Sprain, Ankle

para>Increased risk of fracture in patients with preexisting bone weakness (osteoporosis/osteopenia) ‚
Pediatric Considerations

Increased risk of physeal injuries instead of ligament sprain because ligaments have greater tensile strength than physes
Inversion ankle injuries in children may have a concomitant fibular physeal injury (Salter Harris type I or higher fracture).
Consider tarsal coalition with recurrent ankle sprains.

‚

EPIDEMIOLOGY

Incidence

Peak incidence in children (0 to 12 years old), then adolescents (13 to 17 years old), and finally adults ( ≥18 years old) (1)
1/2 of all ankle sprains are sports-related; highest incidence in indoor/court sports (basketball, volleyball, tennis), followed by football and soccer (2)
Most common sports injury
More common in males age <30 years and females >30 years old

Prevalence

25% of sports injuries in the United States
75% of all ankle injuries are sprains.

ETIOLOGY AND PATHOPHYSIOLOGY

Lateral ankle sprains result from an inversion force with the ankle in plantar flexion.
Medial ankle sprains are due to forced eversion while the foot is in dorsiflexion.
Syndesmotic sprains result from eversion stress/extreme dorsiflexion along with internal rotation of tibia.

RISK FACTORS

The greatest risk factor is a prior history of an ankle sprain (3 " “34% recurrence rate).
Postural instability, gait alterations
Joint laxity and decreased proprioception are not risk factors.

GENERAL PREVENTION

Improve overall physical conditioning:
- Training in agility and flexibility
- Single-leg balancing
- Proprioceptive training (3)
Taping and bracing may help prevent primary injury in selected sports (i.e., volleyball, basketball, football) or reinjury (4). Taping and bracing do not reduce sprain severity.

COMMONLY ASSOCIATED CONDITIONS

Contusions
Fractures
- Fibular head fracture/dislocation (Maisonneuve)
- Fracture of the base of the 5th metatarsal
- Distal fibula physeal fracture (includes Salter-Harris fractures in pediatric patients; most common type of pediatric ankle fracture)

DIAGNOSIS

HISTORY

Elicit specific mechanism of injury (inversion vs. eversion)
Popping/snapping sensation during the injury
Previous history of ankle injuries
Ability to ambulate immediately after the injury
Rapid onset of pain, swelling, or ecchymosis
Location of pain (lateral/medial)
Difficulty bearing weight
Past medical history of systemic disorders

PHYSICAL EXAM

Timing: Initial assessment for laxity may be difficult due to pain, swelling, and muscle spasm. Repeat exam ¢ ˆ ¼5 days after injury may improve sensitivity.
Compare to uninjured ankle for swelling, ecchymosis, weakness, and laxity
Neurovascular exam
Palpate ATFL, CFL, PTFL, and deltoid ligament for tenderness.
Palpate lateral and medial malleolus, base of 5th metatarsal, navicular, and entire fibula.
- High ankle sprain associated with fracture of proximal fibula
Grade I sprain: mild swelling and pain; no laxity; able to bear weight/ambulate without pain
Grade II sprain: moderate swelling and pain; mild laxity with firm end point noted; weight bearing/ambulation painful
Grade III sprain: severe swelling, pain, and bruising; laxity with no end point; significant instability and loss of function/motion; unable to bear weight/ambulate
- Swelling less sensitive for grade of tear in pediatric patient
Special tests:
- Anterior drawer test to check for ATFL laxity
- Talar tilt test to check laxity in CFL (with inversion) or deltoid ligament (eversion)
- Squeeze test: Compress tibia and fibula midcalf to check for syndesmotic injury; sensitivity 30%, specificity 93.5%.
- Dorsiflexion/external rotation test: Positive test is pain at syndesmosis with rotation; sensitivity 20%, specificity 85%.

DIFFERENTIAL DIAGNOSIS

Tendon injury
- Tendinopathy/tendon tear
Fracture and/or dislocation of the ankle/foot
Hindfoot/midfoot injuries
Nerve injury
Contusion

DIAGNOSTIC TESTS & INTERPRETATION

Ottawa Ankle Rules (nearly 100% sensitive, 30 " “50% specific) determine need for radiographs to rule out ankle fractures (patient must be 18 to 55 years; certain patients, e.g., diabetics with diminished sensation, may still need radiographs):
- Pain in malleolar zone
- Inability to bear weight (walk ≥4 steps) immediately and in the exam room
- Bony tenderness at tip/posterior edge of the lateral/medial malleolus
  - Note: Ottawa rule for foot imaging series (reported pain in the midfoot zone AND pain with palpation of navicular or base of 5th metatarsal, OR inability to bear weight immediately and in the ER/office)
- Although Ottawa rules are highly sensitive, they should not overrule clinical judgment.
If radiographs are indicated, obtain anteroposterior, lateral, and mortise views of the ankle.
- Small avulsion fractures are associated with grade III sprains.
Consider CT if radiographs are negative but occult fracture is suspected clinically.
MRI is the gold standard for soft tissue imaging but is expensive and rarely necessary.
- Syndesmotic ankle sprains: MRI is more sensitive.
US is a good second line imaging option with a sensitivity comparable to MRI.

