant subgroups of patients with a potentially better or worse prognosis is important. This study aimed to evaluate injury severity, using ultrasonography (US), as a prognostic factor of acute ankle sprain and other possible factors including age, sex, body mass index (BMI), level of job activity, and level of sports activity.Materials and methodsWe retrospectively reviewed 28 patients with acute ankle sprain who reported at initial examination with an acutely twisted ankle. All patients had received a standard physical examination, radiography and standard ultrasound, to diagnose specific ligament injuries and their ankle sprain had been treated using standard conservative management. Various data including age, sex, BMI, level of sports activity, level of daily job activity, and final functional score (Foot and Ankle Outcome Scores, FAOS) were obtained. Mean comparison and correlations were used to assess risk factors. Risk factors associated with functional outcomes were evaluated using a multiple linear regression test.ResultsAt final follow-up as 1 year after injury, FAOS differed significantly for injury severity, age, and BMI. There were no significant differences in sex, job activity, and exercise levels. The factor most affecting FAOS for both pain (FAOS-Pain) and symptoms (FAOS-Sx) was the number of completely torn ligaments. Age was the most important factor affecting the FAOS-Daily Living Activity (ADL). BMI was the most important factor for sports activity level (FAOS-Sports). Age and the number of completely torn ligaments were both important to FAOS-Sports and quality of life (FAOS-QOL).ConclusionThe severity of injury, defined using US, was a prognostic factor for long-term outcome following acute ankle sprain. Therefore, US imaging of acute ankle ligament injury may be important to predict prognosis of acute ankle sprain.