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You are in: eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskel
Ankle Sprain
Last Updated: January 24, 2007
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AUTHOR INFORMATION
Section 1 o
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Author: Marlon P Rimando, MD, CSCS, Assistant Clinical Professor, Department of Medicine, Univ
Director of Rehabilitation, Ka Punawai Ola; Medical Director, Balance Center of the Pacific; Founder
Director, Pacific Health & Fitness Consultants
Editor(s): Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM, President and Director, Georgia Pai
PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory Univer
Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michael T And
Residency Program Director, Associate Professor, Department of Physical Medicine and Rehabilitati
State University College of Osteopathic Medicine; Kelly L Allen, MD, Consulting Staff, Department
Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical C
Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Al
Care, Immanuel Rehabilitation Center
Disclosure
INTRODUCTION
Section 2 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Background: A large percentage of musculoskeletal injuries observed in the outpatient setting invol
Sprains constitute 85% of all ankle injuries. Of these, 85% are inversion sprains. Up to one sixth of p
lost from sports results from ankle sprains. Proper rehabilitation begins with accurate diagnosis beca
patients with untreated or misdiagnosed ankle injuries develop chronic symptoms. Most injuries resp
Pain reduction is essential, but improvement of any loss of motion, strength, and/or proprioception is
important.
Pathophysiology: The lateral ankle complex (ie, the anterior talofibular, calcaneofibular, posterior ta
ligaments) is the site most commonly injured. Approximately 85% of such injuries are inversion sprai
ligaments, 5% are eversion sprains of the deltoid or medial ligament, and 10% are syndesmosis inju
Osteochondral or chondral injuries of the talar dome should be considered when diagnosing an ankl
Frequency:
In the US: Sprains of the lateral ankle complex make up 38-45% of all injuries in sports. In on
patients with ankle sprains had recurrence.
Mortality/Morbidity: Approximately 25,000 people sprain their ankles daily. Up to 40% of individuals
symptoms due to chronic instability. Because instability is a potential problem following an ankle spra
that this injury be treated aggressively to prevent further disability.
Sex: No good data suggest significant distinctions between men and women in occurrence of ankle
Age: Individuals who are older and/or less active are at risk for ankle sprain. Because they do not ta
physical activities as frequently as younger individuals, they lack conditioning and proprioceptive con
similar reasons, weekend warriors and overweight individuals are at risk for ankle injuries.
CLINICAL
Section 3 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
History: Determining the mechanism of injury is essential. Sudden intense pain and rapid onset of s
bruising suggest a ruptured ligament. Suspect neurovascular compromise if the patient complains of
describes paresthesias. Determine presence of complicating conditions (eg, arthritis, connective tiss
diabetes, neuropathy, previous ankle sprain, trauma).
Physical: Since most ankle sprains are tender during examination, observation can help the clinicia
severity of the injury.
Observe for obvious deformity and note location of ecchymosis and edema.
The patient's ability to bear weight on the affected ankle and ambulate also determines severi
patients who are able to ambulate without severe pain are unlikely to have a fracture or instab
Ankle sprains commonly are classified into the following 3 grades.
o
Grade I sprains have a mild degree of swelling, and stretch has occurred to the ligame
Weight bearing is possible.
o
Grade II sprains have a moderate degree of swelling and an incomplete tearing of ligam
structures. Mild instability may be present, but a definite end point is present on ligame
Pain may be noted with weight bearing.
o
Grade III sprains have severe swelling and are defined by at least 1 ligamentous struct
ruptured completely. Evidence of instability may be noted.
This grading system fails to go on to characterize ankle injuries involving 2 or more ligamento
excludes consideration of other nonligamentous injuries.
Drawer and talar tilt examination techniques are used to assess ankle instability; however, the
techniques is in question with acute injuries because of pain, edema, and muscle spasm. The
compression, or squeeze test, is used if a syndesmotic or fibular injury is suspected.
o
Perform the anterior drawer test with the ankle at 90° to the leg. Grasp the heel and pu
with the other hand, placing posterior force on the tibia. If the test is positive, the so-ca
occurs. Dimpling is observed at the anterolateral aspect of the ankle, indicating compro
anterior talofibular ligament. A firm end point will also be absent.
o
The talar tilt test also is performed with the ankle at 90° to the leg. Abduct and invert th
end point cannot be felt when compared to the opposite ankle, suspect damage to the
ligament. Note that the degree of tilt ranges from 0-23°.
o
To perform the squeeze test, place the thumb on the tibia and the fingers on the fibula
the lower leg. Then, squeeze the tibia and fibula together. Consider pain along the leng
which indicates a positive test result.
Causes: Typically, plantarflexion and inversion of the foot occur, perhaps as the result of uneven ter
the foot of another athlete. Overloading the peroneal muscles also may play a role. Invariably, ankle
trauma.
