Mark Leung, MD, MSc , CCFP(SEM), Dip Sport Med - PowerPoint Presentation

Slide1

Mark Leung, MD,

MSc

, CCFP(SEM), Dip Sport Med

Director, Enhanced Skills Program in Sport & Exercise Medicine

ANKLE SPRAINS:

A Primary Care UpdateSlide2

Faculty/Presenter

d

isclosure

Faculty:

Dr. Mark LeungRelationships with commercial interests: NoneDr. Mark Leung, MD, MSc, CCFP, Dip Sport Med

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Acute lateral ankle sprains

Classification of lateral ankle sprain, treatment, preventionSyndesmosis (“high ankle”) sprainMechanism of injury, anatomy, diagnosis, imaging, grading, and conservative treatment

Deltoid ligament sprainAnatomy, diagnosis, treatmentReturn to play

OutlineSlide4

High prevalenceNCAA studies – of all injuries, basketball (25%), W Volleyball (20%)

UEFA study – top 4 injuries, 40% of allHigh propensity for development of residual symptoms

40% develop chronic instability at 1 year (Gerber et al., 1998)Natural historyFollowing sprain, 2 weeks of rapid improvementFollowed by 2 weeks of slower improvementMost report residual pain at 1 year post-injury

Ankle Sprain

= Ligament InjurySlide5

AgeMechanism of injury

Initial ability to weight bearPotential role for imagingSeriousness of injuryPop/snap

Ligament or tendon rupture Avulsion fracturePrevious injury

Acute Ankle

HistorySlide6

85% of ankle injuries are isolated lateral ligament injuries Among lateral ligament sprains (Bridgman et al, 2003,

Holmer et al., 1994) 80% involve ATFL

20% further involve CFL Mechanism of injury plantar flexion with inversion:ATFL most vulnerable because:

“Narrow” posterior talusATFL length and inherent relative tensile strength

GradingSeveral available, none superior

Sport-specific grading – Hertel et al., 2004; Mallioparous et al., 2006Lateral Ligament: DiagnosisSlide7

Several classification schemes, most useful in RTP prediction:

Limping?

Joint effusion?

Functional testing?

Grade 1:

MildGrade 2: Obvious limp, unable do functional testGrade 3: Unable to weight bear, massive joint effusion Dr. Mark Leung, MD, MSc, CCFP, Dip Sport Med

Mallioparous

et al., 2006

Ankle Sprain ClassificationSlide8

Grade 1: AROM ≤5º reduced, EDE ≤ 0.5cm, AD and TT neg

Grade 2: AROM 5-10º reduced, EDE 0.5-2cm, AD pos, TT

neg Grade 3: AROM ≥10º reduced, EDE > 2cm, AD and TT positiveRTP allowed when:AROM ≤ 5º + isokinetic strength TA, P, G are 85% of unaffected

side + neg advanced hop test

Grade 1: 7-10 daysGrade 2: 2-3 weeksGrade 3a: 4 weeks

Grade 3b: 8 weeksMallioparous et al., 2006Ankle Sprain R.E.S. ClassificationSlide9

Acute management - Re-look at PRICE?

P  Brace/Tape (Grade

1 and 2) (Fatoye & Haigh, 2016) OR Aircast boot (Grade 3)

(CAST Trial, 2009)

R 

Earlier RTP with weightbearing (Cochrane Review 2007)I  Analgesia – good for numbing, minimal harm, but anti-inflammatory effect unlikelyC  VERY important! Less joint effusion, more rapid return to normal functionE  Same as ’C’What’s missing?Early active ROM Isometric strengthening! (Functional gains and reduced pain scores similar to NSAIDs)RCT of non-supervised home exercise program (BMJ) – balance/proprioception 3/week x 30 minutes after return to sport (Hupperets

et al., 2009)Reduced absolute recurrence rate significantly by 12%

NNT = 9Peri-articular HA injections followed by standard care? (Petrella

et al., 2007)

Lateral Ligament: TreatmentSlide10

Good evidence for brace (semi-rigid or lace-up) and taping at preventing recurrent ankle sprain, rather than for prophylaxis (

Shawen et al., 2016; Kaminski et al., 2013)Multi-intervention injury-prevention program lasting at least 3 months that focuses on balance and neuromuscular control to reduce the risk of ankle

injuryAddressing the strength of the leg muscles (evertors, invertors, dorsiflexors

, and plantar flexors) and hip extensors and abductors may be an ankle injury-prevention strategy

Clinicians should consider assessing dorsiflexion ROM in at-risk athletes. If dorsiflexion ROM is limited, clinicians should incorporate techniques to enhance arthrokinematic

and osteokinematic motion for possible prevention of ankle injuryKaminski et al., 2013 – NATA Position StatementLateral Ankle Sprain: Prevention?Slide11

Persistent residual symptoms“Feeling” ankle joint unstable

Fear incur repeat sprain with e.g., uneven surfaces or rapid lateral movement in sport InstabilityGiving way ankle joint

Regular occurrence of uncontrolled or unpredictable episodesWithout excessive pain, swelling, or bruisingExcellent candidates for surgical repair

Dr. Eamonn

Delahunt, 2017

Lateral Ankle Sprain: Chronic InstabilitySlide12

Represent 10% of all athletic ankle injuries

High Ankle SprainSlide13

Forced external rotation

Axial load with forced

dorsiflexion

Image by Dr. J.C. Kennedy

https://

docflynn.com/2016/10/11/the-high-ankle-sprain/High Ankle Sprain: Mechanism of InjurySlide14

Images from http

://ssorkc.com/wp-content/uploads/2016/01/syndes.jpg

Tenderness length (Nussbaum)Strongly correlates with degree of injury and time to return to sport

High Ankle Sprain: Anatomy

A rotation injurySlide15

Sman

AD, et al. Br J Sports Med 2015;49:323–329

It is not possible to rely on a single test for diagnosis of ankle syndesmosis

injury.

Clinicians

are advised to start with sensitive tests: Inability to hopInability to walk at injury Tenderness of the syndesmosis ligament Dorsiflexion-external rotation stress testIf sensitive test is positive, use specific tests: Pain out of proportion to the apparent injurySqueeze testHigh Ankle Sprain: Diagnosis