Sprained ankle

A sprained ankle is a common medical condition where one or more of the ligaments of the ankle is/are stretched, partially or completely torn. Ankle sprains are more common among physically active individuals. The anterior talofibular ligament is one of the most commonly involved ligaments. Sprains to the lateral aspect of the ankle account for 85% of ankle sprains. Females are more commonly affected with an ankle sprain than males. The diagnosis of most ankle sprains is made in the light of history of acute ankle trauma and examination findings.

• Ankle sprain can be graded for functional loss of function^[1]:

• The pathogenesis of ankle sprain is characterized by ankle movement beyond the elastic limits of its supporting structures causing acute ankle pathology.
• Lateral ankle sprain injury is usually caused by forefoot adduction, hindfoot inversion, and tibial external rotation with ankle in plantar flexion. Depending on the amount and direction of the force, one or more of the lateral ligaments can be involved.^[2]
• The ATFL is the most commonly injured structure with the lowest load to failure when compared to the other lateral ligaments. The anterior tallofibular ligament (ATFL) is the most commonly injured ligament and is most susceptible to injury during ankle plantarflexion with the ankle‘s bony anatomy providing less stability. In this position, ATFL acts as a collateral ligament to the ankle. The ATFL prevents talar internal rotation, anterior translation and is a restraint to plantarflexion. The most common mechanism of injury to the ATFL is inversion injury where a plantarflexed ankle undergoes supination and adduction.^[3]
• An ankle sprain can involve any of the following injuries:^[4]
  • Anterior (and/or posterior) talofibular ligament injury
  • Calcaneofibular ligament injury
  • Possible peroneal and flexor tendon injuries
  • Syndesmotic injury
• On microscopic histopathological analysis, microscopic failure of the collagen fibers characterize ankle sprain when the load and velocity applied to outweigh the mechanical strength of the ligament and speed of a corrective muscle reflex.^[5]

A lateral ankle sprain occurs when the ankle is inverted beyond the elastic limits of its supporting structures causing acute ankle pathology.

• Ankle sprain should be differentiated from (click on the disease name to read more):^[6]
  • Tendon pathologies: Tendon rupture, ITiFi ligament tear.
  • Joint pathologies: Joint effusion, and chronic osteoarthritis.
  • Fractures: of the low fibula, Diaphyseal fibula, medial malleolus, postmedial talar process, anterior calcaneal process, os peronei, fifth metatarsal,
  • Microfractures: of the cuboid, calcaneum, and tibia.
  • Stress fracture
  • Subluxation
  • Impingement syndrome, sinus tarsi syndrome, tarsal tunnel syndrome, Talar neck avulsion, peroneal groove pathology, peroneal tenosynovitis.
  • Muscle pathologies: Split peroneus brevis, peroneus longus, tibialis anterior tear, tibialis posterior dislocation, and flexor digitorum brevis tear.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Template:Infobox Anatomy

In human anatomy, the ankle joint is formed where the foot and the leg meet. The ankle, or talocrural joint, is a synovial hinge joint that connects the distal ends of the tibia and fibula in the lower limb with the proximal end of the talus bone in the foot.^[1] The articulation between the tibia and the talus bears more weight than between the smaller fibula and the talus.

The term “ankle” is used to describe structures in the region of the ankle joint proper.^[2]

Movement

The ankle joint is responsible for dorsiflexion (moving the toes up as when standing only on the heels) and plantar flexion of the foot (moving the toes down, as when standing on the toes), and allows for the greatest movement of all the joints in the foot. The ankle does not allow rotation.

In plantar flexion, the anterior ligaments of the joint become longer while the posterior ligaments become shorter. The reverse is true for dorsiflexion.

Articulation

The lateral malleolus of the fibula and the medial malleolus of the tibia along with the inferior surface of the distal tibia articulate with three facets of the talus. These surfaces are covered by cartilage.

The anterior talus is wider than the posterior talus. When the foot is dorsiflexed , the wider part of the superior talus moves into the articulating surfaces of the tibia and fibula, creating a more stable joint than when the foot is plantar flexed.

Ligaments

The ankle joint is bound by the strong deltoid ligament and three lateral ligaments: the anterior talofibular ligament, the posterior talofibular ligament, and the calcaneofibular ligament.

