L11: Ankle Sprains & Ligamentous Instability

What is the talocrural joint composed of?

Relationship between the tibia, fiibula, and the talus

What is the subtalar joint composed of?

Relationship between the talus and calcaneus

What are the static stabilizers of the lateral ankle?

• Anterior Talofibular Ligament (ATFL)

• Posterior Talofibular Ligament (PTFL)

• Calcaneofibular Ligament (CFL)

Of the static stabilizers which is the most likely to be injured / torn?

Anterior Talofibular Ligament (and then the PTFL is the 2nd most commonly injured)

The Anterior Talofibular Ligament is most often injured with an ________ ankle sprain

Inversion

What are the dynamic stabilizers of the lateral ankle?

• Fibularis Longus m.

• Fibularis Brevis m.

• Fibularis Tertius m.

What is the "purpose" of the lateral dynamic stabilizers?

Bring the medial side of the foot "back down"

What is the action of each lateral dynamic stabilizer?

• Fibularis Longus = Plantarflexion + Eversion

• Fibularis Brevis = Plantarflexion + Eversion

• Fibularis Tertius = Dorsiflexion + Eversion
  

What are the static stabilizers of the medial ankle?

Deltoid Ligament Complex

T/F: The deltoid ligament is so strong that you are more likely to avulse part of the tibia before straining / tearing the ligament

True!

What are the dynamic stabilizers of the medial ankle?

• Tibialis Posterior m.

• Flexor Digitorum Longus m.

• Flexor Hallucis Longus m. 

What is the action of each of the medial dynamic stabilizers?

• Tibialis Posterior = Plantarflexion + Inversion

• Flexor Digitorum Longus = Plantarflexion + Inversion

• Flexor Hallucis Longus = Plantarflexion + Inversion
  

What is the "purpose" of the medial dynamic stabilizers?

Stabilizes for eversion movement to get the lateral side of the foot "back down"

The ________ consists of the gastroc and soleus and is considered to be a ________ dynamic stabilizer for the medial ankle

Triceps surae, Secondary

A lateral ankle sprain is also known as an ________ ankle sprain

Inversion

What is the typical MOI for a lateral ankle sprain?

• Plantarflexion + Inversion 

  • Examples -- stepping in a hole, jumping and landing ""weird""

• Common in sports like basketball and volleyball

For patients with a lateral ankle sprain, a lot of them have pain up the lateral side of the shin. Why?

• Since the ligaments "gave out" now the dynamic stabilizers are required to "work harder" in that instance to cause regular positioning

• When you injure the ligaments, the dynamic stabilizers contract so hard that you also can sprain these (hence why the pain can radiate superiorly along these tendons / muscles)

What impact does swelling have following an ankle sprain?

Arthrogenic Inhibition

In a Grade 1 Lateral Ankle Sprain what ligament(s) are typically injured?

Usually the Anterior Talofibular Ligament

In a Grade 2 Ankle Sprain what ligament(s) are typically injured?

Usually the Anterior Talofibular Ligament (ATFL) and Calcaneofibular Ligament (CFL)

In a Grade 3 Ankle Sprain what ligament(s) are typically injured?

Anterior Talofibular Ligament (ATFL), Calcaneofibular Ligament (CFL), and may even include the Posterior Talofibular Ligament (PTFL)

What are the clinical signs/symptoms of a Grade 1 Lateral Ankle Sprain?

• Stretching of the Ligaments (usually ATFL)

• Point Tenderness / tender to palpation over ATFL

• Limited Dysfunction 

• No Laxity

• Able to Bear Full Weight

• Little/No Edema

• No Bruising

What are the clinical signs/symptoms of a Grade 2 Lateral Ankle Sprain?

• Partial tearing of ligaments (usually ATFL and CFL)

• Point and Diffuse Tenderness 

  • Point tenderness = along ATFL

  • Can also be generalized

• Slight to Moderate Dysfunction

• Antalgic Gait

• Pain with FWB (may need AD to ambulate)

• Mild to Moderate Edema

• Often see Bruising

What are the clinical signs/symptoms of a Grade 3 Lateral Ankle Sprain?

• Substantial Tearing of the ligaments (ATFL, CFL, & PTFL)

• Point and Diffuse Tenderness 

• Moderate to Severe Dysfunction 

• Moderate to Severe Laxity 

• Limited / Inable to Weight Bear without AD

• Severe Edema 

• Bruising

What special test(s) of the ankle would be positive with a Grade 1 Lateral Ankle Sprain?

(+) Anterior Drawer

What special test(s) of the ankle would be positive with a Grade 2 Lateral Ankle Sprain?

