Marie Williams, DPM, DHL discusses the basic anatomy and pathophysiology of ankle sprains. Dr Williams also reviews techniques to evaluate and classify ankle sprains as well as their perspective treatments.
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TAPE STARTS – [00:00]
Unidentified Male Speaker: I have the honor to introduce Dr. Marie Williams. I have to say I have worked with Dr. Williams a little bit more recently and I have found her to be incredibly warm and giving person, so she's fabulous. She's the director of the Residency Education Program at Aventura Hospital of which four of her – of the posters were her residents, congratulations, as well as the winners of the rambles. You should be very proud of that. And Dr. Williams is an excellent speaker, so please enjoy.
Marie Williams: Thank you. All right. So I'm going to actually do my lectures altogether in a sense. There's two lectures I'm going to give. One is evaluation and treatment of ankle sprains followed by ankle instability with subtalar joint instability. And hopefully, I can just tie it all into one large lecture in the next 45 minutes or so.
So I basically want you to understand that the evaluation of the ankle is important. Understanding to treat the ankle, you should know about the ligamentous structures around the ankle as well as how to rehabilitate the acute ankle sprain. An ankle sprain is simple. It's a musculoskeletal injury characterized by pain, edema, limitation of range of motion and it includes ligamentous damage. Seventy-five percent of ankle injuries are ligamentous injuries and 85 of those are inversion sprains.
This is just a great picture of the anatomic structures of the anterior talofibular ligament, calcaneofibular ligament and posterior talofibular ligament. And the key of all of those is that the calcaneofibular is an extra articular structure while the anterior talofibular ligament, which originates at the distal anterior fibula and then starts into the body of the talus, and the posterior tibiofibular ligament originates from the fibula fossa, and envelops the lateral tubercle on the posterior talar process, are all intra-articular.
When you do the surgical procedures and/or rehabilitation, you have to understand the ligamentous structures and we'll talk about high ankle sprains as well. Anatomically, what happens is, and this is very important if anyone has ever had an ankle sprain, you lose your proprioceptive fibres, would supply the actual muscular structures in and ability to right yourself.
So the proprioceptive fibres supply the afferent pathway that controls the intrinsic lateral musculature arch. I use LeBron James or even Kobe Bryant as a really incredible example who have total proprioceptive fibres intact until maybe after five, six, seven or eight ankle sprains. But when they're up and they are starting to come down in basketball, and they are starting to right themselves, it's the proprioception and those fibres that are firing to make sure their foot lands appropriately.
Sometimes they hit the wrong spot but if you ever watch closely in a lot of these guys, they'll right themselves very fast. That's because they are always being rehabilitated for that particular factor.
Biomechanically, some people are predisposed to ankle sprains and weakness of the superficial posterior muscle group, gastroc soleus, ankle equinus can lead to, especially an uncompensated ankle equinus, which gives you a heel varus. Ligamentous laxity, tibial – the ligamentous laxity, tibial varum, forefoot valgus, fixed calcaneal varus, forefoot first ray plantar flexion, ankle varus and a supinated subtalar joint. Any one of these biomechanical factors can lead to ankle sprains whether you're playing soccer, basketball or just ambulating.
Clinically, a patient may describe the problem as a rolling of the ankle. Likely mechanism is described as an inversion plantar flexion internal rotation. The ankle pain is usually with – the ankle is usually acutely painful. There's a moderate amount of edema and ecchymosis, and the individual ligament solicits specific pain on palpation, and they're usually unable to initially bear weight.
They come into your office looking like that. You'll see this sometimes lateral ankle with incredible amount of edema, ecchymosis and pain. And without even touching that patient, you know right away ankle sprain. What type of ankle sprain? How much of a problem? And then, that's where you're going to your identification and physical exam.
So you're going to inspect the ankle. I do a very systematic approach. I actually evaluate anterior talofibular ligament, then I enter inferior tibiofibular ligament, then I go to the anterior talofibular ligament, the dorsal CC joint, and the base of the fifth metatarsal and the inferior CC joint. Why? Because you could have the anterior process, fractures of the calcaneus. You could also have base of the fifth metatarsal fractures and you think it's a typical ankle sprain. So make sure you identify that.
I checked the fibula and also the peroneals because the peroneals get strained extensively in an acute ankle sprain. So when you're looking at both ankles, you might see in a thin person, both ankles might look normal to you until you actually inspect them one to the other. And you can see there's a moderate amount of lateral ankle swelling with a significant edema laterally.