• The deltoid ligament supports the medial side of the joint, and is attached at the medial malleolus of the tibia and connect in four places to the sustentaculum tali of the calcaneus, calcaneonavicular ligament, the navicular tuberosity, and to the medial surface of the talus.
• The anterior and posterior talofibular ligaments support the lateral side of the joint from the lateral malleolus of the fibula to the dorsal and ventral ends of the talus.
• The calcaneofibular ligament is attached at the lateral malleolus and to the lateral surface of the calcaneus.

The joint is most stable in dorsiflexion and a sprained ankle is more likely to occur when the foot is plantar flexed. This type of injury more frequently occurs at the anterior talofibular ligament.

Name derivation

The word ankle or ancle is common, in various forms, to Germanic languages, probably connected in origin with the Latin “angulus”, or Greek “αγκυλος”, meaning bent.

Related terms

A common variant of the word “ankle” is “cankle“, which is commonly used derogatorily to describe the ankles of obese individuals where the ankle and calf may be indistinguishable. This insult can be taken further (often jokingly) using the term “thankle”, which implies a person’s thighs and ankles are indistinguishable.

Fractures

Most traumatic incidents involving the ankle result in ankle sprains. Symptoms of an ankle fracture can be similar than for sprains (pain, hematoma) or there may be an abnormal position, abnormal movement or lack of movement (if there is an accompanying dislocation), or the patient may have heard a crack.

On clinical examination, it is important to evaluate the exact location of the pain, the range of motion and the condition of the nerves and vessels. It is important to palpate the calf bone (fibula) because there may be an associated fracture, and to palpate the sole of the foot to look for a Jones fracture.

Evaluation of ankle injuries for fracture is done with the Ottawa ankle rules, a set of rules that were developed to minimize unnecessary X-rays. On X-rays, there can be a fracture of the medial malleolus, the lateral malleolus, or the anterior or posterior margin. If both malleoli are broken, this is called a bimalleolar fracture (some of them are called Pott’s fractures). If three of these are broken at the same time, this is called a trimalleolar fracture (although there are only two malleoli). Ankle fractures are classified according to Weber, depending on their position relative to the anterior ligament of the lateral malleolus (type A = below the ligament, type B = at its level, type C = above the ligament). A special form of type C fracture is the Maisonneuve fracture, which involves a spiral fracture of the fibula with a tear of the distal tibiofibular syndesmosis and the interosseous membrane.

Only type A fractures of the lateral malleolus can be treated like sprains; all other types require surgery (most often an open reduction and internal fixation). A cast may be required to immobilize the ankle following surgery. Trimalleolar fractures or those with dislocation have a high risk of developing arthrosis.

Additional images

• The bones in the foot.
  The bones in the foot.
• 
  Ligaments of the medial aspect of the foot.
• 
  The ligaments of the foot from the lateral aspect.
• 
  Capsule of left talocrura articulation (distended). Lateral aspect.
• 
  Oblique section of left intertarsal and tarsometatarsal articulations, showing the synovial cavities.

References

1. ↑ “eMedicine/Stedman Medical Dictionary Lookup!”. Retrieved 2008-01-14.
2. ↑ “eMedicine/Stedman Medical Dictionary Lookup!”. Retrieved 2008-01-14.

• Calais-Germain, Blandine. “Anatomy of Movement”, Eastland Press, 1993. ISBN 0-939616-17-3
• Martini, Frederic; Timmons, Michael; McKinnley, Michael. “Human Anatomy”, 3rd Edition, Prentice-Hall, 2000. ISBN 0-13-010011-0
• Marieb, Elaine. “Essentials of Human Anatomy and Physiology”, 6th Edition. Addison Wesley Longman, 2000. ISBN 0-8053-4940-5

See also

File:Wiktionary-logo-en-v2.svg

Look up ankle in Wiktionary, the free dictionary.

• Tarsus (skeleton)
• Joints (anatomy)
• Foot
• Leg (anatomy)

External links

Wikimedia Commons has media related to Ankle.

• The Ankle from the University of Glasgow
• How to Diagnose Lateral Ankle Injuries from Podiatry Today
• American Academy of Orthopedic Surgeons website about Foot & Ankle

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Template:WikiDoc Sources

• The prevalence of ankle sprain is approximately [number or range] per 100,000 individuals worldwide. The most common injuries suffered from during athletic/recreational activities is lateral ankle sprains.^[7][8][9]
• The indoor/court sports has a “cumulative incidence rate of 7 per 1,000 exposures or 1.37 per 1,000 athlete exposures and 4.9 per 1,000 h”.^[10]

• A systematic review and meta-analyses of prospective studies reported that children compared with adolescents and adults are more likely to sustain an ankle sprain.^[10]

• A systematic review and meta-analyses of prospective studies reported that females are more commonly affected with ankle sprain than males.^[10]

• There is no racial predilection for ankle sprain.

