1. Lateral Ankle Sprains and Chronic Ankle Instability

2. 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

3. Lateral Ankle Sprain

4. Pathology Lateral Ankle Sprain
An episode of acute inversion/supination injury of the ankle associated with swelling, lateral ankle pain and difficulty weight bearing

5. 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

6. 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

7. 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

8. 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

9. 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

10. Ottawa Ankle Rules

11. Special Test
Anterior drawer test

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

13. 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

14. 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

15. Plan B
Soft tissue repair
Ligament Reconstruction

16. Chronic Ankle Instability

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

18. 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

19. 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

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

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

22. Special Test
Anterior drawer test

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

24. 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

25. 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

26. Plan B
Soft tissue repair
Ligament Reconstruction

27. 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): S
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):
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):
McGovern, R. P. and R. L. Martin (2016). "Managing ankle ligament sprains and tears: current opinion." Open Access J Sports Med 7:
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):