AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Ankle injuries are the most common injuries incurred during sports and recreational activities. They are particularly common in sports such as basketball, soccer, volleyball, or other activities performed on uneven surfaces.

Pathophysiology

Most ankle sprains are due to inversion during extension (plantarflexion) of the ankle. Thus, approximately 85% of injuries involve the 3 distinct lateral ligaments: anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). Of sprains due to inversion, 65% are isolated to the ATFL. In some patients, the subtalar complex may also be injured. The CFL is rarely injured in isolation.

Isolated injury to the medial (deltoid) ligament is rare and usually involves malleolar fractures. Distal tibiofibular syndesmotic rupture is very rare and is associated with flexion (dorsiflexion) and external rotation. Recovery from this injury is significantly prolonged, unlike isolated lateral ligament sprains. Mild syndesmotic sprains are increasingly being recognized and are probably more common than previously thought.

Rupture of the superior peroneal retinaculum results in subluxation or dislocation of the peroneal tendons. The mechanism of injury is usually forced dorsiflexion with reflex contraction of the peroneal muscles. Patients complain of pain and a snapping sensation over the posterolateral ankle with weakness of eversion.

Ankle sprains are classified into 3 grades per the West Point Sprain Grading System, as follows:

• Grade I injuries involve a stretch of the ligament with microscopic tearing but not macroscopic tearing. Generally, little swelling is present, with little or no functional loss and no joint instability. The patient is able to fully or partially bear weight.
• Grade II injuries stretch the ligament with partial tearing, moderate-to-severe swelling, ecchymosis, moderate functional loss, and mild-to-moderate joint instability. Patients are usually unable to bear weight.
• Grade III injuries involve the complete rupture of the ligament with immediate and severe swelling, ecchymosis, an inability to bear weight, and moderate-to-severe instability of the joint. Typically, patients cannot bear weight without experiencing incapacitating pain.

Frequency

United States

Inversion injuries occur at a rate of 1 per 10,000 people per day, which is about 2,800 injuries per day in the United States. Injury to the dominant ankle is 2-3 times more likely than injury to the nondominant ankle.

Mortality/Morbidity

• Ankle sprains are generally considered to be benign and self-limiting. However, ankle sprains can cause significant morbidity. As many as 73% of athletes with an ankle sprain experience recurrent sprains, and 59% have significant disability and impairment of athletic performance. One study found that 72% of patients had residual symptoms at 6-18 months, and another reported residual symptoms in 32% of patients 7 years after their initial ED visit.
• Up to 50% of people who incur an ankle sprain have some type of chronic sequelae. These conditions include functional instability, mechanical instability, chronic pain, stiffness, and recurrent or chronic swelling.
• Eversion injuries are more likely to result in persistent pain or chronic instability.

Sex

Women athletes are 25% more likely to sustain ankle injuries than male athletes.

Age

Ankle injuries primarily involve young people because they participate more often in physically demanding recreational activities and sports. Fractures and tendon ruptures occur more often in older adults.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Assessment of all orthopedic injuries should include the following:
• • Mechanism of injury
  • Previous history of ankle injuries
  • Presence of immediate or delayed pain, swelling in the ankle joint, and ability or inability to bear weight after the incident
  • Presence or absence of any popping-type sensations or actual noise at the time of injury

Physical

• Observe for edema, ecchymosis, or deformity.
• Palpate for tenderness, crepitance, or deformity.
• Assess active and passive range of motion as well as weight-bearing ability.
• Perform the talar tilt test.
• • Place the foot in 20-30° of plantar flexion, and apply slight adduction and gentle inversion stress to the calcaneal midfoot.
  • If both the anterior talofibular and the calcaneofibular ligaments are ruptured, the examiner will detect talar tilt (ie, movement of the talus in the mortise).
• Perform the anterior drawer test.
• • Place the foot in 10-15° of plantar flexion, and apply gentle forward traction to the heel.
  • With anterior talofibular ligament rupture, the deltoid ligament becomes the center of rotation, and a dimple may appear just anterior to the lateral malleolus. Forward motion of the talus is detected by the examiner.
  • For this test, even 3 mm of movement may be significant; 1 cm of movement is certainly significant.
• For syndesmotic injuries, perform the cross-leg test.
• • While sitting in a chair, have the patient cross their injured leg over the other knee. The middle lower leg rests on the unaffected knee
  • Pressure on the medial knee will cause ankle pain in a positive test result.
• Perform and document a neurovascular examination, including checks of the dorsalis pedis and posterior tibial pulses.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Achilles tendon rupture
Peroneal tendon subluxation
Septic joint

