eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Ankle Injury, Soft Tissue

Mircea Muresanu, MD,, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn
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

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

Lateral ligament complex of the ankle.

Deltoid ligament of the ankle.

• 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).

Talar tilt test to assess the integrity of the calcaneofibular ligament (CFL).

• 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.

Anterior drawer test to evaluate the integrity of the anterior talofibular ligament (ATFL). If the ligament is torn, the talus will subluxate anteriorly compared with the unaffected ankle.

• 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.

Crossed-leg test to detect a syndesmotic sprain. A syndesmotic sprain will cause pain in the syndesmosis area when pressure is applied to the medial side of the knee.

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

Differential Diagnoses

Fractures, Ankle
Fractures, Foot
Tendonitis
Tenosynovitis

Other Problems to Be Considered

Achilles tendon rupture
Peroneal tendon subluxation
Septic joint

Workup

Imaging Studies

• Radiographic studies of the ankle should include the following films:
  • An anteroposterior (AP) film with the ankle in 5-15° of adduction
  • A true lateral film
  • A 45° oblique film with the ankle in dorsiflexion (ie, Mortise view)
• The Ottawa foot and ankle rules are a prospectively validated clinical decision tree for radiograph ordering in adults.^16,17,18 By following these rules, emergency physicians can eliminate up to 30% of radiographs that are routinely ordered without missing clinically significant fractures.
• A recent meta-analysis of 12 studies showed the Ottawa foot and ankle rules can be reliably used at excluding fractures in children older than 5 years. Twelve studies included 3,130 patients and identified 671 fractures resulting in a prevalence of 21.4%. With a pooled sensitivity of 98.5% and a missed fracture rate of 1.2%, the Ottawa foot and ankle rules are useful (level 2 evidence) at excluding fractures in children older than 5 years.²⁵  
• Criteria for foregoing radiography are as follows:
  • Ottawa ankle rules: Ankle radiographs are indicated if there is pain in the malleolar area and any of the following:
    • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
    • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
    • An inability to bear weight, both immediately and in the emergency department for 4 steps
  • Ottawa foot rules: Foot radiographs are indicated if there is bony pain in the midfoot and any of the following :
    • Bone tenderness at the base of the fifth metatarsal (for foot injuries)
    • Bone tenderness at the navicular bone (for foot injuries)
    • An inability to bear weight, both immediately and in the emergency department for 4 steps

Other Tests

• Stress radiographs or arthrographies are not mandatory in the ED, but they may be requested by an orthopedic consultant.
• Careful evaluation of the foot, particularly the base of the fifth metatarsal, may reveal tenderness, which would prompt radiographs of the foot to rule out a Jones fracture.

Treatment

Prehospital Care

For patient comfort, all ankle injuries should be placed in a splint prior to transport to the ED.

Emergency Department Care

• First-degree sprains or mild second-degree sprains
  • Rest, ice, and elevation
  • Compression dressing, posterior splint, or commercially available air stirrup splint
  • Initial cessation of weight bearing
  • Consider referral to physical therapy for early range of motion exercise and wobble board training after recovery to reduce the number of recurrent injuries and to prevent functional instability.
• Severe second- or third-degree sprains
  • Rest, ice, and elevation
  • Plaster or fiberglass posterior splint in the ED
  • New evidence suggests that, for severe sprains, a short, 10-day period of immobilization in a below-the-knee cast was the most effective strategy for promoting proper ligament healing and a quicker recovery than an Aircast brace, a Bledsoe boot, or tubular compression bandage.²⁶ At 3 months after the injury, the below-the-knee cast performed significantly better than the tubular compression bandage in terms of pain, activities of daily living, and quality of life indices. The Aircast brace was better than the tubular compression bandage in ankle-related quality of life and mental health. At 9 months, however, there was no difference between the 4 treatment modalities.
  • Orthopedic or sports physician referral is indicated. Most patients require physical therapy to prevent functional loss.

Consultations

• Obtain orthopedic consultation for severe sprains, suspected peroneal tendon subluxation, or associated fractures.
• Emergent orthopedic evaluation rarely is required. Office follow-up in a week usually suffices.

Medication

The goals of therapy are to reduce pain and to prevent complications.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

With analgesic and anti-inflammatory properties, NSAIDs are the ideal agents for treating ankle injuries. Acetaminophen with or without an opiate analgesic may be added to NSAID therapy (or used as a substitute).