Follow-Up Tests & Special Considerations
If patient condition does not improve in 6 to 8 weeks, consider CT, MRI, or US. ‚

TREATMENT

GENERAL MEASURES

Most grade I, II, and III lateral ankle sprains can be managed conservatively.
Conservative therapy: PRICE (protection, relative rest, ice, compression, elevation)
Protection/compression: For grade I/II sprains, lace-up bracing is superior to air-filled/gel-filled ankle brace, which is superior to elastic bandage/taping to provide support and decrease swelling.
- Note: The combination of air-filled brace and compression wrap is superior to each individual for return to preinjury joint function at 10 days and 1 month for grades I and II sprains (5)[A].
- Grade III sprains should have short-term immobilization (10 days) with below-the-knee cast, followed by a semirigid brace (air cast). If a patient refuses casting, a 10-day period of strict non " “weight-bearing with air cast splint and elastic bandage is a comparable alternative if non " “weight-bearing is maintained.

Rest: Initially, activity as tolerated. Early mobilization and physical therapy speed recovery/reduce pain:
- Weight bearing, as tolerated
- Consider crutches if unable to bear weight.
- Exercises should be initiated as early as tolerated and limited to pain-free range of motion.
- Patients can start mobilization by tracing the alphabet with the foot in the air.
- Resistance exercises with an elastic band
Ice: Ice for first 3 to 7 days for pain reduction and decrease recovery time
Elevation: Elevate ankle to decrease swelling.

MEDICATION

NSAIDs: preferably oral; topical forms (e.g., diclofenac 1% gel) may be used to minimize GI side effects. PRN NSAID dosing has similar outcomes to scheduled dosing with improved safety profile.
- Example: Naproxen 500 mg BID PRN
Acetaminophen 650 mg q4 " “6h (max outpatient therapy dose: 3,250 mg/day)
Opioids if severe pain

ISSUES FOR REFERRAL

Malleolar/talar dome fracture
Syndesmotic sprain
Dislocation/subluxation
Tendon rupture
Ongoing instability
Uncertain diagnosis

ADDITIONAL THERAPIES

Physical therapy: ‚

After the acute phase of the injury, patients with grade II or III sprain should start physical therapy as soon as possible to increase range of motion, strength, flexibility, and improve proprioceptive balance (wobble board/ankle disk).
Functional rehabilitation prevents chronic instability and speeds healing.
Athletes should undergo sports-specific rehabilitation before returning to play.

SURGERY/OTHER PROCEDURES

Surgery is typically reserved for treatment of complicated recurrent sprains and certain syndesmotic sprains.
Patients with chronic ankle instability who fail functional rehabilitation or with poor tissue quality may need anatomic repair/reconstructive surgery.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

After an ankle sprain, ankle-stabilizing orthoses (air stirrup braces, lace-up supports, athletic taping, etc.) should be worn for high-risk sports to prevent future ankle sprains.
Moderate and severe sprains require ankle orthoses for ≥6 months during sports participation.
Gradual return to play for athletes with a grade I lateral ankle sprain can generally be accomplished in 1 to 2 weeks; grade II sprain return to play time is 2 to 3 weeks; grade III sprain is approximately 4 weeks.
Syndesmotic sprains take longer (approx. 8 to 9 weeks) to heal than lateral ankle sprains.

Patient Monitoring
If athletes continue to have symptoms when they return to play or if a patient has pain for 6 to 8 weeks after injury, repeat examination and imaging. ‚

PATIENT EDUCATION

Crutch training
Provide training on proper use of elastic bandages, brace, and/or orthoses
Demonstrate mobilization exercises (alphabet trace, towel grab).

PROGNOSIS

Earlier physical therapy and mobilization with bracing allows for faster return to daily living and/or sports.
Higher grade sprains, older patient age, and initial non " “weight-bearing status have poorer prognosis and longer recovery.
Ligamentous strength does not return for months after the injury.

COMPLICATIONS

Joint instability
Intermittent swelling/pain if not properly treated
Accumulation of cartilage damage, leading to degenerative changes
5 " “33% continue to have pain 1 year postinjury.

