ANKLE INJURIES:
ANKLE SPRAIN
Saurab Sharma, MPT
Lecturer/ KUSMS
BPT 3rd Year
Overview
• Introduction
• Stability
• Impact of injury
• Diagnosis
• Clinical features
• Examination
• Management
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Introduction
• Incidence - 2.15 per 1000 person/ years in the general population.
• Highest incidence- between 15 and 19 years of age
• No difference between genders
• Half of all ankle sprains occur during athletic activity, eg: basketball (41.1%), football (9.3%), and soccer (7.9%)
• Ankle injuries account for 10% to 34% of all sport-related injuries, with lateral ankle sprain comprising 77% to 83% of these injuries
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Introduction• Lateral ankle sprains may occur with subtalar, medial,
and/or syndesmotic sprains
• High chances of chronic pain, instabilities, and limitation
in activities and participation and high recurrence rates.
Other structures involved are:
• Lateral subtalar ligaments; Nerve injury
• Fibular (peroneal) tendon injury
• Extensor and peroneal retinaculum injury
• Inferior tibiofiular ligament
• Osteochondral lesions of the talus or tibia
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Anterior Talofibular Ligament
• Extra-articular ligament
• Provides primary restraint to inversion movement when
the ankle is in a plantar-flexed position.
• 50% avulsion from Fibula; 50% mid substance tear
• Lower maximal load tolerance before failure compared to
other structures
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Stability of ankle
• Dynamic and static stability
• Dynamic stabilization of the ankle complex is dependent
on the adjacent musculatures and laterally includes the
fiularis (peroneus) longus and brevis.
• The tibialis anterior and extensor digitorum longus are
thought to eccentrically control ankle plantar flexion.
• Reflex reaction is slow to protect injury, but anticipatory
contraction may help prevent the injury
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Impact of injury
Injury to ankle ligaments may cause:
• Weakness and injury of local muscles
Weakness of remote muscles:
• Lumbar spine- erector spine
• Hip- Gluteus maximus, biceps femoris
Sensory changes can occur in the joint receptors and
cutaneous nerves, such as the sural nerve and distal
superficial peroneal nerve.
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CLINICAL COURSE
• rapid decrease in pain and improvement in function the
fist 2 weeks after the injury.
• 5% to 33% of patients continued to have pain at 1-year;
5% to 25% still experiencing pain after 3 years.
• Residual problems pain (30%), instability (20%), crepitus
(18%), weakness (17%), stiffness (15%), and swelling
(14%).
• Full recovery between 50% and 85% at approximately 3
years after the injury and seemed independent of sprain
severity.
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Clinical features
• Pain (rest and weight bearing)
• Swelling
• Redness, ecchymosis
• Instability
• Weakness
• Impaired proprioception and postural control
• Activity limitations and participation restrictions
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Risk Factors: Intrinsic
• The history of previous sprains
• Age
• ? Gender (younger female; older male)
• Physical characteristics (ie, height, weight, and body
mass index)
• Msculoskeletal characteristics (ie, balance,
proprioception, range of motion, strength, anatomic
alignment, and ligament laxity)
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Risk Factors: Extrinsic
• Use of external support; Footwares
• Type of Sport
• Level of competition
• Participation in neuromuscular training.
• Surface of play
• Inadequate warm up and cool downs
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Diagnosis: Ankle Sprain
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Diagnosis: Ankle instability
The Cumberland Ankle Instability Tool: 9-item
• The test-retest ICC was 0.96.
• Sensitivity and specificity of 85.5 and 82.6 respectively
• The Ankle Instability Instrument – 12 items
• Functional Ankle Instability Questionnaire- 10 items
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Differential Diagnosis
Ottawa Ankle Rules:
Radiographs are indicated if there was pain in the malleolar
zone and any of the following criteria are met:
(1) tenderness along the tip of the posterior edge of the
distal 6 cm of the lateral malleolus,
(2) tenderness along the medial malleolus, and/or
(3) An inability to bear weight for 4 steps.
