How To Diagnose Lateral Ankle Injuries

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Continuing Education Course #135 — October 2005

I am pleased to introduce the latest article, “How To Diagnose Lateral Ankle Injuries,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Diagnosing a lateral ankle injury can be challenging. The initial presentation may be deceptive and some injuries may require more advanced imaging to confirm an accurate diagnosis. Addressing these and other key points, Remy Ardizzone, DPM, and Ronald L. Valmassy, DPM, provide a comprehensive guide to these common injuries that range from chronic lateral ankle instability to peroneal tendon injuries.

At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site ( roughly one month after the publication date. I hope this CE series contributes to your clinical skills.


Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 66 and successfully answering the questions on pg. 74. Use the enclosed card provided to submit your answers or log on to and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. Ardizzone and Valmassy have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
RELEASE DATE: October 2005.
EXPIRATION DATE: October 31, 2006.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• differentiate among grade 1, grade 2 and grade 3 injuries to the lateral collateral ligaments;
• discuss common physical examination findings with chronic lateral ankle instability;
• assess findings from talar tilt and anterior drawer tests;
• discuss contributing factors to peroneal tendon injuries; and
• assess the potential benefits of orthotics as an adjunctive treatment for lateral ankle sprains.

Sponsored by the North American Center for Continuing Medical Education.

Here one can see an acute ankle injury. Once one has ruled out a fracture, acute or chronic lateral ankle injuries represent a diagnostic challenge.
This manual talar tilt/inversion stress radiograph shows excessive talar inversion within the ankle mortise. Note the intraarticular loose body in the lateral gutter.
This manual anterior drawer stress radiograph demonstrates incompetence of the anterior talofibular ligament.
Here one can see a peroneal tenogram showing extensive stenosing tenosynovitis and adhesions.
On this T1-weighted MRI image, one can see a partial tear to the anterior talofibular ligament and a shallow fibular groove.
Here is an extensive talar osteochondral defect on a T1-weighted MRI sequence.
Here one can see a compensated rigid forefoot valgus with an inverted calcaneus.
By Remy Ardizzone, DPM, and Ronald L. Valmassy, DPM

1. Garrick JG: The frequency of injury, mechanism of injury and epidemiology of ankle sprains. Am J Sports Med 5:241-242, 1977.
2. Garrick JG, Requa RK: The epidemiology of foot and ankle injuries in sports. Clin Sports Med 7(1):29-36, 1988.
3. Linklater J: Ligamentous, chondral and osteochondral ankle injuries in athletes. Seminars in Musculoskeletal Radiology 8(1):81-98, 2004.
4. Buddecke R. DE, Mandracchia VJ, Pendarvis JA, et. al.: Is this “just” a sprained ankle? Hosp Med 34:46-52, 1998.
5. Hayes DW, Mandracchia VJ, Webb GE: Nerve injury associated with plantarflexion-inversion ankle sprains. Clin Podiatr Med Surg 17(2):361-369, 2000.
6. DiGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ: Associated injuries found in chronic lateral ankle instability. Foot and Ankle International 21(10):809-815, 2000.
7. DiGiovanni BF, Partal G, Baumhauer JF: Acute ankle injury and chronic lateral instability in the athlete. Clin Sports Med 23:1-19, 2004.
8. Ritchie DH: Functional instability of the ankle and the role of neuromuscular control: a comprehensive review. J Foot and Ankle Surg 40(4):240-251, July/August 2001.
9. Hollis JM, Blaiser RD, Flahiff CM: Simulated lateral ankle ligamentous injury: change in ankle stability. Am J Sports Med 23(6):672-677, 1995.
10. Adamson C, Cymet T: Ankle sprains: evaluation, treatment, rehabilitation. Md Med J 46:530-537, 1997.
11. Drez D, Young JD, Waldmann D, et. al.: Nonoperative treatment of double ligament tears of the ankle. Am J Sports Med 10:197-200, 1982.
12. Hertel J, Denegar CR, Monroe MM, et. al.: Talocrural and subtalar instability after lateral ankle sprain. Med Sci Sports Exerc 31:1501-1508, 1999.
13. Cox JS: Surgical and nonsurgical treatments of acute ankle sprains. Clin Orthop 198:118-126, 1985.
14. Johannsen A: Radiological diagnosis of later ligament lesion of the ankle. Acta Orthop Scand 49:295-301, 1978.
15. Karlsson J, Bergstan T. Lansinger O, et. al.: Surgical treatment of chronic lateral instability of the ankle joint. Am J Sports Med 17:268-273, 1989.
16. Beynnon BD, Webb G, Huber BM, Pappas CN, Renstrom P, Haugh LD: Radiographic measurement of anterior talar translation in the ankle: determination of the most reliable method. Clin Biomech (Bristol, Avon) 20(3):301-306, March 2005.
17. Cardone BW, Erikson SJ, Den Hartog BD, Carrera GF: MRI of injury to the lateral collateral ligamentous complex of the ankle. J Compt Assist Tomgr 17: 102-107, 1995.
18. Frey C, Bell J, Teresi L, et. al.: A comparison of MRI and clinical examination of acute ankle sprains. Foot and Ankle International 17:533-537, 1996.
19. Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL: Effect of rearfoot orthotics on postural sway after lateral ankle sprain. Arch Phys Med Rehabilitation 82:1000-1003, 2001.
20. Hertel J: Functional instability following lateral ankle sprain. Sports Med 29(5):361-371, May 2000.
21. Hiller CE, Refshauge KM, Beard DJ: Sensorimotor control is impaired in dancers with functional ankle instability. Mer J Sports Med 32(1):216-223, 2004.
22. Connolly TJ, Fitzgibbons TC, Weber LE: Injury to the peroneal nerve after ankle sprain. Nebraska Med J:6-7, Jan. 1990.
23. Lentell G, Baas B, Lopez D, et. al.: The contributions of proprioceptive deficits, muscle function and anatomic laxity to functional instability of the ankle. J Orthop Sports Phys Ther 21:206-215, 1995.
24. Lephart SM, Pincivero DM, Giroldo JL, et. al.: The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med 25:130-137, 1997.
25. Purnell ML, Drummond DS, Engbar WD, Breed AL: Congenital dislocations of the peroneal tendons in the calcaneovalgus foot. J Bone Joint Surg 65B:316, 1983.
26. Sobel M, Geppert MJ, Warren RF: Chronic ankle instability as a cause of peroneal tendon injury. Clin Orth Rel Res 296:187-191, 1993.
27. Baumhauer JF, Nawoczenski DA, DiGiovanni BF, Fleimster AS: Ankle pain and peroneal tendon pathology. Clin Sports Med 23:21-34, 2004.
28. Dombek MF, Orsini RC, Mendicino RW, Saltrick K: Peroneus brevis tendon tears. Clin Podiatr Med Surg 18(3):409-427, 2001.
29. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR: Peroneal tendon tears: a retrospective review. J Foot and Ankle Surg 42(5):250-258, 2003.

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