Forced external rotation of the ankle results in a syndesmotic, or high, ankle sprain. These inj
frequently than inversion injuries, but they are more disabling and require prolonged recovery
Recurrent ankle sprains or chronic lateral instability are consequences of Grade III ankle spra
DIFFERENTIALS
Section 4 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Achilles Tendon Injuries and Tendonitis
Complex Regional Pain Syndromes
Postexercise Muscle Soreness
Stress Fracture
Other Problems to be Considered:
Distal fibula fracture
Fifth metatarsal fracture
Navicular fracture
Peroneal tendon dislocation
Acute gout exacerbation
WORKUP
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Lab Studies:
Lab tests typically are not necessary for acute ankle sprains related to trauma or sports injury
rheumatologic condition is suggested.
Imaging Studies:
Plain films of the ankle are not always necessary. Stress x-ray films may provide further asses
patient cooperation may be limited, depending on the severity of the injury. Obtain radiograph
o
Bone tenderness is evidenced upon palpation of the posterior edge or tip of the medial
of the fifth metatarsal bones.
o
Patient shows inability to bear weight, which should alert the clinician to possible fractu
Computed tomography (CT) scanning may be indicated if imaging of soft tissues is warranted
is indicated. In complex injuries, 3-dimensional CT scanning may be useful.
Magnetic resonance imaging (MRI) may be useful when osteochondrosis or meniscoid injury
recurrent ankle sprains and chronic pain.
A bone scan can detect subtle bone abnormalities (eg, stress fracture, osteochondral defects)
syndesmotic disruption.
Other Tests:
Arthroscopy of the ankle may be used diagnostically and therapeutically in subacute or chron
indicated if osteophytes, meniscoid lesions, foreign bodies, or osteochondral defects are pres
TREATMENT
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Rehabilitation Program:
Physical Therapy: Physicians frequently recommend physical therapy for patients who have
sprains, especially those who have chronic instability and recurring symptoms. Following the
provide therapeutic modalities (eg, cryotherapy, electrical muscle stimulation) to speed the red
patient progresses and is able to tolerate further therapy, the goals should be aimed at regain
strength, and stability of the ankle joint. (See the Further Outpatient Care section.)
The physical therapist also completes patient education throughout the rehabilitation process
exercise program for each individual patient. The goal of the program should be to enable the
level of activity. For less severe injuries, immediate protected ambulation should be encourag
emphasize return of ROM, strength, endurance, and proprioception.
Medical Issues/Complications: Treatment goals during the acute phase of injury are to minimize s
walking. The acute phase of treatment should last 1-3 days following the injury. A combination of pro
elevation, and support is used. Remember this approach with the mnemonic PRICES.
Protection: Protective devices include air splints or plastic and Velcro braces. Most sprains ca
on the severity of the sprain, protective devices are used 4-21 days. Criteria to discontinue us
and pain at the site of injury. ROM should be smooth, particularly with dorsiflexion and plantar
Relative rest: Relative rest is advocated, as it promotes tissue healing. Advise the patient to a
or swelling. Advocate early pain-free movements during this time. Patient may perform alphab
tolerated, to maintain ROM.
Ice: Use ice to control swelling, pain, and muscle spasm. As a rule, do not apply ice or cold pa
a towel before use. Recommend that the patient apply ice for 15-20 minutes, 3 times daily. Co
after injury.
Compression: Recommend use of compression with an ACE wrap, elastic ankle sleeve, or lac
that further support of the ankle can be facilitated by wearing high-top lace-up shoes. This can
Elevation: Encourage elevation of the injured ankle to facilitate reduction of swelling. Advise th
level of the heart.
Support: This can include taping or the use of lace-up ankle supports with combination hook-e
Surgical Intervention: Surgery may be indicated when the fibulocalcaneal ligament is torn or a disp
Most ankle sprains do not require surgical intervention.
Consultations: Consultations seldom are indicated unless the physician suspects an unstable ankle
injuries and fractures heal well with guarded weight bearing and guarded motion for 4-6 weeks and a
outlined above. Surgical intervention by an orthopedic or podiatric surgeon may be warranted in thes
determine a comfort level in treating a particular condition. Once that level has been exceeded, cons
is indicated.
MEDICATION
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) frequently are used to control pain an
has the prerogative to determine the most appropriate medication.
Drug Category: Analgesics -- Pain control is essential to quality patient care. Analgesics ensure p
toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or
Drug Name
Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin) -- Used for m
pain or if patient cannot tolerate NSAIDs.
Adult Dose
325-1000 mg PO/PR q4-6h; not to exceed 1 g/dose or 4 g/24 h
Pediatric Dose
<12 years: 10-15 mg/kg PO/PR q6-8h prn
>12 years: 325-650 mg PO/PR q4-6h prn; not to exceed 4g/24h
Contraindications
Documented hypersensitivity; chronic alcohol use; G6PD deficiency;
PKU
Interactions
Rifampin can reduce analgesic effects of acetaminophen;
coadministration with barbiturates, carbamazepine, hydantoins, and
isoniazid may increase hepatotoxicity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Common reactions include rash, urticaria, and nausea; serious
reactions include hepatotoxicity, nephrotoxicity, agranulocytosis,
pancytopenia, thrombocytopenia, hemolytic anemia, pancreatitis, and
angioedema; caution in impaired liver or renal function; hepatotoxicity
possible in chronic alcoholics following various dose levels; severe o
recurrent pain or high or continued fever may indicate a serious illnes
acetaminophen (APAP) is contained in many OTC products and
combined use with these products may result in cumulative APAP
doses exceeding recommended maximum dose
Drug Category: Nonsteroidal anti-inflammatory drugs -- If significant ecchymoses is observed
not prescribing for 24-48 h, which may prevent further hemorrhage into the site of injury. Several oth
listed here are considered first-line drugs on most formularies.