(+) Anterior Drawer and Talar Tilt

What special test(s) of the ankle would be positive with a Grade 3 Lateral Ankle Sprain?

(+) Anterior Drawer, Talar Tilt, and Posterior Drawer

What is a Jones Fracture?

• Avulsion of the Peroneus Brevis / Fracture of the 5th Metatarsal

• Caused by Inversion / Lateral Ankle Sprain

• Should be suspicious of this if your patient complains of pain distally

What is the purpose of the Ottawa Foot & Ankle Rules?

Helps us to determine if someone needs imaging for a possible fracture

According to the Ottawa Ankle Rules, imaging is required if there is bone tenderness in what locations of the malleolar zone?

If there is bone tenderness at the posterior/tip of the lateral or medial malleolus

According to the Ottawa Ankle Rules, imaging is required if there is bone tenderness in what locations of the midfoot zone?

If there is bone tenderness at the base of the 5th metatarsal or on the navicular

According to the Ottawa Ankle Rules, imaging is required if the patient cannot ________ (both immediately & in ED)

Bear weight

What tendon injury can result from an inversion ankle sprain? 

• Peroneal Tendon Subluxation 

• A tear of the peroneal tendon retinaculum can occur with an inversion ankle sprain

• This causes the peroneal tendon to sublux / dislocate and move anteriorly

What is the Anterior Positional Fault of the Fibula?

After injury, the fibula is shifted more anteriorly due to the talus moving anteriorly

When should you NOT test for the Anterior Positional Fault of the Fibula?

If a patient has a high ankle sprain / syndesmotic ankle sprain

How is a peroneal subluxation treated?

• Retinaculum that is torn will be repaired

• The groove will be made deeper

What are signs/symptoms of Osteochondritis Dissecans of the Talar Dome?

• Will either see no swelling or delayed swelling

  • This is indicative of an articular cartilage injury

• Shear Forces and Compression Forces are painful

• Patient may report a "catching" or something "stopping" their ROM

• Pain with palpation over areas of articular cartilage

What are potential surgical interventions for Osteochondritis Dissecans of the Talar Dome?

• Scope and Debridement

• Microfracture

• OATs

• ** NWB for 6 weeks (then tx like lateral ankle sprain)

What are the Lateral Ankle Sprain Tx/Rehab Goals during the Acute Phase of Healing?

• Protect injured structures or prevent re-injury 

• Treat pain, inflammation, and effusion (if present)

• Re-Establish ROM 

• Re-Establish Neuromuscular Control and Strength

What are the Lateral Ankle Sprain Tx/Rehab Goals during the Sub-Acute Phase of Healing?

• Protect injured structures or prevent re-injury 

• Treat pain, inflammation, and effusion (if present)

• Re-Establish ROM 

• Re-Establish Neuromuscular Control and Strength

• Re-Esablish Proprioception and Agility
  

What are the Lateral Ankle Sprain Tx/Rehab Goals during the Maturation Phase of Healing?

• Re-Establish Neuromuscular Control and Strength

• Re-Esablish Proprioception and Agility

• Re-Establish Functional Skills
  

What is typical ROM for great toe extension?

60 degrees of extension

Osteochondritis Dissecans of the Talar Dome is commonly seen in patient with ________

Chronic ankle instability

Osteochondritis Dissecans of the Talar Dome is commonly located at the ________ portion

Anterolateral

What are the two limitations that are seen in patients that have transitioned out of a walking boot?

• Limited Ankle DF

• Limited Great Toe Extension

What are four strengthening options for ankle sprain treatment?

• BAPS Board

• Theraband

• CKC Weight Bearing

• PNF Patterns

What are two treatment options to improve mobility afted transitioning from a walking boot?

• Ankle Mobilizations (Posterior Gliding)

• Talocrural Traction

A high ankle sprain is also known as a ________ ankle sprain

Syndesmotic

What is the typical MOI for a high ankle sprain?

Planted foot with forceful ER and DF

What structures can be involved in a high ankle sprain?

• Tibial-Femoral Syndesmosis

• Anterior-Inferior Tibiofibular Ligament (AITFL)

• Posterior-Inferior Tibiofibular Ligament (PITFL)

• Transverse Ligament

How can a high ankle sprain occur if it a contact MOI?

Lateral blow to the knee (could have MCL or ACL involvement; but likely if there is a high ankle sprain it is indicative of the syndesmosis absorbing the energy instead)

Space in-between the tibia and fibula should be ________; therefore, when looking at an x-ray to dx a high ankle sprain, this is something we will be looking at

< 5 mm

Discuss the healing time frame of a high ankle sprain?

