 Introduction

 Ligamentous Anatomy of Ankle

 Classification
 Mechanism of Injury
 Signs and Symptoms
 Epidemiology
 Diagnostic Tools
 Differential Diagnosis
 Management
 Evidence Based Rehabilitation.
 Recommendations.
Mr. Nasir is a 35-year-old computer programmer who
plays Basketball at the local recreation center. He
sustained a massive inversion sprain of his right ankle
when landing on foot of an opponent after jumping
to rebound the basketball. He wrapped the ankle
and iced it for 2 days. On the 3rd day he went for a
radiograph. No fracture was detected, But he does
have a Grade 2 Instability of the Anterior talofibular
ligament. Observation revealed swelling and
discoloration in the anterior and lateral ankle region.
He experienced a marked increase in pain wit
inversion and Planterflexion tests, with anterior gliding
of the talus, and with palpation over the involved
ligament. Because of muscle guarding strength was
not tested.
 That
has to
hurt!!!

 Ankle injuries are among the most

common injuries presenting to primary
care offices and emergency
departments.
 Also known as twist ankle, rolled ankle
or ankle ligament injury.
 Recurrent ankle sprains can lead to
functional instability and loss of normal
ankle kinematics and proprioception,
which can result in recurrent injury,
chronic instability, and early
degenerative bony changes.

Boruta PM, Bishop JO, Braly WG, Tullos HS. Acute lateral ankle
ligament injuries: a literature review. Foot Ankle 1990; 11:107.
Three ligaments make up the lateral
ankle ligament complex.
 Anterior talofibular ligament (ATFL)
 Calcaneofibular ligament (CFL)
 Posterior talofibular ligament (PTFL)

Usually anterior Talofibular

Ligament (ATFL) is affected
Function of Ligaments
Ankle ligaments provide
mechanical stability,
Proprioceptive information, and
directed motion for the joint.

Attarian DE, McCrackin HJ, DeVito DP, McElhaney JH, Garrett

WE Jr. Biomechanical characteristics of human ankle
ligaments. Foot Ankle. Oct 1985;6(2):54-8
Grade I (First Degree)
 The ligament damage has occurred without
any significant instability developing.
Grade II (Second Degree)
 The ligament has been more significantly
damaged, but there is no significant instability.
Grade III (Third Degree)
 The ligaments have been torn and instability
has resulted.
Moreira V, Antunes F (2008). "[Ankle sprains: from diagnosis to
management. the physiatric view]". Acta Med Port (in
Portuguese) 21 (3): 285–92
Types of Ankle Sprain

Lateral (Inversion) Sprains

 Approximately 70-85% of ankle
sprains are inversion injuries.
High (Syndesmotic) Sprain
 A high ankle sprain is an injury to
the large ligaments above the
ankle that join together the
bones of the lower leg.
Medial (Eversion) Sprains
 This affect the medial side of the
foot and deltoid ligament is
stretched
 The foot is placed in forced inversion
and plantar flexion

 It can be from an unstable/irregular surface

 Also caused by forced trauma

Swelling*
Pain*
Discoloration*
Redness
Warmth
Inability to walk
Ankle Instability
*The most common symptoms

Sprained ankle. American Academy of Orthopaedic Surgeons.

http://www.orthoinfo.org/topic.cfm?topic=a00150. Accessed June 9,
2014
 Sprained ankles have been estimated to
constitute up to 30% of injuries seen in
sports medicine clinics. More than 23,000
people per day in the United States,
including athletes and non-athletes,
require medical care for ankle sprains.
Stated another way, incident cases have
been estimated at 1 case per 10,000
persons per day.
Mahaffey D, Hilts M, Fields KB. Ankle and foot injuries in sports. Clin
Fam Pract; 1999:1(1):233-50
 The Ottawa ankle
rules are a set of
guidelines for
clinicians to help
decide if a patient
with foot or ankle pain
should be offered X-
rays to diagnose a
possible bone
fracture.
 Sensitivity: 98.5%

Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle

rules to exclude fractures of the ankle and mid-foot: systematic
review. BMJ 2003; 326:417.
 The rules are as follows :
An ankle series (Ankle Radiograph) is only indicated for
patients who have pain in the malleolar zone AND
i. Have bone tenderness at the posterior edge or tip of
the lateral or medial malleolus OR
ii. Are unable to bear weight both immediately after
the injury and for four steps in the emergency
department or doctor's office.
A foot series (Foot Radiograph) is only indicated for
patients who have pain in the midfoot zone AND
i. Have bone tenderness at the base of the fifth
metatarsal or at the navicular OR
ii. Are unable to bear weight both immediately after
the injury and for four steps in the emergency
department or doctor's office.
Anterior Draw Test

Purpose:
To test for ligamentous
laxity or instability in the
ankle. This test primarily
assesses the strength of
the Anterior Talofibular
Ligament.
Diagnostic Accuracy:
Sensitivity: .71
Specificity: .33

Docherty, Carrie. "Reliability of the Anterior Drawer and Anterior

Tilt Tests using the Ligmaster Joint Arthometer." 2009
External Rotation Test
Purpose:
To help identify a
tibiofibular Syndesmotic
injury (high ankle sprain).
The term "high ankle
sprain" refers to an isolated
injury to the tibiofibular
syndesmosis
Diagnostic Accuracy:
Sensitivity: 20
Specificity: 84.5
Cesar, Paulo. "Comparison of Magnetic Resonance Imaging
to Physical Examination for Syndesmotic Injury After Lateral
Ankle Sprain ." American Orthopaedic Foot and Ankle
Society. 32.2 (2011): n. page. Web. 23 Sep. 2012
Talar Tilt test
Purpose:
The talar tilt test detects
excessive ankle
inversion. If the
ligamentous tear
extends posteriorly into
the calcaneofibular
portion of the lateral
ligament, the lateral
ankle is unstable and
talar tilt occurs.
Diagnostic Accuracy:
Sensitivity: 67
Specificity: 75
Extracted from Orthopedic Physical Examination Tests:
An Evidence-Based Approach: "Medial Talar Tilt Stress Test": Hertel
et al. Sensitivity 67, Specificity 75, LR+ 2.7, LR- 0.44
 Lateral malleolus fracture
 Osteochondral injury to talus
 Posterior-lateral talar process fracture
 Anterior process of calcaneus (beak) fracture
 Achilles tendon injury
 Fifth metatarsal fracture (styloid process or base)
 Subtalar joint injury
 Calcaneo-fibular Ligament sprain
 Posterior talo-fibular ligament sprain
 Calcaneo-cuboid ligament sprain

Young CC et al, Ankle sprain, Medscape, Sep 2011

Conservative

surgical
Max. protection Mod. Protection Min. protection Return to activity
phase phase phase
1-3 Days 4-10 Days 11-21 Days 3-8 weeks
• PRICE formula • Non weight • Weight bearing as • ↑ Weight bearing as
• Protection with a bearing AROM tolerated tolerated
splint • Cross-fiber • Initiate Eccentric • Agility drills.
• Icing every massage ex. • Adv. Exercises
2hours during 1st • Grade 2 joint • Toe walks Static→dynamic
48hours mobilization • Subtalar • Isokinetic resistance
• Elevation to • Toa curls mobilization training
reduce swelling • Seated calf • Tape or Brace for • Specific sport training
• Gentle stretches sports or other • Protective bracing for
mobilization to • Endurance strenuous participation into a
inhibit pain training activities sports
• Partial WB with • strengthening • Proprioception/
crutches exercises of balance board ex
• Muscle-setting intrinsic foot
Techniques muscles

Caroline, Kysner, and Colby Lyn Allen. "Therapeutic Exercise Foundation and
Techniques." FA. Davis, Philadelphia (1988).
 Surgical repair of ruptured ankle ligaments is
sometimes considered in patients with ankle
sprains.
 It is Usually indicated for Grade III ankle sprain
 A meta-analysis that looked at controlled trials
of surgery for acute ruptures of lateral ankle
ligaments found that compared with functional
treatment, patients treated with surgery were
significantly less likely to experience giving-way
of the ankle (relative risk 0.23, 95% CI 0.17-0.31).

