This document discusses ankle sprains, including the anatomy, classification, grading, examination, and management. It notes that ankle sprains are common injuries presenting to emergency departments. The three main types of ankle sprains are lateral, medial, and syndesmotic. Grades range from I to III based on the severity of ligament tearing. Examination involves special tests like the squeeze, talar tilt, and anterior drawer. Initial management consists of RICE along with exercises to maintain range of motion. Rehabilitation focuses on functional exercises and proprioception training to aid return to activity and prevent chronic instability. Surgery may be considered in severe cases involving ligament ruptures.

1. Ankle Sprain
By
Dr. Ahmed Abdel Ghani
MBBS, MSC.(ORTHO.), MRCS, CPHQ, LRS-PD
Orthopaedic surgeon
Afif General Hospital

2. Introduction
n Ankle injuries are among the most common injuries
presenting to emergency departments.
n Ankle ligaments provide mechanical stability, proprioceptive
sensation, and directed motion for the joint.
n Recurrent ankle sprains can lead to functional instability and
loss of normal ankle kinematics and proprioception, which can
result in recurrent injury, chronic instability, and early
degenerative changes.

3. Anatomy

4. Anatomy

5. Classification
Lateral ankle sprain
n The most common mechanism of ankle injury is inversion of
the plantar-flexed foot.
n The anterior talo-fibular ligament is the first or only ligament
to be injured in the majority of ankle sprains.
 Stronger forces lead to combined ruptures of the anterior
talofibular ligament and the calcaneofibular ligament, which
can result in significant ankle joint instability, usually
accompanied with nerve injury.

6. Lateral ankle sprain

7. Classification
Medial ankle sprain
n The medial deltoid ligament complex is the
strongest of the ankle ligaments and is
infrequently injured.
n Forced eversion of the ankle can cause damage
to this structure but more commonly results in an
avulsion fracture of the medial malleolus because
of the strength of the deltoid ligament.

8. Medial ankle sprain

9. Classification
Syndesmotic sprain
n Dorsiflexion and/or eversion of the ankle may cause sprain of the
syndesmotic structures, which include the anterior tibiofibular, posterior
tibiofibular, and transverse tibiofibular ligaments, and the interosseous
membrane. These structures are critical to ankle stability.
n Syndesmotic ligament injuries contribute to chronic ankle instability
and are more likely to result in recurrent ankle sprain and the formation
of heterotopic ossifications.

10. Syndesmotic sprain

11. Grading
n Grade I sprain:
1. It results from mild stretching of a ligament with microscopic tears.
2. Patients have mild swelling and tenderness.
3. There is no joint instability on examination, and the patient is able to
bear weight and ambulate with minimal pain.

12. Grading
n Grade II sprain
1. Is more severe injury involving an incomplete tear of a ligament.
2. Patients have moderate pain, swelling, tenderness, and ecchymosis.
3. There is mild to moderate joint instability with some restriction of the range
of motion and loss of function.
4. Weight bearing and ambulation are painful

13. Grading
n Grade III sprain
1. involves a complete tear of a ligament.
2. Patients have severe pain, swelling, tenderness, and ecchymosis.
3. There is significant mechanical instability and significant loss of
function and motion. Patients are unable to bear weight or ambulate

14. Examination ( Special tests)
Squeeze test
n The squeeze test consists of
compression of the fibula against the
tibia at the mid-calf level. This maneuver
elicits pain in the region of the
anterior tibiofibular ligament (anterior to
the lateral malleolus and proximal to the
ankle joint) when a syndesmotic sprain
has occurred .

15. Squeeze test

16. Examination ( Special tests)
Talar tilt test
n The talar tilt test detects excessive ankle inversion. If the ligamentous
tear extends posteriorly into the calcaneofibular portion of the lateral
ligament, the lateral ankle is unstable and talar tilt occurs.
n With the ankle in the neutral position, gentle inversion force is applied to
the affected ankle, and the degree of inversion is observed and compared
with the uninjured side.

17. Talar tilt test

18. Examination ( Special tests)
External rotation stress test
n The external rotation stress test can also help identify
a syndesmotic sprain.
n The clinician stabilizes the leg proximal to the ankle
joint while grasping the plantar aspect of the foot and
rotating the foot externally relative to the tibia. The test
is positive if pain is elicited in the region of the anterior
tibiofibular ligament (anterior to the lateral malleolus
and proximal to the ankle joint.

19. External rotation stress test

20. Examination ( Special tests)
Anterior drawer test
n The anterior drawer test detects excessive anterior displacement of
the talus on the tibia. The test is performed with the patient's foot in
the neutral position (slightly plantar flexed and inverted).
n The lower leg is stabilized by the examiner with one hand, and with
the opposite hand, the examiner grasps the heel while the patient's
foot rests on the anterior aspect of the examiner's hand.
n An anterior force is gently but steadily applied to the heel while
holding the distal anterior leg fixed.

21. Anterior drawer test

22. Management
Immediate therapy
n Rest
n Ice
n Compression
n Elevation

23. Management
n Exercises including plantar flexion, dorsiflexion, and foot circles
should be started early, once acute pain and swelling subside, to
maintain range of motion.
n The intensity of rehabilitation is increased gradually.
n Ankle splints or braces can limit extremes of joint motion and allow
early weight bearing while protecting against reinjury.
n The treatment of severe (grade III) ankle sprains is controversial. A
brief period of immobilization may be helpful in some instances.

24. Management
Rehabilitation
n Functional rehabilitation is of great importance in aiding the return to activity and
preventing chronic instability.
n Early functional rehabilitation includes :
1. Range of motion exercises (Achilles tendon stretch, foot circles , alphabet exercises;
have the patient trace letters in the air with his big toe)
2. Muscle strengthening exercises (isometric and isotonic plantar flexion, dorsiflexion,
inversion, eversion, toe curls and marble pickups, heel walks and toe walks).
3. Proprioceptive training (walking on different surfaces) .
4. activity-specific training.

25. Management
Surgery
n Surgical repair of ruptured ankle
ligaments is sometimes considered in
patients with ankle sprains.

27. THANK YOU