Drug Name
Ibuprofen (Ibuprin, Motrin) -- Used for analgesia and anti-inflammator
effect; take with food.
Adult Dose
Mild to moderate pain: 400 mg PO q4-6h; not to exceed 2400 mg/d
Anti-inflammatory use: 600 mg PO qid or 800 mg PO tid x 7-14 d; no
exceed 2400 mg/d
Pediatric Dose
4-10 mg/kg PO q6-8h prn; not to exceed 50 mg/kg/d
Contraindications
Documented hypersensitivity; peptic ulcer disease, recent GI bleedin
or perforation, renal insufficiency, or high risk of bleeding; ASA/NSAID
induced asthma
Interactions
Coadministration with aspirin increases risk of inducing serious NSAI
related side 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 wat
for signs of bleeding); may increase risk of methotrexate toxicity;
phenytoin levels may be increased when administered concurrently
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; caution in congestive hea
failure (CHF), hypertension, and decreased renal and hepatic functio
caution in anticoagulation abnormalities or during anticoagulant thera
Common reactions include dyspepsia, nausea, abdominal pain,
headache, dizziness, rash, elevated liver enzymes, urticaria,
drowsiness, fluid retention, and tinnitus; serious reactions include
anaphylaxis, GI bleed, acute renal failure, bronchospasm,
thrombocytopenia, Stevens-Johnson syndrome, interstitial nephritis,
hepatotoxicity, and agranulocytosis
Drug Name
Naproxen (Aleve, Naprelan, Naprosyn, Anaprox) -- Used as an
analgesic and anti-inflammatory medication; take with food.
Adult Dose
Mild to moderate pain and anti-inflammatory uses: 250-500 mg PO b
not to exceed 1500 mg/d x 3-5d
Pediatric Dose
10-20 mg/kg/d PO divided q8-12h
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleedin
or perforation; renal insufficiency; ASA/NSAID-induced asthma
Interactions
Coadministration with aspirin increases risk of inducing serious NSAI
related side 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 wat
for signs of bleeding); may increase risk of methotrexate toxicity;
phenytoin levels may be increased when administered concurrently
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; 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 occu
rarely, is transient, and usually returns to normal during therapy;
persistent leukopenia, granulocytopenia, or thrombocytopenia warran
further evaluation and may require discontinuation of drug; common
reactions include dyspepsia, nausea, abdominal pain, headache,
dizziness, rash, elevated liver enzymes, urticaria, drowsiness, fluid
retention, elevated liver enzymes, and tinnitus; serious reactions
include anaphylaxis, acute renal failure, bronchospasm,
thrombocytopenia, Stevens-Johnson syndrome, interstitial nephritis,
hepatotoxicity, and agranulocytosis; caution with nasal polyps; GI ble
advanced age; hypertension; CHF
FOLLOW-UP
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Further Outpatient Care:
The recovery phase of rehabilitation begins after the third day of injury and may last up to 2 w
have the patient walk without a limp. Continue ice and elevation if swelling persists. Some pai
however, reevaluate the patient if pain persists.
Initiate therapeutic exercises, including flexibility/ROM, strengthening, and proprioceptive/bala
o
Encourage active ankle motion in inversion and eversion. Add standing lower leg stretc
Achilles tendon) or non–weight-bearing towel stretches to the regimen.
o
Begin strengthening exercises with isometrics. Then, recommend progressing to close
elastic bands or rubber tubing for open-chain loading.
o
Recommend beginning proprioceptive or balance training on the injured leg. As an add
a pillow 2-3 times per day. A wobble board may be helpful during this time, depending o
o
Recovery phase return-to-play criteria include the following:
Full pain-free active and passive ROM
No pain or tenderness
Strength of ankle muscles 70-80% of the uninvolved side
Balance on one leg for 30 seconds with eyes closed
The functional phase of rehabilitation lasts 2-6 weeks. The goal is to return patient to previous
achieved, rehabilitation is complete.
o
The 3 components addressed in the recovery phase reflect an advanced stage of reha
ROM. Strengthening continues with advanced open-chain and closed-chain exercises.
power, including line jumping, 5-point drill, jump rope, and plyometrics.
o
Supportive devices still can be used if the patient is participating in strenuous or compe
examples of these devices.
o
Functional phase return-to-play criteria include the following:
Normal ROM of the ankle joint
No pain or tenderness
Satisfactory clinical examination
Strength of ankle muscles 90% of the uninvolved side
Ability to complete functional examination
Deterrence/Prevention:
Prevention of future ankle sprains depends on the type of activity engaged in. Certain sports (
high incidence of ankle sprains.
