2 -ANKLE INJURIES Flashcards
Description & generalities of ankle sprains
ANKLE SPRAINS
- Lateral ankle sprain more common than medial due to deltoid ligaments in medial that are thicker
- Account for most common injury in sports
- Makes up almost 50% of all injuries in volleyball
- Not to be missed: ankle fractures, osteochondral lesions, 5th meta # in case of inversion
- Dominant leg 2.4x more likely than non-dominant to get injured
Osteochondral lesions: description
- Often seen in patient with grade 2-3 ankle sprain
- Physically appears as ankle sprain (hematoma & swelling)
- Deep pain in joint
- Articular cartilage damage in talus
- Deep pain on weight bearing
Joints of ankle
JOINTS OF ANKLE
- Talocrural joints
- Subtalar joint
- Inferior tib-fib joint (with syndesmosis)
Outcomes for assessment of ankle sprain: acute
Table
During acute assessment: how use Y balance test
Y balance test
- Measured reaching distance & leg length
- Formula: REACH / LEG LENGTH x 100 = % (able to reach …% of leg length)
- Difference of more than 10% between legs could be significant
When is done the acute assessment
Acute assessment not just after injury but some days after
Why do strength assessment:
Strength
- Very important to assess eccentric strength, more like motor control assessment
Describe what could mean somatosensory assessment
Somatosensory assessment
- Put pressure on lateral part of foot & look at reaction to move into inversion (for patient with multiple ankle sprains => delay of response)
Why movement should be more limited in ROM during acute assessment
ROM
- DF should be more limited, take more time to recover & that limit more in activity as running
Chronic assessment of ankle sprain
Table
Imaging description
IMAGING
- X-ray recommended in weight bearing position if x-ray suspected
- US can identify ruptured in ligaments (less sensitive than MRI)
- MRI not recommended due to burden on healthcare system / cost but gold standard for
identifying ligament injuries, syndesmotic injuries & tendon injuries
- CT scan, not routinely used (can imagine well but expensive)
Description & generalities of CAI
Description & generalities
- About 20% of lateral ankle injuries develop CAI (up to 40% possibly)
- Secondary to LAS
- Includes both mechanical & functional instability
- Occur due to damaged mechanoreceptors from time of LAS
- Deficits in proprioception & postural control
- Deficits in fibularis muscle strength, damage in peroneal nerve leading to dysfunction due to
cover stretch / selective reflex inhibition in invertor muscle (when mvt starts into inversion)
- Deficits in conscious perception of afferent somatosensory info, reflex responses & efferent
motor control deficits
- Both feed-forward & feedback mechanisms of motor control affected
- Possible secondary lesions: chronic regional pain syndrome, neuropraxia, sinus tarsi
syndrome, peroneal tendinopathy, dislocation or subluxation, impingement syndromes,
fractures such as anterior calcaneal process, fibula & lateral talar process, loose bodies &
osteochondral lesion of talar dome or distal tibia
Indicators of risk of CAI
Indicators of risk of CAI
- Inability to complete jumping & landing tasks within 2 weeks following injury. Tasks
successfully predicted development of CAI by 67.6%
- Poorer dynamic control on SEBT (hip & knee flexion in posterolateral & posteromedial
directions) at 6 months following LAS injury, was able to predict CAI by 84.8%
- Poorer self-reported function on FAAM
Relevant positive findings for risk of CAI
Table
Management of CAI
Management of CAI
- Balance retraining: SEBT can be used as exercise
- Strengthening / progressive loading: isokinetic strengthening has proven benefits
- Bracing for 6 months following sprain
- Surgery can be considered if conservative not effective: repair of ligaments
Prevention of CAI after LAS
Prevention of CAI after LAS
- Evaluation of all joints affected by injury
- Strategies to correct hypermobility (bracing initially post injury will reduce healing in
lengthened position)
- Correction of hypomobility (consider compensatory mechanisms to overcome limited DF)
- Protection of healing structures
Management of ankle sprains
MANAGEMENT OF ANKLE SPRAINS
- Address missing components
- Treat swelling / pain / bruising
- Treat ROM, accessory mobilization / manipulations
- Poor balance / proprioception
- Poor motor control of stirrup muscles
- Poor eNdurance
+ image
Type of management possible
Peace & love
Electrotherapy
Manual therapy
Bracing taping
Peace & love management
PEACE & LOVE: acute management
- Early protected weight bearing helps with:
o Swelling reduction
o Restoration of normal range of motion
o Return to normal activity
o Preventing mechanical instability long-term
- Ice: 5 min many time but not much than 5 min => not analgesic effect but slow process of
healing
Electrotherapy
Electrotherapy
No evidence for:
- Ultrasound
- E-stim
- Laser
- Shortwave diathermy
More for motor control rehabilitation
Manual therapy techniques
Manual therapy techniques
Assist with:
- Pain reduction
- Reduction of stiffness
- Improvement in ankle dorsiflexion
- Improvement in stride length
- Better proprioceptive awareness
- Functional recovery
AP accessory glides of talocrural joints, talocrural distractions, passive DF physiological mob,
soft tissue massage & manual lymph drainage recommended
Bracing & taping ankle
Bracing / taping ankle
1. Grade I & II ankle sprain: recommendations include early mobilization & functional support
allowing functional rehabilitation
2. Grade III ankle sprain: 10 fays of immobilization using a below-knee cast or rigid brace,
followed by controlled therapeutic exercises
3. Immobilization in form of ankle brace allow loading & protection of damaged tissue & should
be used for minimum 6 months following moderate or severe sprain. Semi-rigid brace or laceup brace better than elastic bandage & more effective than rigid or elastic tape. Type of
bracing recommended for individuals with prior history of ankle sprains
4. Kinesio taping may not provide sufficient mechanical support for unstable joint
Prevention of sport injuries in ankle
PREVENTION OF SPORT INJURIES OF ANKLE
- Functional support (tape or brace) & exercise therapy effective in preventing new or
recurrent LAS, level 1 evidence
- Ankle bracing reduces risk of new & recurrent LAS by 47% & 63%, respectively
- Neuromuscular training reduces incidence of LAS by 38%