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderate pain, if no contraindications exist. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, resulting in the inhibition of prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Ketoprofen (Oruvail, Orudis, Actron)

Used for the relief of mild to moderate pain and inflammation.
Administer small doses initially to patients with small body size, elderly patients, and those with renal or liver disease.
Doses higher than 75 mg do not increase its therapeutic effects. Administer high doses with caution, and closely observe patients for response.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 12 years: 0.1–1 mg/kg PO q6-8h
>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Naproxen (Anaprox, Naprelan, Naprosyn)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and enable physical therapy regimens. Many analgesics have sedating properties that are beneficial for patients who have sustained injuries.

Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1,000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d

Interactions

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; known G-6-PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative doses exceeding recommended maximum dose

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for the treatment of mild to moderate pain.

Dosing

Adult

30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab PO q4h; not to exceed 12 tab/d

Pediatric

0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d acetaminophen

Interactions

Toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAO inhibitors, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity of acetaminophen

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for moderate to severe pain.

Dosing

Adult

1-2 tab PO q4-6h prn pain

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d; single dose should not exceed 10 mg of hydrocodone bitartrate

Interactions

Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity; high-altitude cerebral edema (HACE); elevated intracranial pressure (ICP)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Follow-up

Further Outpatient Care

• Patients with grade I or mild grade II lateral sprains should have a follow-up visit with their primary care physician in 1-2 weeks.
• Consult an orthopedist or a sports medicine specialist for all other injuries.
• Consider physical therapy referral for rehabilitation and strengthening to prevent recurrent injuries.
• Some orthopedic surgeons suggest an operative course for competitive athletes who have failed conservative treatments and whose ankle function did not improve with appropriate rehabilitation.²⁷ Recently, however, a Cochrane Database of Systematic Reviews article of 20 trials concluded that there is insufficient evidence to determine the relative effectiveness of surgical versus conservative management of lateral ligament ankle sprains.²⁸

Deterrence/Prevention

• Ankle sprains are prevalent sports injuries and are associated with a high cost both in medical expenses as well as in forced lifestyle modifications. Therefore, prevention of first time as well as recurrent sprains is a common sense approach to addressing this problem. Over the years, numerous strategies for preventing ankle sprains have been described.¹⁰ They range from balance and coordination training using a wobble board^19,23 to external support (taping/bracing), foot orthotics, specialized footwear, and strengthening and stretching.¹⁰ Most evidence points to the use of the wobble board and external support such bracing and taping as the most effective ways of preventing first-time and recurrent ankle sprains.^10,19,21,22

Complications

• Functional, mechanical instability, or both²⁰
• Impaired proprioception of the affected ankle, leading to further ankle instability¹⁵
• Chronic pain, stiffness, swelling, osteoarthritis^12,13
• Failure to return to previous levels of competitiveness, impaired activities of daily living

Prognosis

• With appropriate initial treatment, referral, and physical therapy, most patients have a rapid and favorable outcome.
• In a systematic literature review 36-85% of the patients reported full recovery at 2 weeks to 36 months, independent of the initial grade of sprain,¹² with most recovery within the first 6 months.²⁴ After 12 months, the risk of recurrent ankle sprain returns to preinjury levels.²³ However, 3-34% of patients reported re-sprains at 2 weeks to 96 months after the initial injury.¹² Furthermore, after 3 years, some patients still had residual pain and instability. One risk factor for residual symptoms seems to be participation in competitive sports.¹²
• Posttraumatic osteoarthritis is common in patients with repetitive ankle injuries. A recent study estimates that approximately 12% of the overall prevalence of osteoarthritis (OA) is in fact posttraumatic OA of the hip, knee, or ankle.¹³ The financial burden is significant, costing an estimated $3.06 billion dollars annually.¹³

Patient Education

• For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center, Sports Injury Center, and Sprains and Strains Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose
  • Failure to obtain a radiograph
  • Misinterpretation of a radiograph
  • Failure to recognize ankle instability
• Failure to treat injury appropriately
  • Failure to immobilize unstable injuries
  • Failure to refer significant injuries to the appropriate specialist
• Unmet expectations - Failure to warn the patient of the potential for prolonged recovery or chronic symptoms or instability

Special Concerns

• Elderly patients may require home health visits to assess mobility and ability to perform activities of daily living (ADL).

Multimedia

Media file 1: Lateral ligament complex of the ankle.

