Acute ankle sprain: an update

Acute ankle injury, a common musculoskeletal injury, can cause ankle sprains. Some evidence suggests that previous injuries or limited joint flexibility may contribute to ankle sprains. The initial assessment of an acute ankle injury should include questions about the timing and mechanism of the injury. The Ottawa Ankle and Foot Rules provide clinical guidelines for excluding a fracture in adults and children and determining if radiography is indicated at the time of injury. Reexamination three to five days after injury, when pain and swelling have improved, may help with the diagnosis. Therapy for ankle sprains focuses on controlling pain and swelling. PRICE (Protection, Rest, Ice, Compression, and Elevation) is a well-established protocol for the treatment of ankle injury. There is some evidence that applying ice and using nonsteroidal antiinflammatory drugs improves healing and speeds recovery. Functional rehabilitation (e.g., motion restoration and strengthening exercises) is preferred over immobilization. Superiority of surgical repair versus functional rehabilitation for severe lateral ligament rupture is controversial. Treatment using semirigid supports is superior to using elastic bandages. Support devices provide some protection against future ankle sprains, particularly in persons with a history of recurrent sprains. Ankle disk or proprioceptive neuromuscular facilitation exercise regimens also may be helpful, although the literature supporting this is limited.     

Diagnostik und Therapie der chronischen Sprunggelenkinstabilität

Ankle sprains are the most common musculoskeletal injuries accounting for approximately 15–25% of injuries treated in the medical practice. Although most of these ligamentous ankle injuries can be successfully treated with physical rehabilitation and non-operative treatment, 20–40% of patients complain of chronic instability and subsequent disability. Many of these patients can be successfully treated by late repair or reconstruction of the lateral ligaments. However, in spite of surgery and extensive physical rehabilitation, many patients suffer from persisting disability including symptomatic instability. New investigation methods such as imaging techniques and arthroscopy have shown that different types of ankle instability exist. Chronic pain, feeling of instability of the ankle during daily and sports activities and recurrent sprains are the main indications for surgical repair or reconstruction of ligaments. Techniques that restore the anatomy have shown better results than non-anatomic procedures as they do not alter the kinematics or the mechanics of the ankle joint complex. Therefore, non-anatomic tenodesis procedures should no longer be performed despite some positive results.     

Syndesmotic ankle sprain

Ankle sprain injuries are the most common type of joint sprain. The prevalence of ankle joint sprains accounts for 21% of joint injuries in the body. Although somewhat rare, high-ankle or syndesmotic ankle sprains occur in up to 15% of ankle trauma. This article will present the pathomechanics of the high-ankle or syndesmotic sprain.     

Place de l’échographie dans le diagnostic de gravité d’une entorse latérale de l’articulation talocrurale et ses complications chez le sportif

Due to the non-specific clinical presentation, and specifically due to the lack of an ankle “Lachmann”, ultrasonography provides crucial information for the diagnosis of severity of a lateral sprain involving the talocrural joint. Ultrasonography enables to differentiate between minor injuries without ligament lesions and serious sprains with a more or less extensive ligament tear. Effusion in the talocrural joint, which can be identified readily with ultrasounds, is a sign of severity. Ultrasonography is also essential for analyzing the ligaments in a subject with an unstable ankle late after a sprain. The performance is equivalent to that of an arthroscan (the gold standard exam for chronic post-trauma ankle pain) for identifying sequelar ligament lesions.     

Fractures and Chronic Recurrence are Commonly Associated with Ankle Sprains: a 5-year Population-level Cohort of Patients Seen in the U.S. Military Health System

BackgroundWhereas ankle-foot injuries are ubiquitous and affect ~16% of military service-members, granularity of information pertaining to ankle sprain subgroups and associated variables is lacking. The purpose of this study was to characterize and contextualize the burden of ankle sprain injuries in the U.S. Military Health System.MethodsThis was a retrospective cohort study of beneficiaries seeking care for ankle sprains, utilizing data from the Military Health System Data Repository from 2009 to 2013. Diagnosis and procedural codes were used to identify and categorize ankle sprains as isolated lateral, isolated medial, concomitant medial/lateral, unspecified, or concomitant ankle sprain with a malleolar or fibular fracture. Patient characteristics, frequency of recurrence, operative cases, and injury-related healthcare costs were analyzed.ResultsOf 30,910 patients included, 68.4% were diagnosed with unspecified ankle sprains, 22.8% with concomitant fractures, (6.9%) with isolated lateral sprains, (1.7%) with isolated medial sprains and 0.3% with combined medial/lateral sprains. Pertaining to recurrence, 44.2% had at least one recurrence. Sprains with fractures were ~2-4 times more likely to have surgery within one year following injury (36.2% with fractures; 9.7% with unspecified sprains) and had the highest ankle-related downstream costs.ConclusionFractures were a common comorbidity of ankle sprain (one in five injuries), and operative care occurred in 16.4% of cases. Recurrence in this cohort approximates the 40% previously reported in individuals with first-time ankle sprain who progress to chronic ankle instability. Future epidemiological studies should consider reporting on subcategories of ankle sprain injuries to provide a more granular assessment of the distribution of severity.Level of evidence3b     

