Marie Williams, DPM reviews a common podiatric problem, the ankle sprain. Dr Williams reviews an initial presentation of a patient with an ankle sprain, as well as an appropriate workup if a questionable sprain presents to your office. She also reviews conservative and surgical options, including the use of the newly popular Kineso tape. She concludes with a short step by step overview of a primary ankle repair.
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Release Date: 03/16/2018 Expiration Date: 12/31/2018
Marie Williams, DPM, DHL
Director, Podiatric Medical Education
Aventura Hospital and Medical Center
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Male Speaker 1: We’re going to kick this off with Marie Williams who is certainly doesn’t need an introduction. And she is going to be talking about ankle and sprains and ankle injuries. But what’s very interesting about Marie is most of you don’t know is her association with.
Marie Williams: The Mighty Max.
Male Speaker 1: The Mighty Max that she was just at the premier opening the other night which is a 1970 college girls basketball team that won three national.
Marie Williams: Three national championships.
Male Speaker 1: Three national championships and so they’ve kind of practice in it and have created the Mighty Max which we all should go and see.
Marie Williams: That’s right.
Male Speaker 1: And she’s really excited. I came to her and she was, she could tell you a little bit about that, but she’s going to be talking ankle sprains and it’s wonderful to have her and kick this off, right.
Marie Williams: Thank you. I’m happy to be here. I’m very happy to be here and it’s true. I actually did have a movie made about our team. And I was on the 74 team and it was based on those three teams. And it’s a great movie but more important than that I’m going to give you a little lecture on ankle sprains. We all actually address ankle sprains every single day in our practices. So let me just and get this scenario. So my lecture was on evaluation and conservative care of the ankle sprain although I will touch upon a little surgery only because it’s in my nature. But more important than that I have some learning objectives that I would like to make sure that we all take from this lecture. To recognize the difference between acute and chronic ankle sprains, able to evaluate the ankle joint for ankle ligament disruption. And to know the difference, types of treatments that are actually out there for ankle sprains. Sometimes it’s very simple and sometimes it becomes more complex. So it’s good that we have a tool for treatment besides surgery. What is an ankle sprain? It’s actually a musculoseletal injury. It is characterized by pain and edema and limitation of range of motion. And it includes ligament damage. 75% of the ankle injuries are ligaments injuries. When we see patients coming in limping most likely it’s an ankle sprain not an ankle fracture. And these are the things sometimes that are very debilitating because it does limit them to go. A, as an athlete back unto the court or just as someone who’s out working and standing on their ankle or foot all day long with an ankle sprain that swells and give some chronic pain. 85% of the ankle sprains are caused by inversion, trauma or injuries. Just important to know your ankle ligament anatomy. When I actually see my residence and I start asking them, it’s amazing to me that I say, okay so let’s palpate the ankle joint and find out what ligament is problematic. And some of them actually sit there and look at me like what are you talking about the ankle is the ankle. Well, the ankle can be very complex from the view point of it’s not just an ankle. And when you look at the ligaments you have the anterior tibiofibular ligament which originates at the distal anterior fibula and it starts with the body of the talus. You have several fibers that go in two directions. You have the calcaneofibular ligaments which is extra articular and it courses posteriorly inferior from the anterior border of the distal fibula to the tubercle on the later aspect of the calcaneus. And the last is the posterior tibiofibular ligament which your originates from the fibular facet. And envelops the lateral tubercle of the posterior tibiofibular process. And many times that ligament is missed as an injured ligament. People have chronic pain in the posterior ankle. That ligament does get disrupted. Propioreception is important because what causes the chronic ankle sprain is lack or propioreception. Take a basketball player for example, they’ve sprain their ankle one time or two times and I’m sure all of us had either experienced treating patients with ankle sprains or had them ourselves. And the fear of that happening again usually comes from the lack propioreception. Propioreception is the thing as you’re coming down like say with a basketball or in tennis, starting to make a twist or turn you lose the ability to right that foot and so propioreception when you come to treatment is very important to reestablish. Some of the predisposing biomechanical factors and you can almost, and so this is very predictable. We can solve the actual superficial posterior muscles, the gastroc soleus equinus can actually predispose ankle sprains. Also ankle joint equinus, that’s uncompensated. The ankle is actually maybe osteophytic anteriorily and the ankle will then go lateral causing instability.
