Pigskin Preview 2009 Issue

When is an ankle sprain something more
William R. Hobbs, MD
Trinity Mother Frances Orthopaedic and Sports Medicine
Ankle sprains are the most common
injury in running and jumping sports,
occurring in one per 10,000 people per
day. They represent 25 -50 percent of
injuries in these sports and most heal
without incident. Only about 10-
30 percent go on to develop chronic
problems of instability or pain. When
problems persist, we must consider other
pathologic process that can mimic an
ankle sprain.
The ankle is a hinged joint and derives
most of its stability from the bony
anatomy made up of the tibia, fibula and
talus. It has a saddle configuration and has three ligaments on the lateral
(outer) side: anterior talofibular (ATFL), calcaneofibular (CFL) and the
posterior talofibular (PTFL). In addition, there is one ligament on the
medial (inner) side, the deltoid. These ligaments primarily function
when the ankle is platarflexed (foot pointing down) and the foot rolls
from side to side.
A sprain can be a stretch, partial tear or a complete tear of the ligament
and leads to swelling and inflammation over the affected ligaments. If
the force is severe enough, there can be a fracture of one or both of
the bones, an injury to the cartilage, or tearing of the tendons running
behind the ankle. The outer ligaments are injured much more frequently
than the inner ligament.
Typically, the athlete will complain of pain along the outer side of the
injury after “rolling” the ankle. They may or may not feel a pop and
swelling usually occurs quickly. On exam, we check for tenderness along
the ligament and look for increased translation (sliding) of the ankle. If
there is tenderness along the medial or lateral ankle bones (tibia/fibula)
or if there is popping with stressing these bones, then the ankle is likely
broken, and we will remove the athlete from the competition until an
X-ray can be taken. We also check a squeeze test (compressing the two
bones of the lower leg and looking for ankle pain) to rule out a “high”
ankle sprain. If the pain is only along the ligament and the swelling is
minimal, we will re-tape the athlete’s ankle and see if he/she can run
on it. If they are unable to perform with the added support, we will
remove the athlete from the competition. Braces and pre-taping before
competition can help prevent some injuries, especially with recurrent
sprains. Taping can stretch out over time and may require reinforcing
during the course of the game.
Ankle sprains are classified from grade 1-3 depending on the severity of
the injury to the ligaments and the number of ligaments involved. A
Grade 1 injury involves partial tearing of the ATFL and a Grade 2 sprain
has a complete tear of the ATFL and partial tearing of the CFL. Grade
3 injuries have complete rupture of both ligaments and are usually the
most susceptible to chronic problems. Grade 3 injuries also require
the longest time for recovery, sometimes as long as -six to eight weeks.
Typically, Grade 1 injuries require one to two weeks and Grade 2 sprains
require two to four weeks for return to sports. Rarely do any of these
injuries require immediate operative repair because of the high rate of
healing with non-operative treatment. Initial treatment involves RICE
(rest, ice, compression and elevation). A walking boot is infrequently
needed and usually only with Grade 3 injuries, until swelling resolves.
Crutches may be indicated if the athlete is having trouble walking on the
foot. Recurrent sprains (loose ankle) may require either a “tightening”
or reconstruction of the outer ligaments, but even these issues can
usually be treated with appropriate strengthening of the supporting ankle
muscles and balance training.
“High” ankle sprains involve the ligament that connects the two bones
of the lower leg, the tibia and fibula, called the syndesmosis. At its lower
edge, near the upper ankle, it thickens to form the anterior and posterior
tibiofibular ligaments. When this is torn, it can take up to three months
to heal. Occasionally, surgery is required to place screws to hold the two
bones together while the syndesmosis is healing. We also have to rule
out a fracture of the fibular bone on the outside of the knee with this
injury.
Fractures of the ankle require surgery if both bones are broken or
if either is out of alignment. Otherwise, casting for two to three
months is appropriate. An injury to the cartilage of the talus, called
osteochondritis dessicans, can lead to persistent ankle pain after a sprain.
It is usually visible on X-rays, but early on may require an MRI to detect.
Pain is usually in the front of the ankle with walking, and there may be
persistent swelling with activities. Tearing or instability of the peroneal
tendons that run behind the fibula can also lead to chronic pain. This is
usually associated with popping on ankle motion, and pain at the outer
ankle. Finally, if the bones of the hind foot do not separate properly
during growth, the athlete can have episodes of frequent ankle sprains
and on exam will have loss of side-to-side motion of the foot. An MRI
or CT scan can identify the fused bone and surgery is usually necessary
to separate the bones and alleviate symptoms.
Ankle sprains are common setbacks for running and jumping athletes.
Most heal quickly with simple, non-operative treatments. The most
important issue to address with an acute injury is to rule out a break
and to determine the safety of returning to the competition at that time.
However, if symptoms persist over several months or injuries continue to
recur, consider some of the other problems discussed here.
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