• A study describing the common risk factors for development of ankle sprain among recreational basketball players reported having a previous history of ankle injury, wearing shoes with air cells in the heel, and not stretching before the game to be the common risk factors.^[11]

• The majority of patients with ankle sprain may remain asymptomatic.
• Early clinical features include tenderness, swelling, and ecchymosis over the anterior talofibuar and calcaneofibular ligaments. Although the patient may be asymptomatic depending upon the extent of injury.
• If left untreated patients with ankle sprain may progress to develop balance problems due to proprioception deficits. ^[12].
• Common complications of ankle sprain include chronic pain, joint instability, arthritis.^[13]
• Prognosis is generally good but acute ankle sprains have been reported to have a high recurrence rate and may also lead to chronic ankle instability.^[14]

• The diagnosis of most ankle sprains is made in the light of history of acute ankle trauma and examination findings. Diagnostic imaging is unnecessary although ultrasound may help assess the extent of tendon injury.^[15][2]

• Acute injuries may not demonstrate any signs and symptoms. Ask the patient to describe injury mechanism. Most sprains involve ankle inversion with some plantar flexion and suggest lateral ligament injury. Another mechanism, such as dorsiflexion, eversion suggest some other ligament involvement.^[1]

• Patients with ankle sprain usually appear fine. But, the patient may be in distress depending upon the intensity of pain.
• Physical examination of a typical lateral ankle sprain may be remarkable for:

• Tenderness, swelling, and ecchymosis over anterior talofibuar and calcaneofibular ligaments. Swelling and bruising of the whole foot and toe may be demonstrated if no proper treatment has been applied and the patient has been ambulating.^[1]
• The patient should be assessed for the degree of instability, site, pain intensity, and an evaluation of neurovascular status.^[16]

• There are no specific laboratory findings associated with ankle sprain.

• There are no ECG findings associated with ankle sprain.

• An x-ray may be helpful in the diagnosis of ankle sprain. The Ottawa criteria (100% sensitivity) helps indicate of the radiography is indicated. According to the criteria, in case of pain in the malleolar or midfoot region, or tenderness of the bone over the potential fracture region, or weight bearing inability for four steps right after the injury warrants radiography.^[17][18]
• Lateral, anteroposterior, and mortise views of the ankle help visualize the lesion.

• Ultrasound findings include thickening and hypoechogenicity of the affected ligament demonstrate a sprain.^[4]

• CT scan may be helpful in the diagnosis of ankle sprain. Findings on CT scan suggestive of sprain include thickening, thinning, irregularity, discontinuity, or an absent ligament. Sometimes bony avulsions can be visible.^[4]

• An ankle MRI may be helpful for ankle injuries involving crepitus or locking, as these symptoms may indicate a displaced osteochondral fragment.^[19]
• An MRI may help identify syndesmosis sprains and peroneal tendon involvement.^[20]

• Although treatment decisions must be made on an individual basis, functional support for most ankle sprains is the first step.^[21] Brace, tape, elastic bandage, or soft cast are preferred over immobilization.^[22] It gives the leg an exercise and yet keeps the damaged part from moving. Crutches and air-braces while conventionally used, are currently out of vogue.
• Immediately following the injury it is important the follow the PRICE protocol – Protection, Rest, Ice, Compression, and Elevation (also known as RICE: Rest, Ice, Compress, and Elevate).^[23]
• Cold therapy for 12 to 20 minutes together with compression until the swelling settles or 48 hours, is found to be helpful.^[24][25][23]
• Severe ankle sprains should be assessed by an orthopedic specialist, although physical therapy is extremely effective for most sprained ankles.
• The evidence of use of ultrasound, LASER, and manual therapy (such as anteroposterior glide of the talus, Mulligan’s mobilization with movement, chiropractic mortise adjustment technique) for reducing swelling and pain is at various levels.^{[26][27][28][21]}

• NSAIDS are helpful for analgesia (both oral or topical are effective).^[29][30][15]

• Surgical repair can be performed for patients with ruptured ankle ligaments. Operative treatment has been shown to have a better long-term outcome for residual pain, recurrent sprains and stability in a randomised clinical trial.^[31]

• Effective measures for the primary prevention of the ankle sprain include warming up before the sports.

• Sprain

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