II. Epidemiology
- Lateral sprains represent 80-85% of Ankle Sprains
- Sports with highest rate of Ankle Sprain
- Basketball
- Ice skating
- Soccer
III. Mechanism
- Ankle Inversion with Plantar Flexion
IV. Pathophysiology
- Anatomy
- See Ankle Anatomy
- Lateral ankle ligaments (In order of injury)
- Anterior talofibular ligament (ATF): Easily injured
- Calcaneofibular ligament (CF)
- Posterior Talofibular ligament (PTF): Rarely injured (third degree sprain)
- TibioFibular Ligaments
- See High Ankle Sprain
- Anterior tibiofibular ligament
- Posterior tibiofibular ligament
- Medial ankle ligament
- See Medial Ankle Sprain
- Ankle Deltoid Ligament (rarely injured, but associated with serious ankle injury)
V. Associated Conditions: Other associated Injuries
- Peroneal Tendon Injury
- Peroneal tendon avulsion Fracture
- Distinguish from Jones Fracture
- Everts foot and prevents inversion
- Palpate lateral foot at its insertion
- Hemorrhage at Peroneal Muscle
- Peroneal Nerve damage may occur
- Peroneal tendon avulsion Fracture
- Bone Injury: Foot
- Jones Fracture at fifth Metatarsal metaphysis
- Peroneal brevis tendon avulsion Fracture
- May require surgery for non-union
- Tarsal Navicular Fracture (or Stress Fracture)
- Lisfranc Fracture-Dislocation (uncommon, but high morbidity)
- Jones Fracture at fifth Metatarsal metaphysis
- Bone Injury: Fibula
- Pott's Fracture-Subluxation
- Maisonneuve Injury (Proximal Fibula Fracture related to Syndesmotic Sprain)
- Bone Injury: Talus
- Talar Dome Fracture (occurs in 6 to 22% of cases)
- Posterior Talus Fracture (Medial or Lateral Tubercle)
- Lateral process of Talus Fracture (most commonly missed Ankle Fracture)
- Bone Injury: Calcaneus
VI. Differential Diagnosis: Delayed healing
- Unrecognized associated injury as listed above
- Talar Dome Fracture
- Reflex Sympathetic Dystrophy
- Chronic Tendonitis
- Peroneal tendon subluxation
- Syndesmotic Sprain (High Ankle Sprain)
- Occult Fracture
- Anterior Superior Calcaneus Fracture
- Lateral Talus Fracture
VII. Symptoms
- "Pop" heard with injury
- Ankle swelling and decreased function
- Inability to walk four feet after Ankle Sprain is higher risk of Fracture
- See Ottawa Ankle Rules
VIII. Signs
- See Ankle Exam
- See Ankle Anatomy
- Ankle Motor Function (Always assess)
- Evaluate for Syndesmotic Sprain (High Ankle Sprain)
- Evaluate ankle stability
- More useful at follow-up at 4-6 weeks after Ankle Sprain
- Used in grading Ankle Sprain (see below)
- Does not typically modify initial management after acute injury
- Ankle Anterior Drawer Test
- Tests anterior talofibular ligament integrity
- Ankle Talar Tilt (Inversion stress Test)
- Tests calcaneofibular ligament integrity
- More useful at follow-up at 4-6 weeks after Ankle Sprain
- Evaluate for associated Fracture
- See Ottawa Ankle Rules
- Ankle bony tenderness
- Medial malleolus or distal tibia tenderness within last 2.4 inches (6 cm)
- May also indicate Growth Plate Fracture in adolescent
- Lateral malleolus or distal fibula tenderness within last 2.4 inches (6 cm)
- Talocrural joint line (anterior talar dome) tenderness or swelling
- May indicate osteochondral Talar Dome Fracture
- Not part of Ottawa Ankle Rules
- Medial malleolus or distal tibia tenderness within last 2.4 inches (6 cm)