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Imaging Studies

• Radiographic studies of the ankle should include the following films:
• • An anteroposterior (AP) film with the ankle in 5-15° of adduction
  • A true lateral film
  • A 45° oblique film with the ankle in dorsiflexion (ie, Mortise view)
• The Ottawa rules are a prospectively validated clinical decision tree for radiograph ordering in adults. By following these rules, emergency physicians can eliminate up to 30% of radiographs that are routinely ordered without missing clinically significant fractures. Criteria for foregoing radiography are as follows:
• • Younger than 55 years
  • Able to walk 4 steps at the time of injury and at the time of evaluation
  • No tenderness over the posterior edge (distal 6 cm) or tip of either malleolus

Other Tests

• Stress radiographs or arthrographies are not mandatory in the ED, but they may be requested by an orthopedic consultant.
• Careful evaluation of the foot, particularly the base of the fifth metatarsal, may reveal tenderness, which would prompt radiographs of the foot.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

For patient comfort, all ankle injuries should be placed in a splint prior to transport to the ED.

Emergency Department Care

• First-degree sprains or mild second-degree sprains
• • Rest, ice, and elevation
  • Compression dressing or commercially available air stirrup splint. Stirrup splints may result in better outcomes.
  • Consider initial cessation of weight bearing.
  • Early range of motion exercises
  • Consider referral to physical therapy for early range of motion exercise and wobble board training after recovery to reduce the number of recurrent injuries and to prevent functional instability.
• Severe second- or third-degree sprains or possible fractures
• • Rest, ice, and elevation
  • Plaster or fiberglass posterior splint
  • Orthopedic or sports physician referral is indicated. Most patients require physical therapy to prevent functional loss.

Consultations

• Obtain orthopedic consultation for severe sprains, suspected peroneal tendon subluxation, or associated fractures.
• Emergent orthopedic evaluation rarely is required. Office follow-up in a week usually suffices.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of therapy are to reduce pain and to prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

With analgesic and anti-inflammatory properties, NSAIDs are the ideal agents for treating ankle injuries. Acetaminophen with or without an opiate analgesic may be added to NSAID therapy (or used as a substitute).

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and enable physical therapy regimens. Many analgesics have sedating properties that are beneficial for patients who have sustained injuries.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Patients with grade I or mild grade II lateral sprains should have a follow-up visit with their primary care physician in 1-2 weeks.
• Consult an orthopedist or a sports medicine specialist for all other injuries.
• Consider physical therapy referral for rehabilitation and strengthening to prevent recurrent injuries.

Complications

• Functional, mechanical instability, or both
• Chronic pain, stiffness, and/or edema

Prognosis

• With appropriate initial treatment, referral, and physical therapy, most patients have a favorable outcome. Five to thirty percent of patients have varying levels of recurrent or chronic symptoms and should be referred.

Patient Education

• For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center, Sports Injury Center, and Sprains and Strains Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to diagnose
• • Failure to obtain a radiograph
  • Misinterpretation of a radiograph
  • Failure to recognize ankle instability
• Failure to treat injury appropriately
• • Failure to immobilize unstable injuries
  • Failure to refer significant injuries to the appropriate specialist
• Unmet expectations - Failure to warn the patient of the potential for prolonged recovery or chronic symptoms or instability

Special Concerns

• Elderly patients may require home health visits to assess mobility and ability to perform activities of daily living (ADL).

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower extremity injuries among U.S. high school athletes. Acad Emerg Med. Jul 2007;14(7):641-5. [Medline].
• Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007;37(1):73-94. [Medline].
• Ivins D. Acute ankle sprain: an update. Am Fam Physician. Nov 15 2006;74(10):1714-20. [Medline].
• Jones MH, Amendola A. Syndesmosis sprains of the ankle: a systematic review. Clin Orthop Relat Res. Feb 2007;455:173-5. [Medline].
• Refshauge KM, Kilbreath SL, Raymond J. Deficits in detection of inversion and eversion movements among subjects with recurrent ankle sprains. J Orthop Sports Phys Ther. Apr 2003;33(4):166-73; discussion 173-6. [Medline].
• Renström PA, Konradsen L. Ankle ligament injuries. Br J Sports Med. Mar 1997;31(1):11-20. [Medline].
• Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. Mar 3 1993;269(9):1127-32. [Medline].
• Thacker SB, Stroup DF, Branche CM, Gilchrist J, Goodman RA, Weitman EA. The prevention of ankle sprains in sports. A systematic review of the literature. Am J Sports Med. Nov-Dec 1999;27(6):753-60. [Medline].
• Wester JU, Jespersen SM, Nielsen KD, Neumann L. Wobble board training after partial sprains of the lateral ligaments of the ankle: a prospective randomized study. J Orthop Sports Phys Ther. May 1996;23(5):332-6. [Medline].
• Williams GN, Jones MH, Amendola A. Syndesmotic ankle sprains in athletes. Am J Sports Med. Jul 2007;35(7):1197-207. [Medline].

Article Last Updated: Sep 13, 2007