- Ankle sprains are the most common type of ankle injury, with lateral ankle sprains making up 80-85% of cases. Inversion injuries are most common. - Chronic ankle instability affects 20-40% of patients with a previous ankle sprain. The ATFL ligament is most frequently injured. - Ankle sprains are classified as low (lateral or medial) or high (syndesmotic). A lateral sprain typically injures the ATFL ligament. - Conservative treatment involves RICE (rest, ice, compression, and elevation) and rehabilitation. Surgical reconstruction may be needed for grade III injuries or recurrent instability.

1. Foot and Ankle
Instability

2.  Ankle is the 2nd most common only injured body site
 Ankle sprains are the most common type of ankle injury
 Inversion injury most common mechanism
 Risk factor is previous ankle sprain
• It is estimated that 80 to 85% of ankle sprains occur to the lateral ligaments
• It is generally accepted that an eversion ankle sprain is more severe, with
greater instability. However, an inversion ankle sprain is more common, with
the lateral ligaments being involved in 80% to 85% of all ankle sprains
• ATFL is most common injured ligament
• High rate of recurrence (20- 40%)
• Chronic ankle instability (20 - 40%)
Introduction
Charles M. Court-Brown, James D. Heckman, Margaret M. Mc Queen, William M Ricci, Paul Tornetta III. (2015). Rockwood and Green's Fractures in adults eighth edition
Solomon, L., Warwick, D., & Nayagam, S. (2010). Apley's system of orthopaedics and fractures ninth edition. CRC press.

3. Anatomy
Netter Concise Orthopedic Anatomy, 2𝑛𝑑 Edition

4. Anatomy
Netter Concise Orthopedic Anatomy, 2𝑛𝑑 Edition

5. Anatomy

6. Anatomy
Netter Concise Orthopedic Anatomy, 2𝑛𝑑 Edition

7. Anatomy
Netter Concise Orthopedic Anatomy, 2𝑛𝑑 Edition

8. Classification
Ankle sprain classified in two categories:
- Low ankle sprain
ㆍLateral ankle sprain "classic sprain" 80 - 85%
ㆍMedial ankle sprain 5 - 10%
- High ankle sprain
ㆍSyndesmotic sprain 5 - 10%
Charles M. Court-Brown, James D. Heckman, Margaret M. Mc Queen, William M Ricci, Paul Tornetta III. (2015). Rockwood and Green's Fractures in adults eighth edition

9. Low Ankle Sprain
Lateral ankle sprain:
• The most common mechanism
of ankle injury is inversion of
the plantar-flexed foot.
• The ATFL is the first or only
ligament to be injured in the
majority of ankle sprains.
Stronger forces lead to
combined ruptures of the ATFL
and the CFL.
Charles M. Court-Brown, James D. Heckman, Margaret M. Mc Queen, William M Ricci, Paul Tornetta III. (2015). Rockwood and Green's Fractures in adults eighth edition

10. Low Ankle Sprain
Medial ankle sprain:
• The medial deltoid ligament
complex is the strongest of the
ankle ligaments and is
infrequently injured.
• Forced eversion of the ankle can
cause damage to the structure
but more commonly results in
an avulsion fracture of the
medial malleolus because of the
strength of the deltoid ligament.
Charles M. Court-Brown, James D. Heckman, Margaret M. Mc Queen, William M Ricci, Paul Tornetta III. (2015). Rockwood and Green's Fractures in adults eighth edition

11. High Ankle Sprain
High ankle sprain (Syndesmotic sprain):
• Dorsiflexion and/or eversion of the
ankle may cause sprain of the
syndesmotic structures.
• There generally tends to be less swelling
with a high ankle sprain, however there
tends to be pain that is more severe and
longer lasting.
• Syndesmotic ligament injuries
contribute to chronic ankle instability
and are more likely to result in recurrent
ankle sprain and the formation of
heterotopic ossification.
Charles M. Court-Brown, James D. Heckman, Margaret M. Mc Queen, William M Ricci, Paul Tornetta III. (2015). Rockwood and Green's Fractures in adults eighth edition

12. Grading & Symptoms
Charles M. Court-Brown, James D. Heckman, Margaret M. Mc Queen, William M Ricci, Paul Tornetta III. (2015). Rockwood and Green's Fractures in adults eighth edition
Netter Concise Orthopedic Anatomy, 2𝑛𝑑 Edition

13. Physical Examination
LOOK
Netter Concise Orthopedic Anatomy, 2𝑛𝑑 Edition
Look at the footwear type and if any, walking aids before examine the patient  clue for any rotational deformity:
• Supination deformity: Early lateral, proximal, and mid shoe wear
• Pronation deformity: Medial border
Static Inspection
Anterior • +/- hallux valgus, deformity of the lesser toe (hammer
toe, mallet toe, claw toe)
• +/- swelling, ulcer, skin color (pallor/congestion), skin
hair decrease in peripheral vasc disease
Lateral Medial arch  flat (planus), high arched (cavus) or normal
and whether both sides are symmetrical
Posterior +/- Achilles joint swelling, cavovarus foot, pump bump, too
many toes sign
Plantar +/- ulcer, callus
Dynamic Inspection
Gait • +/- foot drop, high stepping, external rotaion foot walking

