Posts for tag: Ankle Sprain
Much of my after school hours and summers of my high school and undergraduate years were spent working construction for my father’s company. Specifically, I worked in concrete construction pouring and framing foundations. Obviously, in the world of concrete, an unstable foundation has disastrous ramifications. Now, as a foot and ankle specialist, I like to believe that I am still in the foundation business, and it still holds true that an unstable foundation has its consequences.
Lateral ankle instability is often the long term consequence of an acute ankle sprain or multiple ankle sprains. It often becomes a vicious cycle as ankle instability subsequently leads to redundant injury. As you may recall from Dr. Abdo’s description of high ankle sprains this past January, the ankle is the most frequently injured joint in athletic competition. Since lateral ankle sprains account for nearly 25% of all musculoskeletal injuries, it comes as no surprise that ensuing lateral ankle instability is relatively common as well.
What is ankle instability and how do we treat and prevent its development? There are two types of instability, mechanical and functional. In order to properly explain each type, a basic understanding of the structures involved is necessary. The ankle is a complex arrangement of tendinous, ligamentous, and boney structures, but to obtain a relative understanding of mechanical and functional instability the lateral ankle ligaments are most important. Three ligaments compose the lateral collateral ligaments of the ankle; the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The ATFL is the weakest of the three ligaments but also the most important in regards to lateral ankle stability.
Mechanical instability is the actual rupture or stretching of the ligamentous structures, namely the anterior talofibular ligament. This is an objective, clinical finding. This is often determined by a test known as the anterior drawer test. The ability to manually anteriorly translate the ankle is a positive anterior drawer sign.
Functional instability is the subjective presentation of instability. It is the report that the ankle feels like it is going to give out. It is the recurrent instability in sporting activities or every day activities. Functional instability entails what foot and ankle specialists refer to as a proprioceptive defect. Proprioception is the neurological concept of sensing where ones ankle is in space. Functional and mechanical instability often go hand in hand and it is not uncommon to have a patient that embodies both aspects of lateral ankle instability. However, one may have functional instability and not mechanical instability.
Management of lateral ankle instability may occasionally involve surgical reconstruction, but typically always involves a functional rehabilitation program. In essence, the treatment of instability ought to begin with the first acute injury. Less than 10% of patients with an acute injury will ever need surgical stabilization at a later stage in life if initially treated appropriately. Functional rehabilitation or early controlled movement involves a close relationship between the foot and ankle specialist and their local physical therapist.
Lateral ankle instability is, unfortunately common and can have devastating long term consequences. However, a proper understanding of the lateral ankle can assure prompt, appropriate management. Ankle injuries,specifically lateral ankle sprains, will always be prevalent as our population remains active, but instability, on the other hand, does not have too. You have likely heard it said that when one part of the body suffers, the rest suffers as well. This could not be truer with the foot and ankle. When the foundation is not stable, the remaining structure soon collapses.
While lateral ankle sprains are the most common athletic injury occurring in sports, high ankle sprains have been responsible for more lost time from game play and training activities. Unfortunately, high ankle sprains are commonly mistaken for lateral ankle sprains, thus they are less commonly reported.
Misdiagnosing a high ankle sprain can result in lingering pain and recovery as the treatment course is much longer, requiring longer periods of offloading and rehabilitation in comparison to lateral ankle sprains.
A high ankle sprain refers to injury of the ligaments that join the lower leg bones, tibia and fibula. High ankle sprain injuries commonly occur in collision sports, such as football, hockey, and court sports such as basketball. The most common mechanism of injury is when the foot is anchored to the ground while being struck to the outside aspect of the lower leg. This forceful twisting injury may be accompanied by an audible pop and the patient’s inability to bear weight after the injury.
On examination, patients often present with swelling and bruising above the ankle. The most commonly utilized test is the fibular squeeze test which can produce pain at the lower ankle by squeezing the outside and inside aspect of the leg at the middle of the leg. In addition, your doctor can move the lower leg inward and this can elicit severe pain. At this stage, your doctor will order an x-ray the classic finding is widening of the tibia and fibula at the level of the ankle. If the x-ray is inconclusive then a MRI scan provides the best confirmation of widening of the lower leg and identify specific syndesmotic ligaments that are disrupted. Treatment is then determined based on the degree of separation and the ligaments that are involved.
In some case where the degree of separation is severe usually greater than 4mm than surgical intervention is necessary to achieve anatomic reduction and can improve functional outcomes and facilitate a quicker return to activity. Without this intervention, patients can have long term pain and instability and develop post traumatic arthritis. Patients with less than 4mm of separation can be managed conservatively with immobilization for 1 week then placement in a double upright hinged ankle brace, known as a Velocity Brace this begins the next phase of rehabilitation. Then range of motion exercises are implemented with low intensity resistance and high repetition. Gait training and light balance exercises may begin at the patient’s tolerance. The last phase of rehabilitation begins once a patient is able to hop on the injured foot without any pain. Patients then begin more active range of motion and change of direction exercises and can shortly return to full sports activity.
The key to quick recovery from high ankle sprains is quick diagnosis by an experienced clinician. Then appropriate treatment based on the degree of instability. Most patients make a full recovery and have no limitations once they return to activity. Hopefully this gives you some insight into this injury.