Also sometimes they come in and they're splinted. They come in initially in so much pain that their ankle is turned in and they won't let you touch it. There's a reason for that. This is post injury day two and then day three, and you can see the amount of ecchymosis swelling. But I want to show you something that's really – day four, day five. I was getting pictures from home daily with this patient.
And I want to show you something when – I'm going to go back for a second to the splinting. They splint their foot like that and the reason why they splint their foot like that is because the talus is subluxed out of the ankle joint. It doesn't mean it's like a complete disruption of the talus like the ninja warrior or person coming in, and they just ran up a wall and fell and broke their talar neck.
This is a subtle change in the tibiotalar joint. The talus slides a bit anterior and a bit lateral. And when that happens, it's exquisitely painful. I'm telling you this for a reason. This is something I do every single ankle sprain and I encourage my residents when they get them in the emergency room to do the same thing, and it really makes a difference. So here we go.
Day two and three, and four, you can see the amount of blowout and swelling on that guy who just splinted his ankle and wouldn't move it. And then, you have day five. It's really edematous. This is becoming very ecchymotic. And then, you can see that it's starting to dissipate some just by the different colors that you see.
And then, what I'll do, and this is a different patient, but what I'll do, is I'm showing you he have an ankle sprain. I'll actually take my hand and I'll put it on the forefoot, and then I'll put my other hand on the calcaneus. Let's see if it – it didn't come – okay. So I have my hands, two hands. One is under the calcaneus and one is over the forefoot. And I will actually put traction, distal traction on that ankle and foot.
And what you feel when you do that and you should practice this, it's really remarkable. You'll feel the foot give a little. It will just relax. And then what happens is the talus will slide in the mortise and as soon as you – the patients feel a little more comfortable because they get immediate relief of pain.
Once you pull it out, then you ask them to slightly dorsiflex their foot. And 100% of the time, they do one of two things. A, they hear a little pop and feel better, or B, they automatically feel better and clinically they see that they are better.
So here's this lady, ankle sprain, I actually readjust the foot. The edema goes down right in front of your face from the – there's just an adjustment from one picture to the next in the same day, in the same setting. The rehabilitation from that is 10X, what you would do if you didn't adjust that foot.
There's the picture of it where you're actually holding the heel and pulling the foot straight forward, and I'm really putting tension on it. I'm not hurting them, it does not hurt. It feels great. Then you ask them to dorsiflex their foot. The talus slides back into the mortise and the swelling goes right down.
Here's one in the same day from one to the other. Actually, the picture on my right, your left, is the one that's edematous. The one that's adjusted is the one on the opposite side. And I do that on everything and I suggest that as something that you should really start doing in practice or in the emergency room. You'll be a hero.
Some of the differential diagnosis for an ankle sprain, remember, the fractures of the foot and ankle include the base of the fifth metatarsal, the posterior talus. When someone has a fracture, the posterior talus, if you move their great toe or maybe they'll splint their great toe, or maybe their great toe will be fixed in plantar flexion. It's because the flexor tendon gets caught in the posterior ankle. And usually, there's a little fracture at the lip or the posterior aspect of the talus. The anterior process of the calcaneus can also become injured. So double check those areas.
Sometimes you'll get a little stretch because of the type of strain on the superficial peroneal nerve. You have tendon ligament, tendon injuries as well. The peroneals may get stretched. You might have a foot that goes from inversion to eversion, and put a lot of strain on the posterior tibial tendon. The flexors may become inflamed.
Other areas of injury in the midfoot and hindfoot, the ligamentous injuries, and sometimes with an ankle sprain, depending on how they land if they are coming down, they might even get a Lisfranc injury. You'll see osteochondral lesions and as well as a high ankle sprain. High ankle sprain seem to be very devastating especially for the professional basketball players. It keeps them out of play for quite a long time.
I kind of track that because sometimes you see a patient with an ankle sprain and you're trying to get them back and rehab them, or you have a parent with a kid who plays soccer and their soccer league wants them back now. And I look at them and I go, "Look, you have a million dollar basketball players who are getting rehab for six to eight weeks and not back on the court, and they are getting it every day, so just relax." That's sort of what I tell them. But it's true that everybody wants to get back quick.
