Essential Insights In Treating Medial Ankle Sprains

Christopher Corwin, DPM, MS

   Palpation of the deltoid ligament and medial ankle will usually elicit pain with direct pressure. The clinician should also palpate the lateral ankle ligaments and fibula for injury. If symptoms allow, one may perform an anterior drawer test. Of special concern with eversion injuries is the palpation of the posterior tibial tendon and the proximal fibula. Medial ankle injuries may be associated with Maisonneuve fractures and the posterior tibial tendon can undergo stretching with rearfoot eversion. Evaluate the syndesmosis for possible injury in association with the deltoid ligament.

   Evaluate radiographs of the ankle for associated distal fibular fractures or medial malleolar fractures. Direct attention to the medial ankle joint space. Excessive widening may be present but this usually requires a lateral ankle injury to either the ligamentous structures or distal fibula to allow the talus to translate laterally. An anterior-posterior eversion stress radiograph may show medial widening of the ankle joint space.

   Further evaluation via magnetic resonance imaging (MRI) may be warranted. Examine the deep and superficial deltoid as well as possible stress reactions in the distal tibia, fibula and talus. Evaluate the posterior tibial tendon for tears. Proceed to examine the talonavicular joint and pay particular attention to the spring ligament. Rupture of the spring ligament may accompany deltoid ligament tears due to the mechanism of injury.

What You Should Know About Treatment And The Return To Activity

Treatment of the deltoid ligament injury largely depends on the associated injuries. Distal fibular fractures may require open reduction internal fixation (ORIF) to anatomically restore the ankle joint. If medial gutter widening was present prior to the ORIF or closed reduction, it is important to continue to evaluate the medial gutter during the reduction.

   Sometimes, the lateral ankle joint appears to be fully reduced but the medial gutter widening persists. If this occurs, there must be a high index of suspicion for the posterior tibial tendon moving up and impinging in the ankle joint. This can be a difficult problem with closed reduction and may require surgical intervention to move the posterior tibial tendon and restore the medial ankle to its anatomic position.

   Isolated medial injuries without joint space widening often involve the posterior tibial tendon and the deltoid ligament. Our initial treatment involves early immobilization with a cast (or removable cast boot) with a few days of non-weightbearing that progresses to weightbearing as tolerated for three to four weeks.

   The length of time in the cast is dependent upon symptoms, associated injuries and, for upper-level athletes, timing during the season/off-season. After the first week, the athlete may return to activities that do not place significant pressure on the ankle. Easy spinning on an exercise bike is permitted along with core and seated upper body exercise. The patients then progress to a removable boot for an additional two to three weeks. During this time, they are in aggressive physical therapy and may return to modified sport activity.

   One should coordinate return to activity with the team trainer and perform modified taping to support the medial ankle in conjunction with a supportive lace-up style ankle brace. Many of the lace-up braces have additional crossing straps and the medial strap can “hold up the arch” to support the posterior tibial tendon and the deltoid ligament.

   Athletes gradually progress from the exercise bike to the elliptical machine on a low incline and eventually back to controlled running. Straight ahead running becomes asymptomatic first but cutting and turning can stay somewhat symptomatic for months after the injury. Continued taping and bracing for a few months will help the athlete get back onto the field.

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