ANKLE EXAMINATION WORKSHOP
ANKLE EXAMINATION WORKSHOP
By
Craig K.Seto, MD
Assistant Professor
Dept. of Family Medicine
I. ANKLE SPRAINS: (Diagnosis and Management)
A. What’s the problem with ankle injuries?
1. Lateral ligament sprains:
- Are the most frequent injury sustained by athletes.
- Constitute 5-24% of all injuries sustained in an individual sport.
- Produce 25% of all time loss due to an injury in football, b-ball, and cross-country.
- Account for 85% of grade III ankle injuries of which 40% can potentially progress to chronic problems.
B. Long Term Sequelae of Recurrent ankle injuries
- Recurrent ankle sprains can lead to functional instability and loss of normal ankle kinematics which may lead to chronic recurrent injury (viscious cycle) and ultimately early degenerative changes (arthritis).
- Biomechanics of the ankle joint demonstrate that talar displacement of greater than 1mm reduces the ankle’s weight-bearing surface by 42%.
C. Review of Ankle Anatomy
1. Bony Structures: include distal tibia and fibula including malleoli and the talus.
- The distal tibia and fibula are bound together by the ant. & post. tibio-fibular ligament and the interosseus membrane which runs between the long bones.
- The talus is a wedged shaped bone that is wider anteriorly than posteriorly and fits into the mortise formed by the bound tibia and fibula.
2. Lateral Ligamentous Structures (3 main ligaments)
- Anterior talofibular (ATF) ligament
- Calcaneofibular (CF) ligament
- Posterior talofibular (PTF) ligament
*Represent 85% of all ankle sprains
*Mechanism of injury: Plantar flexion and inversion.
3. Syndesmotic Structures
- Anterior inferior tibiofibular ligament
- Posterior inferior tibiofibular ligament
- Transverse tibiofibular ligament
- Interosseous membrane
*Represents 10% of all ankle sprains.
*Mechanism of Injury: Dorsi-flexion and/or eversion.
4. Medial Ligamentous Structures
- Deltoid ligament complex
- The strongest of the ankle ligaments
*Represent 5% of all ankle sprains.
*Mechanism of injury is forced eversion.
5. Major Functions of the ankle ligaments.
- Provide proprioceptive information for joint function.
- Provide static stability to the joint and prevent excessive motion.
- Guides and directs the motion of the joint.
D. Clinical Evaluation of the injured ankle
1. Taking the History (important things to include)
- Mechanism of injury: What happened? Which way did it twist?
- Could you walk after the injury?
- How much swelling/ecchymosis?
- When did the injury occur?
- What have you done for it?
- Have you injured your ankle before?
2. Examination of the Ankle
- Assess ability to bear weight on the injured ankle
- Inspection and Palpation is most helpful during the acute phase
- Palpate the structures you know (remember your anatomy)
- Tenderness over the malleoli, base of the 5th metatarsal, and navicular bone could indicate a fracture and may require an xray
- Tenderness over the ligamentous structures usually indicate injury of these structures.
- Assess range of motion: plantar and dorsi-flexion, inversion and eversion
- Check neurovascular status
- Ligamentous Testing: “anterior drawer” and “inversion stress”
- Usually not helpful in the acute setting due to pain with the exception of checking for a syndesmotic sprain which is done using the “squeeze test” and the “external rotation test”.
3. To X-ray or not to X-ray?
- The Ottawa Ankle Rules (validated tool to help determine who needs an x-ray)
- According to the rules an X-ray is indicated if:
- Patient presents within 10 days of injury and age is older than 18.
- Unable to bear weight at time of injury or at time of exam.
- Tenderness over the posterior aspect of the distal 6cm of the malleoli
- Tenderness over the base of the 5th metatarsal or navicular bone
*A recent study has validated the tool in patients less than 18 year of age.
E. Classifying Ankle Sprains:
Several Classifications exist based on:
- Ligamentous injury and evidence of instability
- Functional impairment
- Number of ligaments involved
- A combination of the above
1. Grade I Sprain:
- Ligamentous Status:
- Partial tear of the ligament with mild swelling and tenderness
- No instability on exam when stressing the ligament
- Functional Status:
- Slight to no functional loss
- Able to bear weight and ambulate with minimal pain.
2. Grade II Sprain
- Ligamentous Status:
- Incomplete tear of the ligament with moderate pain, swelling, tenderness and ecchymosis.
- Mild to moderate instability of the ligament.
- Functional Status:
- Some loss of motion and function.
- Patient has pain with weight-bearing and ambulation.
3. Grade III Sprain:
- Ligamentous Status:
- Complete tear and loss of integrity of a ligament
- Severe swelling (>4cm around the fibula) and ecchymosis.
- Significant mechanical instability with ligament stressing.
- Functional Status:
- Significant loss of function and motion.
- Patient is unable to bear weight or ambulate.
F. Recovery time following an ankle sprain (inversely related to grade of injury).
1. Grade I injury:
- Requires an avg. 11.7 days before full resumption of athletic activity.
2. Grade II injury:
- Requires an average of 2-6 weeks
3. Grade III injury:
- Average duration of disability ranges from 4.5-26 weeks.
- Only 25-60% being symptom free at 1-4 years after injury.
G. Acute Treatment of an Ankle Sprain: PRICEM
- Protection with an ankle orthosis or brace (ankle stirrup).
- Rest: limit weight-bearing with crutches until able to walk with a normal gait.
- Ice, Compression, Elevation:
- Most important component acutely
- Limiting inflammation and swelling acutely has been shown to speed recovery
- Mobilization
- Early range of motion exercises have been shown to speed recovery.
H. What’s the best treatment for an ankle sprain?
- Grade I & II sprains are best treated as outlined above using the PRICEM approach with an emphasis on limiting swelling and instituting early range of motion exercises.
Grade III sprains are controversial. What does the evidence show?
J Bone Jt Surg (Am) 2000: Treatment of ruptures of lateral ankle ligaments: a meta-analysis.
- Looked at outcomes of time lost, residual pain and giving way.
- Recommendations for practice based on the Meta-analysis:
- Manage Grade III ankle injuries with aggressive functional treatment.
- Or treat with surgery followed by functional treatment.
- Since surgery is costly and can have complications, a trial of functional treatment should be attempted first and surgery considered if the functional treatment fails.
I. Are ankle sprains preventable? Does physical therapy help? Let’s look at the evidence.
A. Cochrane Review in 1997: What’s the best intervention to prevent ankle injuries?
- Reviewed 5 RCT/quasi-RCT
- Concluded:
- There is good evidence of a beneficial effect of semi-rigid orthosis or air-cast braces to prevent ankle sprains during high risk sports.
- Individuals with previous injuries showed the greatest benefit.
B. Am J Sports Med 1999: The prevention of ankle sprains in sports: a systematic review of the literature
- Meta-analysis by the CDC of 113 studies
- Concluded:
- The main risk factor for an ankle sprain is a previous injury.
- Rehabilitating ankle sprains appears to prevent subsequent sprains.
- Recommendations for practice:
- Athletes with a sprained ankle should complete a supervised rehab program prior to returning to competition and should wear an appropriate orthosis for 6 months if the sprain is moderate or severe.
Take Home Message for Treatment of Ankle Sprains:
1. Consider prescribing an ankle orthosis to patients with significant ankle sprains and instruct them to wear them during the time of healing and rehab. Additionally, the literature supports having those patients wear an ankle orthosis during athletic activities in order to prevent a recurrent injury.
2. The literature also supports having patients with a severe or recurrent ankle injury to undergo a supervised ankle rehab. program since it has been shown to decrease the incidence of recurrent injury.
