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Sprain, Ankle

Sprain, Ankle is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

The most common cause of ankle injury comprising a significant proportion of sports injuries:

  • Types of ankle sprains: lateral, medial, and syndesmotic (or high ankle sprain)
    • Lateral ankle sprains are the most common, accounting for up to 89% of all ankle sprains (1):
      • In lateral ankle sprains, the anterior talofibular ligament (ATFL) is most likely to be injured.
      • The calcaneofibular ligament (CFL) is the second most likely ligament to be injured.
      • The posterior talofibular ligament (PTFL) is the least likely to be injured.
    • Medial ankle sprains (5–10%) result from an injury to the deltoid ligament.
    • Syndesmotic (“high ankle sprain”) injuries account for 5–10% of ankle sprains.
      • The syndesmosis between the distal tibia and distal fibula bones consists of the anterior, posterior, and transverse tibiofibular ligaments; the interosseous ligament; and interosseous membrane.
  • Ankle sprains are classified according to the degree of ligamentous disruption:
    • Grade I: mild stretching of a ligament with possible microscopic tears
    • Grade II: incomplete tear of a ligament
    • Grade III: complete ligament tear

Geriatric Considerations
Increased risk of fracture in patients with preexisting bone weakness (osteoporosis/osteopenia)

Pediatric Considerations
  • Increased risk of physeal injuries instead of ligament sprain because ligaments have greater tensile strength than physes
  • Inversion ankle injuries in children may have a concomitant fibular physeal injury (Salter-Harris type I or higher fracture).
  • Consider tarsal coalition with recurrent ankle sprains.

Epidemiology

Incidence
  • Ankle sprains are more common in childhood and adolescents, particularly in active individuals (2).
  • 1/2 of all ankle sprains are sports related; highest incidence in indoor/court sports (basketball, volleyball, tennis), followed by football and soccer (3)
  • Most common sports injury
  • More common in males age <30 years and females >30 years old

Prevalence
  • 25% of sports injuries in the United States
  • 75% of all ankle injuries are sprains.

Etiology and Pathophysiology

  • Lateral ankle sprains result from an inversion force with the ankle in plantar flexion.
  • Medial ankle sprains are due to forced eversion while the foot is in dorsiflexion.
  • Syndesmotic sprains result from eversion stress/extreme dorsiflexion along with internal rotation of tibia.

Risk Factors

  • The greatest risk factor is a prior history of an ankle sprain (3–34% recurrence rate).
  • Postural instability, gait alterations
  • Joint laxity and decreased proprioception are not risk factors.

General Prevention

  • Improve overall physical conditioning:
    • Training in agility and flexibility
    • Single-leg balancing
    • Proprioceptive training
  • Taping and bracing may help prevent primary injury in selected sports (i.e., volleyball, basketball, football) or reinjury (4). Taping and bracing do not reduce sprain severity.
  • Weight loss may help in overweight patients (4)[A].

Commonly Associated Conditions

  • Contusions
  • Fractures
    • Fibular head fracture/dislocation (Maisonneuve)
    • Fracture of the base of the 5th metatarsal
    • Distal fibula physeal fracture (includes Salter-Harris fractures in pediatric patients; most common type of pediatric ankle fracture)

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Citation

Stephens, Mark B., et al., editors. "Sprain, Ankle." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116893/all/Sprain__Ankle.
Sprain, Ankle. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116893/all/Sprain__Ankle. Accessed April 19, 2019.
Sprain, Ankle. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116893/all/Sprain__Ankle
Sprain, Ankle [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 19]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116893/all/Sprain__Ankle.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Sprain, Ankle ID - 116893 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116893/all/Sprain__Ankle PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -