Lateral ankle sprain
Lateral ankle sprains are defined as traumatic injury to the lateral ankle ligament complex due to an inversion injury or plantar flexion and adduction and are one of the most common injuries in sportive as well as recreational activities.
Lateral ankle sprains are the most common ankle injuries with an estimated incidence of 0.2% per year. About half of lateral ankle sprains are due to sports injuries, and they account for many athletic injuries 1-5. The most common ankle injury is ankle sprain and of ankle sprains, lateral ankle sprain is by far the most common, accounting for up 75-80% of ankle sprains 1. There is a higher incidence in children and adolescents than in adults 2,3. Women are thought to be more frequently affected 2,4.
The following team sports have an increased incidence in lateral ankle sprain 1-4:
- basketball, volleyball (indoor), handball, netball, aero ball
- field hockey, cricket
- football (soccer), Gaelic football
- rugby, Australian football
In addition, the following sports or activities are considered risk factors 1,2:
- gymnastics, cheerleading, martial arts
- orienteering, mountaineering
- wall and rock climbing
- field events in track and field athletics, running, jogging, ultramarathon
Further non-sports-related risk factors are 3-5:
- high-heeled shoes
- previous ankle sprain
- hindfoot varus
- increased body mass and index
- impaired proprioception
- impaired postural balance or neuromuscular deficits
- strength deficits
- anterior talofibular ligament injury (in about 73% of ankle sprains)
- calcaneofibular ligament injury
- talocrural joint capsule injury
- subtalar joint injury
Typical complaints are acute pain and swelling after an unlucky landing or sudden turn during sports activity, or a misstep, “slipping” or “tripping” in daily routine activities 3,4. Stiffness, weakness, crepitus and instability are other complaints 1. A lateral ankle sprain is usually diagnosed based on clinical signs such as tenderness, hematoma and a positive anterior drawer test 3. Excessive medial translation of the calcaneus on the talus can be additionally assessed with the subtalar glide test 5.
Ankle ligament sprains can be graded according to severity 8:
- grade 1: sprain without macroscopic tear/rupture or joint instability
- grade 2: partial rupture with moderate pain and swelling
- grade 3: complete rupture with swelling hematoma and pain
- chronic ankle instability (in particular in repetitive cases – up to 38% for ≥5 ankle sprains) 1,3,5
The pathological correlate of a lateral ankle sprain is often an anterior talofibular ligament injury and/or calcaneofibular ligament injury with possible other associated injuries such as a talocrural joint capsule injury or ligamentous injuries of the subtalar joint. Additionally, injury to the tibialis posterior, peroneus brevis or longus tendon can occur 3,4.
The typical mechanism of a lateral ankle sprain is a result of excessive ankle supination of the hindfoot in an externally rotated leg leading to an inversion type injury. Inversion injuries often occur with the foot in plantar flexion and internal rotation or with internal rotation and slight dorsiflexion 5. This causes a strain or distraction forces across the whole anterolateral ankle, in particular, the anterior talofibular and the calcaneofibular ligaments 4,5. If the tensile strengths of those ligaments are surpassed they sustain injury and tear or rupture.
Depending on the ligamentous injury this can lead to anterolateral rotary instability (anterior talofibular ligament injury) and/or talar tilt (calcaneofibular ligament injury) and additional problems depending on the type of additional injury.
For initial evaluation of an ankle injury radiographs of the ankle are usually obtained to exclude a fracture or fracture-dislocation. Further imaging of ankle injuries can be done with ultrasound or magnetic resonance imaging 2.
Stress radiographs had been used for the quantification of subtalar tilt but similar information can be obtained clinically with the subtalar glide test 5.
CT can better illustrate subtle fractures, detect avulsion fractures or show a higher-grade osteochondral injury.
Ultrasound findings include thickening and hypoechogenicity of the affected ligament in case of a sprain. A tear will show an anechoic defect, a loss of continuity or absence of the ligament.
Common indications include prolonged pain after conservative management, or to exclude more extensive injuries. MRI can demonstrate anterior talofibular ligament and/or calcaneofibular ligament injury as well as injuries of flexor or the peroneal tendons.
The anterior talofibular ligament can be assessed in axial slices or in oblique axial slices with a mild anteroinferior tilt in the suspected course of the ligament. The calcaneofibular ligament is best evaluated on oblique axial/coronal with a posteroinferior tilt again in the suspected course of the ligament and on coronal images.
Ligament injury might reveal thickening, thinning, irregularity, discontinuity or an absent ligament. Sometimes bony avulsions can be seen.
In case of a lateral ankle sprain the report should include the following:
- anterior (and/or posterior) talofibular ligament injury (sprain, partial tear, complete tear)
- calcaneofibular ligament injury (sprain, partial tear, complete tear)
- concomitant subtalar joint or midtarsal injury
- concomitant or old avulsion injuries of the lateral malleolus
- possible injuries of the peroneal and flexor tendons
- possible concomitant syndesmotic injury
- fractures or fracture-dislocations
- chondral or osteochondral injury
Treatment and prognosis
Lateral ankle sprains are usually treated conservatively with rest, ice, compression and limb elevation, also referred to as RICE (rest, ice, compression, elevation) regimen in the initial phase 3,8.
In addition, external stabilization can be beneficial in the initial period for protection from inversion and to prevent uncontrolled stresses. Best results are apparently achieved with a semi-rigid ankle brace 8. The same can be one in cases of lateral ankle sprains complicated by small nondisplaced fractures. In more severe injuries a short-term immobilization can be prescribed beforehand 8.
Further management includes physical therapy and a comprehensive rehabilitation with early motion or movement exercises, followed by strengthening exercises, balance training and endurance and agility exercises in the later stages, emphasizing proprioception as well as neuromuscular and postural control 5.
Surgical treatment plays a minor role in the treatment of acute ankle sprains and includes arthroscopy and/or ligament repair or reconstruction e.g in chronic cases, more severe cases in athletes or in extensive ligamentous injuries. The indication is recommended to be done on an individual basis and should also be focused on preventing repetitive sprains 8.
A major sequel of lateral ankle sprains in particular if repetitive is chronic ankle instability 1-3.
More than half of the patients have still residual symptoms between 6 weeks and 18 months 5,10 and up to 30% report pain on activity 2.5 to 5 years after the acute event 9. Up to 5% of athletes sustaining an ankle sprain have to change and up to 4% to stop their sportive activities 3. In non-athletes, up to 6% are not able to continue their previous occupation and a further 15% need additional support to continue it 1. Short-term prognostic factors include weight-bearing status and injury grade, medium-term pain, weight-bearing and a functional activity score 6. There are also reports, which found that MRI is an independent predictor 9.
In the case of combined anterior talofibular and calcaneofibular ligament injury, special scrutiny should be placed on the deltoid ligament to look out for additional deltoid ligament injury as well as on a possible associated subtalar injury.
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