Transcript Lateral-Ankle-Sprain-and-Chronic-Ankle-Instability

Lateral Ankle Sprains and
Chronic Ankle Instability
Normal Anatomy
• Lateral ankle ligament complex consists of
• Anterior talofibular ligament (ATFL)
• Calcaneofibular ligament (CFL)
• Posterior talofibular ligament (PTFL)
• ATFL blends with the ankle capsule, from
anteroinferior margin of fibula to lateral
margin of talus
• CFL is from the inferior margin of the
fibular, distal to the ATFL and runs
underneath the peroneal tendons to the
lateral tubercle of the calcaneus
• PTFL is a thickening of the capsule from
the posterior fibula to the lateral tubercle
of the posterior process of the talus
• ATFL stress in plantarflexion
Lateral Ankle Sprain
Pathology
• Lateral Ankle Sprain
• An episode of acute
inversion/supination injury of the
ankle associated with swelling,
lateral ankle pain and difficulty
weight bearing
Mechanism of Injury
• Traumatic
• Foot and ankle inversion of a
plantar-flexed or internally rotated
foot
• External rotation of the lower leg
with respect of the ankle
Risk Factors
• Intrinsic
• Reduced invertors and evertors
strength
• Reduced proprioception
• Reduced balance
• Reduced dorsiflexion range of
movement
• Lower limb mal alignment
• Extrinsic
• Previous lateral ligament sprain
• Twisting, pivoting sports
• Contact sport
• Playing on artificial grass
Classification
• Grade 1
• Mild
• Painful
• Minimal ligament tearing
• Grade 2
• Moderate
• Painful
• Significant ligament tearing
• Grade 3
• Severe
• Sometimes not painful
• Complete ligament rupture
Subjective Examination
• History of:
• Foot and ankle inversion of a plantar-flexed foot
• External rotation of the lower leg with respect of the ankle
• Swelling (immediate suggests rupture more likely)
• Maybe unable to continue to play
Objective Examination
• Haematoma
• Pain on palpation lateral
ligaments
• Abnormal anterior drawer test
• Pain on palpation of the medial
malleolus is not unlikely
• Delayed physical exam (4-5 days)
gives better diagnosis
• Reduced proprioception
Ottawa Ankle Rules
Special Test
• Anterior drawer test
Further Investigation
• X-ray (rule out fracture)
• Ultrasound
• MRI
Management
• Conservative management always explored
• Reduce swelling initially although swelling may never go completely
• Emphasis on prevention of future injury
• Emphasis on proprioception and dynamic stability
Conservative
• Reduce pain and inflammation
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Immobilisation
NSAID’s
Ice
Massage
• Restore Normal Range of Movement
• Ankle
• Massage
• Joint mobilisation
• Joint manipulation
• Restore Normal Muscle Activation
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Evertors
Invertors
Plantarflexors
Dorsiflexors
Intrinsic Foot Muscles
• Restore Dynamic Stability
• Proprioceptive Training
• Sport Specific Training
Plan B
• Soft tissue repair
• Ligament Reconstruction
Chronic Ankle Instability
Pathology
• Chronic Ankle Instability
• The perception by the patient of
an abnormal ankle with a
combination of symptoms
Mechanism of Injury
• Insidious
• Intrinsic
• Reduced invertor and evertor
strength
• Reduced proprioception
• Reduced balance
• Ligament laxity
• Lower limb mal alignment
• Extrinsic
• Previous or repeated lateral
ligament sprain
Classification
• Functional Ankle Instability
• Instability due to proprioceptive
deficits, neuromuscular deficits,
postural control deficits and
muscle weakness
• Mechanical Ankle Instability
• Instability due to ligament laxity
Subjective Examination
• History of multiple sprains
• Feeling of unstable ankle
• Regular giving way
Objective Examination
• Reduced proprioception
• Weakness ankle evertors
• Tenderness palpation lateral
ligaments
• Instability on anterior drawer
test
Special Test
• Anterior drawer test
Further Investigation
• X-ray (rule out fracture)
• Ultrasound
• MRI
Management
• Conservative management useful but not always successful
• Large emphasis on restoring neuromuscular control and strength
• Manual therapy can be used if acute sprain is present but general
manual therapy is not useful
Conservative
• Restore Normal Muscle
Activation
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Evertors
Invertors
Plantarflexors
Dorsiflexors
Intrinsic Foot Muscles
• Restore Strength
• Entire kinetic chain
• Restore Dynamic Stability
• Proprioceptive Training
• Sport Specific Training
Plan B
• Soft tissue repair
• Ligament Reconstruction
References
• Guillo, S., T. Bauer, J. W. Lee, M. Takao, S. W. Kong, J. W. Stone, P. G. Mangone, A. Molloy,
A. Perera, C. J. Pearce, F. Michels, Y. Tourne, A. Ghorbani and J. Calder (2013). "Consensus
in chronic ankle instability: aetiology, assessment, surgical indications and place for
arthroscopy." Orthop Traumatol Surg Res 99(8 Suppl): S411-419.
• Kerkhoffs, G. M., M. van den Bekerom, L. A. Elders, P. A. van Beek, W. A. Hullegie, G. M.
Bloemers, E. M. de Heus, M. C. Loogman, K. C. Rosenbrand, T. Kuipers, J. W. Hoogstraten,
R. Dekker, H. J. Ten Duis, C. N. van Dijk, M. W. van Tulder, P. J. van der Wees and R. A. de
Bie (2012). "Diagnosis, treatment and prevention of ankle sprains: an evidence-based
clinical guideline." Br J Sports Med 46(12): 854-860.
• Knupp, M., T. H. Lang, L. Zwicky, P. Lötscher and B. Hintermann (2015). "Chronic Ankle
Instability (Medial and Lateral)." Clinics in Sports Medicine 34(4): 679-688.
• McGovern, R. P. and R. L. Martin (2016). "Managing ankle ligament sprains and tears:
current opinion." Open Access J Sports Med 7: 33-42.
• van den Bekerom, M. P., G. M. Kerkhoffs, G. A. McCollum, J. D. Calder and C. N. van Dijk
(2013). "Management of acute lateral ankle ligament injury in the athlete." Knee Surg
Sports Traumatol Arthrosc 21(6): 1390-1395.