So classifications of ankle sprains, there's several different types. DS has the one that actually is very simple. Grade one is a parcel, calcaneal fibular, anterior talofibular tear. Grade two is a complete tear, the anterior talofibular ligament. Grade three is a complete rupture of the anterior talofibular ligament, calcaneofibular ligament and/or the posterior tibiofibular ligament. And grade four is a complete disruption of all with possible tear of the deltoid. So remember not to leave the deltoid out when you're checking on your ankle evaluation.
Some on the clinical test, anterior drawer sign. Remember, there's a formula meter increase in the anterior displacement of the talus. It means loss of the anterior talofibular ligament. Make sure you test side to side so that you don't have one side. Maybe there's ligamentous laxity and you haven't tested both the right and the left foot.
The talar tilt test is an inversion test. You test mainly for the calcaneofibular ligament. It seems like that's always a test question. There's a five degree increase in the talar tilt which indicates loss of the calcaneofibular ligament and the integrity. Remember, always compare both sides.
A 10 degree talar tilt is significant and just means there's been a tear. You may not even have to check the other side. Test the peroneal muscle strength. There's sometimes where you have an ankle sprain, the ankle sprain gets better but they have chronic pain. You may have a peroneal – longitudinal tear in the peroneals or you have a little tear on the peroneals and not pick it up. So just be aware of that.
When you ask him to just hop on one leg, the one leg single hop, they'll look at you like you're crazy, they won't do it. That's really, really problematic. And then, you have the syndesmotic evaluation. I'll show you a couple of pictures but I use the squeeze test, which is when you squeeze medial and lateral over the malleoli, and it creates incredible amount of pain and if you externally rotate at rest. So that they're the things that really help you to look at this syndesmotic tears.
So here's just a schematic drawing of the anterior drawer, the talar tilt, and this is a really good one. You have them sit in a chair, cross their legs. You're putting pressure on the lateral fibula and the foot is dropping and they have incredible amount of pain, because you're externally rotating the foot and that creates a lot of pain and pressure on the syndesmotic ligament.
This is just another example. So the X-rays that you take are just pretty much – people take X-rays just to say, "Okay, let's rule out any fractures," and there's a whole bunch of, you know, types of diagnostic tools, MRI. You know, you can do ultrasounds, things like that. But a simple X-ray, you see all your anatomical structures, right?
This is a great picture of just how the X-ray should be. And the clear space and the medial talar – the medial clear space as well as the tibiofibular overlap. And when you look at it in X-ray, especially on the lateral view, you want to be able to see the fibula through the tibia, and to make sure there's no fibula fractures and you'll see it like that. This is very normal. And then you look at your ankle mortise view and you do not want anything to be greater overlap on the tibiofibular area of greater than six millimetres on the anterior, AP view.
And in the clear space, you should have less than four millimetres. So greater – or you're looking at significant ankle sprain or tissue. That's without the MRI. And of course, when you look through, sometimes you'll see something like this. You may not see that fracture as easy but when you look through it, you can see how the fibula is fractured. And then when you take the AP, you have a significant injury that's, you know, with the fibular fracture. So you know that that's fractured but your X-rays can pick up quite a bit just by looking at the joints, how much clear space you have, and you can already pretty much diagnose a ligament injury and/or fracture.
MRI's diagnostic injuries, ultrasound and MRI are used to help if you need to understand what type of disruption you have. I use them if I'm going to do surgical intervention or I haven't been able to come up with a complete diagnosis of tear, or they're not getting better. That's when I use an MRI because pretty much my clinical exam and what I see, and what I feel is 90% in my hands pretty well diagnostic and it should be for you too. You know that ankle very well so you can come up with quite a bit.
If you're going to do something surgically, you might need the MRI to see how much loss you have. We're going to talk in this lecture conservative treatment. I'll touch upon surgery but we'll move on from there. The conservative treatment is very simple. There's the prevention. So if you have a biomechanical dysfunction with somebody that's starting maybe a new sport, you might want to start with the prevention activity where you might have them by a low high-top shoe. You might want to have them change their lace structure of their shoe.
You might have them do tapings sometimes in the schools, you know, young kids. Their trainers are taping them prior to ever having an injury so you have some prevention going on. The grade one to two is based on your phases of wound healing. You know, basically everything that we do is based on wound healing. And in the very first – when you first see people with a grade one to two ankle sprain, you want to RICE – do the rest, ice, compression, elevation, that RICE concept with compression, Jones compression is what I use.
