Mastering The Treatment Of Complex Ankle Sprains

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By Bob Baravarian, DPM, FACFAS

Ankle sprains are the most common athletic injuries and the most common orthopedic injuries presenting to emergency rooms. What we do not often consider is that only a small fraction of ankle sprains present to the emergency room and patients treat most injuries at home with differing levels of conservative care.

   Furthermore, the number of ankle sprains presenting to emergency rooms is so large that physicians often deal with them with in a limited fashion with an Ace wrap of some sort. This often results in pain for the patient, a delay in recovery, potentially untreated injuries and the need for surgery. Most ankle sprains will improve with conservative care as long as they are treated in a timely and aggressive manner.

   When a patient presents with an acute ankle sprain, the physical examination and diagnostic testing are essential to understand the level of trauma and what needs to happen to facilitate a rapid and optimal recovery.

   Check the skin for areas of bruising and swelling, and any skin breaks. Skin bruising is a clear sign of the area of injury. For example, if there is bruising or bleeding in the anterior shin region, one must suspect a syndesmosis or high ankle injury.

   Check the vascular supply to the foot by palpating pulses. It is rare to have a vascular issue with ankle sprains but cases of severe swelling may cause a compartment syndrome, resulting in potential vascular insufficiency. If a suspected compartment syndrome is present, measure the pressure of the foot and ankle compartments.

When Nerve Damage Factors Into Ankle Sprains

One of the most commonly missed issues in ankle sprains is neurologic injury. With medial ankle sprains, the tarsal tunnel, tibial nerve, medial plantar, lateral plantar and calcaneal nerves can be stretched or damaged. This is a less common type of ankle sprain and also a less common type of nerve injury.

   The more common lateral ankle sprains can present with a tension injury to the common peroneal nerve, the dorsal cutaneous nerves of the foot and ankle, or the sural nerve. I have seen several patients with common peroneal nerve problems after ankle sprain that were not detected and resulted in a drop foot deformity. Make sure to check for pain at the fibular head region and also check the strength of the dorsiflexors of the ankle. Also make sure to check dorsal foot and ankle sensation as a common peroneal nerve problem can result in dorsal lateral foot numbness.

What To Look For In Sprains That Are Musculoskeletal In Nature

The most common problems with ankle sprain are musculoskeletal in nature and result in ligament tear, tendon tear, cartilage damage or fracture of the ankle. Some of these problems commonly include partial or full ligament tear of the lateral ankle region. However, some of the problems are less common and one may miss them. A missed diagnosis of these problems may result in devastating problems such as a syndesmosis injury.

   The ankle examination is difficult with early, very swollen ankle sprains but one needs to reassure the patient and perform testing in a timely manner. Anterior drawer testing and talar tilt testing are the most common tests. Palpation of the anterior ankle for crepitus and synovitis is also essential. Also check peroneal tendon tenderness or weakness as a severe inversion sprain can result in a peroneal tendon tear. In the event of medial ankle injuries, check the deltoid ligament and posterior tibial tendon for laxity or weakness.

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