0. Society for Adolescent Health and Medicine Sports Medicine Workshop
March 10, 2017
Albert C. Hergenroeder, M.D.
Keith Loud, M.D

1. Ankle Injuries: Diagnosis and Management

2. Goal
The audience will understand the diagnosis and management of common ankle injuries

3. Objectives The audience will be able to discuss:
The two most common mechanisms of ankle injuries
The key physical examination findings in examining the acutely injured ankle
Explain the Ottawa Rules regarding indications for xrays
Outline the acute treatment program

4. Mechanism of ankle sprains
Inversion
85% of those that present to EC (Brostrom 1966)
Eversion
More likely associated with fracture
Low index of suspicion for xray
There is a 3rd mechanism:
“Don’t remember”

5. Physical examination Inspection Active ROM x 6 Resisted ROM x 6
NV/Gait
Active ROM x 6
Resisted ROM x 6
Provocative tests
Palpation
Functional tests

6. Active ROM Dorsiflexion (extension) Plantarflexion (flexion)
Then each with inversion and eversion

7. Resisted ROM x 6
Dorsiflexion
Inversion
Eversion
Plantarflexion

8. Anterior drawer
Positive test indicates tear of ATFL and CFL

9. Palpation Lateral joint line/lateral malleolus
Base of fifth metatarsal
Medial joint line/medial malleolus
Navicular
Proximal fibula
Anterior joint line/talus

10. Functional testing

11. Ottawa Rules for obtaining ankle xray series (Steill 1993)
Pain in the malleoli and > 1 of following
Inability to walk pain free immediately after the injury or take 4 steps in the EC
Or, tenderness at the tip of the malleoli

12. Ottawa Rules for obtaining foot xray series (Steill 1993)
Pain in the midfoot (navicular, cuboid, cuneiforms), anterior talus, base of 5th, and
The inability to bear weight, or
Point tenderness over navicular, base of 5th, cuboid

13. Tibiofibular syndesmosis injury
More serious
Eversion is a risk factor
Tender proximal to anterior joint line
Squeeze test

14. Treatment
The Goal is to limit disability

15. Initial treatment
RICE
Rest
Ice
Compression
Elevation
Analgesia

16. Injuries while using crutches
Estimated 15,849 injuries to < 19 yo in the US, – 2008
National Electronic Injury Surveillance System
Reported to ED
8,800 LE, 3,800 UE, 1,600 head
Barnard 2010

17. Wearing stirrup for a year lowers risk of respraining ankle
RCT, male professional soccer players
For those with previous history of ankle sprain, wearing the orthosis was associated with a 5-fold reduction in the incidence rate in the next year, compared to those with previous injuries who did not wear the orthosis.
Surve 1994

18. Initial rehabilitation exercises
Relative rest
Start as soon as possible
Stretching
Strengthening
Get off crutches asap

19. Day #
walk
jog
1, 2 5
3, 4 10
5, 6 15
7, 8 20
9, 10
5, 10
11, 12
5, 5
13, 14
10%/week

20. Gradual return to play guidelines associated with ↓ LE reinjury rate
Male, amateur soccer players
Norway, RCT
10 return to play: jog > figure of eight > zig-zag jog, jog with 90° turns, jog with 180° turn, jog with 360° turns > ball drills > shooting, jumping, sprinting > team training > match play
11% reinjury rate intervention vs 29% cont
Hagglund 2008

21. Summary 2 common mechanisms PE findings Inversion, eversion NV first
Active, resisted ROM; provocative tests
Functional tests

22. Summary (cont’d) Ottawa rules for ankle
Initial rehab – RICE, analgesia
Start pain free rehab asap

23. Summary (cont’d) Functional rehab Walk-jog > figure of 8 >sports
Air stirrup for 6 months
Some evidence for preventive, preseason programs

24. Thank you!
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