1. Ankle Sprain A&E REHABILITATION DEPARTMENT

2. Ankle Sprain Dr David Tran A&E department FVHospital Medical meeting 25/07/12

3. Anatomy of the external ligament 1.Anterior talo-fibular ligament (ATFL) 2.Medium ligament (calcaneo-fibular = CFL) 3.Posterior talo-fibular ligament (PTFL)

4. Ankle Sprain mechanism Varus of the ankle (internal rotation)+/- Inversion Often during sport activity (football, tennis, basket, jogging), sometime just walking…

5. Physical examination External side of the ankle swollen Pain at palpation of the malleola Sometime pain at the base of the 5 th metatarsus

6. Indication for Xray (Ottawa rules) Patient unable to walk 4 steps Patient more than 55 years old Pain at one of the zones detailed here-under

7. Normal Xray of the ankle

8. Ankle laxity after ankle sprain Xray: Dynamic view of the ankle Laxity > 12 degree = Severe Sprain Laxity < 12 degree = Medium Sprain

9. The development of high-frequency transducers allows excellent visualization of ligaments. Normal ligaments are hyperechoic and are 2 to 3 mm in width. Tear ligament is characterized by swelling of the ligament, discontinuity, redundancy, and retraction. Ultrasound evaluation of bone is rarely requested, but the radiologist should be aware of incidental findings in bone, particularly fracture. Interest of ultrasound of ligaments

10. Ultrasound of the ankle ligament (A)Normal deltoid ligament. Note the navicular, talar, and calcaneal components. (B)Positioning of the transducer for the anterior tibiotalar portion of the ligament. (C)Normal anterior tibiotalar deltoid ligament (arrows). Note the triangular echogenic appearance of the ligament. (D)Normal tibiocalcaneal portion of the deltoid ligament. Note the hyperechoic tibiocalcaneal ligament running from the medial malleolus to the sustentaculum tali (arrows). Note also the small effusion in the ankle (arrowhead). MM, medial malleolus; SST, sustentaculum tali.

11. Indication of MRI ? MRI could be indicated in case of doubt about the level of seriousness and in case of unexpected delay in the recovery period MRI could also be indicated for professional sport competitor who need accurate diagnosis.

12. 3 levels of seriousness 1.Benign sprain 2.Mild sprain 3.Severe sprain

13. PRICE protocol Protection protect and stabilize the ankle joint. Rest: stop activity to reduce the bleeding and swelling Ice: Straight after injury, use ice twenty minutes from 3 to 6 times per day during the first three days or until swelling has substantially decreased Compression: Wrap the injured to keep it reducing bleeding and decreasing swelling. Elevation: Elevate the ankle higher than the heart for maximum benefit. Elevation decreases blood flow into already damaged and bleeding tissues

14. Treatment of benign ankle sprain PRICE Strapping/aircast Duration 7-10 days Can walk (Stop sport activity) Rehabilitation only recommended if athlete or repetitive ankle sprain

15. Treatment of mild sprain PRICE Splint like Aircast Duration: 21 days Crutches 7 days Proprioceptive rehabilitation recommended after 2 weeks

16. Treatment of severe sprain PRICE Splint or cast 45 days Crutches Proprioceptive rehabilitation recommended based on immobilization condition Anticoagulation with Heparin (Lovenox 40mg) daily is necessary if immobilization by Cast

17. Principle of treatment PRICEImmobilizationCrutchesPhysiotherapy Benign sprain Yes ++ Strapping 7 days If painNot compulsory Mild sprain Yes +++ Splint (Aircast) 21 days 7 to 10 daysYes Serious sprain Yes +++ Splint (Aircast or Cast splint) 45 days 14 to 21 daysYes

18. P.R.I.C.E. RE-EVALUATION J3 to 5 Benign SprainMedium SprainSevere Sprain ANKLE SPRAIN P.R.I.C.E.

19. Other medical treatment Painkillers (Efferalgan + Codeine or Tramadol) Non Steroid Anti-inflammatory (Voltaren, Ibuprofen) Rest and limit displacement (with crutches)

20. Sprain ankle with complications Fracture of the lateral malleole (fibula) Rupture of inter- osseous ligament Fracture of the base of the 5 th metatarsus

21. Do not miss other diagnosis Fractures & Dislocation (laxity)

22. Other diagnosis to look for Fracture of the base of the 5 th metatarsus

23. ANKLE SPRAIN REHABILITATION C.COUSIN FV Hospital -Physiotherapy & Rehabilitation Department

24. Rehabilitation for which level of sprain? Benign Sprain Stage I Medium Sprain Stage II Severe Sprain Stage III No Rehabilitation except for: - Athlete - Ankle sprain recurrence Rehabilitation recommended

25. Ankle Sprain Rehabilitation When can you refer? At Protective stage –For P.R.I.C.E management –For gait training with crutches At Early Recovery stage with bracing –To re-start muscular & skeletal function At Rehabilitative Stage –To help return back to daily and sportive activity CAUTION: Appropriate rehabilitation referral prevents: Repetitive ankle sprain, later on any joints dysfunction such as knee or spine.

26. PROTECTIVE STAGE Goals: 1. Decrease pain, swelling 2. Protect from over mobilization 3. Maintain appropriate weight bearing status PRICETechniques Ice compressive therapy Gait training with crutches

27. EARLY RECOVERY STAGE Bracing is removed during rehabilitation Techniques Ice or Ice- compressive therapy Ultrasound Isometric exercise - neuro muscular electro stimulation Joint alignment Proprioception Weight bearing pain/swelling adapted Goals 1.Decrease pain as swelling 2.Begin isometric strengthening 3.Non-weight bearing proprioceptive rehabilitation

28. REHABILITATIVE STAGE Goals Increase ROM free of pain Progress strengthening Progress proprioceptive training Increase pain free of activity daily living Pain free full weight bearing Uncompensated gait Plyometrics exercises, agility drills, running progression

29. REHABILITATIVE STAGE Techniques

30. Rehabilitation program Ankle sprain Ice + compre ssion Weight bearing bracingExercising propriocep tive Sessions recommen ded Benign sprain 2 first days Full weight bearing Strapping 3 to 7 days Only for Athlete Medium sprain 3 first days Pain adapted with crutches from 5 to 10 days Lateral bracing (air cast) 3 weeks Started after 2 weeks 3 to 6 sessions Severe sprain 4 to 6 first days Pain adapted with crutches from 2 to 3 weeks bracing 3 to 6 weeks Started after 3 weeks 6 to 12 sessions Recurrent sprain As required Full weight bearing Strapping or bracing as required Started immediately 6 to 12 sessions

31. Rehabilitation Intervention is based on -Sprain level -Patient’s condition, -Patient’s goals, 3 to 12 rehabilitation’s sessions could be recommended

32. ! Recurrent ankle sprain At all stages, rehabilitation is recommended for: Joint alignment Intensive proprioceptive program