Isolated partial tear of extensor digitorum longus tendon with overlying muscle herniation in acute ankle sports injury: role of high resolution musculoskeletal ultrasound

Lateral Ankle sprain is a common sports-related trauma with the mechanism of injury ranging from inversion to plantar flexion. These injuries commonly affect the ligaments but can also affect the associated soft tissue structures like the eversion muscles and tendons. Prompt and accurate diagnosis of such injuries is warranted so as to ensure early return to play and prevent long-term complications. Lateral ankle sprain injuries in sports may not always be associated with ligament injuries. We report a never before reported case of lateral ankle sprain injury in a soccer player with the unusual finding of isolated partial tear of Extensor digitorum longus muscle and its fascia leading to myo-fascial herniation. The lateral ankle ligaments were intact. The diagnosis was clinched on a high-frequency ultrasound scan supported by dynamic maneuvers which in fact proved to be superior to MRI as the latter failed to demonstrate the myo-fascial herniation in our case. We therefore propose that real-time ultrasound scanning with dynamic maneuvers should be the first line of investigation to assess sports injuries in anatomically complex joints like the ankle.     

MR imaging of ligamentous abnormalities of the ankle and foot.

Ankle sprains are among the most common musculoskeletal injuries. MR imaging is useful in establishing an accurate diagnosis and, before initiation of treatment, excluding other causes of persistent ankle pain. This article reviews the common features of acute and chronic ligamentous injuries on MR imaging and site-specific pathologic lesions related to the injured ligaments.     

Ankle injuries in athletes.

Ankle injuries are the most frequent cause of physician evaluation in a sports-oriented environment. The lateral ligaments are most commonly injured. With a detailed history, physical and radiographic examination to avoid missing underlying pathology, the primary care physician can diagnose and treat the majority of ankle injuries. Occasionally, stress radiographs, arthograms, or magnetic resonance imaging (MRI) is needed. The vast majority of ankle sprains can be treated with adhesive tape strapping or semirigid orthotics and nonsteroidal anti-inflammatory medication followed by rehabilitation. Key points of rehabilitation are control of pain and swelling acutely with nonsteroidal anti-inflammatories and RICE (rest, ice, compression, and elevation), then restoring normal range of motion, strengthening muscle groups, and retraining proprioception of the ankle joint.     

The Ubiquitous Lateral Ankle Sprain: Time to Reconsider Our Management?

Ankle sprains are one of the more common musculoskeletal injuries among physically active individuals, but these are not benign injuries. The rate of recurrence, the chronicity of symptoms, and the rising costs of the evaluation and management of lateral ankle sprains should give us pause. Lateral ankle sprains are simultaneously over- and undertreated, creating a burden on the health care system. Rethinking our approach to the management of lateral ankle sprains is important to improving patient outcomes.     

Lower trunk kinematics and muscle activity during different types of tennis serves

This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. For extrinsic risk factors to ankle sprain injury, prescribing orthosis decreases the risk while increased exercise intensity in soccer raises the risk. For intrinsic factors, a foot size with increased width, an increased ankle eversion to inversion strength, plantarflexion strength and ratio between dorsiflexion and plantarflexion strength, and limb dominance could increase the ankle sprain injury risk. Players with a previous sprain history, players wearing shoes with air cells, players who do not stretch before exercising, players with inferior single leg balance, and overweight players are 4.9, 4.3, 2.6, 2.4 and 3.9 times more likely to sustain an ankle sprain injury. The aetiology of most ankle sprain injuries is incorrect foot positioning at landing – a medially-deviated vertical ground reaction force causes an explosive supination or inversion moment at the subtalar joint in a short time (about 50 ms). Another aetiology is the delayed reaction time of the peroneal muscles at the lateral aspect of the ankle (60–90 ms). The failure supination or inversion torque is about 41–45 Nm to cause ligamentous rupture in simulated spraining tests on cadaver. A previous case report revealed that the ankle joint reached 48 degrees inversion and 10 degrees internal rotation during an accidental grade I ankle ligamentous sprain injury during a dynamic cutting trial in laboratory. Diagnosis techniques and grading systems vary, but the management of ankle ligamentous sprain injury is mainly conservative. Immobilization should not be used as it results in joint stiffness, muscle atrophy and loss of proprioception. Traditional Chinese medicine such as herbs, massage and acupuncture were well applied in China in managing sports injuries, and was reported to be effective in relieving pain, reducing swelling and edema, and restoring normal ankle function. Finally, the best practice of sports medicine would be to prevent the injury. Different previous approaches, including designing prophylactice devices, introducing functional interventions, as well as change of games rules were highlighted. This paper allows the readers to catch up with the previous researches on ankle sprain injury, and facilitate the future research idea on sport-related ankle sprain injury.     

