Ankle Sprains

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An ankle sprain is one of the most common injuries seen in professional and recreational athletes1, 2. The injury usually involves inversion (turning in) of the ankle with some amount of injury to the lateral (outer) ligaments.  Most of these injuries heal with little to no treatment, and infrequently develop long term instability and pain. Long-lasting problems have been found in up to 20% of patients who get twisting injuries and typically are a result of stiffness (lack of motion) or instability (loose joints).3-7  Surgery is hardly ever needed, and can be avoided with good teaching, bracing, and/or therapy as directed by the clinical findings.

 

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Author

Alejandro Pino, MD

 

 

Bullet Points

Authors Preferred Treatments

Summary

Background Information

Diagnosis

Initial Treatment

Chronic Symptoms

Surgical Options

Outcomes

Conclusion

References

Abstract

An ankle sprain is one of the most common injuries seen in professional and recreational athletes1, 2. The injury usually involves inversion (turning in) of the ankle with some amount of injury to the lateral (outer) ligaments.  Most of these injuries heal with little to no treatment, and infrequently develop long term instability and pain. Long-lasting problems have been found in up to 20% of patients who get twisting injuries and typically are a result of stiffness (lack of motion) or instability (loose joints).3-7  Surgery is hardly ever needed, and can be avoided with good teaching, bracing, and/or therapy as directed by the clinical findings.

 

Background Information

The ankle is steadied through a mixture of bones, ligaments and tendons, which together, work to keep the ankle in its normal place and, at the same time, avoid irregular inversion (inward twisting of the ankle).  These structures include static (not moving) and dynamic (moving) structures.  When a patient get an ankle sprain, the ligaments that support the ankle may become stretched or torn.  Ligaments are the thickened parts of joints that hold bone to bone. The typical ligaments involved in ankle sprains, where the foot and ankle roll inward, are the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) 8-10.

The injury is usually caused by either stepping or falling onto an uneven surface, causing this abnormal motion to the ankle.  It can also happen due to ineffectual ligaments, usually resulting from an undertreated previous ankle sprain, or because of a foot position that may make patients more likely to get ankle sprains.  No matter what the cause, these ligaments can heal due to their broad nature, so as long as the patient avoids reinjuring them during the healing process and they do not have any secondary issues causing their ankle sprain.

 

How do we diagnose it? What are the symptoms?

Diagnosis is typically based on clinical findings in combination with the patient’s history of a twisting injury.  The patient typically presents with some degree of difficulty in bearing weight on the involved extremity, and may have swelling and bruising of the ankle11.  The patient may complain of an unstable ankle, and may have increased slackness on anterior drawer and inversion testing compared to the uninjured ankle. Patients may have difficulty performing a single leg hop on the involved side in some variants of ankle sprains.

Part of the routine workup of an ankle sprain typically involves x-rays, especially if patients have tenderness along some of the bony structures surrounding the ankle. Typically, the patient presents with diffuse tenderness throughout the foot and ankle, leading to difficulty in localizing any specific anatomic structures.  On occasion, the evaluating physician may perform what is described as a stress x-ray to look for severe instability, but this is typically not necessary and does not influence the choice of initial treatment12-19.  MRI or other advanced imaging is rarely indicated in the acute, common ankle sprain.

The physician will also look for other reasons why patients may have sustained an ankle sprain, such as recurrent or undertreated instability, abnormal foot alignment, nerve disorders or injuries to the supporting structures of the ankle, such as tendon tears or fractures.

 

Initial treatment

Initial treatment of ankle sprains involves the RICE protocol, consisting of rest, ice, compression and elevation.  Most physicians support conservative treatment for acute ligamentous injuries3,9,20-22.  Patients may benefit from a short period of immobilization, but studies have shown no long term benefit to immobilization or acute surgery when compared to functional rehabilitation.  Functional rehabilitation involves bracing and therapy geared towards keeping motion and improving balance.  A patient’s symptoms may also dictate a need for a short period of protected weight bearing, but a switch to full weight bearing as tolerated as soon as possible may improve early outcomes, and should be stressed.  Patients should continue to advance their activity as dictated by symptoms.

 

Chronic symptoms

Chronic disability after an ankle sprain is typically due to continued instability or connected, unrecognized injury like a cartilage or tendon tear.  It may also be due to an accumulation of scar tissue produced as a result of the healing process from the initial ankle sprain.  Once patients have failed non-operative treatment, an MRI may show the reason for continued pain.  If the follow up exam shows continued laxity of the ankle, typically tested with the anterior drawer test in which the physician tries to determine whether the ankle moves abnormally, then the patient may benefit from surgical repair of the chronically injured ligaments.  In the case were an MRI shows a cartilage or tendon injury, these disorders may need to be surgically fixed in order to have a good outcome.

 

Surgical options

The surgical treatment of lateral ligamentous injuries can be classified as either anatomic, in which the injured ligaments are repaired to their normal location, or non-anatomic reconstructions, in which other tissue besides the injured ligament is used in a alignment other than the natural ligament orientation in order to obtain stability of the ankle.  The most commonly used technique is the ligament repair popularized by Brostrom in which the goal is to re-establish continuity to both the ATFL and CFL through direct repair, which may further be improved with local tissue sutured over the ligament repair9,23.