You want to do a short period of immobilization. Taping or bracing, modify shoe gear. There's a lot of things you can do in the very initial grade one to two ankle ligament. The key in the latest treatments in sports medicine is early active range of motion and moving them. Getting the edema down and getting them into movement, which we're going to talk about.
In the grade three, it's a – you get functional rehabilitation versus acute repair or cast immobilization. You know, I don't actually use regular cast anymore. You know, the CAM boot has really replaced that so you can put them in a CAM walker, which allows early weight bearing dorsiflexion, plantar flexion of the foot so they get better movement of the foot itself.
Functional rehabilitation heals a quicker return to activity greater than an acute repair, two to four weeks. And surgery might be indicated if you have decreased range of motion, decreased strength, constant chronic ankle sprains after an acute tear. I'll show you one time when I thought acutely that it's time to go in a repair right away but I don't do that often.
This is just a really quick reminder of your phases of wound healing, whether it's a wound that's due to an ulcer or wound that's due to a twist of a knee, or an ankle or whatever. You have the early phase of wound healing, the inflammatory phase, which is the first day or so, and you have all the PMNs coming in. You have all the bleeding. You have all the beginnings of the swelling and ecchymosis.
But then, you go into the proliferative phase and you have that between three to 10 days, and that's when you have all the fibroblasts and collagens, and collagen synthesis taking place and the extracellular matrix coming in. And this is where you're having your maximum healing of that acute wound.
And then after that, around the 10th day, maybe a little bit longer, you have the epithelial phase or the reparative phase. Now, the remodelling or reparative phase is where you're going to start to get all that scoring and you want to reduce that. So just remember how that goes because it's important when you see an ankle sprain, it still goes through these common characteristics of healing a trauma.
This is called the three phases of recovery. It includes this risk, protection, reduction of swelling first week. The key is getting rid of that edema. Reducing the ankle if it's out of place because the ankle talus does slip out.
You cannot tell radiographically if it's totally out. Sometimes I can pick it up because I can see where the anterior part of the – when you do a lateral view, the anterior part of the tibia to the talus is a little bit impinged – there appears to be a small impingement. But that's just if you're really looking for it.
Phase two includes restoring the range of motion, strength and flexibility. Maybe one to two weeks. And phase three is a gradual return to activity. And that's really important because getting them back to activity with good strength, it may take weeks to months but you really want to shorten the recovery phase so that you can get them back to gradual return to activity.
I love kinesiology tape. I use it for everything from ingrown, toenails to headaches. No, I'm just teasing. I use it a lot.
I actually – believe it or not, found out a lot about this tape from my daughter who was a student in our chiropractic school. She ended up in her chiropractic clinic. She went into chiropractic to stay away from podiatry. And when she got to clinic, they gave her all the foot cases. People that would come in post op, swollen toes from the podiatrist, and the people where there generally for other things, and they'd say, "Here, take care of those swollen toes." And she'd be like, "Why me?"
So what they started doing in their clinic is they started using K-tape on these swollen toes. And then she said – called me up and she said, "You wouldn't believe the results I'm getting on these postop hammertoes." I'm like, "Tell me about that." Of course, my chiropractic daughter is telling me about how she's getting postop – better postop recovery. And I go, she says, "It's Kinesio tape, it's a technique. It's based on the body's own natural healing."
I'm like, "Okay, now I'm interested." She says, "It actually creates more circulatory flow to the area and actually gives better tissue – better repair to the nerves." I'm like, "Now, I'm listening." And she says, "It also gives you support and stability around the muscles, and joints and all the athletes are using it." "Now, I'm really interested." And she says, "It also has its use for muscle inhibition and it increases circulation, and it creates lymphatic drainage."
I go, "Okay, let's get some tape," right. So I started taping my toes and I started doing longitudinal tapes. So these hammertoes and the swelling was going down, and I was like, "Whoa, this is really incredible." Then I was selling the tape to my patients and they were coming in all happy.
So believe it or not, Kinesio tape has its place in podiatry. It has his place for ankle sprains. The technology behind K-tape has now grown so much that I used to buy the Kinesio Tex Gold. But you know if you get online – now, my patients come in and go, "I stopped buying the gold, now I'm buying the pro." And I'm like, "The what?"
And you look at all of them, you know, and that's only just six. There's probably 20 types of K-tape out there now. And if you say K-tape to everybody, they're like, "Oh, yeah, I know all about that." You're like, "Wow." The industry is changing. It's really growing and it's actually quite good. There's rock tape. There's dynamic tape. There's tons of it and it's great for ankle sprains.
