ANKLE SPRAINS Learning objectives

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1 ANKLE SPRAINS Learning objectives Upon viewing this presentation, the physical therapist will be able to define the 3 types of ankle sprains. discuss which ligament (s) are involved in the injury. interpret the severity of the ankle sprain as determined by the diagnostic grade of the injury. design the most appropriate rehabilitative program for strength, endurance, and proprioceptive exercises.

2 Ankle Sprain Knowledge Pre-test 1) The primary determinant of an ankle sprain is? a. Foot wear b. Playing surface c. Previous ankle sprain d. Lack of conditioning 2) A Grade II ankle sprain in a teenager requires the following diagnostic test (s)? a. Drawer test b. X-rayX c. Toe walk test d. a and b

Three Types of Ankle Sprains Lateral 85% of all ankle sprains.

PTFL) ligaments Medial Strongest ankle ligament. Involved ligament: Deltoid High Most severe.

, D Alessandro D M. (2005, April). A Pediatric Digital Library and Learning Collaboratory.

org/2005/04/18. Smith A., & Bach B. (2004 Dec).

3 Three Types of Ankle Sprains Lateral 85% of all ankle sprains. Involved ligaments: Anterior Talofibular (ATFL), Calcaneofibular (CFL), & Posterior talofibular PTFL) ligaments Medial Strongest ankle ligament. Involved ligament: Deltoid High Most severe. Involved ligaments: Syndesmotic tissue between the tibia and fibula D Alessandro D., D Alessandro D M. (2005, April). A Pediatric Digital Library and Learning Collaboratory. Pediatric Education.org. Retrieved December 5, 2006 from Smith A., & Bach B. (2004 Dec). High Ankle Sprains Minimizing the Frustration of a Prolonged Recovery. [Electronic version]. The Physician and Sports Medicine, 32,12. Retrieved Dec. 4, 2006 from

Ankle Sprain Sequelae Lateral / Inversion Plantar-flexed foot and forceful inversion of the ankle. ATFL resists inversion moment during PF. CFL resists inversion moment as the ankle goes into DF.

4 Ankle Sprain Sequelae Lateral / Inversion Plantar-flexed foot and forceful inversion of the ankle. ATFL resists inversion moment during PF. CFL resists inversion moment as the ankle goes into DF. Medial / Eversion Dorsi-flexed foot and forceful eversion of the ankle. Often results in avulsion of medial malleolus. High / Syndesmotic - Dorsi-flexed foot and forced external rotation of the leg. Malone, T., McPoil T., & Nitz A. (Eds.). (1997). Orthopedic and Sports Physical Therapy. (pp. 287)St. Louis: Mosby. Smith A., & Bach B. (2004 Dec). High Ankle Sprains Minimizing the Frustration of a Prolonged Recovery. [Electronic version]. The Physician and Sports Medicine, 32,12. Retrieved Dec. 4, 2006 from Naradzay J., (2006, November 15). Fractures, Ankle. Emedicine. Retrieved December 5,2006. from

A Pediatric Digital Library and Learning Collaboratory. Pediatric Education.org.

5 Ankle Sprain Severity Grade I Most common Grade II Ligaments are partially torn Grade III Most serious D Alessandro D., D Alessandro D M. (2005, April). A Pediatric Digital Library and Learning Collaboratory. Pediatric Education.org. Retrieved December 5, 2006 Taylor M., (2005, December 9). Talofibular Ligament Injury. Emedicine. Retrieved December 5,2006. from

6 Grade of Sprain and Physical Therapy Management Grade I Mild stretch with no instability. Partial involvement of ATFL only. Grade II ATFL torn with a 3 5 mm drawer sign. Grade III ATFL and CFL torn with greater than 5mm drawer sign. I & II = RICE, external control, early ROM, proprioception, and strengthening exercises. Disability may last 2 to 8 weeks. III = Complete immobilization? Disability may last 2 months to 1 year. Scuderi G., McCann P., Bruno P. (1997). Sports Medicine Principles of Primary Care.. St. Louis; Mosby: (pp ). 91).