Lateral and syndesmotic ankle sprain injuries: a narrative literature review

Objective

The purpose of this article is to review the literature that discusses normal anatomy and biomechanics of the foot and ankle, mechanisms that may result in a lateral ankle sprain or syndesmotic sprain, and assessment and diagnostic procedures, and to present a treatment algorithm based on normal ligament healing principles.

Methods

Literature was searched for years 2000 to 2010 in PubMed and CINAHL. Key search terms were ankle sprain$, ankle injury and ankle injuries, inversion injury, proprioception, rehabilitation, physical therapy, anterior talofibular ligament, syndesmosis, syndesmotic injury, and ligament healing.

Discussion

Most ankle sprains respond favorably to nonsurgical treatment, such as those offered by physical therapists, doctors of chiropractic, and rehabilitation specialists. A comprehensive history and examination aid in diagnosing the severity and type of ankle sprain. Based on the diagnosis and an understanding of ligament healing properties, a progressive treatment regimen can be developed. During the acute inflammatory phase, the goal of care is to reduce inflammation and pain and to protect the ligament from further injury. During the reparative and remodeling phase, the goal is to progress the rehabilitation appropriately to facilitate healing and restore the mechanical strength and proprioception. Radiographic imaging techniques may need to be used to rule out fractures, complete ligament tears, or instability of the ankle mortise. A period of immobilization and ambulating with crutches in a nonweightbearing gait may be necessary to allow for proper ligament healing before commencing a more active treatment approach. Surgery should be considered in the case of grade 3 syndesmotic sprain injuries or those ankle sprains that are recalcitrant to conservative care.

Conclusion

An accurate diagnosis and prompt treatment can minimize an athlete's time lost from sport and prevent future reinjury. Most ankle sprains can be successfully managed using a nonsurgical approach.     

Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankle and foot rules by specialized emergency nurses

OBJECTIVES: The ED is often confronted with long waiting periods. Because of the progressive shortage in general practitioners, further growth is expected in the number of patients visiting the ED without consulting a general practitioner first. These patients mainly present with minor injuries suitable for a standardized diagnostic protocol. The question was raised whether these injuries can be treated by trained ED nurses (specialized emergency nurses [SENs]). The aim of this study was to evaluate the diagnostic accuracy and reproducibility of SENs in assessing ankle sprains by applying the Ottawa Ankle Rules (OAR) and Ottawa Foot Rules (OFR). METHODS: In a prospective study, all ankle sprains presented in the ED from April to July 2004 were assessed by both a SEN and a junior doctor (house officer [HO]) randomized for first observer. Before the study, SENs were trained in applying OAR and OFR. In all patients, radiography was performed (gold standard). The diagnostic accuracy for the application of OAR and OFR was calculated for both groups and was compared using z statistics. Furthermore, from the paired results, reproducibility was calculated using kappa statistics. RESULTS: In total, 106 injuries were assessed in pairs, of which 14 were ultimately found to concern acute fractures (prevalence, 13%). The sensitivity for the SEN group was 0.93 (95% confidence interval [CI], 0.64-1.00) compared with 0.93 (95% CI, 0.64-1.00) for the HO group (no significance [ns]). The specificity of the nurses was 0.49 (95% CI, 0.38-0.60) compared with 0.39 (95% CI, 0.29-0.50) for the doctors (ns). The positive predictive value for the SEN group was 0.22 (95% CI, 0.13-0.35) compared with 0.19 (95% CI, 0.11-0.31) for the HO group (ns). The negative predictive value for the nurses was 0.98 (95% CI, 0.87-1.00) compared with 0.97 (95% CI, 0.84-1.00) for the doctors (ns). The interobserver agreement for the OAR and OFR subsets was kappa = 0.38 for the lateral malleolus; kappa = 0.30, medial malleolus; kappa = 0.50, navicular; kappa = 0.45, metatarsal V base; and kappa = 0.43, weight-bearing. The overall interobserver agreement for the OAR was kappa = 0.41 and kappa = 0.77 for the OFR. CONCLUSION: Specialized emergency nurses are able to assess ankle and foot injuries in an accurate manner with regard to the detection of acute fractures after a short, inexpensive course.     

