eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Ankle Injury, Soft Tissue

Author: Mircea Muresanu, MD,, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn
Coauthor(s): Antonia Quinn, DO, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate Medical Center/Kings County Hospital Center; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Sep 25, 2009

Introduction

Background

Ankle injuries are the most common injuries incurred during sports and recreational activities. They are particularly common in sports such as basketball, soccer, hiking,¹ volleyball, ice skating, or other activities performed on uneven surfaces. About 81% of ankle injuries are ankle sprains.¹ In the United States, the frequency of ankle sprains is estimated to be between 1-10 million per year, and approximately 20% of all sports injuries.^5,6

Pathophysiology

The bones involved in the ankle joint are the tibia and the fibula superiorly, which together form a mortise, and the talus inferiorly. The talus, one of the 2 hind foot bones fits in the mortise formed by the tibia and fibula. The articular surface of the talus is called the trochlea, and it is wider anteriorly than it is posteriorly. At the level of the ankle joint, the tibia and fibula are connected anteriorly by the anterior inferior tibiofibular ligament and posteriorly by the posterior tibiofibular ligament. The interosseous membrane connects the tibia and fibula along their length. Laterally, the ankle is stabilized by the anterior talofibular ligament, the calcaneofibular ligament, and the posterior tibiofibular ligament. The deltoid ligament provides stability to the medial aspect of the ankle. Movement at the ankle joint occurs in the vertical plane only, as plantarflexion and dorsiflexion. Inversion and eversion occur at the subtalar joint.⁵

• Isolated injury to the deltoid ligament is rare and usually involves medial malleolar and distal fibula fractures.
• Distal tibiofibular syndesmotic rupture (also called high ankle sprain) is very rare and is associated with flexion (dorsiflexion) and external rotation. The anterior talofibular ligament (ATFL) and posterior talofibular ligament (PTFL) can also be injured with this type of mechanism.⁶ Recovery from this injury is significantly prolonged, unlike isolated lateral ligament sprains. Mild syndesmotic sprains are increasingly being recognized and are probably more common than previously thought.⁸ Symptoms are pain and swelling to the lateral ankle, accompanied by perceived ankle instability, and these sprains tend to last longer than those of a typical sprained ankle.⁹
• Rupture of the superior peroneal retinaculum results in subluxation or dislocation of the peroneal tendons. The mechanism of injury is usually forced dorsiflexion with reflex contraction of the peroneal muscles. Patients complain of pain and a snapping sensation over the posterolateral ankle with weakness of eversion. 

Ankle sprains are classified into 3 grades per the West Point Sprain Grading System, as follows:

• Grade I injuries involve a stretch of the ligament with microscopic tearing but not macroscopic tearing. Generally, little swelling is present, with little or no functional loss and no joint instability. The patient is able to fully or partially bear weight.
• Grade II injuries stretch the ligament with partial tearing, moderate-to-severe swelling, ecchymosis, moderate functional loss, and mild-to-moderate joint instability. Patients are usually unable to bear weight.
• Grade III injuries involve the complete rupture of the ligament with immediate and severe swelling, ecchymosis, an inability to bear weight, and moderate-to-severe instability of the joint. Typically, patients cannot bear weight without experiencing incapacitating pain.

Frequency

United States

Inversion injuries occur at a rate of 1 per 10,000 people per day, which adds up to about 23,000 injuries per day in the United States.¹⁰ Injury to the dominant ankle is 2-3 times more likely than injury to the nondominant ankle.

Mortality/Morbidity

Ankle sprains are generally considered benign and self-limiting. However, ankle sprains can cause significant morbidity, and they do represent a significant health problem, accounting for an estimated 1.6 million physician office visits and 8000 hospitalizations per year.^10,11 As many as 32% of top athletes with an ankle sprain will experience recurrent sprains after 1 year.^12,14 Approximately 30-70% of those experiencing a first-time ankle sprain will develop chronic ankle instability.¹⁰ One systematic literature review found that 33-53% of patients had residual symptoms at 36.2 months,¹² and many patients reported residual symptoms as long as 3 years after their initial ED visit.¹² These symptoms include functional instability, mechanical instability, chronic pain, stiffness, and recurrent or chronic swelling.

