A Guide To Treating Ankle Sprains From Start To Finish

By Babak Baravarian, DPM

   An ankle sprain can be a debilitating and often difficult problem to overcome. In most cases, patients do not seek treatment immediately and/or the treatment offered is not up to par. I have spent a great deal of time at the local family practice and emergency room offices explaining how the treatment they offered their patients at the initial visits was not aggressive enough. Indeed, when initial treatment for ankle sprains is not aggressive enough, it may result in chronic instability and the need for surgery.    Accordingly, let us take a closer look at the rationale behind the ankle sprain treatment protocol at our institution.    To put it simply, an ankle sprain is a partial dislocation of the ankle joint. The most common form is an inversion injury with the foot rolling internally below the tibia, resulting in the talus pushing anterior to the tibia and tearing the lateral ankle ligaments. The less common and far less problematic sprain is the eversion sprain. The deltoid ligament is so strong that most eversion sprains result in either a minor problem or a fracture of the medial malleolus.    Grading for sprains is simple. Grade 1 is a minor strain with no tear. Grade 2 is a partial tear. Grade 3 is a full tear. Often, the level of pain in a grade 3 full tear is less than a partial tear and results in the patient seeking less treatment. A more descriptive grading should include the level of instability and the potential number of ligaments torn. For example, a grade 2 sprain of both the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) is far more problematic than a grade 3 tear of just the ATFL ligament. However, one must carefully consider the specifics of each case prior to selecting a treatment.

What You Can Learn From The Initial Workup

   The initial workup for an ankle sprain begins with obtaining a full history of the type of injury, the motion of the foot at the time of injury and the feeling after the injury. During the subsequent physical exam, palpate both the medial and lateral ankle, the base of the fifth metatarsal, the Lisfranc’s region and the medial, lateral and posterior tendons. Be sure to check the syndesmosis for stability and palpate the fibula along its course. In a day-old ankle sprain, the level of pain will often result in a difficult physical exam but the exam will still alert you to severe pain regions and anything truly out of the ordinary.    Proceed to take radiographs of the ankle. When it comes to inversion sprains, I often will only take a medial oblique view of the foot with three ankle views. I will take full ankle and foot views with an eversion stress injury. Be sure to check radiographs for small fracture fragments, stress fractures, avulsion fractures, osteochondral lesions and joint instability or dislocation. In most cases, a sprain is a ligament injury and cannot be diagnosed with radiographs. However, radiographs can be helpful if there is a joint dislocation or gross instability.    Furthermore, an osteochondral lesion that is visible on radiographs warrants surgery. In the case of dislocation or joint instability such as with a syndesmosis injury, surgery is required to stabilize the syndesmosis and realign the mortise.    In most cases, radiographs are negative and it is far too early in the treatment protocol to consider expensive testing such as an MRI. In our institute, we have used diagnostic ultrasound for a soft tissue check of ankle sprains. The testing is relatively simple to perform and also inexpensive when compared to an MRI. One may check the ATFL, CFL and deltoid ligaments as well as the syndesmosis. Using diagnostic ultrasound, you can also check the peroneal tendons and posterior tibial tendon as well as the other structures about the foot and ankle. However, having diagnostic ultrasound as the only source of testing prior to surgery may leave you open to doubt. Therefore, if you suspect an injury that requires surgery, back up your opinion with an MRI or CT as needed.

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