Ankle Injury

Level 1 Common Presentation

Level Ankle
One
Sports Principles of examination
Muscle injury
Tendonopathy
On-field injury
Knee
Shoulder
Ankle Sprain
Extremely common U.S.: 25,000 ankle
sprains
per day! (Kannus, JBJS, 1991; 73A, 305)
Thought to be benign or trivial, but recurrence
and therefore disability is very high
Inadequate diagnosis, management
Subjective/ History
Mechanism of injury inversion versus eversion
Site of pain
Swelling/bruising and timing
Previous history
Examination
Swelling/bruising location, size, onset
Examination
Swelling/bruising location, size, onset
Palpation non-pain into painful area
Examination
Swelling/bruising location, size, onset
Palpation non-pain into painful area
Stress Testing lateral ligaments
Anterior Drawer
Talar Tilt
Examination
Swelling/bruising location, size, onset
Palpation non-pain into painful area
Stress Testing lateral ligaments
Anterior Drawer
Talar Tilt
Reproduce patients pain/instability (beware
previous injury coexisting)
Practice
Palpation identify and mark structures of interest
ATFL
CFL
AITFL
TCL
Stress Testing
Anterior Drawer
End of bed
Foot supported
Talar Tilt
Management
Prevent future ankle sprain by
Strength?
Reaction time/balance (feedback mechanism)
Fong et al, AJSM, 2009
Rapid inversion
Dorsiflexion
Grade I ATFL
Normal conduction velocity =
35 60m/sec
Quads Jerk = 0.03sec
To travel 1.5m at 50m/sec =
0.03sec
To get back to the ankle =
0.06 sec
To get to higher centres,
process, and get back: ~ 0.20 -
0.50sec
Feed-back or feed-forward
mechanism?
Assessment
Balance how to measure this?
Standing single leg balance
On flat
On toes
Eyes open/ closed
Times, number of touches
 Star Excursion Balance

Kinzey SJ, Armstrong CW. The reliability of the star excursion test in assessing
dynamic balance. J Orthop Sports Phys Ther. 1998;27:356-360.
Star Excursion Balance
Hertel J, Braham RA, Hale SA, Olmsted-Kramer LC.
Simplifying the star excursion balance test: analyses
of subjects with and without chronic ankle
instability.
J Orthop Sports Phys Ther. 2006;36:131-137.
Placement Ability
Accuracy of 5mm
Progression:
Initially cardinal planes, then combinations
Distance
Short step
Normal step
Large stride
(Largest stride)
~ 4/5 correct, confident
Placement accuracy
Placement Accuracy
Feed-forward accuracy
Train for 2 3 minutes per day
Integrate into normal walking hit a target
Patients relate improved confidence on uneven
surfaces
Calf Raise - endurance
90

80

70

60

50

40

30

20

10

0
0 4 9 13 17 22 26 30 34 39 43 47 52 More
Results
Calf Raise Endurance
Injured Healthy
Average 17.3 22.8
SD 8.2 8.0

Left Right Age

Mea
n 20.9 20.9 32.21(27)
SD 8.5 8.4 14.11
Min 1 0 8
Max 56 55 75
Endurance v Running Frequency
p<0.0
Left 5 Right
60 60
Running Frequency
50 50
0 Never Runs
40 1 40 Runs < 1 /
week
30 30
Endurance
2
Endurance Runs 1-2 /
f(x) = 1.8x + 17 .06 f(x) = 1.98x + 16.7 2
20 R = 0.16 20 R = 0.19week

3 Runs 2-3 /
10 10
week
0 4 0 Runs 3-4 /
0 1 2 3 4 5
week
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Running Frequency Running Frequency

5 Runs > 4 /
week
Return to sport
Define deficits
Pre-injury data (screening)
Other side comparison
Normative data (for that sport)
Measureable parameters
Flexibility
Strength
Proprioception (feed-forward, feedback)
Tissue healed/stable?
Deficits
Structural
ATFL, CFL
Range of motion
DF, PF, Inversion, Eversion
Strength, endurance
Plantarflexion, eversions
Proprioception
Feedforward (feedback)
Star Excursion, Placement
Stress testing, imaging
DF: 12-15cm (L-R < 1cm)
Calf Raise >20RM (jog),
>25RM jump/sprint,
Eversion Strength in stance
Left-Right <5cm
Placement to large stride, 4/5
correct
Summary
History
Examination
Management
Other injures
Syndesmosis
Medial/Deltoid ligament
Maisonneuve
Fractures
Peroneal tendons
Medial Injuries
Mechanism is usually varus injury coupled with
rotation
Structures to check:
Syndesmosis
Medial Malleolus
Proximal Fibula
Tibialis Posterior
Syndesmosis
Often missed, and significant cause of delayed
recovery
Pain lateral, medial, and anterior
Weight bearing, especially with rotation.
Imaging Syndesmotic Sprains
Typically anterior view, better is mortise view
and look for widening
However, this can be subtle
Imaging Syndesmosis Sprains
Better to recreate the injury (as able)
Rotary mechanism of sprain
Intact, no load
5Nm Load applied
Imaging Syndesmotic Sprains
Lateral versus A-P
Base of the 5th Fracture
Different mechanisms
With stress #, may benefit
from ORIF.
With closed treatment the rate
of non-union is 50%.
If non-union has developed,
with widening of # line &
sclerosis, cast mobilization is
unlikely to be successful.
(Bone-grafting & internal
fixation + compression screw).
Chronic Ankle Instability
Range of motion Sagittal plane and rotation
Strength ? Normal eversion strength
Proprioception Reaction, feedforward and
feedback
Unstable surface training
Stability = Function
Single leg balance training
Single leg stance
Single leg stance, smaller base (on toes)
Single leg stance on unstable surface
Single leg stance on unstable surface and add
complexity
Ankle Taping
Simon 1969 JAT No difference tape and cloth
wrap
Taping made no improvement in balance in
comparison to Swede-O, Aircast, and no brace
Barkoukis Perc & Motor Skills 2002
Immediate positional change no post exercise
change - Low Dye taping Radford et al JOSPT
2006
Ankle Taping
Arnold & Docherty Clin J Sp Med 2004:
Bracing/taping: marked reduction in ROM reduction following
activity, but still above normal (46% - 84%)
EMG amplitude initially misinterpreted as a , but when viewed c.f.
ROM showed 1.6X
EMG latency (peronei) not improved by taping, and is too slow anyway
H Reflex (excitability of motor neuron pool) -10%
Velocity of inversion is slowed perhaps enough (25%, 156ms to
injure, 176ms to protect, 196ms is increased in lab; 10-80ms on court)
Increase rigidity (thereby shift shock)
Improves postural sway in FAI ankles, not in normals
No negative effects on ability e.g. Vertical jump & isokin strength.
May improve shuttle run performance
Loose circular straps, bottom of
gastroc belly.
No Creases, not tight, two (or more)
overlapping
Stirrup first one is critical.
Must pass under axis of ankle (through Malleoli)
All subsequent straps pass through same spot under
foot
Vary ant/post to limit PF/DF
Heel Lock/ Figure 6
One starting medially, One laterally
Doesnt matter which you do first
Beware creases under foot
MUST practice this
Practice
Normal ankle taping
1. Circular Straps
2. Stirrups
3. Heel Locks
Prevent PF (posterior impingement)
Prevent DF (anterior impingement, ?unload TA)