Ankle sprain

A sprained ankle, twisted ankle, rolled ankle, floppy ankle, ankle injury or ankle ligament injury, is a common medical condition where one or more of the ligaments of the ankle is torn or partially torn.

Can occur through either sports or activities of daily living, and individuals can be at higher or lower risk depending on a variety of circumstances including race, age, sex, or profession.

Individuals aged 10–19 years old have the highest incidences of ankle sprains.

Over 50% of ankle sprains are due to sport related injuries.

Ankle sprains for the general U.S. population are estimated at 5-7 ankle sprains for every 1000 person-years.

Male and female counterparts have the same incidence rates of ankle sprains.

At the range of 19–24 years old, males have a substantial increased rate of ankle sprains than females.

At ages 30 and over, females showed higher incidences of ankle sprains than males.

Age and activity levels are better indicators of ankle sprain risks than gender.

Affects up to 23,000 individuals in the U.S. each day.

Most commonly injured joint with sports injuries.

Almost 1 million people are evaluated annually for ankle sprain and accounts for 25% of all sports-related injury.

Incidence 2.15 per 1000, person-years .

Incidence highest in 15-19 age age group at 7.2 per 1000 person-years.

Approximately 70% of basketball players have sprained an ankle, and the likelihood of reinjury is as high as 80%.

When a sprain occurs, blood vessels leak fluid into the tissue surrounding the joint.

White blood cells responsible for inflammation migrate to the area of sprain.

Ankle sprains associated with increased blood flow, with increased warmth and redness.

Patients experience inflammation, swelling and pain.

Ankle injury makes the nerves in the area become more sensitive, with throbbing pain that worsens if there is pressure placed on the area.

Associated with decreased mobility of the joint.

Movements of twisting, turning, and rolling of the foot, are the primary cause of an ankle sprain.

The risk of a sprain is greatest due movement that involve side-to-side motion, such as tennis or basketball.

Can occur during normal daily activities such as stepping off a curb or slipping on ice.

Most ankle sprains occur in active population, such as athletes and exercisers.

Following ankle injury, resuming activity before the ligaments are fully healed may cause them to heal in a stretched position, resulting in chronic ankle instability.

Factors contributing to an increased risk:

Weak muscles/tendons that cross the ankle joint,

Weak or lax ligaments that join together the bones of the ankle joint,

Poor ankle flexibility,

Inadequate warm-up and/or stretching,

Impaired joint proprioception,

Slow neuromuscular response to an off-balance position,

Running on uneven surfaces,

Using shoes with inadequate heel support.

Wearing high-heeled shoes.

Occur as a manifestation of excessive stress on the ligaments of the ankle, with excessive external rotation, inversion or eversion of the foot caused by an external force.

When the foot is moved past its range of motion, the excess pressure strains the ligaments causing damage to them.

Ankle sprains are classified as grade 1, 2, and 3.

Each sprain is classified from mild to severe.

A grade 1 sprain is defined as mild damage to a ligament or ligaments without instability of the affected joint.

A grade 2 sprain reflects a partial tear to the ligament, in which it is stretched to the point that it becomes loose.

A grade 3 sprain is a complete tear of a ligament, causing instability in the affected joint.

The most common type of ankle sprain occurs when the foot is inverted too much, affecting the lateral side of the foot resulting with outer, or lateral, ligaments are stretched.

Approximately 70-85% of ankle sprains are inversion injuries, with the anterior talofibular ligament one of the most commonly involved ligaments in this type of sprain.

In an inversion ankle sprain, excessive plantar flexion and supination causes the anterior talofibular ligament to be affected.

Ankle Inversion is associated with damage to the anterior talofibular and calcaneofibular ligaments.

Eversion or medial ankle sprains are less common type of ankle sprain.

The eversion injury, affecting the medial side of the foot occurs when the medial, or deltoid, ligament is stretched too much.

A high ankle sprain refers to an injury to the large ligaments above the ankle that join together the two long bones of the tibia and fibula.

High ankle sprains commonly occur from a sudden and forceful outward twisting of the foot.

High ankle sprains commonly occur in contact and cutting sports.

Diagnosis relies on the medical history, including symptoms, as well as making a differential diagnosis, mainly in distinguishing it from bone fractures.

The Ottawa ankle rule helps differentiate fractures of the ankle or mid-foot from other ankle injuries that do not require x-ray radiography.

Ottawa ankle rule has a sensitivity of nearly 100%, such that a patient who tests negative, does not have an ankle fracture.

Three types of ankle sprains: lateral, medial and syndesmotic.

Lateral ankle sprains account for 90% of all ankle injuries.

Most common mechanism of ankle sprain is plantar inversion while the foot is plantar flexed.

Lateral ankle sprains are due to lateral structures are weaker than the medial ones.