The athlete must understand the importance of adequate training and conditioning to prevent
severity. An adequate warm-up period and gradual transition into activity are general principle
future injury. The athlete should wear shoes with good stability and exercise on even surfaces
ankle braces, Velcro ankle braces, and/or ankle taping may add stability during activities and
Complications:
Complications following ankle sprain are limited. If pain persists despite rehabilitation, further
consider include the following:
o
Chronic lateral ankle instability typically is accompanied by the patient's feeling unstabl
recovery is prolonged.
o
Intra-articular meniscoid lesions represent localized fibrotic synovitis in the lateral ankle
condition also is known as impingement syndrome.
o
Peroneal tendon subluxation is due to detachment of the peroneal retinaculum from its
border of the fibula to the lateral surface of the fibula.
o
Talar dome fracture occurs with inversion and eversion injuries, but it may not be seen
o
Anterior process fracture of the calcaneus occurs with inversion injuries. Patients comm
than ligamentous point tenderness.
o
Complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy, can develo
Regional Pain Syndromes). The reason for this is unknown; however, the condition ma
and/or splinting of the foot and ankle. Early controlled activity and rehabilitation may pr
Prognosis:
Outcomes following ankle sprains are usually very favorable; however, more severe sprains, e
ligament disruption, may have prolonged or permanent ankle instability and symptoms. Strict
principles outlined maximizes potential for proper recovery.
Patient Education:
Review the self-care techniques of acute sprain with patients, so that they can take an active
mnemonic PRICES.
Provide information on when to call for advice. Instruct the patient to call a doctor or nurse if o
observed:
o
The joint is wobbly or moves past its normal ROM.
o
The bone is deformed or bends abnormally.
o
Pain prevents putting weight on the injured area after 24 hours.
o
Weight bearing still is difficult after 4 days.
o
Extreme pain, bruising, or severe swelling are present.
o
The toes below the injury feel cold to the touch, or they become numb or blue.
These instructions can be tailored to each individual practice and by no means should be con
For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Cente
education articles Ankle Sprain and Sprains and Strains.
MISCELLANEOUS
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Medical/Legal Pitfalls:
Failure to perform a thorough examination following a traumatic ankle injury
Failure to diagnose one or more of the following represent typical medicolegal pitfalls:
o Peroneal nerve injury
o Severe peroneal tendon injury
o Occult fracture
o Compartment syndrome
PICTURES
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Caption: Picture 1. Example of lace-up ankle support. Courtesy of Swede-O, Inc.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 2. Example of a brace for immobilization or functional purposes.
Courtesy of Swede-O, Inc.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 3. Example of a brace that can be used for functional purposes.
Courtesy of Swede-O, Inc.
View Full Size Image
eMedicine Zoom View
(Interactive!)
Picture Type: Photo
Caption: Picture 4. Example of a brace secured with Velcro straps. Courtesy of
Swede-O, Inc.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 5. Example of a lace-up ankle support brace with figure-8 straps.
Courtesy of Swede-O, Inc.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Photo
BIBLIOGRAPHY
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Bencardino J, Rosenberg ZS, Delfaut E: MR imaging in sports injuries of the foot and ankle. M
131-49.
DeLee JC, Drez D: Orthopaedic Sports Medicine: Principles and Practice. Vol 2. WB Saunder
Foster AP, Thompson NW, Crone MD: Rupture of the tibialis posterior tendon: an important di
injuries. Emerg Med J. 2005; 22: 915-6.
Hubbard TJ, Denegar CR: Does Cryotherapy Improve Outcomes With Soft Tissue Injury?. J A
279[Medline].
Ivins D: Acute ankle sprain: an update. Am Fam Physician 2006 Nov 15; 74(10): 1714-20[Med
Kibler WB: Rehabilitation of the ankle and foot. Functional Rehabilitation of Sports and Muscu
Inc; 1998:273-279.
LeBlanc KE: Ankle problems masquerading as sprains. Prim Care 2004 Dec; 31(4): 1055-67[
Man IO, Morrissey MC: Relationship between ankle-foot swelling and self-assessed function a
2005 Mar; 37(3): 360-3[Medline].
Singer KM, Jones DC: Ligament injuries of the ankle and foot. The Lower Extremity and Spine
497.
Singh-Ranger G, Marathias A: Comparison of current local practice and the Ottawa Ankle Rul
radiography in acute ankle injury. Accid Emerg Nurs 1999 Oct; 7(4): 201-6[Medline].
