AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

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

INTRODUCTION

Section 2 of 11  

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

Background

Ligamentous injuries of the ankle are common among athletes. Inversion injuries of the ankle account for 40% of all athletic injuries. The anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) are sequentially injured when a plantar-flexed foot is forcefully inverted. The posterior talofibular ligament (PTFL) rarely is injured, except in association with a complete dislocation of the talus.

Ligamentous injuries of the ankle are classified into the following 3 categories, depending on the extent of damage to the ligaments:

• Grade I is an injury without macroscopic tears. No mechanical instability is noted. Pain and tenderness is minimal.
• Grade II is a partial tear. Moderate pain and tenderness is present. Mild-to-moderate joint instability may be present.
• Grade III is a complete tear. Severe pain and tenderness, inability to bear weight, and significant joint instability are noted.

Frequency

United States

Approximately 3600 cases per 100,000 people are reported per year.

Functional Anatomy

The lateral articular capsule of the ankle can be divided into anterior and posterior segments. The anterior segment attaches proximally to the anterior portion of the distal tibia superior to the articular surface and to the border of the articular surface of the medial malleolus. The posterior segment attaches distally to the talus just posterior to its superior articular facet and attaches laterally to the depression in the medial surface of the lateral malleolus.

The ATFL is intracapsular and attaches anteriorly to the anterior border of the distal fibula and laterally to the neck of the talus. The PTFL attaches posteriorly to the digital fossa of the fibula and laterally to the lateral tubercle on the posterior portion of the talus.

Sport Specific Biomechanics

The talofibular ligaments along with the CFL are components of the lateral ligament complex. This complex becomes stressed when the ankle is inverted and plantar flexed. Supination of the foot in neutral flexion usually results in injury of the CFL. Supination and adduction injuries tear both the ATFL and the CFL. The PTFL is the strongest of the lateral ligaments, and extreme inversion with plantar flexion is required to place the PTFL under stress; as a result, the PTFL is less commonly injured. Transient subluxation or dislocation of the talus from the tibial mortise usually results in injury of all 3 lateral ligaments. Prevention of anterior displacement of the talus is primarily a function of the ATFL. Little additional motion occurs when the CFL also is damaged. Instability to inversion is greater when both the CFL and the ATFL are injured than when either ligament is injured alone.

CLINICAL

Section 3 of 11  

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

History

The history portion of the examination should include the following:

• Mechanism of injury
• Time of injury
• Concurrent injuries
• Position of the body at the time of injury
• Rotational component to injury
• Ability or inability to bear weight immediately after the injury
• The time of onset of pain and swelling (immediate or delayed)
• Whether the patient heard or felt a popping sound or sensation at the time of the injury
• Information regarding any previous ankle injuries

Physical

The physical examination should include the following:

• Inspect the ankles.
• • Both ankles should be completely uncovered so the injured side can be compared with the uninjured side.
  • Note any swelling, ecchymosis, lacerations, abrasions, or deformities.
• Palpate the injured ankle, noting any tenderness or crepitus.
• Perform a neurovascular examination of the foot distal to the injury. Document findings.
• Assess the stability of the ankle joint.
• • The anterior drawer test assesses the stability of the lateral ligaments.
    • To perform this test, the foot is placed in slight inversion and 20° of plantar flexion. The heel is grasped firmly and drawn forward while the tibia is stabilized by the examiner's other hand.
    • A positive sign occurs when the talus moves forward on the tibia.
    • The injured side also should be tested for maximal inversion compared to the uninjured side.
    • If the ATFL is torn, forward motion is detected on performing the anterior drawer test.
    • If the ATFL and the CFL are torn, abnormal inversion is elicited.
  • Grade I sprains are partial tears of the ligaments and are stable to stress testing.
  • Grade II sprains have a mildly increased anterior drawer test and are stable to inversion.
  • Grade III sprains are unstable to both the anterior drawer test and the talar tilt test. Instability with these tests indicates a complete tear of the ATFL and at least a partial tear of the CFL.