• Syndesmotic Injuries are slow to heal 

• In fact, they take 2-3x longer to heal compared to a Grade III Ankle Sprain

T/F: Bracing is efficacious in patients with a high ankle sprain

False 
(bracing is not efficacious d/t rotary forces, etc. not be stopped)

Where can pain be located with a syndesmotic injury?

Pain can be on lower ankle (at distal tibiofibular joint) and/or pain can radiate up along the lenth of the tibia

Pain can also radiate below the distal tibiofibular joint (but this is less common)

A Grade 1 High Ankle Sprain can return to activity after ________

2-6 weeks

A Grade 2/3 High Ankle Sprain can return to activity after ________

3-6 months

What imaging is used to confirm a high ankle sprain?

• Stress X-Ray (DF and ER)

• Weight Bearing X-Ray

A Grade 1 High Ankle Sprain is indicative of a ________ to the syndesmosis

Stretch

A Grade 2 High Ankle Sprain is indicative of a ________ to the syndesmosis

Partial tear

A Grade 3 High Ankle Sprain is indicative of a ________ to the syndesmosis

Complete tear

If someone has a Grade 1 Sydesmotic Injury, what history do they report?

• ER Injury

• Sub-Acute Pain and Swelling

• Continued Athletic Activity

If someone has a Grade 1 Sydesmotic Injury, what are the exam findings?

• Mild Swelling

• Mild AITFL Tenderness

• Stable Ankle

• (+) or (-) Squeeze Test

• (+) or (-) ER Stress Test
  

If someone has a Grade 2 Syndesmotic Injury, what history do they report?

• ER Injury

• Acute Pain and Swelling

• Inabiltiy to continue athletic activity 

• Painful gait
  

If someone has a Grade 2 Syndesmotic Injury, what are the exam findings?

• Moderate Swelling

• Moderate AITFL Tenderness

• (+) or (-) Squeeze Test

• (+) or (-) ER Stress Test

If someone has a Grade 3 Syndesmotic Injury, what history do they report?

• ER Injury with a "pop"

• Acute Severe Pain and Swellng

• Inability to Walk
  

If someone has a Grade 3 Syndesmotic Injury, what are the exam findings?

• Severe Swelling

• Severe AITFL Tenderness

• (+) Squeeze Test

• (+) ER Test

What does Phase 1 of treatment include for a Grade 1 Syndesmotic Injury?

• WB in a walking boot 

• ACE Wrap for compression

• Pain control

• Encourage motion within a pain-free ROM

• Toe Yoga ("TOGA") for Circulation

What does Phase 1 of treatment include for a Grade 2 / 3 Syndesmotic Injury?

• Probably not WB; this is to prevent spread of mortise

• Also...

  • ACE Wrap for Compression

  • Pain Control

  • Encourage Motion within Pain-Free ROM

  • Toe Yoga for Circulation

What should be avoided within Phase 1 of treatment for a syndesmotic injury?

• Closed-Kinetic Chain Exercises

  • Especially anything with rotation

• Forced DF

  • This would spread the mortise (which we do not want)

What does Phase II treatment include for a syndesmotic injury?

• Partial WB with an AD

• Isometrics (work towards dynamic)

• Weight Shifting

• ** really want to restore ROM and continue to avoid over-stressing tissue

What does Phase 3 treatment include for a syndesmotic injury?

• Full WB

• Transition out of walking boot

  • If still slightly unstable / there are other ligamentous injuries, patient may transition to less restrictive bracing

• Improve DF

  • Patients have decreased ROM d/t walking boot, therefore DF is soemthing that will need to be worked on

  • A heel lift may need to be used during transition from walking boot to shoes to make ROM change not as vastly different

• Single Leg Balance

What does Phase 4 treatment include for a syndesmotic injury?

• Return to Sport

• Jogging

• Change of Direction (cutting / pivoting)

• Able to Perform Single-Leg Heel Raise, Single-Leg Hop, and Repeated Hop

• (All of these should be able to be done without pain)

Discuss the surgical repair for a syndesmotic injury.

• Patient will have a ORIF to address fracture 

• Additionally, a syndesmotic screw (essentially, very long screw from fibula to tibia) will be placed to hold together syndesmosis

  • Note -- syndesmotic screw can causes issues later on after injury

• Patient will then be in a boot for 4-6 weeks 

  • After this we can treat like a lateral ankle sprain

What is a non-operative treatment option for syndesmotic injury?

• Platlet-Rich Plasma (PRP) Injection

• Ultrasound can be used to guide injection

• Commonly seen with Grade III syndesmotic injury

What is a Syndesmotic Tightrope?

