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Sports Medicine > 5) Lateral Ankle (Inversion) Injury > Flashcards

5) Lateral Ankle (Inversion) Injury Flashcards

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1
Q

Lateral ankle (inversion) sprains incidence

A
  • 40 % of all sports injuries (most common injury in all of sports)
  • 25 % of all time lost in sports
  • Lateral: 85 %
  • Medial: 5 %
  • Syndesmosis: 10 %
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2
Q

Sprain

A
  • Stretching injury which may involve partial or complete tearing of the lateral ankle ligaments
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3
Q

Lateral ankle inversion injury anatomy

A
  • Shape of the talar dome: Wide anterior and narrow posterior
  • Results in decreased frontal plane stability of the ankle when plantarflexed
  • Increased stability with ankle dorsiflexion
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4
Q

STJ and ankle joint biomechanics

A
  • Subtalar joint: 2:1 inversion to eversion ratio

- “Ankle” inversion is generated at the subtalar joint

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5
Q

Biomechanics: contributing factors

A
  • Ankle equinus
  • Gastrocnemius / soleus weakness
  • Forefoot / rearfoot deformity
  • Transverse plane abnormality
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6
Q

Lateral ankle injury history

A
  • Mechanism ?
  • Could bear weight initially ?
  • History of previous injury, treatment and outcome ?
  • Audible “pop” ?
  • Immediate treatment ?
  • Inappropriate shoe gear
  • Excessive cushioning; shoe or surface
  • Irregular surface (ie some ones’ shoe !)
  • Any contributory neurological history
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7
Q

Palpation on physical examination

A
  • Lateral malleolus
  • Anterior talo – fibular ligament (ATF)
  • Calcaneofibular ligament
  • Posterior talofibular ligament
  • Anterior – inferior syndesmosis
  • Medial malleolus
  • Deltoid ligament
  • Achilles tendon
  • Fifth metatarsal base
  • Calcaneal anterior process
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8
Q

Physical tests

A
  • Squeeze test: anterior – inferior syndesmosis
    Anterior drawer test (push – pull test; “dimple sign”)
  • Muscle testing (esp. peroneals and flexors)
  • Dorsi / plantarflexion of the MTPJ: shepards fracture / flexor tendon injury
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9
Q

Lateral ankle sprain physical examination order

A
  • Vitals
  • Begin proximal
  • Begin at least painful areas
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10
Q

Syndesmotic injury tests

A
  • Squeeze test
  • Tibio–talar shuck test
  • External rotation test
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11
Q

Lateral ligaments palpation

A
  • Anterior talo – fibular
  • Calcaneofibular
  • Posterior malleolus
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12
Q

Lateral ankle sprain grading

A
  • Grade 1: Partial tear of the anterior talo – fibular ligament (“anterior sprain”)
  • Grade 2: Complete tear of the ATF and partial tear to the calcaneofibular ligament
  • Grade 3: Complete tear of the ATF and CF
  • Grade 4: (some authors) posterior talo fibular ligament injury
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13
Q

Lateral ankle sprain radiographic evaluation

A
  • The Ottawa ankle rules: who gets an x – ray ?
  • Can not bear weight initially and / or
  • Pain over syndesmosis or posterior malleolus
  • AP, MO, Lat ankle and MO foot
  • In the USA: everyone gets an x – ray !
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14
Q

Lateral ankle sprain associated injuries

A
  • Ankle fracture
  • Syndesmotic (“high”) ankle injury
  • Shepard’s (Steida’s) fracture: posterior -lateral process of the talus
  • Talar dome fracture
  • Calcaneal anterior process fracture
  • Fifth metatarsal base avulsion fracture
  • Sinus tarsi syndrome
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15
Q

Rare associated injuries

A
  • Pseudo aneurism of the lateral malleolar artery
  • Neoplasm
  • Compartment syndrome
  • Reflex sympathetic dystrophy
  • Achilles rupture
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16
Q

Calcaneal anterior process lateral injuries

A
  • Avulsion injury via bifurcate ligament
17
Q

Fifth met base avulsion fracture

A
  • Avulsion from a lateral slip of the plantar fascia and to a lesser extent, the peroneus brevis
  • Jones fracture uncommon
18
Q

