Abstract
The ankle joint is comprised of three articulations: the talocrural joint, the tibiofibular joint (syndesmosis), and the subtalar (talocalcaneal) joint. There are three major classifications of ligamentous ankle injuries: lateral, medial (deltoid), and syndesmotic (high) ankle sprains. The anterior talofibular ligament (ATFL) is the most commonly injured ligament in lateral ankle sprains. A high ankle sprain is a sprain of the distal syndesmotic ligaments that connect the distal tibia and fibula. PRICEMMMS (Protection, Rest, Ice, Elevation, Medications, Modalities, Mobilization, and Strengthening) is employed during the acute phase of treating ankle sprains.
Keywords
ankle rehabilitation, ankle sprain, ankle anatomy, high ankle sprain, lateral ankle sprain, Ottawa Ankle Rules, Ottawa Foot Rules
General Information
1
What is an ankle sprain?
Ligaments serve to provide mechanical stability, directed motion, and proprioceptive information for the joint. An ankle sprain occurs when one or more ligaments stretch beyond their limits. They range from mild to severe, depending on how much damage there is to the ligament (e.g., stretching, partial rupture, or complete rupture). This chapter focuses on lateral and high ankle sprains.
2
What are the different types of ankle sprains?
There are three major classifications of ligamentous ankle injuries: lateral, medial (deltoid), and syndesmotic (high) ankle sprains.
3
What is the incidence of ankle sprains?
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Ankle ligament injuries are among the most common orthopedic injuries encountered in the primary care office and emergency department.
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The incidence of ankle sprains in the United States is 2.15 per 1,000 person-years, with teenagers and young adults (15–19 years of age) having the highest rates, with a peak incidence of 7.2 per 1,000 person-years.
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Acute ankle sprains result in an estimated annual aggregate health care cost of $2 billion.
4
Is there a difference in ankle sprains between populations?
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No difference in the incidence of ankle sprains between men and women.
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Slight preponderance in Caucasians and African Americans compared with other ethnicities.
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Approximately half of acute ankle sprains occur during athletic activity, most commonly basketball.
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Increased incidence in those who were near overweight and overweight (body mass index [BMI] >25).
5
What is the greatest risk factor for ankle sprains?
The greatest risk factor for ankle sprain is a previous ankle sprain that has not been appropriately rehabilitated.
6
What are the signs and symptoms of acute ankle sprain?
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Pain
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Swelling
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Tenderness
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Ecchymosis
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Difficulty with weight bearing
7
What are the long-term effects of repeated ankle sprains?
Repeated ligamentous injuries may result in chronic instability, degenerative bony changes, and chronic pain.
Anatomy
8
Describe the bony anatomy of the ankle joint
The ankle joint is a hinge-type synovial joint that forms the articulation between the lower leg and foot composed of three articulations. The talocrural joint is the articulation between the tibia and fibula proximally and the talus distally. The tibiofibular joint (syndesmosis) is the distal articulation between the medial side of the fibula and the lateral side of the tibia. The subtalar (talocalcaneal) joint is the articulation between the inferior talus and the superior calcaneus.
9
What is the ankle mortise?
The mortise is a three-sided, rectangular socket formed by the tibial plafond, the medial malleolus, and lateral malleolus.
10
Describe the ligamentous anatomy of the ankle joint
The ligamentous complexes of the ankle include the lateral, deltoid, and syndesmotic ankle ligaments, which in addition to the surrounding musculotendinous structures provide dynamic stability to the ankle joint ( Fig. 41.1 ).
11
What comprises the lateral ligamentous complex of the ankle joint?
The lateral ankle ligamentous complex is composed of the anterior talofibular (ATFL), calcaneofibular (CFL), and posterior talofibular (PTFL) ligaments.
12
Describe the anatomy and function of the anterior talofibular ligament (ATFL)
The ATFL is a flat band that extends anteromedially from the anterior border of the lateral malleolus and inserts onto the lateral neck of the talus. It is taut in plantar flexion and loose in dorsiflexion and prevents internal rotation and adduction of the talus. It is relatively weak and has the lowest load to failure among the other lateral ankle ligaments and is thus the most commonly injured ankle ligament.
13
Describe the anatomy and function of the calcaneofibular ligament (CFL)
The CFL is a round, cord-like, extracapsular ligament that is confluent with the peroneal tendon sheath. It passes posteroinferiorly from the distal tip of the lateral malleolus and inserts onto the lateral calcaneus. The CFL is slack in plantar flexion and tense in dorsiflexion, preventing adduction of the talus within the talocrural joint.
14
Describe the anatomy and function of the posterior talofibular ligament (PTFL)
The PTFL is a capsular ligament that extends from the posteromedial aspect of the lateral malleolus and inserts onto the posterolateral aspect of the body of the talus. It has maximal tension in ankle dorsiflexion and prevents external rotation of the ankle while dorsiflexed.
15
What is the syndesmosis?
The distal tibiofibular joint is a fibrous syndesmotic articulation consisting of the concave surface of the distal tibia and convex shape of the distal fibula. The syndesmotic ligamentous complex connects the tibia and fibula through four ligamentous structures.
16
Describe the four ligamentous structures that make up the syndesmosis
The interosseous ligament (IOL) extends from the fibular notch of the tibia to the medial surface of the distal fibula. It travels superiorly with the interosseous membrane running the length of the tibia and fibula and forms the principal connection between them. It is strengthened by the anterior-inferior tibiofibular ligament (AITFL) and posterior-inferior tibiofibular ligament (PITFL), which extend from the fibular notch of the tibia to the anterior and posterior surfaces of the lateral malleolus, respectively. The deep, inferior portion of the PITFL is called the inferior the transverse ligament (ITL) and functions to reinforce the posterior capsule of the ankle joint ( Fig. 41.2 ).
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