Less common injuries occur to ankle evert injuries due to the stronger medial deltoid ligament complex.

Dorsiflexion and and eversion cause injuries to the syndesmotic structures, the tibiofibular ligament.

The lateral ligament complex has 3 ligaments: anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL).

Typical injury results from invert of the ankle while walking, playing sports or stepping off a curb with lateral ligamentous complex injury.

Most frequent initial complains are pain, swelling and decreased proprioception.

Long-term complaints include pain instability and stiffness of the ankle.

Edema may be present, but gross deformities suggest fracture.

Residual symptoms may last for months to years.

Grading of ankle sprains: grade I mild or no tearing, grade II moderate or partial tearing, and grade III with sever or complete rupture of the ligament.

Grading is difficult and inaccurate.

Exam includes placing direct pressure on ATFL, CFL, PTFL, medial deltoid ligament complex, tibia and fibula, Achilles to assess gore pain, edema, and crepitus.

Exam includes active and passive movement of the joint through all planes of motion in plantar flexion, dorsiflexion, inversion, and eversion, and inversion/eversion in flexion.

An anterior drawer test can assess the interior talofibular ligament and is reliable if performed within 48 hours of injury: The examiner places one hand above the joint line and cups the heel with the other hand with force pulling the heel anterior, a shift of greater than 3 mm indicates a positive sign.

The Talar tilt test examines the deltoid and lateral movements using eversion inversion stresses.

The Thompson test is performed by gripping the midcalf with the knee at 90° and observing for plantar flexion on the foot show the Achilles tendon is intact, a lack of plantar flexion suggests an Achilles tendon rupture.

The squeeze test evaluates for syndesmosis injury or high ankle sprain: The mid calf is squeezed to push the tibia and fibula together and is positive pain if elicited distally to the region of the tibiofibular syndesmosis.

Severe instability implies prolonged healing times.

72% of patients in one study revealed persistent symptoms from 6-18 months.

Priority management is prompt control of swelling with compression, ice and elevation of the ankle.

Previously immobilization was recommended but now functional treatment with elastic bandage, soft cast, tape, orthoses and coordination training have improved symptoms and outcomes in short, intermediate and long term follow-up.

Plain radiographs indicated when patients have an inability to walk 4 steps immediately after the injury or at the time of evaluation, if there is localized tenderness at the posterior edge or tip of either malleolus, if there is localized tenderness of the navicular bone or base of the fifth metatarsal.

When indicated plain films should include anterioroposterior, lateral, medial oblique and mortise films.

Initial treatment commonly consists of compression wraps, warming pads and icing.

Rest, icing, compression and elevation (RICE) are recommended for the treatment of soft tissue sprained ankles.

RICE is intended to reduce blood and fluid flow to the affected region of the body, in this case the ankle.

An ankle injury that hurts to walk on, has limited mobilization, but is not swollen should consider wearing an orthopedic walking boot for two weeks and be on crutches for the first week.

Initially ice is often used to reduce swelling.

In lateral ankle sprains soft tissue swelling can be prevented with compression around both malleoli, elevation of the injured ankle higher than the heart, and pain-free exercises.

Walking boots, braces and crutches are also used to help alleviate the pain,

Compression bandages are used to provide support and compression for sprained ankles, but are less effective than casts,

Compression bandage wrapping is started at the ball of the foot and continued to the base of the calf muscle.

Many types of rehabilitation exercises can be done to aid an ankle to regain strength and flexibility.

Edema within the ankle tissue is the basis of pain, and its reduction is the main goal during the initiation of rehabilitation.

The first week of rehabilitation should be on protecting the ankle to avoid further damage.

The implementation of different types of ankle sprain exercises to increase the range of motion, flexibility, strengthening, balance and agility is required.

Improper ankle sprain healing may lead to an unstable joint and chronic pain.

Ankle immobilization compared to a tubular compression bandage may lead to a faster recovery at 3 months, however, a randomized controlled trial has concluded that appropriate exercise immediately after a sprain improves function and recovery.

After an ankle injury it is advisable to not to walk for a couple of days, with rest accelerating the healing process.

Returning to vigorous activities should be deferred until hopping on the ankle is achieved without pain

Wearing high-top tennis shoes may also help prevent ankle sprains.

Manual joint mobilization/manipulation of the ankle diminishes pain and increases range of motion.

Preventing sprains or ankle re-injury with strengthening and stretching exercises should be done to improve ankle mobility, and joint flexibility.

To prevent ankle injury include: provide proper warm-up prior to stretching and activity, running on level surfaces and avoid rocks or holes, proper shoes with heel support.

5-30% have problems with pain and instability after 1 year, while most people improve significantly with their ankle injury within the first two weeks.

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