Also peroneal weakness, ligamentous laxity is very common especially after the one sprain or two sprain patient. Now you have ankle joint ligamentous laxity and inherent now more prone to sprains continually. And tibial varum, you can almost see someone walking and with that varus leg. And tibial varum that they can be very prone to spraining. They’ll tell you that themselves. For foot valgus, fix calcaneal varus actually the plantar flex first ray although it’s a stable foot at many times when they push off with the forefoot in plantar flexion, sometimes they’ll actually roll out and that ankle well then become sprained. And the ankle varus in the supinated subtalar joint. Clinically patients will tell you that they’ve rolled their ankle. They heard a pop or a twist. They come in sometimes with an exquisite pain lateral perineal area, 5th metatarsal area and lateral ankle, anterior ankle as well. And I’m going to address the anterior ankle which we don’t really often have addressed and then we’ll talk about it in a minute. It’s an inversion plantar flexion with an internal rotation, acute pain, swelling ecchymosis and individual ligaments, elicit pain on palpation. When I actually evaluate an ankle, I look at the ankle. I first do observation. You know, one of the key things to our ability is just to be able to sit and observe and look. So I compare ankle to ankle because some people have very swollen lateral ankles just naturally. They have a fat pad in the subtalar joint. They look swollen and maybe they’re not. That’s normal, right? So I look from ankle to ankle then I’ll start to palpate and I do it in a very sequential manner. I’ll palpate the anterior tibiofibular ligament and if that elicits pain that’s very classic. They’ll jump. They’ll say yes that’s swollen, that hurts. Then you do the calcaneofibular ligament and then I’ll palpate posteriorly to the posterior ligament and then also the peroneus. Also on top of that, I’ll do the deltoid ligament and posterior tendon and then I’ll do range motion of the ankle. And I do that in that order and I do that every single time so I don’t miss something. These people, when they come in with an acute sprain they have an inability to bare weight many times. They don’t have fractures often but they cannot bare weight on the ankle and I’ll tell you why that is. This is just an example of someone who’s a chronic ankle sprainer and she had a little bit of a sprain, but you can see where it starts to get a little bit swollen, a little black and blue, lateral ankles painful, you can see the peroneus were a bit swollen. That foot hurts. She can’t really bare weight on it. Even though it doesn’t look like very blown out or extremely swollen, but this is a chronic ankle sprain patient who continually twists the ankle and after many therapies and she may end up with reconstruction. But this is what it classically looks like in someone who constantly sprains the ankle and maybe not a new sprain. This is the ankle anteriorily and I’ll go over that. I’m going to show you something very important in my practice. This is another lady who came in with a bandage on her foot. She said, I twisted my ankle. You can’t really define the fibula and you can’t define peroneus and you can’t define the anterior lateral ankle in the sinus tarsi. It’s a very swollen ankle though. If you just look at it by itself you wouldn’t know that. And then this is just form the side. Now what, why I’m showing this is anteriorly there’s a little ecchymosis in anterior ankle. It is very, very painful there. What I find in the anterior ankle is what happens when you have an ankle sprain and this is very much often missed. The talus slips from the ankle mortise anteriorly and laterally. So when you see a patient and they can’t bare weight and they can’t dorsiflex their foot then you may think it’s just because it’s painful, it’s not. It’s because the talus gets somewhat sub-locks. It’s not a fracture. It’s not a true dislocation. It’s a mild subluxation of that ankle mortise. And it’s exquisitely painful and the ankle becomes very swollen. So with every single ankle sprain that comes into my office and I find that one for one these patients starts to get relief of pain and swelling almost immediately. What I’ll do is I’ll take my hand on the posterios aspect to the heel and I’ll grab the calcaneus. And I’ll take the forefoot and I’ll pull it towards me. So now I’m opening up the whole ankle joint mortise. And then with the patient’s help because this is something that they do. I’m going to slide that talus back into the mortise and they are relieved of pain as immediate. So what I’ll do is I’ll pull out and pull up. And then you can see the patient is helping me dorsiflex their foot. And the talus is now slipping back into the mortise. And I’m talking very subtle. You’re not going to find this on x-ray. But what you will find is that if you palpate the ankle anteriorly the pain goes away. And then what happens is immediately anteriorly the swelling starts to subside almost immediately in front of you eyes. So I wanted to show you that because it’s something that I do at every single ankle sprain and my success on reduce of swelling is significant.