(4) Pain in the mid-foot area
The Bernese ankle rules
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Differential Diagnosis
• Syndesmotic injury
• Cuboid syndrome
• Peroneal tendon tendinitis/tendinopathy
• Sensory nerve injury
• Medial collateral ligament ankle sprain
• Lisfranc fracture/dislocation
• Subtalar sprain
• Spring or bifurcate ligament injury
• Achilles tendon rupture
• Lateral talar process injury
• Anterior process of the calcaneus injury
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Examination: Outcome measures
• The Foot and Ankle Ability Measure (FAAM)
• The Foot and Ankle Disability Index (FADI)
• Lower Extremity Functional Scale (LEFS)
• The Chronic Ankle Instability Scale
• The Sports Ankle Rating System
• The Ankle Joint Functional Assessment Tool
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Examination: Activity limitation and
participation restriction measures
• side hop
• 6-m crossover hop
• 40-m walk time; 40-m run time
• Figure-of-eight run
• Single-limb forward hop
• Crossover hop
• Stair hop
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Examination: Activity limitation and
participation restriction measures
• When evaluating a patient in the post-acute period
following a recent or recurring lateral ankle sprain,
assessment of activity limitation, participation restriction,
such as single-limb hop tests that assess performance
with lateral movements, diagonal movements, and
directional changes.
(GRADE B RECOMMENDATION)
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Examination: Physical impairment
• Swelling
• ROM- ankle joint, subtalar joint
• Ankle and foot pronation and supination
• Anterior drawer test
• Talar tilt test
• Isokinetic Muscle Strength of Inversion and Eversion
• Single-Limb Balance
• Star Excursion Balance Test
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Measurement of swelling
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ROM
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Special tests
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Single limb balance test (SLBT)
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Eyes open and eyes closed for 1 minutes each
Star excursion balance test (SEBT)
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Interventions
• ACUTE/ PROTECTED MOTION PHASE
OF REHABILITATION
• PROGRESSIVE LOADING/ SENSORIMOTOR
TRAINING PHASE OF REHABILITATION
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ACUTE/ PROTECTED MOTION PHASE
• Early weight bearing with support – I
• External support - I
• Cryotherapy – I
• Manual Therapy – II
• Pulsed Diathermy – II
• Stimulation – II
• Laser II
• Ultrasound- I (no benefit)
• Therapeutic exercises- I
(active range-of-motion exercises, and progressive resistive
exercises incorporating progressive weight bearing)
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PROGRESSIVE LOADING/
SENSORIMOTOR TRAINING PHASE• Manual Therapy– I
Clinical prediction rule to predict likely rapid responders
to manual therapy. Subjects meeting at least 3 of 4 criteria
were up to 95% likely to respond favorably to intervention
within 3 treatment sessions.
• Worse symptoms with standing,
• Worse symptoms in the evening,
• Navicular drop test of 5 mm or more, and
• Hypomobility of the distal tibiofiular joint.
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PROGRESSIVE LOADING/
SENSORIMOTOR TRAINING PHASETherapeutic Exercise and Activities- I
• ROM exercises
• Weight-bearing functional exercises
• Single-limb balance activities using unstable surfaces
• Exercises to improve mobility, strength, coordination, and
postural control
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Scope for Self learning:
• Refining your assessment skills
• Outcome tools related to ankle and foot
• Functional assessment tools
• Special tests
• Other differential diagnoses
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References
• Martin et al. Ankle Stability and Movement Coordination
Impairments: Ankle Ligament Sprains Clinical Practice Guidelines
Linked to the International Classification of Functioning, Disability and
Health From the Orthopaedic Section of the American Physical
Therapy Association. J Orthop Sports Phys Ther. 2013;43(9):A1-
A40. doi:10.2519/jospt.2013.030
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