So here's how it works. It's basically put on the skin and fascia to relieve pain and swelling, and it actually causes the increase to the blood flow in the lymphatic system. So it's really not immobilizing an area but its reducing the swelling, which reduces the pain, which increases the blood flow to the area, which creates healing. Simply stated.
So I use all kinds of methods. The skin should be free of oils and sweat. You can kind of rub it down. It's heat-sensitive. There's a glue that's heat-sensitive. By rubbing up and down on the surface, the tape sticks better and it actually starts to work better. Sometimes there's all kinds of ways of taping things. Sometimes you do an extreme stretch to the tape. Sometimes you just lay it on, depending on what you're trying to do.
So I usually apply it approximately one hour prior to – they tell them to put it on before showers. It stays on. The skin is irritated at times. So if there is a lot of heat, I tell them to just avoid it or cut back a day or two. This is really some of the conditions, plantar fasciitis, post surgical edema, ankle sprains and prevention.
Now, where you see these finger like pieces, that's for lymphatic drainage just so you know and it works incredible. So for an ankle sprain, that's how I do it. I'll cut them in little strips and lay them on and these people feel so much better. And then, I might even put a brace on that just depending. So I just wanted to put that in there because that's something that's not being used as often as it should and it works extremely well.
In rehabilitation, remember early. Ankle mobilization, decreased stiffness, increase your proprioception. Get good muscular control with the [Bob Sport] [24:08] trampoline, whatever you can do to get that proprioception back and then muscle strength. Toe raises, TheraBand, and some of the key to the success and rehabilitation is early active or passive range of motion, and isometric contractions.
So remember that sometimes they can't passively do it – actively do it so get them to do – get passive range of motion, but at least there's movement. Just some examples of some of the techniques that are used, just quickly. And then acupuncture, I've known people to get acupuncture to their ankles. I walked into my house one day and I saw my son sitting there with these needles sticking out of his foot. I'm like, "What are you doing?"
He goes, "Oh, I have a really bad ankle sprain." And my daughter who's a chiropractic said, "She stuck these needles in me." I go, "Are you okay?" He goes, "I feel great." I'm like, "Okay, let me take a picture of that." So acupuncture is something that I don't know anything about really, except that it does work for soft tissue injuries.
Chronic lateral ankle instability. I'm not going to belabor this. Remember that the exam is the same. The thing that you want to do is if you have someone who's been constantly giving out or giving way, and they've had several ankle sprains, you might have to change your treatment plan a bit, and you want to make sure that the peroneals are strong and/or not torn. And an MRI would be a god way to actually evaluate that.
Surgical intervention is used for failed conservative measures. You need to make sure that you consider rehabilitation, orthotic devices, tapings, bracings, and you want to make sure the mechanical instability is actually relieved. And you may go to surgery if there's a daily activity compromise. They can't do what they used to do.
People come in very upset because now they can't run, they can't jump. They can't play basketball. They can't go to play soccer and that's the time for surgery to be considered. And then, just I'm going to go pass this because we'll go – but there's primary anatomic repair. There's stabilization and reconstruction where you have tenodesis with the use of other ligamentous or tendon structures.
And remember that arthroscopy is an alternative. There are a lot of guys doing ankle ligament repair through arthroscopy. I honestly can tell you that I'm not very well-trained in that and I'd rather open it up for 50 minutes and fix it as opposed to trying to struggle through the scope, so I don't. But I can identify problems with the scope. I go in and clean out the ankle for synovitis. But to do the ligament repair, I'm not – I would rather open it.
And then, just remember there's a primary anatomic repair. There's the end to end approach in acute injuries and in most – common in the athlete. And then, the postop protocol for those types is splinting with ankle at the ankle for 90 degrees. Foot is slightly everted, non-weight bearing at least two weeks. Early active motion. You avoid inversion for approximately four to six weeks with passive and active range of motion, physical therapy and back to full activity.
Some of the complications are residual instability, non-physiological ankle mechanics, which cause them to have other problems maybe even ankle joint arthritis, stiffness. I've seen overtightening of an ankle ligament, which is he worse because now, they can't move. They have chronic pain. There's abnormal subtalar motion, nerve pairs. There's nerve injuries, stiffness and sometimes RST, so just be aware that these things can occur.
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