Pijnenburg AC, Van Dijk CN, Bossuyt PM, Marti RK. Treatment of
ruptures of the lateral ankle ligaments: a meta-analysis. J Bone
Joint Surg Am 2000; 82:761
Reference Study Design Study method Results

Bleakley, C. M. Randomized Group 1 It was Assessed

McDonough, S. controlled trial n = 46 standard from the study
M. et al. Aug ice application that Intermittent
2006. Group 2 applications may
Cryotherapy for n = 43 intermittent enhance the
acute ankle sprains: ice application. therapeutic effect
a randomised Function, pain, of ice in pain
controlled study of
and swelling were relief after acute
two different icing
protocols recorded at soft tissue injury
baseline and
one, two, three,
four, and six
weeks after injury.
Reference Study Design Study method Results

Michel P.J. van den Randomized After deduction of It was concluded

Bekerom, et al, controlled trial the overlaps among that Insufficient
July/Aug. 2012, the different evidence is
What Is the databases,
available from
Evidence for Rest, evaluation of the
Ice, Compression, abstracts, and randomized
and Elevation contact with some controlled trials to
Therapy in the authors, 24 determine the
Treatment of Ankle potentially eligible relative
Sprains in Adults? trials remained. The effectiveness of
full texts of these RICE therapy for
articles were acute ankle
retrieved and
sprains in adults.
thoroughly assessed
as described. This
resulted in the
inclusion of 11 trials
involving 868
patients.
Reference Study Design Study method Results

Axelsen, S. M. Randomized 40 patients were After assessment

Bjerno, T. 1993, controlled trial randomly pain was
effect of Laser selected from the significantly
therapy in casualty ward reduced. There
management of All pts. Received was no significant
ankle sprain the low-level effect on swelling
Laser treatment and
unless ankle discoloration.
sprain was
painless
Reference Study Design Study method Results

Green, T. et al. April Randomized N=41 subjects with Study Revealed

2001, Effectiveness controlled trial acute ankle that addition of a
of passive inversion sprains talocrural
accessory joint (<72 hours) & no
mobilization to
mobilization on other injury in L.L
acute ankle were Randomly the RICE protocol
inversion sprains Assigned to 1 of 2 in the
treatment groups management of
1. Control group ankle inversion
Received only injuries
RICE protocol necessitated
2. Treatment Group fewer treatments
received
to achieve pain-
Antero-posterior
gliding of Talus free dorsiflexion
in addition to and to improve
RICE protocol stride speed
Reference Study Design Study method Results

Vicenzino, B. A double-blind N=16 It was found that

Branjerdporn, M. randomized subjects with Both the weight-
et al. july 2006, crossover (mean +/- SD age, bearing and non-
Initial changes in experimental 19.8 +/- 2.3 years) weight-bearing
posterior talar study with a history of MWM treatment
recurrent lateral
glide and techniques
ankle sprain and
dorsiflexion of the deficits in posterior significantly
ankle after talar glide (71%) improved
mobilization with and weight-bearing posterior talar
movement in dorsiflexion (34%) glide by 55% and
individuals with were studie 50% Respectively.
recurrent ankle Treatment group:
sprain weight-bearing
MWM, non-weight-
bearing MWM
Control group:
No treatment
Reference Study Design Study method Results

Verhagen, E. A. Prospective n=116 male & This study

van Tulder, M. et Randomized female Volleyball highlights that
al. Sep. 2005, controlled trial teams followed Significantly fewer
prospectively during
Effect of ankle sprains in
the 2001-2002
Proprioceptive season. the intervention
balance board Teams were group were found
training Randomized into compared to the
programme for Control and control group.
the prevention of Intervention Group
ankle sprains in
volleyball Players
Reference Study Design Study method Results

Refshauge, K. M. Controlled 16 participants with It was found that

Raymond, J. et al. laboratory study recurrent ankle Taping the ankle
Feb. 2009, sprain under 2 decreased the
The effect of ankle conditions: with the ability to detect
taping on detection ankle taped or movement in the
of inversion-eversion untaped were inversion-eversion
movements in selected. The plane in
participants with threshold for participants with
recurrent ankle movement recurrent ankle
sprain. detection was sprain.
examined at 3
velocities (0.1
deg/s, 0.5 deg/s,
and 2.5 deg/s) and
in 2 directions
(inversion and
eversion).
Patient-reported comfort
and satisfaction during
treatment with a semi-rigid
brace was significantly
increased. The rate of skin
complication in this group
was significantly lower
compared to the tape
group (14.6% versus 59.1%,
P < 0.0001).

