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
A positive anterior drawer sign is consistent for an injury to the:
a) Body of the talus
b) Sustentaculum tali
c) Posterior process of the calcaneus
d) Peroneus tertius
e) Anterior talar fibular ligament
5. A positive inversion stress is noted when talar tilt measures ...
a) 0 to 3 degrees
b) 3 to 6 degrees
c) 6 to 12 degrees
d) 12 to 18 degrees
e) 18 to 24 degrees
6. Four millimeters of excursion of the talus from under the tibia is consistent with:
a) Positive posterior drawer sign
b) Tear of the peroneus longus tendon sheath
c) Neuropraxia of the sural nerve
d) Tear of the anterior talar fibular ligament
e) Osteochondral defect of the talus
7. Which of the following is most likely to contribute to chronic lateral ankle instability?
a) Forefoot supinatus of 10 degrees
b) Rigid forefoot valgus of 8 degrees
c) Flexible forefoot valgus of 5 degrees
d) Compensated rearfoot varus
e) 18 degrees of tibial torsion
8. A positive talar tilt test confirms injury to which of the following?
a) Sinus tarsi
b) Cartilage overlying the talus
c) Calcaneal fibular ligament
d) Peroneus brevis
e) Posterior talar fibular ligament
9. Appropriate physical therapy for the initial treatment of an inversion ankle injury involving a ruptured lateral collateral ligament does not include:
a) Ice
b) Compression
c) Laced-up ankle brace
d) Contrast baths
e) Massage therapy
10. Which of the following does not enhance increased ankle proprioception?
a) Ankle brace
b) Functional foot orthosis
c) High-heeled shoes
d) U-shaped padding
e) Contrast baths
Instructions for Submitting Exams
Fill out the enclosed card that appears on the following page or fax the form to the NACCME at (610) 560-0502. 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. Responses will be accepted up to 12 months from the publication date.

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