eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Ankle Injury, Soft Tissue
Updated: Sep 13, 2007
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, volleyball, or other activities performed on uneven surfaces.
Pathophysiology
Most ankle sprains are due to inversion during extension (plantarflexion) of the ankle. Thus, approximately 85% of injuries involve the 3 distinct lateral ligaments: anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). Of sprains due to inversion, 65% are isolated to the ATFL. In some patients, the subtalar complex may also be injured. The CFL is rarely injured in isolation.
Isolated injury to the medial (deltoid) ligament is rare and usually involves malleolar fractures. Distal tibiofibular syndesmotic rupture is very rare and is associated with flexion (dorsiflexion) and external rotation. 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.
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 is about 2,800 injuries per day in the United States. Injury to the dominant ankle is 2-3 times more likely than injury to the nondominant ankle.
Mortality/Morbidity
- Ankle sprains are generally considered to be benign and self-limiting. However, ankle sprains can cause significant morbidity. As many as 73% of athletes with an ankle sprain experience recurrent sprains, and 59% have significant disability and impairment of athletic performance. One study found that 72% of patients had residual symptoms at 6-18 months, and another reported residual symptoms in 32% of patients 7 years after their initial ED visit.
- Up to 50% of people who incur an ankle sprain have some type of chronic sequelae. These conditions 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.
Sex
Women athletes are 25% more likely to sustain ankle injuries than male athletes.
Age
Ankle injuries primarily involve young people because they participate more often in physically demanding recreational activities and sports. Fractures and tendon ruptures occur more often in older adults.
Clinical
History
- Assessment of all orthopedic injuries should include the following:
- Mechanism of injury
- Previous history of ankle injuries
- Presence of immediate or delayed pain, swelling in the ankle joint, and ability or inability to bear weight after the incident
- Presence or absence of any popping-type sensations or actual noise at the time of injury
Physical
- Observe for edema, ecchymosis, or deformity.
- Palpate for tenderness, crepitance, or deformity.
- Assess active and passive range of motion as well as weight-bearing ability.
- 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 their 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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References
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Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. Mar 3 1993;269(9):1127-32. [Medline].
Thacker SB, Stroup DF, Branche CM, Gilchrist J, Goodman RA, Weitman EA. The prevention of ankle sprains in sports. A systematic review of the literature. Am J Sports Med. Nov-Dec 1999;27(6):753-60. [Medline].
Wester JU, Jespersen SM, Nielsen KD, Neumann L. Wobble board training after partial sprains of the lateral ligaments of the ankle: a prospective randomized study. J Orthop Sports Phys Ther. May 1996;23(5):332-6. [Medline].
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Further Reading
Keywords
ankle injury, soft tissue ankle injury, soft-tissue ankle injury, ankle sprain, sprained ligament, twisted ankle, Ottawa ankle rules, sports-related ankle injury, ankle injuries, anterior talofibular ligament rupture, ATFL rupture, recurrent ankle sprain, calcaneofibular ligament rupture, CFL rupture, posterior talofibular ligament rupture, PTFL rupture, distal tibiofibular syndesmotic rupture, superior peroneal retinaculum rupture, ankle ligaments, inversion ankle injury