- Foot bony tenderness (midfoot)
- Fifth Metatarsal tenderness or pain at base or metaphysis (e.g. Jones Fracture)
- Tarsal Navicular tenderness or pain at medial, proximal foot (Tarsal Navicular Fracture)
- Lisfranc Joint tenderness, swelling or deformity at midfoot region (Lisfranc Fracture Dislocation)
IX. Evaluation: Red Flags suggestive of more complicated injury
- See Ottawa Ankle Rules
- Mechanism different than classic inversion injury
- Eversion injury (see Medial Ankle Sprain)
- Forced severe plantar flexion (see Fifth Metatarsal Fracture)
- Dorsiflexion
- Atypical signs on acute evaluation immediately after injury
- Children with tenderness over physis
- Suspect Salter-Harris Fracture I (physis is weaker than ligaments)
- Safest to apply splint despite negative XRay
- Low risk of Salter Harris I Fractures on MRI in these patients
X. Imaging: Initial
-
Ankle XRay Indications
- See Ottawa Ankle Rules (adults and children over age 5 years old)
- See Low Risk Ankle Rule (children over age 3 years old)
- See ankle bony tenderness above
- Inability to walk four feet at injury site (e.g. sideline) or at acute evaluation by medical provider
-
Foot XRay Indications
- See foot bony tenderness above
XI. Imaging: Delayed healing (suspected Talar Dome OCD)
- Indications
- Symptomatic beyond 6 weeks
- Persistent crepitus
- Locking or catching Sensation
- Imaging
- Repeat Ankle XRay and foot XRay
- Ankle CT or Ankle MRI
XII. Grading
- Indications
- Ankle stability at 4-6 weeks after Ankle Sprain
- Instability directs additional management with rehabilitation (or possibly surgery for third degree Ankle Sprain)
- Inaccurate and not useful on initial Ankle Sprain evaluation
- Does not modify initial management
- Ankle stability at 4-6 weeks after Ankle Sprain
- First degree Lateral Ankle Sprain
- Mild pain and swelling (able to ambulate)
- No mechanical instability
- Anterior talofibular ligament stretched
- Localized tenderness anteriorly
- Second degree Lateral Ankle Sprain
- Moderate pain and swelling with Ecchymosis present
- Pain with ambulation
- Moderate lateral ankle instability
- Partial tear of anterior talofibular ligament
- Third degree Lateral Ankle Sprain
- Severe Ecchymosis and swelling (>4 cm at fibula)
- Unable to bear weight
- Severe lateral ankle instability
- Total disruption of lateral ligaments
- Anterior talofibular ligament
- Calcaneofibular ligament
- Heard "Pop" with immediate pain and swelling
XIII. Management
XIV. Prognosis
- Outcomes generally good
- Full recovery may require months
- Severe Lateral Ankle Sprains
- Syndesmotic Sprains (High Ankle Sprains)
XVI. References
- Orman and Ramadorai in Herbert (2016) EM:Rap 16(3): 8-9
- Rifat (1996) Am Fam Physician 53(8):2491-8 [PubMed]
- Rubin (1996) Am Fam Physician 54(5):1609-18 [PubMed]
- Sitler (1995) Sports Med 20(1):53-7 [PubMed]
- Swain (1993) Postgrad Med 90(3):91-100 [PubMed]
- Tiemstra (2012) Am Fam Physician 85(12): 1170-6 [PubMed]
- Wolfe (2001) Am Fam Physician 63(1):93-104 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
Concepts | Injury or Poisoning (T037) |
MSH | D016512 |
ICD9 | 845.00, 845.0 |
ICD10 | S93.4 , S93.40 |
SnomedCT | 157297008, 269333001, 209537006, 157299006, 263132007, 209530008, 44465007 |