Sonographic Findings of Chondral Avulsion Fractures of the Lateral Ankle Ligaments in Children

In this series, we aimed to describe the sonographic findings of chondral avulsion fractures that develop concomitant with lateral ankle ligament injury in children. We performed stress sonography during a manual anterior drawer stress procedure of the ankle in 9 skeletally immature patients who had recently had a lateral ankle sprain. Echo videos were obtained through the course of treatment, and all videos were reviewed. We elucidated the common features of chondral avulsion fractures of the lateral ankle ligaments in the children. The features of avulsion fractures on conventional sonography included absence of a fracture with hyperechoic spots (sonographic occult fracture type), cortical discontinuity with hyperechoic spots (cortical disruption fracture type), fracture line in the cortical bone (double‐line fracture type), and a step‐off deformity of the cortical bone with cartilage (displaced fracture type). In contrast, the features of chondral fractures on stress sonography included abnormal motion of the chondral lesions and mobility/fluidity of hyperechoic spots along the chondral fracture site. The presence of hyperechoic spots around the chondral lesion is an important sonographic sign for diagnosing chondral fractures concomitant with ankle lateral ligament injury. Hence, we believe that stress sonography should be considered for the detection of chondral fractures concomitant with radiographically negative ankle lateral ligament injuries in skeletally immature patients with lateral ankle pain and ankle sprains, if hyperechoic spots are present in the cartilage of the distal fibula.     

The Diagnostic Challenge of Ankle Injuries in the Emergency Department

An ankle injury is a very common musculoskeletal problem that can be easily misdiagnosed. About 15% to 20% of these injuries result in fractures, whereas the rest can range from a simple sprain to more complicated injuries, including tears to ligaments and the interosseous membrane. Ankle injuries that are not properly assessed may result in a lifetime of joint instability, pain, and problems with ambulation.     

A pooled analysis of the Ottawa ankle rules used on adults in the ED

A pooled analysis was conducted of the seven studies on the clinical diagnostic effectiveness of the Ottawa ankle rules when used with adult patients in the emergency department (ED). The seven studies, conducted in university and community hospital EDs, had examined the sensitivity, specificity, and positive and negative predictive values of the Ottawa ankle rules. ED physicians applied the Ottawa ankle rules with adult patients who had blunt ankle injuries. The gold standard was radiography. The combined sensitivity for the seven studies was 97% or higher for ankle/foot, original/refined Ottawa ankle rules and negative predictive value was greater than 99%. These results support the effectiveness of the Ottawa ankle rules for ruling out a fractured ankle or foot. Specificity was lower, ranging from 31% to 63%; positive predictive value was <20%. Thus, the Ottawa ankle rules should not be used for ruling in a fractured ankle or foot. This pooled analysis shows the Ottawa ankle rules to be effective as clinical practice guidelines for acute ankle and foot injuries in the adult ED patient. Patients with negative results when the rules are used are highly unlikely to have a fractured ankle or foot, but the diagnosis for positive patients is much less certain, suggesting the need for radiography.     

Sprain or fracture? An analysis of 2000 ankle injuries.

A retrospective survey of over 2000 patients with inversion injuries of the ankle joint was undertaken to examine the validity of criteria commonly used in an accident and emergency department to assess severity. Swelling alone is an unreliable indicator of the severity of the injury. Patients with severe pain and inability to weight bear show a high incidence of fractures and must be X-rayed. Conversely, a combination of minimal pain and swelling, and ability to bear weight are indicative of a soft-tissue injury. Young people sustain most inversion injuries and have a lower incidence of significant fractures of the lateral malleolus. Analysis of presenting features did not reveal any reliable indicants which could be used to reduce the number of radiographs requested, without substantially increasing the risk of missing patients with significant fractures. However, it has been possible to formulate guidelines for the more rational and consistent use of X-rays in the initial assessment of patients with ankle sprains.     