Windsor RE: Overuse injuries of the leg, ankle and foot. PM&R Clinics of North America: Spo
NOTE:
Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors,
efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical
possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate
errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particul
be confirmed in the package insert. FULL DISCLAIMER
Ankle Sprain excerpt
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Consumer Health
You are in: eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskel
Ankle Sprain
Last Updated: January 24, 2007
Rate this Article
Email to a Colleague
Get CME/CE for article
AUTHOR INFORMATION
Section 1 o
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Author: Marlon P Rimando, MD, CSCS, Assistant Clinical Professor, Department of Medicine, Univ
Director of Rehabilitation, Ka Punawai Ola; Medical Director, Balance Center of the Pacific; Founder
Director, Pacific Health & Fitness Consultants
Editor(s): Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM, President and Director, Georgia Pai
PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory Univer
Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michael T And
Residency Program Director, Associate Professor, Department of Physical Medicine and Rehabilitati
State University College of Osteopathic Medicine; Kelly L Allen, MD, Consulting Staff, Department
Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical C
Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Al
Care, Immanuel Rehabilitation Center
Disclosure
INTRODUCTION
Section 2 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Background: A large percentage of musculoskeletal injuries observed in the outpatient setting invol
Sprains constitute 85% of all ankle injuries. Of these, 85% are inversion sprains. Up to one sixth of p
lost from sports results from ankle sprains. Proper rehabilitation begins with accurate diagnosis beca
patients with untreated or misdiagnosed ankle injuries develop chronic symptoms. Most injuries resp
Pain reduction is essential, but improvement of any loss of motion, strength, and/or proprioception is
important.
Pathophysiology: The lateral ankle complex (ie, the anterior talofibular, calcaneofibular, posterior ta
ligaments) is the site most commonly injured. Approximately 85% of such injuries are inversion sprai
ligaments, 5% are eversion sprains of the deltoid or medial ligament, and 10% are syndesmosis inju
Osteochondral or chondral injuries of the talar dome should be considered when diagnosing an ankl
Frequency:
In the US: Sprains of the lateral ankle complex make up 38-45% of all injuries in sports. In on
patients with ankle sprains had recurrence.
Mortality/Morbidity: Approximately 25,000 people sprain their ankles daily. Up to 40% of individuals
symptoms due to chronic instability. Because instability is a potential problem following an ankle spra
that this injury be treated aggressively to prevent further disability.
Sex: No good data suggest significant distinctions between men and women in occurrence of ankle
Age: Individuals who are older and/or less active are at risk for ankle sprain. Because they do not ta
physical activities as frequently as younger individuals, they lack conditioning and proprioceptive con
similar reasons, weekend warriors and overweight individuals are at risk for ankle injuries.
CLINICAL
Section 3 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
History: Determining the mechanism of injury is essential. Sudden intense pain and rapid onset of s
bruising suggest a ruptured ligament. Suspect neurovascular compromise if the patient complains of
describes paresthesias. Determine presence of complicating conditions (eg, arthritis, connective tiss
diabetes, neuropathy, previous ankle sprain, trauma).
Physical: Since most ankle sprains are tender during examination, observation can help the clinicia
severity of the injury.
Observe for obvious deformity and note location of ecchymosis and edema.
The patient's ability to bear weight on the affected ankle and ambulate also determines severi
patients who are able to ambulate without severe pain are unlikely to have a fracture or instab
Ankle sprains commonly are classified into the following 3 grades.
o
Grade I sprains have a mild degree of swelling, and stretch has occurred to the ligame
Weight bearing is possible.
o
Grade II sprains have a moderate degree of swelling and an incomplete tearing of ligam
structures. Mild instability may be present, but a definite end point is present on ligame
Pain may be noted with weight bearing.
o
Grade III sprains have severe swelling and are defined by at least 1 ligamentous struct
ruptured completely. Evidence of instability may be noted.
This grading system fails to go on to characterize ankle injuries involving 2 or more ligamento
excludes consideration of other nonligamentous injuries.
Drawer and talar tilt examination techniques are used to assess ankle instability; however, the
techniques is in question with acute injuries because of pain, edema, and muscle spasm. The
compression, or squeeze test, is used if a syndesmotic or fibular injury is suspected.
o
Perform the anterior drawer test with the ankle at 90° to the leg. Grasp the heel and pu
with the other hand, placing posterior force on the tibia. If the test is positive, the so-ca
occurs. Dimpling is observed at the anterolateral aspect of the ankle, indicating compro
anterior talofibular ligament. A firm end point will also be absent.
o
The talar tilt test also is performed with the ankle at 90° to the leg. Abduct and invert th
end point cannot be felt when compared to the opposite ankle, suspect damage to the
ligament. Note that the degree of tilt ranges from 0-23°.
o
To perform the squeeze test, place the thumb on the tibia and the fingers on the fibula
the lower leg. Then, squeeze the tibia and fibula together. Consider pain along the leng
which indicates a positive test result.
Causes: Typically, plantarflexion and inversion of the foot occur, perhaps as the result of uneven ter
the foot of another athlete. Overloading the peroneal muscles also may play a role. Invariably, ankle
trauma.
