1. ANKLE SPRAINS: A Primary Care Update
Mark Leung, MD, MSc, CCFP(SEM), Dip Sport Med
Director, Enhanced Skills Program in Sport & Exercise Medicine

2. Faculty/Presenter disclosure
Dr. Mark Leung
Relationships with commercial interests:
None
Dr. Mark Leung, MD, MSc, CCFP, Dip Sport Med

3. Outline Acute lateral ankle sprains Syndesmosis (“high ankle”) sprain
Classification of lateral ankle sprain, treatment, prevention
Syndesmosis (“high ankle”) sprain
Mechanism of injury, anatomy, diagnosis, imaging, grading, and conservative treatment
Deltoid ligament sprain
Anatomy, diagnosis, treatment
Return to play

4. Ankle Sprain = Ligament Injury
High prevalence
NCAA studies – of all injuries, basketball (25%), W Volleyball (20%)
UEFA study – top 4 injuries, 40% of all
High propensity for development of residual symptoms
40% develop chronic instability at 1 year (Gerber et al., 1998)
Natural history
Following sprain, 2 weeks of rapid improvement
Followed by 2 weeks of slower improvement
Most report residual pain at 1 year post-injury

5. Acute Ankle History Age Mechanism of injury
Initial ability to weight bear
Potential role for imaging
Seriousness of injury
Pop/snap
Ligament or tendon rupture
Avulsion fracture
Previous injury

6. Lateral Ligament: Diagnosis
85% of ankle injuries are isolated lateral ligament injuries
Among lateral ligament sprains (Bridgman et al, 2003, Holmer et al., 1994)
80% involve ATFL
20% further involve CFL
Mechanism of injury plantar flexion with inversion:
ATFL most vulnerable because:
“Narrow” posterior talus
ATFL length and inherent relative tensile strength
Grading
Several available, none superior
Sport-specific grading – Hertel et al., 2004; Mallioparous et al., 2006

7. Ankle Sprain Classification
Several classification schemes, most useful in RTP prediction:
Limping?
Joint effusion?
Functional testing?
Grade 1: Mild
Grade 2: Obvious limp, unable do functional test
Grade 3: Unable to weight bear, massive joint effusion
Mallioparous et al., 2006
Dr. Mark Leung, MD, MSc, CCFP, Dip Sport Med

8. Ankle Sprain R.E.S. Classification
Grade 1: AROM ≤5º reduced, EDE ≤ 0.5cm, AD and TT neg
Grade 2: AROM 5-10º reduced, EDE 0.5-2cm, AD pos, TT neg
Grade 3: AROM ≥10º reduced, EDE > 2cm, AD and TT positive
RTP allowed when:
AROM ≤ 5º + isokinetic strength TA, P, G are 85% of unaffected side + neg advanced hop test
Grade 1: days
Grade 2: 2-3 weeks
Grade 3a: 4 weeks
Grade 3b: 8 weeks
Mallioparous et al., 2006

9. Lateral Ligament: Treatment
Acute management - Re-look at PRICE?
P  Brace/Tape (Grade 1 and 2) (Fatoye & Haigh, 2016) OR Aircast boot (Grade 3) (CAST Trial, 2009)
R  Earlier RTP with weightbearing (Cochrane Review 2007)
I  Analgesia – good for numbing, minimal harm, but anti-inflammatory effect unlikely
C  VERY important! Less joint effusion, more rapid return to normal function
E  Same as ’C’
What’s missing?
Early active ROM
Isometric strengthening! (Functional gains and reduced pain scores similar to NSAIDs)
RCT of non-supervised home exercise program (BMJ) – balance/proprioception 3/week x 30 minutes after return to sport (Hupperets et al., 2009)
Reduced absolute recurrence rate significantly by 12%
NNT = 9
Peri-articular HA injections followed by standard care? (Petrella et al., 2007)

10. Lateral Ankle Sprain: Prevention?
Good evidence for brace (semi-rigid or lace-up) and taping at preventing recurrent ankle sprain, rather than for prophylaxis (Shawen et al., 2016; Kaminski et al., 2013)
Multi-intervention injury-prevention program lasting at least 3 months that focuses on balance and neuromuscular control to reduce the risk of ankle injury
Addressing the strength of the leg muscles (evertors, invertors, dorsiflexors, and plantar flexors) and hip extensors and abductors may be an ankle injury-prevention strategy
Clinicians should consider assessing dorsiflexion ROM in at-risk athletes. If dorsiflexion ROM is limited, clinicians should incorporate techniques to enhance arthrokinematic and osteokinematic motion for possible prevention of ankle injury
Kaminski et al., 2013 – NATA Position Statement

11. Lateral Ankle Sprain: Chronic Instability
Persistent residual symptoms
“Feeling” ankle joint unstable
Fear incur repeat sprain with e.g., uneven surfaces or rapid lateral movement in sport
Instability
Giving way ankle joint
Regular occurrence of uncontrolled or unpredictable episodes
Without excessive pain, swelling, or bruising
Excellent candidates for surgical repair
Dr. Eamonn Delahunt, 2017

12. High Ankle Sprain
Represent 10% of all athletic ankle injuries

13. Forced external rotation Axial load with forced dorsiflexion
High Ankle Sprain: Mechanism of Injury
Image by Dr. J.C. Kennedy
Forced external rotation
Axial load with forced dorsiflexion

14. High Ankle Sprain: Anatomy
A rotation injury
Images from
Tenderness length (Nussbaum)
Strongly correlates with degree of injury and time to return to sport

15. High Ankle Sprain: Diagnosis
Sman AD, et al. Br J Sports Med 2015;49:323–329
It is not possible to rely on a single test for diagnosis of ankle syndesmosis injury.
Clinicians are advised to start with sensitive tests:
Inability to hop
Inability to walk at injury
Tenderness of the syndesmosis ligament
Dorsiflexion-external rotation stress test
If sensitive test is positive, use specific tests:
Pain out of proportion to the apparent injury
Squeeze test