Lardenoye S, Theunissen E, Cleffken B, Brink PR, de Bie RA,

Poeze M. The effect of taping versus semi-rigid bracing on
patient outcome and satisfaction in ankle sprains: a
prospective, randomized controlled trial. BMC musculoskeletal
disorders. 2012; 13: 81
Reference Study Design Study method Results

Boyce, S. H. Prospective N=50 pts. It was analyzed that

Quigley, M. A. Randomized Randomized into 2 the use of an
Campbell, S. Jan. controlled trial Groups Aircast ankle brace
Group 1: produces a
2005,
Elastic support significant
Management of bandage + improvement in
ankle sprains: a standard RICE ankle joint function
randomized Group 2: compared with
controlled trial of Air cast brace + standard
the treatment of standard RICE management with
inversion injuries an elastic support
using an elastic bandage.
support bandage
or an Aircast
ankle brace
Reference Study Design Study method Results

Ismail, M. M. Randomized N=22 athletes This study reports

Ibrahim, M. M. controlled trial (aged from 20 to 35 that Plyometrics
et al. June, 2010, years) of both sexes were more effective
Plyometric training with grade I or II than resistive
versus resistive unilateral inversion exercises in
exercises after ankle sprain (at improving
acute lateral ankle least 3 weeks after functional
sprain acute injury) were performance of
randomly allocated athletes after lateral
Group 1: ankle sprain.
Pylometric training
Group 2:
Resistive training for
6 weeks
Isokinetic peak
torque/body weight
for invertors and
evertors at 30 & 120
degree/s
A Metaanalysis suggests that
Subjects who were Braced
with Ankle-Stirrup has
significantly Reduced
Inversion Stress at ankle than
those who were not braced.

Kimura IF, Nawoczenski DA, Epler M, Owen MG. Effect of the AirStirrup
in Controlling Ankle Inversion Stress. The Journal of orthopedic and
sports physical therapy. 1987; 9(5): 190-3
 There is a strong evidence that
Star Excursion Balance training is
more effective than the
conventional therapy program in
improving functional stability of
the sprained ankle.

Chaiwanichsiri D, Lorprayoon E, Noomanoch L. Star excursion balance

training: effects on ankle functional stability after ankle sprain. Journal of
the Medical Association of Thailand = Chotmaihet thangphaet. 2005; 88
Suppl 4: S90-4.
Mild sprain
 Acute phase (0-3 days): reducing pain and swelling, partial load-bearing
 Information/advice: rest, elevate foot, perhaps ice, load-bearing (perhaps with
 crutches) determined by pain, actively moving foot and toes
 Instruction: compression bandage
 If necessary re-evaluation / check-up after 1 week.
Severe sprain
 Acute phase: as in mild sprain
 Proliferation phase: regaining functions and activities; increasing loads
 tape or brace: depending on load-bearing capacity required and patient's preference
 exercises for functions and activities: range of motion, active stability, coordination, and
walking
 Early remodeling phase: increasing muscular strength, active (functional) stability,
walking
 exercises for functions and activities: dynamic stability, balance, coordination
 Late remodeling phase: regaining ADL activities
 exercises for activities: progression to normal load-bearing, exercises at home
 If recovery normal, treatment once a week, maximum duration of treatment 6 weeks.
Wees P, Lenssen A, Feijts Y, Bloo H, van Morsel S, Ouderland R, et al. KNGF guideline for physical
therapy in patients with acute ankle sprain-practice guidelines. Suppl Dutch J Phys Ther. 2006;
116: 1-30.
Being a Physiotherapist I’ll recommend:

•PRICE
•Ankle Taping/Bracing/ splints
•Gentle Mobilization
Acute Injury/ •Strengthening ex for intrinsic foot Muscles
Minor Tear •Proprioception training
•Balance training
•Plyometric training to regain functional level of
activity

Chronic or
recurrent Ankle • Surgical Repair
Sprain