Forced external rotation of the ankle results in a syndesmotic, or high, ankle sprain. These inj
frequently than inversion injuries, but they are more disabling and require prolonged recovery
Recurrent ankle sprains or chronic lateral instability are consequences of Grade III ankle spra
DIFFERENTIALS
Section 4 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Achilles Tendon Injuries and Tendonitis
Complex Regional Pain Syndromes
Postexercise Muscle Soreness
Stress Fracture
Other Problems to be Considered:
Distal fibula fracture
Fifth metatarsal fracture
Navicular fracture
Peroneal tendon dislocation
Acute gout exacerbation
WORKUP
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Lab Studies:
Lab tests typically are not necessary for acute ankle sprains related to trauma or sports injury
rheumatologic condition is suggested.
Imaging Studies:
Plain films of the ankle are not always necessary. Stress x-ray films may provide further asses
patient cooperation may be limited, depending on the severity of the injury. Obtain radiograph
o
Bone tenderness is evidenced upon palpation of the posterior edge or tip of the medial
of the fifth metatarsal bones.
o
Patient shows inability to bear weight, which should alert the clinician to possible fractu
Computed tomography (CT) scanning may be indicated if imaging of soft tissues is warranted
is indicated. In complex injuries, 3-dimensional CT scanning may be useful.
Magnetic resonance imaging (MRI) may be useful when osteochondrosis or meniscoid injury
recurrent ankle sprains and chronic pain.
A bone scan can detect subtle bone abnormalities (eg, stress fracture, osteochondral defects)
syndesmotic disruption.
Other Tests:
Arthroscopy of the ankle may be used diagnostically and therapeutically in subacute or chron
indicated if osteophytes, meniscoid lesions, foreign bodies, or osteochondral defects are pres
TREATMENT
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Rehabilitation Program:
Physical Therapy: Physicians frequently recommend physical therapy for patients who have
sprains, especially those who have chronic instability and recurring symptoms. Following the
provide therapeutic modalities (eg, cryotherapy, electrical muscle stimulation) to speed the red
patient progresses and is able to tolerate further therapy, the goals should be aimed at regain
strength, and stability of the ankle joint. (See the Further Outpatient Care section.)
The physical therapist also completes patient education throughout the rehabilitation process
exercise program for each individual patient. The goal of the program should be to enable the
level of activity. For less severe injuries, immediate protected ambulation should be encourag
emphasize return of ROM, strength, endurance, and proprioception.
Medical Issues/Complications: Treatment goals during the acute phase of injury are to minimize s
walking. The acute phase of treatment should last 1-3 days following the injury. A combination of pro
elevation, and support is used. Remember this approach with the mnemonic PRICES.
Protection: Protective devices include air splints or plastic and Velcro braces. Most sprains ca
on the severity of the sprain, protective devices are used 4-21 days. Criteria to discontinue us
and pain at the site of injury. ROM should be smooth, particularly with dorsiflexion and plantar
Relative rest: Relative rest is advocated, as it promotes tissue healing. Advise the patient to a
or swelling. Advocate early pain-free movements during this time. Patient may perform alphab
tolerated, to maintain ROM.
Ice: Use ice to control swelling, pain, and muscle spasm. As a rule, do not apply ice or cold pa
a towel before use. Recommend that the patient apply ice for 15-20 minutes, 3 times daily. Co
after injury.
Compression: Recommend use of compression with an ACE wrap, elastic ankle sleeve, or lac
that further support of the ankle can be facilitated by wearing high-top lace-up shoes. This can
Elevation: Encourage elevation of the injured ankle to facilitate reduction of swelling. Advise th
level of the heart.
Support: This can include taping or the use of lace-up ankle supports with combination hook-e
Surgical Intervention: Surgery may be indicated when the fibulocalcaneal ligament is torn or a disp
Most ankle sprains do not require surgical intervention.
Consultations: Consultations seldom are indicated unless the physician suspects an unstable ankle
injuries and fractures heal well with guarded weight bearing and guarded motion for 4-6 weeks and a
outlined above. Surgical intervention by an orthopedic or podiatric surgeon may be warranted in thes
determine a comfort level in treating a particular condition. Once that level has been exceeded, cons
is indicated.
MEDICATION
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) frequently are used to control pain an
has the prerogative to determine the most appropriate medication.
Drug Category: Analgesics -- Pain control is essential to quality patient care. Analgesics ensure p
toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or
Drug Name
Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin) -- Used for m
pain or if patient cannot tolerate NSAIDs.
Adult Dose
325-1000 mg PO/PR q4-6h; not to exceed 1 g/dose or 4 g/24 h
Pediatric Dose
<12 years: 10-15 mg/kg PO/PR q6-8h prn
>12 years: 325-650 mg PO/PR q4-6h prn; not to exceed 4g/24h
Contraindications
Documented hypersensitivity; chronic alcohol use; G6PD deficiency;
PKU
Interactions
Rifampin can reduce analgesic effects of acetaminophen;
coadministration with barbiturates, carbamazepine, hydantoins, and
isoniazid may increase hepatotoxicity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Common reactions include rash, urticaria, and nausea; serious
reactions include hepatotoxicity, nephrotoxicity, agranulocytosis,
pancytopenia, thrombocytopenia, hemolytic anemia, pancreatitis, and
angioedema; caution in impaired liver or renal function; hepatotoxicity
possible in chronic alcoholics following various dose levels; severe o
recurrent pain or high or continued fever may indicate a serious illnes
acetaminophen (APAP) is contained in many OTC products and
combined use with these products may result in cumulative APAP
doses exceeding recommended maximum dose
Drug Category: Nonsteroidal anti-inflammatory drugs -- If significant ecchymoses is observed
not prescribing for 24-48 h, which may prevent further hemorrhage into the site of injury. Several oth
listed here are considered first-line drugs on most formularies.
