Lateral Ankle Sprains and Chronic Ankle Instability

Normal Anatomy Lateral ankle ligament complex consists of Anterior talofibular ligament (ATFL) Calcaneofibular ligament (CFL) 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

Lateral Ankle Sprain

Pathology Lateral Ankle Sprain 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

Classification Grade 1 Grade 2 Grade 3 Mild Painful Minimal ligament tearing Grade 2 Moderate Significant ligament tearing Grade 3 Severe Sometimes not painful Complete ligament rupture

Subjective Examination History of: Foot and ankle inversion of a plantar-flexed foot External rotation of the lower leg with respect of the ankle Swelling (immediate suggests rupture more likely) Maybe unable to continue to play

Objective Examination 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

Special Test Anterior drawer test

Further Investigation X-ray (rule out fracture) Ultrasound MRI

Management 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 Reduce pain and inflammation Immobilisation NSAID’s Ice Massage Restore Normal Range of Movement Ankle Joint mobilisation Joint manipulation Restore Normal Muscle Activation Evertors Invertors Plantarflexors Dorsiflexors Intrinsic Foot Muscles Restore Dynamic Stability Proprioceptive Training Sport Specific Training

Plan B Soft tissue repair Ligament Reconstruction

Chronic Ankle Instability

Pathology Chronic Ankle Instability The perception by the patient of an abnormal ankle with a combination of symptoms

Mechanism of Injury Insidious Intrinsic Extrinsic 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

Subjective Examination History of multiple sprains Feeling of unstable ankle Regular giving way

Objective Examination Reduced proprioception Weakness ankle evertors Tenderness palpation lateral ligaments Instability on anterior drawer test

Special Test Anterior drawer test

Further Investigation X-ray (rule out fracture) Ultrasound MRI

Management 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 Restore Normal Muscle Activation Restore Strength Evertors Invertors Plantarflexors Dorsiflexors Intrinsic Foot Muscles Restore Strength Entire kinetic chain Restore Dynamic Stability Proprioceptive Training Sport Specific Training

Plan B Soft tissue repair Ligament Reconstruction

References 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.