• There are two "buttons" and a "tight rope" to hold the tibia and fibula together

• Allows for a better relationship between the tibia and fibula as well as the mortise

  • Not as "rigid" and allows for more ROM

What is a Masionneuve Fracture?

• Rare & commonly missed

• Comprised of 3 things:

  • Fracture of Proximal Fibula

  • Distal Tibial Fracture

  • Syndesmotic Injury

________ is the precursor for OA in the ankle

Chronic Ankle Instability

What are mechanical factors that can lead to chronic ankle instability?

• Pathological Laxity

• Arthrokinetic Restriction

• Synovial Changes (thickening)

• Degenerative Changes

What are functional factors that can lead to chronic ankle instability?

• Impaired proprioception / joint position sense

• Impaired neuromuscular control

• Impaired postural control

• Strength deficits

T/F: Prophylatic bracing is beneficial for patients with chronic ankle instability

True! 

(especially for patients have had previous ankle sprain insult)

Chronic Ankle Instability (CAI) is common in individuals after they have a(n) ________

Ankle sprain
only 1 ankle sprain is needed to increase risk of chronic ankle instability

What is the problem with ankle taping?

• Tape loosens over time

• After approximately 45 minutes of activity -- tape has lost its structural stiffness and thus is not providing proper support

What is the Brostrum Procedure?

• Stabilization Surgery for Chronic Ankle Instability

• "Pants Over Vest Technique"

• Remnants of the stretched ligaments are sutured back together

What is the Brostrum Repair Gould Modification?

• Another type of Stabilization Surgery for Chronic Ankle Instability

• Exact same thing as Brostrum Repair but the extensor retinaculum is flipped over to provide extra lateral instability

What is the Biotenodesis Brostrum?

• Third type of Stabilization Surgery for Chronic Ankle Instability 

• Can be an allograft (from cadaver) or an autograft (from self)

• Ligaments are made out of other structures

  • Examples = semitendinosus m., gracilis m., or plantaris m.

What do we need to be cautious of following all ankle repairs? 

Avoid inversion & adduction for 6 weeks
(just prevent anything that stresses the repair)

How does aggressive vs less aggressive therapy progression differ?

• Aggressive: 

  • Partial Weight-Bearing or WBAT in a Walking Boot for 2-4 weeks

• Conservative / Less Aggressive:

  • NWB for 2-4 weeks while in a Walking Boot

  • Continue in Walking Boot for 6-8 Weeks w/ WBAT

  • Bracing

What are common interventions / exercises for patients who have undergone ankle surgery?

• AROM in a pain-free range

• Toe Scrunches (helps with inflammation)

• Strength Quads, Hamstrings, Hip Abductors

• Joint Mobilizations

  • If for pain -- can be performed earliy

  • If going for tissue extensibility / stretching -- wait for 8 weeks

• Isometrics (Submax --> Max ISO --> Concentric)

  • Be careful of inversion

• Weight Shifts

• Single-Leg Balance

The ________ Classification is the most common classification system for a lateral malleolar fracture

Danis Weber

The more proximal a fibular fracture is → the increased risk for ________ and ________

Syndesmotic disruption, Ankle instability

What is the treatment for a non-displaced lateral malleolar fracture?

Patient is put in a walking boot for 6-8 weeks

What is the treatment for a displaced lateral malleolar fracture?

• Patient will likely have an ORIF (d/t unstable fx or comminuted fx)

• Booted for 4-6 weeks; and progress to WB once physician approval is received

• After that → treat like a lateral ankle sprain!

  • Focus on ROM once patient out of boot

  • Joint mobilizations (subtalar, talocrural, and 1st MTP)

What is the treatment for a bi-malleolar fracture?

• Patient will often have an ORIF 

  • Though -- surgery may not occur right away to wait for swelling to go down (during this time, patient may be in splint)

  • However, if fx / dislocation could impact nerves and vascular structures they will just go ahead with surgery

• Work on mobility with these patients

  • No joints mobs until 8-weeks post-op

What structures are involved with a trimalleolar fracture?

• Medial Malleolus

• Lateral Malleolus

• Tibial Plafound (aka -- "3rd malleolus")

What is the typical MOI for a tri-malleolar fracture?

Often results from a significant trauma (e.g., fall)

What is the treatment for a tri-malleolar fracture?

• Patient will require ORIF with hardware

• Booted for 6-8 weeks

  • May be longer depending on the severity

• Can take a long time for patients to regain functionality

  • Could be up to 1-2 years before back to full function