An overview for non-specialists

1. Model Injuries
Classroom Look At
Ankle Sprains
Stephen M. Pribut, DPM
Clinical Assistant Professor of Surgery, GWUMC
Thursday, February 14, 13

2. Lateral Ankle Instability
and Injury
• Overview
• Evaluation
• Treatment
• Intersection of mechanics & biology
Thursday, February 14, 13

3. Overview
• 40% of all sport injuries
• Account for 25% of time lost in athletics
• 23,000 sprains per/day in the U.S.
• 10% of all ER visits in U.S.
• Lateral ankle injuries = 85%
• Medial ankle injury = 5%
• Syndesmosis = 10%
• Long term problems in up to 50%
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4. Anatomy
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5. Sagittal
Plane
Axis of Motion
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6. Peroneal Tendons
• Assist lateral stability
• Pulleys aid functioning
• Behind malleolus
• Around Cuboid
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7. Lateral Ankle
Structures Affected
• Anterior Talo-Fibular ligament
• Calcaneo-fibular ligament
• Posterior talo-fibular ligament
• Anterior-inferior tibio-fibular ligament
Thursday, February 14, 13

8. Lateral Ankle
Structures Affected (2)
• Peroneus brevis tendon
• Peroneus longus tendon
• Os peroneum
• 5th metatarsal base - fracture
• variant: Jone’s fracture
• Interosseus ligament tear
• Fibular fracture
• Osteochondral fracture of Talus
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9. Peroneal Tendons
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10. Examination &
Assessment
• Look
• Symmetry, Color, Swelling
• Touch
• Temperature, texture, tenderness
• Move
• Range of motion, limitations, pain on motion
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11. Anterior Draw
Stress X-ray
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12. Ottawa Ankle Rules
• Less than 15% of ankle injuries presenting to the
ER have a fracture. Rules were set up for ankle
and foot x-rays following ankle sprain
• Tenderness at distal 6 cm of the posterior aspect
of medial or lateral malleolus
• Tenderness at tip of malleolus
• Inability to walk 4 steps
• Tenderness of base of 5th metatarsal or navicular
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13. Thursday, February 14, 13

14. Long Term Prognosis
• Residual instability, pain and swelling can
occur in 20% to 40% of patients after a
Grade II lateral ankle sprain.
Review articles & Lectures: Doug Richie, Jr., DPM
Thursday, February 14, 13

15. Immediate Treatment
• PRICE
• Protection
• Rest
• Ice (24h - 48h) (long term - adverse
impact to nerves, skin, blood flow)
• Compression
• Elevation
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16. Staged Recovery
• Immediate: PRICE
• minimize swelling, hemorrhage,
inflammation, pain
• Week 1 - 3: Protection
• collagen - proliferative phase (initially
Type 3 collagen)
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17. Staged Recovery (2)
• Week 3+
• Exercise & Rehabilitation
• Improvement in collagen maturation
phase
• Graduated exercise program
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18. Staged Exercises
• Range of motion
• ROM - all directions
• Alphabet painting with toes
• Theraband
• Wobble board
• Figure 8 running
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19. Wobble Board Training
• Muscle strength
• Balance
• Joint position sense / proprioception
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20. Problems:
Ankle Instability
• Mechanical
• Laxity
• Functional
• Subjective sensation of instability
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21. Ankle Instability and Sensorimotor
Deficits
Cutaneous Alpha Motor
Receptors Neurons
Articular Extrafusal
CNS
Receptors Muscle Fibers
Tendon & Muscle Articular Gamma Motor
Receptors Receptors Neurons
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22. Factors In Ankle Instability and
Sensorimotor Deficits
Reflex Reactions Walking Mechanics
Postural Control Muscle Strength Running Mechanics
Proprioception Jumping & Landing
Passive Active
Sensory Motor
Thursday, February 14, 13

23. Ankle Instability and Sensorimotor
Deficits
Postural Running
Reflex Reactions
Control Mechanics
Muscle Walking Jumping &
Proprioception
Strength Mechanics Landing
Passive Active
Sensory Motor
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24. Deficits
• Proprioception = Primary Deficit
• Improve balance
• Improve strength
• Peroneal tendon reflex & responsiveness
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25. Bracing
• Stability
• Proprioceptive feedback
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26. Early Stages
• AFO
• Cam walker
• Pneumatic walking boot
• Control of ankle and STJ
• Allows early ambulation with Grade II &
Grade III injury
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27. Later Stage or
Mild Injury
• Gauntlet (lace-up) - Swede-O
• Stirrup - semirigid plastic slabs
• 3 in 1
• Airsplint sport - sleeve, stirrup, locking
wrap
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28. Bracing
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29. Brace Selection
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30. Smaller Braces
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31. Brace Limitations
• Age considerations
• Balance in elderly
• Leg length differences
• Creation of new pains
• Smaller braces - don’t fit in all shoes
• Joint axis interactions
• Weight of braces and boots
Thursday, February 14, 13

32. Other Lateral Injuries
• 5th metatarsal avulsion fracture
• Jones fracture
• Peroneus brevis tendon tear
• Peroneus longus tendinopathy
• Cuboid fracture
Thursday, February 14, 13