The deferential diagnosis of acute injuries. We have to look for fractures, fractures of the 5th metatarsal base is very, very important. Sometimes a posterior talus and if you want dorsiflex and plantar flex the great toe, you’ll find that if you have a fracture in the posterior talus and anterior calcaneal process, sometimes the sinus tarsi will be exquisitely tender. And in there you’ll have a little flick fracture or a small fracture the anterior process or the calcaneus and you must look for that. Occasionally you’ll have peroneal injury, superficial peroneal nerves, sural nerve, injury from the swelling and the intermediate dorsal cutaneous nerve as well. And tendons get missed occasionally because you’re always thinking of ligament. Remember you can get tenosynovitis of the peroneal tendons. You can get posterior tib tendonitis and flexor tendonitis. And that should be evaluated as well. There are other ligamentous injuries with ankle sprains. Sometimes you’ll get mid-foot injury. You’ll get a subluxation of the cuboid that navicular will become problematic and you need to address it. Also look for osteochondral lesions and a chronic ankle pain and the high ankle sprain. That’s common in the football players then they fell they get those high ankle sprains and the syndesmotic ligament gets disrupted. And that could be very limiting for activity and back to exercise. So classifications, I’m not going to bore with all the classifications except that I use the grading system by DS Partial Calcanea Fibular and Anterior Talofibular Ligament here is a grade one, grade two complete, anterior talofibular ligament disruption is grade two. Grade three complete. Anterior talofibular, Calcaneal Fibular and/or Posterior Talofibular Ligament Rapture. And grade four is a complete rapture of all three lateral ligaments as well as possible disruption of the deltoid ligament. Remember that we do have diagnostic test, anterior drawer test. And if you get 4 millimeters off displacement, of the talus. It means there’s lost anterior fibular ligament. You should always compare side to side. Talar tilt test for the calcaneal fibular ligament, 5, degrees of increased talar tilt and is indicative of loss of the calcanea fibular integrity and compare that also with the lateral side. If you have 10 degrees of talar tilt it’s very significant and very classic for a calcaneal fibular ligament disruption. Peroneal tendon muscle strain, I always check that. These patients if they have a really significant ankle sprain they’re not going to be able to do a single hop on there ankle or foot. And I don’t ask them to do that initially, but in a chronic ankle they’ll be very weak. And as in this monic tear you want to squeeze side to side in the kneel to lateral and you’ll get exquisite pain in the anterior lateral ankle. Again just to picture anterior dural talar tilt. And interestingly because diagnostic imaging is a big deal and I don’t know if this is happening in your hospitals and areas, but now patients are going to be getting these little disks and told how much radiation they’re getting in a year. They’re doing that in our area. So people come in very aware of radiation now and they say I don’t want an ankle x-ray. I x-ray everybody. I don’t want miss a fracture, but this actual auto ankle rules came out and I just wanted to review that with you. I do not follow the rules so much as I said I always x-ray because if I miss something then I’m liable for it. More important though, I just wanted you to know that there are some things that come out a series of ankle x-ray film is required only if and this is auto rules. Only if there is any pain in the malatin malleolar zones in any of these findings. Bone tenderness at zone A, which is the posterior edge or the tip of the lateral malleolus and 6 centimeters above that. Also bone tenderness at the medial and lateral posterior ankle also inability to bare weight. So this is just an example of how, who knows what’s coming in the future, but also if you have mid foot pain check for the navicular and the base of the 5th metatarsal also the cuboid can get sublux because the peroneal tendon as it comes to the base of the 5th metatarsal and the peroneus as along as across the foot will post significantly onto the cuboid and sublux that cuboid causing chronic ankle pain and the ankle has good motion, but they sense ankle pain. So just be aware of that. Diagnostic imaging, ultrasound. Ultrasound is very much a standard for many people. It’s non evasive, it’s dynamic, but the key to that is it’s user dependent. If you’re very stood at ankle ultrasound for the ligaments then you’re going to do a very good test and get a good result. And if you’re not you may get maybe not a good result.
So I think it’s very accurate, but very user dependent. Then I don’t use CT Scans very often frontal sprains, but definitely my MRI is very helpful to tell which ligament is disrupted and you’ll see that at it you’ll have an attenuated signal and that’s just an example of that. Treatments, you want of course prevention, ankle bracing and taping is important. A low top shoe, low brace with a shoe, high top shoe and taping, taping alone. These are all types of treatments that are done in athletes. They sometimes get both. It depends on the trainer, but in the everyday scene where you are, you know you’re going to actually use your taping and your bracing to help them, physical therapy is important. In Grade 1 and 2, it’s based on the phases of wound healing. Remember Grade 1 and 2, you use your ice elevation compression and rest in short periods. You need short term immobilization. I don’t keep my ankle sprain immobilized for very long. I get them moving very fast. I use taping. I’ll show you what type of taping I use. Suture and orthotic modification for the bio-mechanically unstable foot and anti-inflammatory, cold therapy and rehabilitation. Disabilities with ankle sprain usually 1 to 2 weeks. If you can get them going faster that’s good. When it comes to a Grade 3, you may have to do more aggressive rehabilitation. Sometimes putting them in a cask or a cam boot, even in the Grade 3 I’ll put them in a cam walker with active range and motion for 2 to 4 weeks. And if they have