Non-anatomic ligamentous reconstructions, such as the Evans, Watson-Jones and Chrisman-Snook procedures, have been described in the literature, but are not commonly used due to stiffness connected with these techniques, as well as no known advantage when compared to anatomic repairs10,24-32.  These non-anatomic reconstructions may best be fit for those patients that have failed anatomic repairs and lack local tissue that can be used for traditional techniques, or those patients that have local tissue that is of poor quality, as seen in some patients with certain diseases17.

 

Outcomes/Results of treatment/Prognosis

Patient satisfaction rates after an acute ankle sprain treated with a functional rehabilitation protocol approaches 90%, with the remaining patients typically limited by either continued instability or pain.  Reviews of the published literature have supported the use of functional rehabilitation as a first line treatment as opposed to either cast immobilization or surgical repair of the ligament injury.  Many of these same studies have demonstrated that patients can have an excellent outcome even with delayed repair, allowing for a trial of therapy as a first line treatment for ankle sprains.  Recent studies have also shown a significant incidence of associated injuries identified with arthroscopy, thus supporting its role as an adjuvant to surgical repair33-35

Those patients that go on to surgical repair for chronic instability with anatomic techniques, such as a modified Brostrom, tend to have satisfaction rates greater than 85%.  Other techniques, which use either tissue from another location in the patient’s ankle or tissue from a cadaver, tend to have lower satisfaction rates when compared to anatomic repair techniques33,36-38.  No strong evidence exists to suggest that nonanatomic reconstruction leads to better outcomes. Additionally, they tend to be technically more difficult, suggesting that these methods should be set aside for salvage situations.

 

Authors Preferred Treatments

Acute injuries are initially evaluated and treated symptomatically with a short period of protected weight bearing, bracing or CAM boot immobilization, depending on the extent of damage due to the injury.  Patients immediately begin range of motion exercises to prevent stiffness and are encouraged to advance activity and return to normal shoe wear as dictated by symptoms.  If patients have difficulty returning to their previous level of activity due to pain, stiffness or instability, they are then referred to physically therapy to focus on strengthening the supporting structures of the ankle, decrease swelling and train the ankle to balance itself.

In those patients that fail to improve in spite of a full course of therapy, a reevaluation is undertaken to rule out injury to structures other than the typically injured ankle ligaments.  This is done with a focused exam to identify which of the structures may be injured and to ensure that the ankle is no longer unstable.  If any abnormal findings are found, then an MRI is obtained to further evaluate the ankle.

In those patients that have instability in spite of therapy, or have abnormal findings on MRI, surgery can be discussed.  Surgery for chronic instability that has failed to improve with therapy involves a combination of an arthroscopic examination of the ankle, where a camera in inserted into the ankle joint to treat any injuries or inflammation in the joint, some of which are occasionally not appreciated on MRI, followed by repair of the injured ligaments.  This repair of the ligaments is reinforced with a sleeve of local tissue sutured over the ligament repair, improving the strength of the overall construct.  Any other injuries seen on the MRI that may be a source of pain and can be treated surgically are addressed during the same surgery.

After surgery, the patients are placed in a splint, or soft cast, and stay non-weight bearing for 2 weeks until seen in the office for suture removal.  They are then switched to a cast for an additional 4 weeks, after which they begin to walk in a boot and start physical therapy to regain motion and normal balance of the ankle.  Typically, patients are allowed to return to normal sporting activity at about the 6 month postoperative mark, but may need to use an ankle brace for the first postoperative year, at a minimum.

 

Conclusion

In spite of the high incidence of ankle sprains, most patients can expect excellent outcomes with functional rehabilitation.  The goal of treatment for acute injuries is to prevent chronic instability with a combination of symptomatic treatment and a protocol directed for early weight bearing and recovering range of motion.  In the rare situation where patients are limited due to continued instability or pain in spite of a full course of nonoperative treatment, the literature supports anatomic repair of the torn ligaments in combination with arthroscopy to address any associated injuries.  The surgical approach may be modified as dictated by the preoperative workup.  The majority of patients treated with these techniques can expect good to excellent outcomes.

 

 

Bullet Points

Ankle sprains are one of the most common injuries sustained by professional and recreational athletes.

The majority of patients that have sustained an ankle sprain have excellent outcomes with non-operative treatment.

Treatment is typically symptomatic, and may involve a short period of bracing or therapy.

Surgery is reserved for patients that fail to improve with therapy, or have chronic and recurrent instability of the ankle.

The most common surgical treatment for recurrent ankle sprains is a repair of the ankle ligaments.  This may be done in conjunction with an ankle arthroscopy to ensure no other injuries to the ankle are missed.

Other injuries, such as cartilage or tendon tears, may be a reason for continued pain after an ankle sprain, and can be addressed surgically if patients do not improve with their initial treatment.

 

References

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