Media file 2: Deltoid ligament of the ankle.

Media file 3: Talar tilt test to assess the integrity of the calcaneofibular ligament (CFL).

Media file 4: Anterior drawer test to evaluate the integrity of the anterior talofibular ligament (ATFL). If the ligament is torn, the talus will subluxate anteriorly compared with the unaffected ankle.

Media file 5: Crossed-leg test to detect a syndesmotic sprain. A syndesmotic sprain will cause pain in the syndesmosis area when pressure is applied to the medial side of the knee.

References

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2. Beynnon BD, Vacek PM, Murphy D, Alosa D, Paller D. First-time inversion ankle ligament trauma: the effects of sex, level of competition, and sport on the incidence of injury. Am J Sports Med. Oct 2005;33(10):1485-91. [Medline].

3. Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower extremity injuries among U.S. high school athletes. Acad Emerg Med. Jul 2007;14(7):641-5. [Medline].

4. Nelson AJ, Collins CL, Yard EE, Fields SK, Comstock RD. Ankle injuries among United States high school sports athletes, 2005-2006. J Athl Train. Jul-Sep 2007;42(3):381-7. [Medline].

5. Wexler RK. The injured ankle. Am Fam Physician. Feb 1 1998;57(3):474-80. [Medline].

6. Ivins D. Acute ankle sprain: an update. Am Fam Physician. Nov 15 2006;74(10):1714-20. [Medline].

7. Dias LS. The lateral ankle sprain: an experimental study. J Trauma. Apr 1979;19(4):266-9. [Medline].

8. Jones MH, Amendola A. Syndesmosis sprains of the ankle: a systematic review. Clin Orthop Relat Res. Feb 2007;455:173-5. [Medline].

9. Williams GN, Jones MH, Amendola A. Syndesmotic ankle sprains in athletes. Am J Sports Med. Jul 2007;35(7):1197-207. [Medline].

10. McKeon PO, Mattacola CG. Interventions for the prevention of first time and recurrent ankle sprains. Clin Sports Med. Jul 2008;27(3):371-82, viii. [Medline].

11. Praemer A, Furner S, Rice D. Musculoskeletal conditions in the Unites States. American Academy of Orthopedic Surgeons. 1999;173-5.

12. van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. Apr 2008;121(4):324-331.e6. [Medline].

13. Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA. Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. J Orthop Trauma. Nov-Dec 2006;20(10):739-44. [Medline].

14. Linde F, Hvass I, Jurgensen U, Madsen F. Early mobilizing treatment in lateral ankle sprains. Course and risk factors for chronic painful or function-limiting ankle. Scand J Rehabil Med. 1986;18(1):17-21. [Medline].

15. Refshauge KM, Kilbreath SL, Raymond J. Deficits in detection of inversion and eversion movements among subjects with recurrent ankle sprains. J Orthop Sports Phys Ther. Apr 2003;33(4):166-73; discussion 173-6. [Medline].

16. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. Mar 3 1993;269(9):1127-32. [Medline].

17. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. Feb 22 2003;326(7386):417. [Medline].

18. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. Apr 1992;21(4):384-90. [Medline].

19. 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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21. 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].

22. Handoll HH, Rowe BH, Quinn KM, de Bie R. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2001;(3):CD000018. [Medline].

23. Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W. The effect of a proprioceptive balance board training program for the prevention of ankle sprains: a prospective controlled trial. Am J Sports Med. Sep 2004;32(6):1385-93. [Medline].

24. Verhagen RA, de Keizer G, van Dijk CN. Long-term follow-up of inversion trauma of the ankle. Arch Orthop Trauma Surg. 1995;114(2):92-6. [Medline].

25. Dowling S, Spooner CH, Liang Y, Dryden DM, Friesen C, Klassen TP. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. Apr 2009;16(4):277-87. [Medline].

26. Lamb SE, Marsh J, Hutton J, Nakash R, Cooke MW, on behalf of the Collaborative Ankle Support Trial (CAST Group). Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial. Lancet. 2008;373:575-81.

27. Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. Oct 2008;16(10):608-15. [Medline].

28. Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. Apr 18 2007;CD000380. [Medline].

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   

Contributor Information and Disclosures

Author

Mircea Muresanu, MD,, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn
Mircea Muresanu, MD, is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

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
Antonia Quinn, DO is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Christopher F Richards, MD, to the development and writing of this article.
 

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