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Ankle Sprains

By Danielle Campagne, MD , Assistant Clinical Professor, Department of Emergency Medicine, University of San Francisco - Fresno

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Patient Education

Ankle sprains are very common, most often resulting from turning the foot inward (inversion). Common findings are pain, swelling, and tenderness, which are maximal at the anterolateral ankle. Diagnosis is by clinical evaluation and sometimes x-rays. Treatment is protection, rest, ice, compression, and elevation (PRICE) and early weight bearing for mild sprains and immobilization followed by physical therapy for moderate and severe sprains; some very severe sprains require surgical repair.

The most important ankle ligaments are the following:

  • Deltoid (the strong, medial ligament)

  • Anterior and posterior talofibular (lateral ligaments)

  • Calcaneofibular (lateral ligaments—see Figure: Ligaments of the ankle.)

Ligaments of the ankle.

Inversion (turning the foot inward) tears the lateral ligaments, usually beginning with the anterior talofibular ligament. Most tears result from inversion. Severe 2nd- and 3rd-degree sprains sometimes cause chronic joint instability and predispose to additional sprains. Inversion can also cause talar dome fractures, with or without an ankle sprain.

Eversion (turning the foot outward) stresses the joint medially. This stress often causes an avulsion fracture of the medial malleolus rather than a ligament sprain because the deltoid ligament is so strong. However, eversion can also cause a sprain. Eversion also compresses the joint laterally; this compression, often combined with dorsiflexion, may fracture the distal fibula or tear the syndesmotic ligaments between the tibia and fibula just proximal to the ankle (called a high ankle sprain). Sometimes eversion forces are transmitted up the fibula, fracturing the fibular head just below the knee (called a Maisonneuve fracture).

Recurrent ankle sprains can damage ankle proprioception and thus predispose to future ankle sprains. Most ankle sprains are mild (1st- or 2nd-degree).

Symptoms and Signs

Ankle sprains cause pain, swelling, and sometimes muscle spasms. The location of pain and swelling varies with the type of injury:

  • Inversion sprains: Usually maximal at the anterolateral ankle

  • Eversion injuries: Maximal over the deltoid ligament

  • Maisonneuve fracture: Over the proximal fibula as well as the medial and sometimes lateral ankle

  • Third-degree sprains (complete tears, often involving both medial and lateral ligaments): Often diffuse (sometimes the ankle appears egg-shaped)

Generally, tenderness is maximal over the damaged ligaments rather than over the bone; tenderness that is greater over bone than over ligaments suggests fracture.

In mild (1st-degree) ankle sprains, the pain and swelling are minimal, but the ankle is weakened and prone to reinjury. Healing takes hours to days.

In moderate to severe (2nd-degree) ankle sprains, the ankle is often swollen and bruised; walking is painful and difficult. Healing takes days to weeks.

In very severe (3rd-degree) ankle sprains, the whole ankle may be swollen and bruised. The ankle is unstable and cannot bear weight. Nerves may also be damaged. Healing usually takes 6 to 8 wk.

Diagnosis

  • Clinical evaluation

  • Sometimes x-rays to exclude fractures

  • Occasionally MRI

Diagnosis of ankle sprains is primarily clinical; not every patient requires x-rays.

If evaluation of the injury is impossible (eg, because of muscle spasm or pain), the ankle may be immobilized for a few days and then reexamined after pain and spasm subside.

Stress testing to evaluate ligament integrity is important. However, if patients have marked pain and swelling or spasm, the examination is typically delayed until x-rays exclude fractures. Also, swelling and spasm may make joint stability difficult to evaluate; thus, reexamination after several days is helpful. The ankle may be immobilized until examination is possible.

The ankle anterior drawer test is done to evaluate the stability of the anterior talofibular ligament and thus help differentiate between 2nd- and 3rd-degree lateral ligament sprains. For this test, patients sit or lie supine with the knee at least slightly flexed; one of the practitioner's hands prevents forward movement of the anterior distal tibia while the other hand cups the heel, pulling it anteriorly.

High ankle sprains should be considered when eversion is the mechanism and when eversion reproduces pain; the distal tibiofibular joint, just proximal to the talar dome, may be tender.

If findings suggest a deltoid ligament or high ankle sprain, practitioners should check for evidence of a proximal fibular fracture.

Ankle sprains should be differentiated from avulsion fractures of the base of the 5th metatarsal, Achilles tendon injuries, and talar dome fractures, which may cause similar symptoms.

Imaging

Anteroposterior, lateral, and oblique (mortise) ankle x-rays are taken to exclude clinically significant fractures. Clinical criteria (Ottawa ankle rules) are used to determine whether x-rays are needed; these criteria are used to help limit x-rays to patients more likely to have a fracture that requires specific treatment. Ankle x-ray is required only if patients have ankle pain and one of the following:

  • Age > 55

  • Inability to bear weight without assistance immediately after the injury and in the emergency department (for 4 steps), with or without limping

  • Bone tenderness within 6 cm of the posterior edge or tip of either malleolus

If a Maisonneuve fracture is present, x-rays may show a widened mortise.

Sprains that are painful after 6 wk may require additional testing (eg, MRI) to identify overlooked and subtle injuries, such as talar dome fractures, high ankle sprains, or other complex ankle sprains.

Treatment

  • RICE (rest, ice, compression, and elevation) and early mobilization for mild sprains

  • Immobilization and/or surgical repair for moderate or severe sprains

Most ankle sprains heal well with minimal intervention and early mobilization. Splinting alleviates pain but does not appear to affect final outcome. Crutches are used for all sprains until gait is normal.

Other treatment depends on severity of the sprain:

  • Mild (eg, 1st-degree) sprains: RICE and weight bearing and mobilization as soon as it can be tolerated (usually within a few days)

  • Moderate (eg, 2nd-degree) sprains: PRICE, including immobilization of the ankle in a neutral position with a posterior splint or a commercially available boot, followed by mobilization and physical therapy

  • Severe (eg, 3rd-degree) sprains: Immobilization (possibly with a cast), possibly surgical repair, and physical therapy

High ankle sprains usually require a cast for several weeks.

Key Points

  • Before diagnosing an ankle sprain, consider an avulsion fracture of the base of the 5th metatarsal, an Achilles tendon injury, and a talar dome fracture.

  • Use the Ottawa ankle rules to help decide whether x-rays are necessary.

  • Evaluate joint stability by stress testing (eg, anterior drawer test), but if needed, delay this testing until swelling and pain subside.

  • Encourage early mobilization if the sprain is mild.

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