1. Ankle Injuries: Sprains and More John F. Meyers M.D.

2. Bony Anatomy Tibia Fibula Talus Tibia Fibula Talus

3. Mortice and Tenon Joint

4. Lateral Ligaments Anterior talofibular Calcaneofibular Posterior talofibular Anterior talofibular Calcaneofibular Posterior talofibular

5. Medial ligaments Deltoid

6. Mechanism of Injury Definitions Plantar flexion: toes down Dorsiflexion: Toes up Inversion: Heel in Adduction: Heel in Eversion: Heel out Abduction: Heel out Plantar flexion: toes down Dorsiflexion: Toes up Inversion: Heel in Adduction: Heel in Eversion: Heel out Abduction: Heel out

7. Inversion Injury

8. Eversion Injury

9. External Rotation Injury

14. Ankle Sprain Occurrence 27,000 ankle ligament injuries per day in United States Ankle sprains are more than 25% of injuries in football, basketball, soccer and volleyball 27,000 ankle ligament injuries per day in United States Ankle sprains are more than 25% of injuries in football, basketball, soccer and volleyball

15. Making The Diagnosis History Mechanism of injury –Plantar flexion and inversion –Uneven terrain-stepping in a hole –Landing on another player’s foot –Teammate on back of ankle while foot is externally rotated Mechanism of injury –Plantar flexion and inversion –Uneven terrain-stepping in a hole –Landing on another player’s foot –Teammate on back of ankle while foot is externally rotated

16. Making The Diagnosis History Audible pop Immediate swelling Inability to bear weight These are all signs of a more severe injury Audible pop Immediate swelling Inability to bear weight These are all signs of a more severe injury

17. Physical Examination Observe for: –Swelling –Deformiity Palpate for tenderness –Ligaments –Bones Observe for: –Swelling –Deformiity Palpate for tenderness –Ligaments –Bones

18. Physical Exam Drawer test ATFL >4mm difference ATFL >4mm difference

19. Physical Exam Talar Tilt Test CFL > 6° difference CFL > 6° difference

20. Physical Exam Squeeze Test Anterior tibiofibular ligament High ankle sprain Anterior tibiofibular ligament High ankle sprain

21. Physical Exam External Rotation Test Anterior tibiofibular ligament High ankle sprain Anterior tibiofibular ligament High ankle sprain

22. Physical Exam Palpation Length of tenderness predicts severity One week for each cm above ankle joint Length of tenderness predicts severity One week for each cm above ankle joint

24. Classification and Return to Sport Grade I7-14 days Grade II2-6 weeks Grade III4-26 weeks High ankle sprain1 week per cm Grade I7-14 days Grade II2-6 weeks Grade III4-26 weeks High ankle sprain1 week per cm

25. Differential Diagnosis Physeal Fractures OCD

26. Differential Diagnosis Jones Fracture Peroneal Tendon Subluxation

27. Treatment RICE Rest Ice Compression Elevation Rest Ice Compression Elevation

28. Treatment Grade I and II Functional Bracing

29. Treatment Grade III and Syndesmosis

30. Surgery or cast – NO! Functional Bracing –YES! Return to work 2 to 4 times sooner No difference in long term stability No surgical complications 87% excellent and good results with bracing 60% excellent and good results with surgery Return to work 2 to 4 times sooner No difference in long term stability No surgical complications 87% excellent and good results with bracing 60% excellent and good results with surgery

31. Rehabilitation Decrease swelling Regain range of motion Strengthen muscles Balance and proprioceptive training Functional drills Decrease swelling Regain range of motion Strengthen muscles Balance and proprioceptive training Functional drills

32. Balance and Proprioception

33. Return to Play Run without pain or limitations Sport specific movements without pain or limitation 90% strength Protective brace Run without pain or limitations Sport specific movements without pain or limitation 90% strength Protective brace

34. Failure to Recover Giving Way and Recurrent Sprains  Rehabilitation  Bracing  Surgical reconstruction of ligaments  Rehabilitation  Bracing  Surgical reconstruction of ligaments

35. Failure to Recover Intra Articular Problems OCD Loose bodies Bone spurs Arthritis Soft tissue impingment OCD Loose bodies Bone spurs Arthritis Soft tissue impingment

36. Prevention High top shoes Taping Shoes and tape Braces High top shoes Taping Shoes and tape Braces

37. Prevention Conditioning –Agility –Flexability Proprioception Strengthening Stretching and warming up Recognize effects of fatigue Conditioning –Agility –Flexability Proprioception Strengthening Stretching and warming up Recognize effects of fatigue

38. Thank You Orthopaedic Research of Virginia