DIFFERENTIALS

Section 4 of 11  

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

Other Problems to be Considered

Ankle dislocation
Calcaneus bone injuries
Midfoot Injuries

WORKUP

Section 5 of 11  

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

Lab Studies

• Laboratory studies are not indicated in the workup of ligamentous injuries of the ankle.

Imaging Studies

• Indications for imaging studies include the following:
• • Bony tenderness or deformity
  • Suspicion of a fracture or syndesmotic injury
  • Severe pain or swelling that makes the physical examination unreliable
  • Inability to walk
• Initial radiologic studies of the ankle should include the following:
• • An anteroposterior (AP) view with the ankle in slight adduction
  • A true lateral view
  • A mortise view (45° oblique view with the ankle in dorsiflexion)
  • Consider stress views of the ankle
  • If a syndesmotic injury is suspected, then AP and lateral views of the tibia and fibula also should be obtained to rule out associated fibular fractures.

TREATMENT

Section 6 of 11  

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

Acute Phase

Rehabilitation Program

Physical Therapy

Initial treatment of all grades of lateral ankle sprains consists of rest, ice, compression, and elevation (RICE) and nonsteroidal anti-inflammatory drugs (NSAIDs). Ice should be applied to the injured ankle for approximately 20 minutes, 3-4 times per day. Compressive dressings should be used to control swelling. Weight bearing should be encouraged as soon as it is tolerated. With grade III injuries, an ankle brace should be worn at all times for 6 weeks.

Studies have shown no difference in long-term outcome when comparing early mobilization to cast immobilization or early surgical repair. In the short-term, patients treated with early mobilization return to sports and work 2-4 times faster than those not treated with early mobilization. Also, no difference is found in long-term outcome when comparing early surgical repair with delayed surgical repair following failed conservative therapy. Therefore, there is no indication for routine early surgical repair.

The early phase of rehabilitation is begun approximately 48 hours postinjury. Icing is continued and range of motion (ROM) exercises are initiated. Writing the alphabet with the great toe moves the ankle through full ROM in all planes. Stationary biking and stretching of the Achilles tendon also are beneficial. As strength and mobility improve, isometric exercises for ankle dorsiflexion, plantar flexion, inversion, and eversion are initiated. The isometric exercises are followed by resistance exercises (initially using a Thera-Band strap) and then heel and toe raises. Agility training also aids in return to sports.

Surgical Intervention

Primary repair of acute lateral ligament tears is rarely indicated. Open repair seems to offer no advantage over closed management at the time of initial injury. Delayed repair may be necessary in patients with chronic mechanical instability on clinical examination and functional instability; however, surgical intervention in these cases should only be considered after an aggressive rehabilitation program has failed.

Consultations

• An emergent consultation is rarely required.

• Consultation with an orthopedist should be obtained for patients with unstable ankles, dislocations, or associated fractures.

Recovery Phase

Rehabilitation Program

Physical Therapy

When the early phase rehabilitation goals of decreased swelling, full weight bearing, and no tenderness to palpation are met, more aggressive strengthening and proprioceptive training are added. Increased stretching of the Achilles tendon, as well as the gastrocnemius and soleus muscles, is performed using an incline board. Thera-Band exercises are continued for strengthening. Exercises such as one-leg stands and wobble board training are added for proprioception. This training continues until the ankle is at 80-90% of full strength and there are no deficits in proprioception. When these goals are met, the patient may be discharged from therapy.

Surgical Intervention

Maximum benefit from conservative therapy is reached after approximately 10 weeks of active rehabilitation. At this time, 20% of athletes continue to have symptoms secondary to either a functional or mechanical instability. If the patient has reached his/her maximal benefit from functional rehabilitation and has a persistent deficit, then surgical reconstruction should be considered.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The patient should be independent with a home exercise program with sport-specific activities and gradually return to play when functional goals are met. The physician and/or physical therapist may recommend taping or bracing the ankle upon returning to activity. Taping or bracing a previously injured ankle during athletic activity has been shown to reduce the incidence of recurrent injury.

