Ankle Sprains and Injuries Overview

Ankle Sprains and Injuries - Types and Risk Factors

• Ankle sprains are categorized by severity of ligament damage:
  • 1st degree: Rupture of the Anterior Talofibular (ATF) ligament.
  • 2nd degree: Ruptures of ATF and Calcaneofibular ligaments.
  • 3rd degree: Ruptures of ATF, Calcaneofibular, and Posterior Talofibular ligaments.
• Risk factors for lateral ankle sprains include:
  • Reduced ankle dorsiflexion range of motion.
  • Decreased eccentric ankle inversion strength.
  • Proprioception deficits.

Associated Injuries and Treatment

• Lateral ankle injuries may also cause:
  • Avulsion of Peroneus Brevis muscle.
  • Fractures:
    • 5th metatarsal fractures (healing influenced by location).
    • Medial malleolus fractures.
    • Talar and calcaneus fractures (often due to falls).
• Fracture treatment may involve casting or internal fixation.

Medial and High Ankle Sprains

• Medial ankle sprains:
  • Involve the Deltoid ligament.
  • Account for 2% of ankle sprains.
  • Have a significantly longer healing time (often twice as long as lateral sprains).
• High ankle sprains:
  • Syndesmosis injuries above the ankle joint.
  • Usually caused by excessive dorsiflexion or rotation while bearing weight.

Conditions Related to Foot and Ankle

• Avascular Necrosis (AVN): Bone tissue death due to lack of blood flow; can affect the foot and ankle.
• Medial Tibial Stress Syndrome (MTSS) "Shin Splints":
  • Pain on distal and medial third of tibia.
  • Contributing factors include:
    • Increased pronation.
    • Increased body mass index (BMI).
    • Limited dorsiflexion range of motion.
    • Weakness in posterior tibialis and toe flexors.
  • Grades of MTSS (severity): 1 (pain after activity), 2 (pain during/after), 3 (pain before/during/after), 4 (constant pain).

Tendon and Nerve Conditions

• Achilles Tendinitis:
  • Contributing factors:
    • Limited gastrocnemius stretching.
    • Overtraining.
    • Rigid foot structure (leading to compensatory pronation).
    • Weak calf muscles.
  • Treatment: Heel lifts/wedges, stretching (focus on eccentric exercises during subacute phase).
• Morton's Neuroma: Enlarged, painful nerve between 3rd and 4th metatarsal heads.
  • Diagnosis: Squeeze test.
  • Treatment: Wider/softer footwear, or surgery if needed.

Plantar Fasciitis and Related Conditions

• Plantar Fasciitis: Inflammation at the medial calcaneal tubercle due to repetitive stress on plantar fascia.
  • Contributing factors:
    • Excessive pronation.
    • Obesity.
    • Tightness in the gastrocnemius/soleus complex.
  • Treatment: RICE, anti-inflammatories, heel cups, walking boots, night splints, foot intrinsic stretching.
• Heel Spurs: Bony protrusions on anterior edge of medial calcaneal tubercle; often associated with plantar fasciitis.
  • Treatment similar to plantar fasciitis.
  • Can occur without symptoms.

Hallux Valgus and Tarsal Tunnel Syndrome

• Hallux Valgus: Lateral angulation of great toe at 1st metatarsophalangeal joint.
  • Treatment: Bunionectomy with osteotomy, toe spacers, stretching, orthotics.
• Tarsal Tunnel Syndrome: Entrapment neuropathy of posterior tibial nerve behind medial malleolus.
  • Common cause: Overpronation.
  • Symptoms: Intermittent burning pain, tingling, and numbness in medial foot.
  • Treatment: Orthotics, ice, ultrasound, phonophoresis/iontophoresis, surgery (flexor retinaculum release - potential for flexor tendon inflammation).

Compartment Syndrome

• Acute vs. Chronic Compartment Syndrome:
  • Acute: Sudden compression of nerves, blood vessels, and muscles; medical emergency. Causes include fractures, casts, crush injuries, burns, or hemorrhage.
  • Chronic: Muscular overuse/repetitive activities; dull, aching pain during/after exercise (not an emergency, but potential long-term damage).
• Five P's of Compartment Syndrome:
  • Pain: Severe and disproportionate to injury.
  • Paresthesia: Tingling/numbness.
  • Pallor: Pale skin.
  • Pulselessness: Weak or absent pulse.
  • Paralysis: Loss of function.
• Four Compartments of the Leg:
  • Anterior, Lateral, Superficial posterior, Deep posterior.
  • Each contains specific muscles and nerves.

Common Foot and Ankle Conditions

• Sever's Disease: Pain at Achilles tendon insertion, often in children experiencing growth spurts; similar mechanism to Osgood-Schlatter disease.
  • Treatment: Rest, bilateral heel lifts.
• Plantar Flexion Contracture: Tight gastrocnemius/soleus muscles; limit ankle dorsiflexion.
  • Causes: Spasticity (closed head injury, spinal cord injury, cerebral palsy).
  • Consequences: Increased ankle sprains, pronation deformities, plantar fasciitis.
  • Treatment: Active/assisted/passive stretching, ensuring foot supination.
• Pes Planus (Flatfoot): Low medial longitudinal arch; overpronation.
  • Symptoms: Foot pain (especially after prolonged standing/activity).

Surgical Interventions

• Total Ankle Arthroplasty: Replace ankle joint with prosthesis for full range of motion.
• Joint Replacement of 1st MTP Joint: Replace damaged joint due to OA/RA.
  • Options: Hemi-titanium (one surface), total replacement.
  • Concerns: Potential long-term failure due to bone size.

Diagnostic Tests and Assessments

• Forefoot Varus Measurement: Assess forefoot varus position.
• Feiss Line Test: Evaluates navicular tuberosity position relative to line drawn from medial malleolus to first MTP joint; identifies structural/functional pes planus.
• Thompson's Test: Assess Achilles tendon rupture (absence of plantar flexion = positive).
• Anterior Drawer Test: Assess ankle instability (excessive motion = positive, ATFL disruption).
• Tinel's Sign Test: Assess for tarsal tunnel syndrome (tingling/pain = positive).