3 Goals and ObjectivesBetter understand the prevalence of ankle injuries in athletics and its long term sequelae.Review the functional anatomy of the ankle.Review the clinical ankle exam and how to classify ankle sprains.Briefly discuss treatment of an acute ankle sprain.
4 Ankle Injury: What’s the problem? Lateral ligament sprainsthe most frequent injury sustained by athletesconstitute 5-24% of all injuries sustained in an individual sportproduce 25% of all time loss due to an injury in football, b-ball, and CCLateral ligaments sprainsaccount for 85% of grade-III ankle sprainsgreater than 40% can potentially progress to chronic problems
5 Long term Sequelae of Sprains Functional instability and loss of normal ankle kinematics as a complication of ankle sprains may lead to chronic recurrent injury and early degenerative changes.Talar displacement of greater than 1mm reduces the ankle’s weight-bearing surface by 42%
6 Ankle Anatomy 101 Review the following structures of the ankle joint Osseous structures (bones)Ligamentous structuresTendons/muscles around the ankle
7 Bony Anatomy of AnkleTibia and fibula bound together by the ant. & post. Tibiofibular ligaments and the interosseus membrane which runs between the long bonesCollectively called the Syndesmotic ligament
8 Bony Anatomy The Talus is a wedged shaped bone Wider anteriorly than posteriorlyFits into the mortise formed by the bound tibia and fibulaAllows plantar flexion and dorsi-flexion
18 Clinical Exam of the Ankle History is always good!What happened?Which way did it bend?Could you walk?How much swelling/ecchymosis?When did it happen?What have you done for it?Have you sprained it before?
19 Clinical Exam of Ankle Inspection & Palpation: Most helpful during the acute phaseRemember your anatomy!Palpate the structures you knowBoney prominencesLigamentsTendon insertions
20 Clinical Exam of the Ankle Check Range of MotionPlantar and Dorsi-flexionInversion and EversionNeurovascular statusStrength?Not helpful in the acute settingLigamentous testingMay be very difficult to do in the acute setting
21 The Anterior DrawerTests the integrity of the anterior talofibular ligament
22 Inversion Stress TestTests the integrity of the calcaneo-fibular ligament
23 Evaluating for Syndesmotic injury 2 Tests for injury to the syndesmosisThe Squeeze testExternal rotation test
24 Don’t forget the Achilles Tendon The Thompson TestTests the integrity of the Achilles tendonTest patient prone with feet hanging off tablesqueezing the gastrocnemius muscle should cause plantar flexion of the foot…..If the Achilles tendon is intact!It is poor form to miss this diagnosis
25 To X-ray or not to X-ray? Let’s talk Ottawa Ankle Rules Xrays are indicated to r/o fx if:Presents within 10 days of injuryUnable to bear weight at time of injury or in officeTenderness of distal 6cm of malleoli on the post. Aspect.Tenderness over the base of the 5th met or navicular bone
26 Classification of Ankle Sprains Several Classifications Exist based on:Ligamentous injury and evidence of instabilityClassification based on functional impairmentNumber of ligaments involvedCombination of the above
27 Grade I sprain Ligament status Functional status partial tear of the ligamentmild tenderness and swellingno instability on exam when stressing ligamentFunctional statusSlight or no functional lossable to bear weight and ambulate with minimal pain
28 Grade II Ankle Sprain Ligament Status Functional status Incomplete tear of the ligamentModerate pain swelling and tendernessMild to mod. ecchymosisMild to moderate instability of the ligamentFunctional statusSome loss of motion and functionpatient has pain with weight-bearing and ambulation
29 Grade III Ankle Sprain Ligament Status Functional Status Complete tear and loss of integrity of a ligament.Severe swelling (more than 4cm around the fibula)Severe ecchymosisSignificant mechanical instability with ligament stressingFunctional StatusSignificant loss of function and motionpatient is unable to bear weight or ambulate.
30 Prognosis inversely related to Grade Grade IRequire an avg days before full resumption of athletic activityGrade IIRequire approximately 2-6 weeksGrade IIIAvg duration of disability ranges wksOnly 25-60% being symptom free 1-4 yrs after injury
31 Acute Treatment of Ankle Sprains PRICEMProtection: (orthosis or brace)Rest: limit wt. Bearing until non-painfulIce, Compression, and ElevationMost important component acutelyLimiting inflammation and swelling has been shown to speed recoveryMobilizeearly range of motion has also been shown to speed recovery