1. High Ankle Sprain: Initial X-Rays
Mortise (lateral talar shift)
1. tibio-fibular clear space >5mm
2. Tibiofibular overlap < 1mm

2. West Point Grading System (Gerber et al.)
High Ankle Sprain:
West Point Grading System (Gerber et al.)
Grade 1: No instability, partial AITFL tear
Grade 2: Some instability, AITFL full tear, partial IOL tear
Grade 3: Full tear all syndesmosis ligaments
Clear diastasis on x-ray
Associated injuries (Bartonicek):
ATFL rupture 83%
Acute bone bruises 78%
Talar dome OCD 48%
MRI Web Clinic — August 2014 Accessory Anterior Inferior Tibiofibular (Bassett’s) Ligament
Leon Toye, M.D.

3. High Ankle Sprain: Treatment
3 stage conservative treatment:
Short period of protection in Aircast boot
Grade 1 or 2: Like grade 3 ATFL sprain – PWBAT 7-10 days
Grade 3: NWB 4-6/52
Active rehabilitation
Strengthening
Return to play

4. Deltoid Ligament Injury: Diagnosis
Relatively uncommon – 3-4% of all ankle ligament injuries
Risk factors: Male athlete, possible link with pes planus deformity
Typical history
Hindfoot valgus, eversion
High impact injury
“Pop”
+/- difficulty weight bearing
Chronic residual medial pain, instability, “doesn’t feel right” especially downhill or downstairs

5. Deltoid Ligament: Anatomy

6. Deltoid Ligament: Diagnosis
Typical history
Focused physical exam maneuvres for deltoid ligament
Examine superficial deltoid
Palpation anterior MM
External rotation in slight plantar flexion
Examine deep deltoid
Prone posterior translation of talus (relative to tibia)
Positive medial malleolar pointing sign (chronic)
Common associated injuries that change management:
Rule out high ankle sprain – squeeze test, forced ER test, TOP over high ankle
Rule out spring ligament tear – hindfoot valgus, corrects with single leg heel raise to hindfoot varus
Rule out significant PTT dysfunction – hindfoot valgus that fails to correct

7. Deltoid Ligament: Treatment
Combined injuries with spring ligament or PTT – foot/ankle referral
Isolated deltoid sprain:
Grade 1 sprain: Semi-rigid brace, WBAT, early active rehab, return to play over 4-6 weeks
Grade 2 and 3 sprain:
Evaluate for clinical instability if rupture suspected  foot/ankle referral
If conservative, cast or boot with medial longitudinal arch, WBAT, ROM limited.
4 weeks increase to 5-30 deg ROM, starting active ROM.
6 weeks unlock boot and start active rehab, transition to brace

8. Return to Play?

9. Strategic Assessment of Risk and Risk Tolerance (StARRT) Framework for return-to-play decision making
Ian Shrier
Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
Ian Shrier Br J Sports Med 2015;49:

10. Summary Lateral ligament sprain High ankle sprain
Grading according to ROM, edema, ligament laxity testing
Treatment and prevention
Chronic ankle instability
High ankle sprain
High index of suspicion
Rule out with sensitive tests: Tenderness anterior syndemosis and DF-ER test
Rule in with specific tests: Squeeze test
Role for imaging to rule out diastasis and associated injury
Conservative management controversial – treat grade 1 & 2 like severe lat ankle sprain

11. Summary Deltoid sprain
Evaluate superficial and deep ligament on exam
Rule out associated injury clinically – Spring ligament, PTT dysfunction, high ankle sprain
StARRT framework for return to play decision-making
Tissue health
Tissue load
Risk tolerance

13. Ottawa Ankle Rules Limitations:
medial
Bachmann et al., 2003
Limitations:
Specificity in multi-centre trials was 10% to 79% (Bachmann et al., 2003)
Sensitivity 98%; Outcome measure is fractures – majority of ankle injuries are ligament sprains
Age < 18yo? Less sensitive in children – more missed fractures (Beckenkamp et al., 2016)
Good history and physical exam

14. Low Risk Ankle Rule Ages 3-16y The injury is acute (≤3 days old)
The child is not at risk for pathological fractures (eg, osteogenesis imperfecta or known focal bone lesion such as an osteoid osteoma)
The child has no congenital anomaly of the feet or ankles
The child can reliably express pain or tenderness
Physical examination demonstrates tenderness or swelling confined to the distal fibula and/or adjacent lateral ligaments distal to the anterior tibial joint line
No gross deformity, neurovascular compromise, or other serious and potentially distracting injury are present