Talar dome fractures

A
  • A common latent complaint
19
Q

Lateral ankle sprain initial management

A
  • Protection
  • Rest
  • Ice
  • Compression
  • Elevation
  • NSAID’s ?
20
Q

Lateral ankle sprains management (general/continuous)

A
  • Jones compression for 0- 5 days
  • Syndesmotic injury: wb immobilization 6 -8 weeks
  • Limit the period of non – weight bearing
  • CAM walker for early weight - bearing
  • Consider bone scan / MRI / CT
  • Begin rehabilitation ASAP
21
Q

CAM walker

A
  • Allows for early weight – bearing and maintains (ankle dorsiflexed) ATF in close approximation (less pain !)
22
Q

Rehabilitation

A
  • Acute phase
  • Rehabilitative phase
  • Functional phase
  • Return to activity phase
23
Q

Functional phase: improve strength and proprioception

A
  • BAPS (biomechanical ankle platform system) board
  • Plyometrics
  • Toe raises / other balancing exercises
  • Side – to – side lateral movement (slide board, shuttle machine)
  • Cybex / Biodex
24
Q

Return to activity phase

A
  • Sport – specific movements
  • Preventative strategies
  • Equipment modifications
25
Q

Requirements for the athlete to return to full activity

A
  • Minimal / no edema
  • No limp with normal gait
  • Be able to perform one – legged toe raise
  • Ability to descend stairs (without using the hand rail)
  • One – legged lateral hop test
  • Ankle dorsiflexion test
26
Q

Ankle braces and tape

A
  • Both reduce the incidence of ankle inversion sprains by increasing peroneal reactivity (reaction time) and strength through direct contact with the skin (propricoeptors)
  • Braces&raquo_space;> tape
  • Tape lasts 10 min (40% reduction)
  • Both do not alter athletic performance if applied correctly
  • Both&raquo_space;> orthoses and high – top shoes
  • Athletes should be braced for up to 6 months following an injury
27
Q

Peroneal muscular strengthening and proprioceptive exercise

A
  • Out-perform bracing, taping, orthoses and high tops in the prevention of lateral ankle inversion sprains
  • Cross – over effect of rehabilitation
28
Q

1 complication of inversion ankle sprains

A
  • Chronic ankle instability and pain
29
Q

Stress radiography

A
  • Must have a negative contralateral history
  • Common peroneal nerve block

+ inversion stress (talar tilt) = > 5 degrees compared with contralateral ankle

+ anterior drawer (push – pull) = > 10 mm of anterior talar displacement or > 4 mm compared with the contralateral ankle

30
Q

Anterior drawer (push-pull)

A
  • Specific for the ATF
31
Q

Inversion stress

A
  • Specific for CFL
32
Q

Radiographic finding inversion stress testing (by grading)

A
  • Grade 1: + push – pull, -/+ inversion stress (>5 degrees)
  • Grade 2: + push – pull, + inversion stress (>10 degrees)
  • Grade 3: + push – pull, + inversion stress (>15 degrees)
  • Grade 4: + push – pull, + inversion stress ( > 15 degrees)
33
Q

Lateral ankle instability surgical intervantion

A
  • Delayed primary ligamentous repair (Brostrom procedure)
  • Chrisman – Snook
  • Watson – Jones
  • Split peroneus brevis
  • Evans
  • Etc.
34
Q

Surgical management outcome studies

A
  • Indicate that delayed primary ligamentous repair yields improved results when compared with stabilization procedures
  • Stabilization procedures are more disruptive to normal anatomy, more technically difficult and are more likely to result in over-tightening of the ankle
35
Q

Brostrom procedure

A
  • Anterior talo-fibular ligament imbricated and repaired with non – absorbable suture (eg 00 – 2.0 ethibond)
  • Anterior – inferior extensor retinaculum over – sewn to anterior boarder of the fibula (Gould modification)
  • Repair of calcaneo – fibular ligament unnecessary
36
Q

Other treatment options for lateral ankle instability

A
  • Prioltherapy: Thermal “shrinking” of the lateral ligaments with the “wand”
  • Prolotherapy: injectable sugar solution to enhance proprioception

Sports Medicine (5 decks)

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