Drug Name
Ibuprofen (Ibuprin, Motrin) -- Used for analgesia and anti-inflammator
effect; take with food.
Adult Dose
Mild to moderate pain: 400 mg PO q4-6h; not to exceed 2400 mg/d
Anti-inflammatory use: 600 mg PO qid or 800 mg PO tid x 7-14 d; no
exceed 2400 mg/d
Pediatric Dose
4-10 mg/kg PO q6-8h prn; not to exceed 50 mg/kg/d
Contraindications
Documented hypersensitivity; peptic ulcer disease, recent GI bleedin
or perforation, renal insufficiency, or high risk of bleeding; ASA/NSAID
induced asthma
Interactions
Coadministration with aspirin increases risk of inducing serious NSAI
related side 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 wat
for signs of bleeding); may increase risk of methotrexate toxicity;
phenytoin levels may be increased when administered concurrently
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; caution in congestive hea
failure (CHF), hypertension, and decreased renal and hepatic functio
caution in anticoagulation abnormalities or during anticoagulant thera
Common reactions include dyspepsia, nausea, abdominal pain,
headache, dizziness, rash, elevated liver enzymes, urticaria,
drowsiness, fluid retention, and tinnitus; serious reactions include
anaphylaxis, GI bleed, acute renal failure, bronchospasm,
thrombocytopenia, Stevens-Johnson syndrome, interstitial nephritis,
hepatotoxicity, and agranulocytosis
Drug Name
Naproxen (Aleve, Naprelan, Naprosyn, Anaprox) -- Used as an
analgesic and anti-inflammatory medication; take with food.
Adult Dose
Mild to moderate pain and anti-inflammatory uses: 250-500 mg PO b
not to exceed 1500 mg/d x 3-5d
Pediatric Dose
10-20 mg/kg/d PO divided q8-12h
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleedin
or perforation; renal insufficiency; ASA/NSAID-induced asthma
Interactions
Coadministration with aspirin increases risk of inducing serious NSAI
related side 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 wat
for signs of bleeding); may increase risk of methotrexate toxicity;
phenytoin levels may be increased when administered concurrently
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; 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 occu
rarely, is transient, and usually returns to normal during therapy;
persistent leukopenia, granulocytopenia, or thrombocytopenia warran
further evaluation and may require discontinuation of drug; common
reactions include dyspepsia, nausea, abdominal pain, headache,
dizziness, rash, elevated liver enzymes, urticaria, drowsiness, fluid
retention, elevated liver enzymes, and tinnitus; serious reactions
include anaphylaxis, acute renal failure, bronchospasm,
thrombocytopenia, Stevens-Johnson syndrome, interstitial nephritis,
hepatotoxicity, and agranulocytosis; caution with nasal polyps; GI ble
advanced age; hypertension; CHF
FOLLOW-UP
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Further Outpatient Care:
The recovery phase of rehabilitation begins after the third day of injury and may last up to 2 w
have the patient walk without a limp. Continue ice and elevation if swelling persists. Some pai
however, reevaluate the patient if pain persists.
Initiate therapeutic exercises, including flexibility/ROM, strengthening, and proprioceptive/bala
o
Encourage active ankle motion in inversion and eversion. Add standing lower leg stretc
Achilles tendon) or non–weight-bearing towel stretches to the regimen.
o
Begin strengthening exercises with isometrics. Then, recommend progressing to close
elastic bands or rubber tubing for open-chain loading.
o
Recommend beginning proprioceptive or balance training on the injured leg. As an add
a pillow 2-3 times per day. A wobble board may be helpful during this time, depending o
o
Recovery phase return-to-play criteria include the following:
Full pain-free active and passive ROM
No pain or tenderness
Strength of ankle muscles 70-80% of the uninvolved side
Balance on one leg for 30 seconds with eyes closed
The functional phase of rehabilitation lasts 2-6 weeks. The goal is to return patient to previous
achieved, rehabilitation is complete.
o
The 3 components addressed in the recovery phase reflect an advanced stage of reha
ROM. Strengthening continues with advanced open-chain and closed-chain exercises.
power, including line jumping, 5-point drill, jump rope, and plyometrics.
o
Supportive devices still can be used if the patient is participating in strenuous or compe
examples of these devices.
o
Functional phase return-to-play criteria include the following:
Normal ROM of the ankle joint
No pain or tenderness
Satisfactory clinical examination
Strength of ankle muscles 90% of the uninvolved side
Ability to complete functional examination
Deterrence/Prevention:
Prevention of future ankle sprains depends on the type of activity engaged in. Certain sports (
high incidence of ankle sprains.