Sprunggelenk

Injuries of the ankle joint are very common in both the general population and especially in athletes. Persistent complaints can often lead to restriction of individual sporting and even everyday activities. Ankle ligament lesions of the syndesmotic complex, peroneal tendon and retinaculum injuries and contusions or fractures of the bony structures or in the osteochondral area may occur. Unfortunately delayed or insufficient treatment of these injuries may lead to chronic instability and impingement syndromes causing more or less severe pain and early degenerative changes. An exact diagnosis is mandatory to prevent long-term sequelae. Because magnetic resonance (MR) imaging provides superior soft tissue resolution, high sensitivity for osteochondral contusions and occult fractures and the ability to image the cartilage and ankle ligaments directly, it is the modality of choice in the evaluation of ankle injuries. However, an initial conventional radiography should not be omitted.     

The accuracy of ultrasound evaluation in foot and ankle trauma

ObjectivesFoot and ankle injuries that result in sprains or fractures are commonly encountered at the emergency department. The purpose of the present study is to find out the accuracy of ultrasound (US) scanning in injuries in the aforementioned areas.MethodsOttawa Ankle Rules–positive patients older than 16 years who presented to the emergency department with foot or ankle injuries were eligible. For all patients, US evaluation of the whole foot and ankle was performed by an emergency physician before radiographic imaging. All radiographic images were evaluated by an orthopedic specialist and compared with the interpretations of the US.ResultsOne hundred thirty-one patients were included in the study. Radiographic evaluation enabled the determination of fractures in 20 patients, and all of these were identified with US imaging. Moreover, US evaluation radiographically detected a silent ankle fracture in 1 patient. The sensitivity of US scanning in detecting fractures was 100% (95% confidence interval [CI], 83.8-100), the specificity was 99.1% (95% CI, 95-99.8), the positive predictive value was 95.2% (95% CI, 89.6-98), and the negative predictive value was 100% (95% CI, 96.4-100), respectively. The most common fractures were detected at the lateral malleolus and at the basis of the fifth metatarsal.ConclusionsUltrasound imaging permits the evaluation of foot and ankle fractures. Because it is a highly sensitive technique, US can be performed in the emergency department with confidence.     

Implementation of the Ottawa Ankle Rules by nurses working in an accident and emergency department.

OBJECTIVE: To assess whether accident and emergency (A&E) nurses using the Ottawa Ankle Rules could detect all ankle fractures. DESIGN: Prospective observational study. SETTING: A&E department of a university teaching hospital. SUBJECTS: All patients who presented with ankle injuries who were initially assessed by a nurse taught the Ottawa Ankle Rules. OUTCOME MEASURES: (1) The numbers of patients referred by the nurse for ankle radiography; (2) of these, the number with ankle fractures; (3) of those not sent for radiography initially by the nurse, the number who subsequently had x rays (ordered by the doctor) and had a fracture; (4) of those having no x rays, the number who reattended later. RESULTS: 324 patients were eligible; 238 had x rays at the request of the nurse (73%); 48 of these (20%) were diagnosed as having a fracture. Of those 86 patients not sent for radiography by the nurse, 19 subsequently had x ray examinations at the request of a doctor and no fracture was detected. Of the 67 not sent for radiography, none returned within the subsequent eight weeks. CONCLUSIONS: Nurses can apply the Ottawa Ankle Rules safely without missing acute fractures; that is, of those who were not sent for radiography by nurses, none subsequently reattended the A&E department or the trauma service of the Bristol Royal Infirmary during the following two months.     

Imaging of impingement lesions in the ankle

Ankle impingement and instability are well-recognized complications of ankle sprain. Ankle impingement is an important cause of chronic ankle pain in active populations, particularly in the professional athlete. Depending on anatomical location and the structures involved, impingement syndromes are classified into anterolateral, anterior, posterior, posteromedial, and anteromedial types. Clinically, impingement syndromes are characterized by painful limitation of full-ankle movement. Ankle impingement results from repetitive subclinical trauma due to overuse injuries, which, in the subacute or chronic situation, lead to abnormal osseous and soft-tissue thickening within the ankle joint. Various imaging techniques can be used in the diagnosis of ankle impingement. Usually, radiography is the initial imaging technique performed to rule out bony trauma and identify potential anatomical bony abnormalities. Use of computed tomography and isotope bone scanning is largely superseded by magnetic resonance imaging, although with variable sensitivity and specificity. Arthrographic techniques, using computed tomography or magnetic resonance, are useful for exquisite demonstration of capsular recesses and synovial abnormalities. Imaging-guided injection techniques can be used in the management of impingement for pain ablation and to aid clinical diagnosis, especially in hind foot pain.