This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different soft tissue injuries are the part of curriculum for the undergraduate students at KUSMS.

1. ANKLE INJURIES:
ANKLE SPRAIN
Saurab Sharma, MPT
Lecturer/ KUSMS
BPT 3rd Year

2. Overview
• Introduction
• Stability
• Impact of injury
• Diagnosis
• Clinical features
• Examination
• Management
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3. Introduction
• Incidence - 2.15 per 1000 person/ years in the general
population.
• Highest incidence- between 15 and 19 years of age
• No difference between genders
• Half of all ankle sprains occur during athletic activity, eg:
basketball (41.1%), football (9.3%), and soccer (7.9%)
• Ankle injuries account for 10% to 34% of all sport-related
injuries, with lateral ankle sprain comprising 77% to 83% of
these injuries
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4. Introduction
• Lateral ankle sprains may occur with subtalar, medial,
and/or syndesmotic sprains
• High chances of chronic pain, instabilities, and limitation
in activities and participation and high recurrence rates.
Other structures involved are:
• Lateral subtalar ligaments; Nerve injury
• Fibular (peroneal) tendon injury
• Extensor and peroneal retinaculum injury
• Inferior tibiofiular ligament
• Osteochondral lesions of the talus or tibia
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5. Anterior Talofibular Ligament
• Extra-articular ligament
• Provides primary restraint to inversion movement when
the ankle is in a plantar-flexed position.
• 50% avulsion from Fibula; 50% mid substance tear
• Lower maximal load tolerance before failure compared to
other structures
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6. Stability of ankle
• Dynamic and static stability
• Dynamic stabilization of the ankle complex is dependent
on the adjacent musculatures and laterally includes the
fiularis (peroneus) longus and brevis.
• The tibialis anterior and extensor digitorum longus are
thought to eccentrically control ankle plantar flexion.
• Reflex reaction is slow to protect injury, but anticipatory
contraction may help prevent the injury
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7. Impact of injury
Injury to ankle ligaments may cause:
• Weakness and injury of local muscles
Weakness of remote muscles:
• Lumbar spine- erector spine
• Hip- Gluteus maximus, biceps femoris
Sensory changes can occur in the joint receptors and
cutaneous nerves, such as the sural nerve and distal
superficial peroneal nerve.
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8. CLINICAL COURSE
• rapid decrease in pain and improvement in function the
fist 2 weeks after the injury.
• 5% to 33% of patients continued to have pain at 1-year;
5% to 25% still experiencing pain after 3 years.
• Residual problems pain (30%), instability (20%), crepitus
(18%), weakness (17%), stiffness (15%), and swelling
(14%).
• Full recovery between 50% and 85% at approximately 3
years after the injury and seemed independent of sprain
severity.
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9. Clinical features
• Pain (rest and weight bearing)
• Swelling
• Redness, ecchymosis
• Instability
• Weakness
• Impaired proprioception and postural control
• Activity limitations and participation restrictions
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10. Risk Factors: Intrinsic
• The history of previous sprains
• Age
• ? Gender (younger female; older male)
• Physical characteristics (ie, height, weight, and body
mass index)
• Msculoskeletal characteristics (ie, balance,
proprioception, range of motion, strength, anatomic
alignment, and ligament laxity)
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11. Risk Factors: Extrinsic
• Use of external support; Footwares
• Type of Sport
• Level of competition
• Participation in neuromuscular training.
• Surface of play
• Inadequate warm up and cool downs
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12. Diagnosis: Ankle Sprain
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13. Diagnosis: Ankle instability
The Cumberland Ankle Instability Tool: 9-item
• The test-retest ICC was 0.96.
• Sensitivity and specificity of 85.5 and 82.6 respectively
• The Ankle Instability Instrument – 12 items
• Functional Ankle Instability Questionnaire- 10 items
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14. Differential Diagnosis
Ottawa Ankle Rules:
Radiographs are indicated if there was pain in the malleolar
zone and any of the following criteria are met:
(1) tenderness along the tip of the posterior edge of the
distal 6 cm of the lateral malleolus,
(2) tenderness along the medial malleolus, and/or
(3) An inability to bear weight for 4 steps.
(4) Pain in the mid-foot area
The Bernese ankle rules
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15. Differential Diagnosis
• Syndesmotic injury
• Cuboid syndrome
• Peroneal tendon tendinitis/tendinopathy
• Sensory nerve injury
• Medial collateral ligament ankle sprain
• Lisfranc fracture/dislocation
• Subtalar sprain
• Spring or bifurcate ligament injury
• Achilles tendon rupture
• Lateral talar process injury
• Anterior process of the calcaneus injury
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16. Examination: Outcome measures
• The Foot and Ankle Ability Measure (FAAM)
• The Foot and Ankle Disability Index (FADI)
• Lower Extremity Functional Scale (LEFS)
• The Chronic Ankle Instability Scale
• The Sports Ankle Rating System
• The Ankle Joint Functional Assessment Tool
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17. Examination: Activity limitation and
participation restriction measures
• side hop
• 6-m crossover hop
• 40-m walk time; 40-m run time
• Figure-of-eight run
• Single-limb forward hop
• Crossover hop
• Stair hop
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18. Examination: Activity limitation and
participation restriction measures
• When evaluating a patient in the post-acute period
following a recent or recurring lateral ankle sprain,
assessment of activity limitation, participation restriction,
such as single-limb hop tests that assess performance
with lateral movements, diagonal movements, and
directional changes.
(GRADE B RECOMMENDATION)
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19. Examination: Physical impairment
• Swelling
• ROM- ankle joint, subtalar joint
• Ankle and foot pronation and supination
• Anterior drawer test
• Talar tilt test
• Isokinetic Muscle Strength of Inversion and Eversion
• Single-Limb Balance
• Star Excursion Balance Test
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20. Measurement of swelling
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21. ROM
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22. Special tests
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23. Single limb balance test (SLBT)
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Eyes open and eyes closed for 1 minutes each