14. Physical Examination
FEEL
Bony
Structure
1st MP joint/MT& head
Lesser MPT joint/MT
Tarsal bones/midfoot
Calcaneus/heel
Malleoli
Soft Tissue Skin
Between metatarsal heads
Medial ankle ligaments
Tendons (at med. malleolus)
Lateral ankle ligaments
Peroneal tendons (LM)
Achilles tendon
Evaluate the color, temperature, +/- pain, tenderness, swelling
Netter Concise Orthopedic Anatomy, 2𝑛𝑑 Edition

15. Netter Concise Orthopedic Anatomy, 2𝑛𝑑 Edition
MOVE :

16. Management
Conservative Management
Initial Management
Initial management of ankle sprains requires the PRICE regimen:
P = Protection (crutches, splint or brace)
R = Rest
I = Ice (cold compresses 20 minutes every 2 hours & after any activity that
exacerbates the symptoms
C = Compression
E = Elevation (RICE continued for 1-3 weeks)
Rehabilitation:
• This is probably the single most important factor in treatment, particularly with
Grade I and Grade Il injuries.
• Pain and swelling can be reduced with the use of electrotherapeutic modalities.
• Analgesics (NSAID) may be required.
Solomon, L., Warwick, D., & Nayagam, S. (2010). Apley's system of orthopaedics and fractures ninth edition. CRC press.

17. Management
Conservative Management
Restoring Full Range of Motion
• The patient may be non-weight-bearing on
crutches for the first 24 hours but should then
commence partial weight-bearing in normal heel-
toe gait.
• It will be necessary from this stage to protect the
damaged joint with strapping or bracing.
• As soon as pain allows, active range of motion
exercises can be commenced.
Solomon, L., Warwick, D., & Nayagam, S. (2010). Apley's system of orthopaedics and fractures ninth edition. CRC press.

18. Management
Conservative Management
Muscle Conditioning:
• Strengthening exercises should be commenced as soon
as pain allows.
• Active exercises should be performed initially with
gradually increasing resistance.
• Exercises should include plantarflexion and dorsiflexion,
inversion and eversion.
Functional Exercise:
• Functional exercises (e.g. jumping, hopping, twisting,
figure-of-eight running) should be commenced when
the athlete is pain-free, has full range of motion and
adequate muscle strength and proprioception.
Solomon, L., Warwick, D., & Nayagam, S. (2010). Apley's system of orthopaedics and fractures ninth edition. CRC press.

19. Management
Conservative Management
Treatment of Grade III Injuries:
• Treatment of Grade III ankle injuries requires initial
conservative management over a six-week period.
• If the patient continues to make good progress and is
able to perform sporting activities with the aid of
taping or bracing and without persistent problems 
surgery may not be required.
• If patient complains of recurrent episodes of instability
or persistent pain  surgical reconstruction is
indicated.
Solomon, L., Warwick, D., & Nayagam, S. (2010). Apley's system of orthopaedics and fractures ninth edition. CRC press.

20. Management
Tiemstra, J. D. (2012). Update on acute ankle sprains. American family physician, 85(12), 1170-1176.

21. Surgical Treatment
Ankle: Anterolateral Approach
• Can access hind foot
• Preserving fat pad (sinus tarsus) helps wound
healing
Indication :
• Fusions/triple arthrodesis
• Fractures (e.g., pilon, talus)
• Intertarsal joint access
Arthroscopy Portals
• Anteromedial: Least risky portal, should be established first
• Anterloateral: Can establish with needle under direct visualization
• Posterolateral: Can establish with needle under direct
visualization
Indication :
• synovectomy,
• loose body removal
• osteochondral lesions
• impingement
• chondroplasty
• some arthrodeses
Netter Concise Orthopedic Anatomy, 2𝑛𝑑 Edition

22. • Conservative treatment supported for acute injuries.
• No difference in overall result, functional scores, objective or
subjective stability.
• Conservative group - return to activities 5.4 weeks sooner
• 10-30% develop residual instability
• Trends in the Literature
• Anatomic vs. Non-anatomic
• Gold Standard - Brostrom-Gould
• Numerous modifications
• Open vs. Arthroscopic Procedures
Surgical Treatment
Charles M. Court-Brown, James D. Heckman, Margaret M. Mc Queen, William M Ricci, Paul Tornetta III. (2015). Rockwood and Green's Fractures in adults eighth edition

23. Non-anatomic tenodesis procedures
Initially, excellent-good short term results
Change in ankle kinematics -> long-term
deterioration of results.
Surgical Treatment
Anatomic vs. Non-anatomic
Charles M. Court-Brown, James D. Heckman, Margaret M. Mc Queen, William M Ricci, Paul Tornetta III. (2015). Rockwood and Green's Fractures in adults eighth edition

24. SurgicalTreatment
Gold Standard
Anatomic repair with Brostrom-Gould was gold Standard
Charles M. Court-Brown, James D. Heckman, Margaret M. Mc Queen, William M Ricci, Paul Tornetta III. (2015). Rockwood and Green's Fractures in adults eighth edition

25. THANK YOU