REFERENCES

11 Doherty ‚ C, Delahunt ‚ E, Caulfield ‚ B, et al. The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med. 2014;44(1):123 " “140.22 Waterman ‚ BR, Owens ‚ BD, Davey ‚ S, et al. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279 " “2284.33 McGuine ‚ TA, Keene ‚ JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med. 2006;34(7):1103 " “1111.44 Pedowitz ‚ DI, Reddy ‚ S, Parkeh ‚ SG, et al. Prophylactic bracing decreases ankle injuries in collegiate female volleyball players. Am J Sports Med. 2008;36(2):324 " “327.55 Beynnon ‚ BD, Renstr ƒ ¶m ‚ PA, Haugh ‚ L, et al. A prospective, randomized clinical investigation of the treatment of first-time ankle sprains. Am J Sports Med. 2006;34(9):1401 " “1412.

ADDITIONAL READING

Bleakley ‚ CM, O 'Connor ‚ SR, Tully ‚ MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964.
Farwell ‚ KE, Powden ‚ CJ, Powell ‚ MR, et al. The effectiveness of prophylactic ankle braces in reducing the incidence of acute ankle injuries in adolescent athletes: a critically appraised topic. J Sport Rehabil. 2013;22(2):137 " “142.
Hiller ‚ CE, Nightingale ‚ EJ, Lin ‚ CW, et al. Characteristics of people with recurrent ankle sprains: a systematic review with meta-analysis. Br J Sports Med. 2011;45(8):660 " “672.
Kerkhoffs ‚ GM, van den Bekerom ‚ M, Elders ‚ LA, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012;46(12):854 " “860.
Massey ‚ T, Derry ‚ S, Moore ‚ RA, et al. Topical NSAIDs for acute pain in adults. Cochrane Database Syst Rev. 2010;(6):CD007402.
Petersen ‚ W, Rembitzki ‚ IV, Koppenburg ‚ AG, et al. Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg. 2013;133(8):1129 " “1141.
Raymond ‚ J, Nicholson ‚ LL, Hiller ‚ CE, et al. The effect of ankle taping or bracing on proprioception in functional ankle instability: a systematic review and meta-analysis. J Sci Med Sport. 2012;15(5):386 " “392.

CODES

ICD10

S96.919A Strain of unsp msl/tnd at ank/ft level, unsp foot, init
S93.499A Sprain of other ligament of unspecified ankle, init encntr
S93.419A Sprain of calcaneofibular ligament of unsp ankle, init
S93.429A Sprain of deltoid ligament of unspecified ankle, init encntr
S93.492A Sprain of other ligament of left ankle, initial encounter
S93.491A Sprain of other ligament of right ankle, initial encounter
S93.439A Sprain of tibiofibular ligament of unsp ankle, init encntr
S93.432A Sprain of tibiofibular ligament of left ankle, init encntr
S93.422A Sprain of deltoid ligament of left ankle, initial encounter
S93.421A Sprain of deltoid ligament of right ankle, initial encounter
S93.412A Sprain of calcaneofibular ligament of left ankle, init
S93.411A Sprain of calcaneofibular ligament of right ankle, init
S93.402A Sprain of unspecified ligament of left ankle, init encntr
S93.401A Sprain of unspecified ligament of right ankle, init encntr
S93.431A Sprain of tibiofibular ligament of right ankle, init encntr

ICD9

845.00 Sprain of ankle, unspecified site
845.09 Other sprains and strains of ankle
845.02 Sprain of calcaneofibular (ligament) of ankle
845.01 Sprain of deltoid (ligament), ankle
845.03 Sprain of tibiofibular (ligament), distal of ankle

SNOMED

44465007 sprain of ankle (disorder)
307139007 Tear of talofibular ligament (disorder)
24730004 Sprain of calcaneofibular ligament
88906006 Sprain of deltoid ligament of ankle
209531007 Sprain, ankle joint, medial (disorder)
209532000 Sprain, ankle joint, lateral (disorder)
11833631000119105 Sprain of left ankle (disorder)
11833591000119105 Sprain of right ankle (disorder)
74383007 Sprain of distal tibiofibular ligament

CLINICAL PEARLS

Children are at an increased risk of physeal injuries because ligaments are stronger than physes.
Conditioning, including proprioceptive training, before participating in sports and throughout the season helps to prevent ankle sprains.
Functional rehabilitation, rather than total immobilization, is recommended for quicker return to sport and work.
If patient 's condition is not improving in 6 to 8 weeks, consider advanced imaging with CT, MRI, or US.

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