English | Ankle sprain NOS, Ankle sprain, unspecified, Sprn ligament ankle joint, ankle sprain, ankle sprain (diagnosis), Sprain of ankle NOS, Sprained ankle NOS, Sprain;ankle, sprained ankle, ankle sprains, ankles sprain, Sprained ankle, Unspecified site of ankle sprain, Ankle sprains, Sprain of ankle, unspecified site, Sprain, Ankle, Sprains, Ankle, Ankle Sprains, Ankle Sprain, (Sprain - ankle NOS) or (twisted ankle) (disorder), Sprain of ligament of ankle joint (disorder), Sprain - ankle NOS, Ankle sprain, unspecified (disorder), (Sprain - ankle NOS) or (twisted ankle), Twisted ankle, Ankle sprain NOS (disorder), Sprain of ankle joint (disorder), Ankle sprain, Sprain of ankle joint, Sprain of ligament of ankle joint, Sprain of ankle (disorder), Sprain of ankle, Sprain of ankle, NOS |
Spanish | Esguince de una zona no especificada del tobillo, Esguince de tobillo, Torcedura de tobillo, esguince del tobillo, estrema de tobillo, esguince de tobillo (trastorno), esguince del tobillo (trastorno), esguince de tobillo, esguince de tobillo, no especificado (trastorno), esguince de tobillo, SAI (trastorno), esguince de tobillo, SAI, esguince de tobillo, no especificado |
Portuguese | Entorse do tornozelo, Tornozelo com entorse, Localização NE de entorse do tornozelo |
Dutch | enkelverstuiking, verstuikte enkel, niet-gespecificeerde plaats van enkelverstuiking |
French | Entorse d'un site non précisé de la cheville, Entorse - cheville, Entorse de la cheville |
German | unspezifische Stelle einer Knoechelverstauchung, Knoechelverstauchung, Verstauchung des Knoechels |
Hungarian | Megrándult boka, Bokahúzódás, nem meghatározott lokalizáció, Bokarándulás |
Czech | Podvrtnutý kotník, Neurčené podvrtnutí kotníku, Podvrtnutí kotníku |
Italian | Distorsione della caviglia a sede non specificata, Caviglia distorta, Distorsione della caviglia |
Japanese | 足関節捻挫, アシカンセツネンザ, 足関節捻挫、部位不明, アシカンセツネンザブイフメイ, ソクカンセツネンザブイフメイ, ソクカンセツネンザ |
Ontology: Calcaneofibular (ligament) ankle sprain (C0160090)
Concepts | Injury or Poisoning (T037) |
ICD9 | 845.02 |
English | Sprain calcaneofibular, Calcaneofibular (ligament) ankle sprain, Sprain of calcaneofibular (ligament) of ankle, Calcaneofibular ligament ankle sprain, Calcaneofibular ankle sprain |
Spanish | Esguince (del ligamento) calcaneoperoneo del tobillo |
Portuguese | Estiramento do ligamento calcaneoperoneal |
Dutch | calcaneofibulair (ligament) enkelverstuiking |
French | Entorse du ligament calcanéo-péronier |
German | kalkaneofibulare (Ligament) Knoechelverstauchung |
Hungarian | Calcaneofibularis (szalag) bokarándulás |
Czech | Podvrtnutí kalkaneofibulárního (vazu) kotníku |
Italian | Distorsione del (legamento) calcaneofibulare |
Japanese | 足関節踵腓(靱帯)捻挫, ソクカンセツショウヒジンタイネンザ, アシカンセツショウヒジンタイネンザ |
Ontology: Sprain, ankle joint, lateral (C0434477)
Concepts | Injury or Poisoning (T037) |
SnomedCT | 209532000 |
English | Sprain, ankle joint, lateral, Sprain, ankle joint, lateral (disorder) |
Spanish | esguince de articulación del tobillo, lateral (trastorno), esguince de articulación del tobillo, lateral |
Ontology: talofibular; sprain (strain) (C1395626)
Concepts | Injury or Poisoning (T037) |
English | sprain (strain); talofibular, talofibular; sprain (strain) |
Dutch | distorsie; talofibulair, talofibulair; distorsie |