Eversion injuries are more likely to result in persistent pain or chronic instability.

Syndesmotic sprains and rupture of the superior peroneal retinaculum tend to be associated with a prolonged recovery course and a higher incidence of residual symptoms, including ankle instability and chronic pain.^8,9

Sex

Female athletes are 25% more likely to sustain ankle injuries than male athletes. Female basketball players are at a higher risk of a first-time inversion injury than those participating in other sports.² Soccer and volleyball are other leading causes of ankle sprains in high school and college female athletes.^3,10 Some studies attribute a higher incidence of ankle injuries in high school football, basketball, and soccer players.^1,3,4 Other studies conclude that there seems to be no difference in the risk of suffering and ankle sprain in college men involved in basketball, soccer, or football.²

Age

Ankle injuries primarily involve young people, perhaps because of greater participation in physically demanding recreational activities and sports. The risk of a first-time inversion injury is similar between high school and college athletes.² The most common ankle injuries were ligament sprains with incomplete tears.⁴ There is a higher incidence of ankle injuries during competition than during practice.⁴ Fractures and tendon ruptures occur more often in older adults. Salter-Harris fractures occur in children and teenagers with open growth plates.

Clinical

History

Assessment of all orthopedic injuries should include the following:

• Mechanism of injury: Find out about the nature of activity in which the patient was involved at the time of the injury. The type of sport and if the injury occurred during practice or competition are also valuable components of the history of present illness (HPI). Inquire about ankle positioning, such as inversion, eversion, plantarflexion, or severe dorsiflexion. Also inquire about any direct blows or trauma to the ankle.
• Inquire about previous history of ankle injuries, since a history of a previously sprained ankle has been cited as a common risk factor for further sprains.⁶ Establish the presence or absence of residual symptoms from previous ankle sprains.
• Inquire about improper shoe wear and impaired activities of daily living (ADL) in elderly persons.
• Ask about improper stretching and previous joint laxity.
• Inquire about the presence of immediate or delayed pain, swelling in the ankle joint, and ability or inability to bear weight after the incident.
• Also inquire about the presence or absence of any popping-type sensations or actual noise at the time of injury.

Physical

• Observe and inspect both ankles for symmetry.
• Observe for edema, ecchymosis, or deformity.
• Palpate for bone, soft tissue tenderness, or crepitance.
• Assess active and passive range of motion as well as weight-bearing ability.
• Carefully assess the foot for bony tenderness over the proximal fifth metatarsal, which may indicate an associated Jones fracture.
• In cases of eversion injuries, compress the tibia and the fibula proximally and palpate the fibular head to exclude the possibility of a proximal fibular fracture associated with a Maisonneuve fracture.
• Perform the talar tilt test.
  • Place the foot in 20-30° of plantar flexion, and apply slight adduction and gentle inversion stress to the calcaneal midfoot.
  • If both the anterior talofibular and the calcaneofibular ligaments are ruptured, the examiner will detect talar tilt (ie, movement of the talus in the mortise).

• Perform the anterior drawer test.
  • Place the foot in 10-15° of plantar flexion, and apply gentle forward traction to the heel.
  • With anterior talofibular ligament rupture, the deltoid ligament becomes the center of rotation, and a dimple may appear just anterior to the lateral malleolus. Forward motion of the talus is detected by the examiner.
  • For this test, even 3 mm of movement may be significant; 1 cm of movement is certainly significant.

• For syndesmotic injuries, perform the cross-leg test.
  • While sitting in a chair, have the patient cross his or her injured leg over the other knee. The middle lower leg rests on the unaffected knee.
  • Pressure on the medial knee will cause ankle pain in a positive test result.

• Perform and document a neurovascular examination, including checks of the dorsalis pedis and posterior tibial pulses.

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