MEDICATION

Section 7 of 11  

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

The goal of medical therapy is to reduce pain during the acute phase of recovery.

Drug Category: Nonsteroidal anti-inflammatory drugs

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 and enable physical therapy regimens. Many analgesics have sedating properties that are beneficial for patients who have sustained injuries.

FOLLOW-UP

Section 8 of 11  

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

Return to Play

Athletes may return to sports when they are able to run and pivot without pain while the ankle is braced. Bracing and taping of the injured ankle is continued during athletic activities for 6 months.

Complications

Up to 20% of patients with an acute inversion injury develop chronic functional instability. Electromyography (EMG) has demonstrated prolonged reaction times of the peroneal muscle in this group of patients. Strengthening and proprioception exercises can lead to improvement. Patients who do not respond and have continued mechanical laxity and functional instability may be candidates for lateral ligament reconstruction.

Prevention

Completion of an adequate rehabilitation program, as well as functional bracing or taping for 6 months following injury, minimizes the chance of recurrent injury.

Prognosis

Eighty percent of patients with lateral ankle injuries make a full recovery following conservative rehabilitation. Up to 20% demonstrate chronic ankle instability requiring prolonged therapy and possibly surgical repair.

Education

To help prevent recurrent injury, patients should be instructed regarding the proper techniques for ankle taping and bracing. Ankle-strengthening and proprioception exercises also should be an important part of rehabilitation, and the patient should be instructed in an appropriate home exercise program.

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

MISCELLANEOUS

Section 9 of 11  

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

Medical/Legal Pitfalls

• Failure to diagnose a fracture
• Misinterpretation of radiograph
• Failure to recognize unstable ankle
• Failure to refer significant injuries

ACKNOWLEDGMENTS

Section 10 of 11  

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

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Michael Taylor, MD, to the development and writing of this article.

REFERENCES

Section 11 of 11

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

• Anderson RB. Ankle and foot: reconstruction. In: Kasser JK, ed. Orthopaedic Knowledge Update 5. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1996:525-548.
• Brage ME, Colville MR, Early JS. Ankle and foot: trauma. In: Beaty JH, ed. Orthopaedic Knowledge Update 6. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:597-612.
• Fong BL, Brunet ME. The leg, ankle, and foot. In: Perrin DH, ed. The Injured Athlete. 3^rd ed. Philadelphia, Pa: Lippincott-Raven; 1999:432-439.
• Garrett WE. Trauma: soft tissue. In: Fitzgerald RH, ed. Orthopaedic Knowledge Update 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1987:89-96.
• Jackson MD, Moeller JL, Hough DO. Basketball injuries. In: Sallis RE, Massimino F, eds. Essentials of Sports Medicine. New York, NY: Churchill Livingstone; 1996:558-559.
• Kelikian H, Kelikian AS. Disruption of the fibular collateral ligament. In: Disorders of the Ankle. Philadelphia, Pa: WB Saunders Co; 1985:437-490.
• Leach RE. Ligamentous injuries. In: Ankle Injuries. New York, NY: Churchill Livingstone; 1983:193-208.
• Mann RA. Ankle and foot: reconstruction. In: Fitzgerald RH, ed. Orthopaedic Knowledge Update 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1987:455-463.
• Rubin A. Ankle ligament sprains. In: Sallis RE, Massimino F, eds. Essentials of Sports Medicine. New York, NY: Churchill Livingstone; 1996:450-452.
• Scranton PE. Ankle and foot: trauma. In: Fitzgerald RH, ed. Orthopaedic Knowledge Update 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1987:447-454.
• Simons S. Rehabilitation of ankle injuries. In: Essentials of Sports Medicine. St. Louis, Mo: Mosby-Year Book; 1996:458-461.
• Snell R, Smith M. The bony pelvis and lower extremity. In: Clinical Anatomy for Emergency Medicine. St. Louis, Mo: Mosby-Year Book; 1993:708-709.

Article Last Updated: Dec 9, 2005