24. Star excursion balance test (SEBT)
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25. Interventions
• ACUTE/ PROTECTED MOTION PHASE
OF REHABILITATION
• PROGRESSIVE LOADING/ SENSORIMOTOR
TRAINING PHASE OF REHABILITATION
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26. ACUTE/ PROTECTED MOTION PHASE
• Early weight bearing with support – I
• External support - I
• Cryotherapy – I
• Manual Therapy – II
• Pulsed Diathermy – II
• Stimulation – II
• Laser II
• Ultrasound- I (no benefit)
• Therapeutic exercises- I
(active range-of-motion exercises, and progressive resistive
exercises incorporating progressive weight bearing)
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27. PROGRESSIVE LOADING/
SENSORIMOTOR TRAINING PHASE
• Manual Therapy– I
Clinical prediction rule to predict likely rapid responders
to manual therapy. Subjects meeting at least 3 of 4 criteria
were up to 95% likely to respond favorably to intervention
within 3 treatment sessions.
• Worse symptoms with standing,
• Worse symptoms in the evening,
• Navicular drop test of 5 mm or more, and
• Hypomobility of the distal tibiofiular joint.
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28. PROGRESSIVE LOADING/
SENSORIMOTOR TRAINING PHASE
Therapeutic Exercise and Activities- I
• ROM exercises
• Weight-bearing functional exercises
• Single-limb balance activities using unstable surfaces
• Exercises to improve mobility, strength, coordination, and
postural control
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29. Scope for Self learning:
• Refining your assessment skills
• Outcome tools related to ankle and foot
• Functional assessment tools
• Special tests
• Other differential diagnoses
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30. References
• Martin et al. Ankle Stability and Movement Coordination
Impairments: Ankle Ligament Sprains Clinical Practice Guidelines
Linked to the International Classification of Functioning, Disability and
Health From the Orthopaedic Section of the American Physical
Therapy Association. J Orthop Sports Phys Ther. 2013;43(9):A1-
A40. doi:10.2519/jospt.2013.030
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