The athlete must understand the importance of adequate training and conditioning to prevent
severity. An adequate warm-up period and gradual transition into activity are general principle
future injury. The athlete should wear shoes with good stability and exercise on even surfaces
ankle braces, Velcro ankle braces, and/or ankle taping may add stability during activities and
Complications:
Complications following ankle sprain are limited. If pain persists despite rehabilitation, further
consider include the following:
o
Chronic lateral ankle instability typically is accompanied by the patient's feeling unstabl
recovery is prolonged.
o
Intra-articular meniscoid lesions represent localized fibrotic synovitis in the lateral ankle
condition also is known as impingement syndrome.
o
Peroneal tendon subluxation is due to detachment of the peroneal retinaculum from its
border of the fibula to the lateral surface of the fibula.
o
Talar dome fracture occurs with inversion and eversion injuries, but it may not be seen
o
Anterior process fracture of the calcaneus occurs with inversion injuries. Patients comm
than ligamentous point tenderness.
o
Complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy, can develo
Regional Pain Syndromes). The reason for this is unknown; however, the condition ma
and/or splinting of the foot and ankle. Early controlled activity and rehabilitation may pr
Prognosis:
Outcomes following ankle sprains are usually very favorable; however, more severe sprains, e
ligament disruption, may have prolonged or permanent ankle instability and symptoms. Strict
principles outlined maximizes potential for proper recovery.
Patient Education:
Review the self-care techniques of acute sprain with patients, so that they can take an active
mnemonic PRICES.
Provide information on when to call for advice. Instruct the patient to call a doctor or nurse if o
observed:
o
The joint is wobbly or moves past its normal ROM.
o
The bone is deformed or bends abnormally.
o
Pain prevents putting weight on the injured area after 24 hours.
o
Weight bearing still is difficult after 4 days.
o
Extreme pain, bruising, or severe swelling are present.
o
The toes below the injury feel cold to the touch, or they become numb or blue.
These instructions can be tailored to each individual practice and by no means should be con
For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Cente
education articles Ankle Sprain and Sprains and Strains.
MISCELLANEOUS
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Medical/Legal Pitfalls:
Failure to perform a thorough examination following a traumatic ankle injury
Failure to diagnose one or more of the following represent typical medicolegal pitfalls:
o Peroneal nerve injury
o Severe peroneal tendon injury
o Occult fracture
o Compartment syndrome
PICTURES
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Caption: Picture 1. Example of lace-up ankle support. Courtesy of Swede-O, Inc.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 2. Example of a brace for immobilization or functional purposes.
Courtesy of Swede-O, Inc.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 3. Example of a brace that can be used for functional purposes.
Courtesy of Swede-O, Inc.
View Full Size Image
eMedicine Zoom View
(Interactive!)
Picture Type: Photo
Caption: Picture 4. Example of a brace secured with Velcro straps. Courtesy of
Swede-O, Inc.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Photo
Caption: Picture 5. Example of a lace-up ankle support brace with figure-8 straps.
Courtesy of Swede-O, Inc.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: Photo
BIBLIOGRAPHY
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Bencardino J, Rosenberg ZS, Delfaut E: MR imaging in sports injuries of the foot and ankle. M
131-49.
DeLee JC, Drez D: Orthopaedic Sports Medicine: Principles and Practice. Vol 2. WB Saunder
Foster AP, Thompson NW, Crone MD: Rupture of the tibialis posterior tendon: an important di
injuries. Emerg Med J. 2005; 22: 915-6.
Hubbard TJ, Denegar CR: Does Cryotherapy Improve Outcomes With Soft Tissue Injury?. J A
279[Medline].
Ivins D: Acute ankle sprain: an update. Am Fam Physician 2006 Nov 15; 74(10): 1714-20[Med
Kibler WB: Rehabilitation of the ankle and foot. Functional Rehabilitation of Sports and Muscu
Inc; 1998:273-279.
LeBlanc KE: Ankle problems masquerading as sprains. Prim Care 2004 Dec; 31(4): 1055-67[
Man IO, Morrissey MC: Relationship between ankle-foot swelling and self-assessed function a
2005 Mar; 37(3): 360-3[Medline].
Singer KM, Jones DC: Ligament injuries of the ankle and foot. The Lower Extremity and Spine
497.
Singh-Ranger G, Marathias A: Comparison of current local practice and the Ottawa Ankle Rul
radiography in acute ankle injury. Accid Emerg Nurs 1999 Oct; 7(4): 201-6[Medline].
Windsor RE: Overuse injuries of the leg, ankle and foot. PM&R Clinics of North America: Spo
NOTE:
Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors,
efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical
possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate
errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particul
be confirmed in the package insert. FULL DISCLAIMER
Ankle Sprain excerpt
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