Download Lateral-Ankle-Sprain-and-Chronic-Ankle-Instabilty

Lateral Ankle Sprains
Normal Anatomy
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Lateral ankle ligament complex consists of
o Anterior talofibular ligament (ATFL)
o Calcaneofibular ligament (CFL)
o Posterior talofibular ligament (PTFL)
ATFL blends with the ankle capsule, from anteroinferior margin of fibula to lateral margin of
talus
CFL is from the inferior margin of the fibular, distal to the ATFL and runs underneath the
peroneal tendons to the lateral tubercle of the calcaneus
PTFL is a thickening of the capsule from the posterior fibula to the lateral tubercle of the
posterior process of the talus
ATFL stress in plantarflexion
Pathology
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An episode of acute inversion/supination injury of the ankle associated with swelling, lateral
ankle pain and difficulty weight bearing
Mechanism of Injury
Traumatic
 Foot and ankle inversion of a plantar-flexed or internally rotated foot
 External rotation of the lower leg with respect of the ankle
Risk Factors
Intrinsic
 Reduced invertors and evertors strength
 Reduced proprioception
 Reduced balance
 Reduced dorsiflexion range of movement
 Lower limb mal alignment
Extrinsic
 Previous lateral ligament sprain
 Twisting, pivoting sports
 Contact sport
 Playing on artificial grass
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Classification
Grade 1
 Mild
 Painful
 Minimal ligament tearing
Grade 2
 Moderate
 Painful
 Significant ligament tearing
Grade 3
 Severe
 Sometimes not painful
 Complete ligament rupture
Examination
Subjective
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History of:
o Foot and ankle inversion of a plantar-flexed foot
o External rotation of the lower leg with respect of the ankle
Swelling (immediate suggests rupture more likely)
Maybe unable to continue to play
Objective
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Haematoma
Pain on palpation lateral ligaments
Abnormal anterior drawer test
Pain on palpation of the medial malleolus is not unlikely
Delayed physical exam (4-5 days) gives better diagnosis
Reduced proprioception
Ottawa Ankle Rules
 Helps identify those that require an X-ray following lateral ankle sprains
 Sensitivity of 97.6%
A. Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral
malleolus
B. Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus
C. Bony tenderness at the base of the 5th metatarsal
D. Bony tenderness at the navicular
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E. Inability to weight bear both immediately after injury and for 4 steps during initial
evaluation
Ankle X–ray = Pain around the malleolus + A OR B OR E
Foot X-ray =Pain around the midfoot + C OR D OR E
Special Tests
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Anterior drawer test
Further Investigations
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X-ray (rule out fracture)
Ultrasound
MRI
Management
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Conservative management always explored
Reduce swelling initially although swelling may never go completely
Emphasis on prevention of future injury
Emphasis on proprioception and dynamic stability
Conservative
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Reduce pain and inflammation
o Immobilisation
o NSAID’s
o Ice
o Massage
Restore Normal Range of Movement
o Ankle
 Massage
 Joint mobilisation
 Joint manipulation
Restore Normal Muscle Activation
o Evertors
o Invertors
o Plantarflexors
o Dorsiflexors
o Intrinsic Foot Muscles
Restore Dynamic Stability
o Proprioceptive Training
Sport Specific Training
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Plan B
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Soft tissue repair
Ligament Reconstruction
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Chronic Ankle Instability
Normal Anatomy


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Lateral ankle ligament complex consists of
o Anterior talofibular ligament (ATFL)
o Calcaneofibular ligament (CFL)
o Posterior talofibular ligament (PTFL)
ATFL blends with the ankle capsule, from anteroinferior margin of fibula to lateral margin of
talus
CFL is from the inferior margin of the fibular, distal to the ATFL and runs underneath the
peroneal tendons to the lateral tubercle of the calcaneus
PTFL is a thickening of the capsule from the posterior fibula to the lateral tubercle of the
posterior process of the talus
ATFL stress in plantarflexion
Pathology
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The perception by the patient of an abnormal ankle with a combination of symptoms
including recurrent sprains, pain and swelling or avoidance of activities
Mechanism of Injury
Insidious
Intrinsic
 Reduced invertor and evertor strength
 Reduced proprioception
 Reduced balance
 Ligament laxity
 Lower limb mal alignment
Extrinsic
 Previous or repeated lateral ligament sprain
Classification
Functional Ankle Instability
 Instability due to proprioceptive deficits, neuromuscular deficits, postural control deficits
and muscle weakness
Mechanical Ankle Instability
 Instability due to ligament laxity
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Examination
Subjective
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History of multiple sprains
Feeling of unstable ankle
Regular giving way
Objective
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Reduced proprioception
Weakness ankle evertors
Tenderness palpation lateral ligaments
Instability on anterior drawer test
Special Tests
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Anterior drawer test
Further Investigations
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X-ray (rule out fracture)
Ultrasound
MRI
Management
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Conservative management useful but not always successful
Large emphasis on restoring neuromuscular control and strength
Manual therapy can be used if acute sprain is present but general manual therapy is not
useful
Conservative
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Restore Normal Muscle Activation
o Evertors
o Invertors
o Plantarflexors
o Dorsiflexors
o Intrinsic Foot Muscles
Restore Strength
o Entire kinetic chain
Restore Dynamic Stability
o Proprioceptive Training
Sport Specific Training
Plan B
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Soft tissue repair
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Ligament Reconstruction
References
(Kerkhoffs, van den Bekerom et al. 2012, Guillo, Bauer et al. 2013, van den Bekerom, Kerkhoffs et al.
2013, Knupp, Lang et al. 2015, McGovern and Martin 2016)
Guillo, S., T. Bauer, J. W. Lee, M. Takao, S. W. Kong, J. W. Stone, P. G. Mangone, A. Molloy, A. Perera,
C. J. Pearce, F. Michels, Y. Tourne, A. Ghorbani and J. Calder (2013). "Consensus in chronic ankle
instability: aetiology, assessment, surgical indications and place for arthroscopy." Orthop Traumatol
Surg Res 99(8 Suppl): S411-419.
Kerkhoffs, G. M., M. van den Bekerom, L. A. Elders, P. A. van Beek, W. A. Hullegie, G. M. Bloemers, E.
M. de Heus, M. C. Loogman, K. C. Rosenbrand, T. Kuipers, J. W. Hoogstraten, R. Dekker, H. J. Ten
Duis, C. N. van Dijk, M. W. van Tulder, P. J. van der Wees and R. A. de Bie (2012). "Diagnosis,
treatment and prevention of ankle sprains: an evidence-based clinical guideline." Br J Sports Med
46(12): 854-860.
Knupp, M., T. H. Lang, L. Zwicky, P. Lötscher and B. Hintermann (2015). "Chronic Ankle Instability
(Medial and Lateral)." Clinics in Sports Medicine 34(4): 679-688.
McGovern, R. P. and R. L. Martin (2016). "Managing ankle ligament sprains and tears: current
opinion." Open Access J Sports Med 7: 33-42.
van den Bekerom, M. P., G. M. Kerkhoffs, G. A. McCollum, J. D. Calder and C. N. van Dijk (2013).
"Management of acute lateral ankle ligament injury in the athlete." Knee Surg Sports Traumatol
Arthrosc 21(6): 1390-1395.
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