continued chronic pain and they have a chronic ankle sprain I will consider ligament repair. It also depends on the type of patient. If it’s a young athlete and they constantly sprain their ankle, it’s time to fix it. If it’s an elderly patient and they sprained their ankles, you’re going to treat them conservatively. So you would definitely just that it would be patient dependent and activity dependent. I put this up not because I want you to know all about wound healing, but what’s kind of cool about this, is in the first three days. You have the inflammatory phase of wound healing in any wound. I don’t care if it’s an ulcer type wound or a tendon injury or a surgical wound. First 3 days is the inflammatory phase. This is where you would might want to do ice aggressively. In 3 to 30 day phase, this is where your maximum growth factors are. This is where you’re anti inflammatory cells are, androgenesis epithelialization, fibroblast and proliferation. And so during this period of time is really a good time for aggressive therapy. So you’re going to keep that actually going. And then of course they have the remodeling phase where you get ankle strength and tensile strength to the area. Ligaments, I don’t think really get increased tensile strength but the ligament structures or the structures around the injury do. So just keep that, aware of that. One of the things that I like. This is basically something a little bit new. I don’t know if you’ve used it. The kinesio taping techniques. I like it on my ankle sprains. I use in many, many ways. And I’ll tell you how, but for the ankle it’s actually quite incredible. Kinesio tape is a technique base on the body’s own natural healing. And what it is, it exhibits, it actually 120 to 140 times stretch ability on the tape itself. It has cross fibers. And that actually works in conjunction with the tissue around the injury to reduce swelling and pain and can actually increase stability. You’ll see a lot of the professional athletes and college athletes now with their kinesio tape of all colors. It actually exhibits efficiency through activation of the neurologic and circulatory system. It actually gives support and stability to the muscles and joints without affecting range of motion. So it moves with the body which I really like. And actually it increases lymphatic drainage. Now think about that. Here you want to get reduced swelling and edema around a part. So I’m going to give a hot tip. I use this also on post hammertoes surgery just as a plug because, you know, sometimes the toes stay swollen. I’ll put it on each side of the toe that I’ve done surgery and the reduction of swelling is remarkable. It’s actually quite cool. It helps drain all lymphadenitis and that’s the key to it. Others, all types of taping methods, you know, the skin should be free of oils, so you wipe it down with some alcohol. It’s heat sensitive. So as it gets on to the body it has more stretch ability and motion. And if you actually rub it, it activates it even more. You want to avoid, the tape is very stretchy, so you want to avoid stretching it overly unlit you put it on to the body. You apply it about an hour prior to activity or showering. And it can have skin irritation just like any tape does, but you actually have less sensitivity.
I left the website to read about. It’s really kind of fun to read because it’s very different. Just strips of tape here. It’s also used in a plantar fasciitis, post-surgical ankle sprains and preventative, some of the taping techniques that are used. The one in the top where the plantar fasciiti, that’s what I use for plantar fasciitis. And I don’t really do the low dye strapping as much anymore. I find they get incredible relief very fast. So, just as a hot tip. The ankle, you actually can put on the lateral ankle and place it on the side of the foot and it moves with the ligaments and actually becomes part of the ligament structure. They get incredible relief. There’s many other techniques and there’s actually a whole course that people take on the techniques of that tape, but I like it. Early active range in motion is important to decrease stiffness in the ankle joint for rehabilitation, remember proprioception is key. And there’s the box board and. I personally like a small trampoline on these young athletes. Getting them jumping on the trampoline that builds proprioception. And it actually gives them a lot of confidence that they can use the ankle again. And also muscle strengthening to raise and the thoroughbred therapy. So it’s just a little example of that. Chronic lateral instability, just basically, you know constantly giving way and I don’t need to reiterate that, but the hind foot ligaments are due to hind foot varus ligaments, laxity, peroneal spasm. And we need to strengthen those and get the proprioception back in full range. Your MRI is most useful in the chronic condition. You’ll see disk continuous fibers, swelling, lax or wavy fibers and no visualization at all. So that’s a very good way to evaluate those ligaments. I’m going to skip the surgical technique you definitely can use diagnostic ankle arthroscopy. And if you have osteochondral lesion, it’s as great way to treat that. And we’re just going to move through the surgery and so. Failed conservatory treatment is where surgical intervention is indicated and I do that when I have ankle athlete who has a really incredibly bad blown out ankle and ligaments need to be repaired. And there are several excellent techniques out there now where we don’t have rune or disrupt our peroneal tendons for ligament repair. So we’re just going to skip through that. Is that all right with you? Okay. All right, I’m sorry I didn’t know that they were there, but anyway we’ll just skip them and. Remember some of the complications in anything is residual instability, non physiological ankle mechanism over. If you do surgery you might over tighten. Subtalar joint motion can be disrupted. You may have some supper facial peroneal nerve palsy or parestesias, stiffness and you definitely don’t want RST. Now these are the references for you to follow up on and there’s also reference on the pictures. Thank you very much for letting me speak and you have a great day.
Male Speaker 1: Good job.