Prevention First-Time Ankle Sprains Female vs.

, Vacek P., Murphy D., Alosa D., Paller D. (2005, Oct).. First-time time inversion ankle trauma: the effects of sex, level of competition, and sport on the incidence of injury.

High versus low top shoes for the prevention of ankle sprains in basketball players. A prospective randomized study. American Journal of Sports Medicine: : 21(4): 582-85. 85. Bahr R., Lian O.

7 Prevention First-Time Ankle Sprains Female vs. Male No statistical difference Type of Sport - Female = Basketball; Male Sport Type of Shoe No statistical difference Predictors Decreased DF, Postural sway, Diminished proprioception Beynnon B., Vacek P., Murphy D., Alosa D., Paller D. (2005, Oct).. First-time time inversion ankle trauma: the effects of sex, level of competition, and sport on the incidence of injury. American Journal of Sports Medicine; ; 33(10): Barret J., Tanji J., Drake C., Fuller D., Kawasaki R., Fenton R.,, (1993 Jul-Aug). High versus low top shoes for the prevention of ankle sprains in basketball players. A prospective randomized study. American Journal of Sports Medicine: : 21(4): Bahr R., Lian O., Bahr I, (1997, June). A twofold reduction in the incidence of acute ankle sprains in volleyball after the introduction of an injury prevention program: a prospective cohort study. Scand J Med Sci Sports: 7(3): denoronha M., Refshauge K., Herbert R., Kilbreath S., Hertel J. (2006, Oct). Do voluntary strength, proprioception, range of motion, or postural sway predict occurrence of lateral ankle sprain? British Journal of Sports Medicine:;40(10):

Prevention Management of Chronic Lateral Ankle Sprains Primary Determinant Previous ankle sprain * 75% reported at least one prior sprain * 5 x more likely to sustain a second sprain Prevention

A one season prospective cohort study of volleyball injuries. British Journal of Sports Medicine; ; 38(4): 477-81. McKay G., Goldie P., Payne W., Oakes B. (2001 Apr).

8 Prevention Management of Chronic Lateral Ankle Sprains Primary Determinant Previous ankle sprain * 75% reported at least one prior sprain * 5 x more likely to sustain a second sprain Prevention Strategies * Technical training * Proprioceptive training * Prophylactic bracing Verhagen E., Van der Beek A., Bouter L., Bahr R., Van Mechelen W. W (2004, Aug). A one season prospective cohort study of volleyball injuries. British Journal of Sports Medicine; ; 38(4): McKay G., Goldie P., Payne W., Oakes B. (2001 Apr). Ankle injuries in basketball: Injury rate and risk factors. British Journal of Sports Medicine; ; 35(2): Stasinopoulos D., (2004, Apr). Comparison of three preventative methods in order to reduce the incidence of ankle inversion sprains among female volleyball players. British Journal of Sports Medicine; ; 35(2): Handoll H., Rowe B., Quinn K., de Bie R. (2001). Interventions for f preventing ankle ligament injuries. Cochrane Database Syst. Rev.;(3): CD

9 Ankle Sprain Knowledge Post-test test 1) The ligament most often disrupted in a lateral ankle sprain is? a) Syndesmotic ligament b) Calcaneofibular ligament c) Anterior Talofibular ligament d) Posterior Talofibular ligament 2) Excessive plantar flexion with inversion may lead to a lateral ankle sprain. What also may contribute? a) Decreased DF b) Deficient proprioception c) Improper landing technique d) All of the above

10 ANKLE SPRAINS Conclusions Three Types Lateral, Medial, High Ligaments Involved ATFL, Deltoid, Syndesmotic Prognosis Dependent on grade diagnosis Determinants Previous sprain Deficient DF Diminished proprioception Poor landing technique Physical Therapy Prevention & rehabilitation

Ankle Sprains and Their Imitators

Ankle Sprains and Their Imitators Mark Halstead, MD Dr. Mark Halstead is the Associate Professor of the Departments of Orthopedics and Pediatrics at Washington University School of Medicine; Director of