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Ankle sprains
Dr. Girish Motwani is a consultant foot and ankle surgeon with extensive qualifications focusing on both pediatric and adult orthopedics. He emphasizes the prevalence and diagnosis of acute lateral ankle sprains, detailing treatment options, rehabilitation, and indications for surgical intervention. The document concludes by discussing various ankle injuries, their assessment, and the effectiveness of the Brostrom-Gould technique for lateral ligament reconstruction.
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Ankle sprains
- 1. DR. GIRISH MOTWANI ConsultantFoot & Ankle surgeon (Paediatric & Adult) 1)Sushrut Hospital, Research Centre & PostGraduate Institute of Orthopaedics, Nagpur west 2)Aman hospital,Nagpur east 3)South point clinic, Nagpur south Qualifications o MS orthopaedics (Gold medalist) o Fellowship in Foot & Ankle ortho (university of Alabama at Birmingham ,USA) o Fellowship in paediatric ortho (B.J.wadia hospital for childrens ,Mumbai) o Certification in Ankle sports medicine (Northwestern university ANKLE SPRAINANKLE SPRAIN
- 3. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle Acute Lateral Ankle SprainsAcute Lateral Ankle Sprains 23,000 injuries a day in the U.S.23,000 injuries a day in the U.S. 7-10% of E.R. visits7-10% of E.R. visits Most common athletic injuryMost common athletic injury
- 4. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle Acute Lateral Ankle SprainsAcute Lateral Ankle Sprains Ligaments- passive stabilityLigaments- passive stability Muscles- active stabilityMuscles- active stability Lateral ligamentsLateral ligaments ATFL- anterior talo-fibular ligamentATFL- anterior talo-fibular ligament CFL- calcaneo-fibular ligamentCFL- calcaneo-fibular ligament PTFL- posterior talo-fibular ligamentPTFL- posterior talo-fibular ligament
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- 6. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle Acute Lateral Ankle SprainsAcute Lateral Ankle Sprains Injury depends on direction and magnitudeInjury depends on direction and magnitude Deformities contribute to injuriesDeformities contribute to injuries More common in previously injured anklesMore common in previously injured ankles Occur indirectly from plantar flexion andOccur indirectly from plantar flexion and inversioninversion
- 7. DiagnosisDiagnosis Careful History TakingCarefulHistory Taking Physical ExamPhysical Exam Useful additional diagnostic testingUseful additional diagnostic testing ArthroscopyArthroscopy
- 8. History TakingHistory Taking Determineif the pain is mechanical-Determine if the pain is mechanical- brought on by activity, relieved by restbrought on by activity, relieved by rest Where is the pain located?Where is the pain located? Is there swelling, catching, pain onlyIs there swelling, catching, pain only with certain motions or activitieswith certain motions or activities??
- 9. History TakingHistory Taking Canyou bear weight?Can you bear weight? Feel like it is going to give out?Feel like it is going to give out? Has it done this before?Has it done this before?
- 10. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle Acute Lateral AnkleAcute Lateral Ankle SprainsSprains HistoryHistory Twist with foot inTwist with foot in provocative positionprovocative position ““Snap”Snap” Return to activityReturn to activity acutely then stop fromacutely then stop from swellingswelling
- 11. Physical ExamPhysical Exam Areasof pointAreas of point tenderness-check jointtenderness-check joint margins; over ligaments,margins; over ligaments, specifically lateral, andspecifically lateral, and syndesmosis; oversyndesmosis; over tendons, including FHL;tendons, including FHL; over nervesover nerves Check range of motion,Check range of motion, including ankle, subtalar;including ankle, subtalar; xs motion, soft end feel?xs motion, soft end feel? Pain with inversion,Pain with inversion, eversion, externaleversion, external rotation?rotation?
- 12. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle Acute Lateral Ankle SprainsAcute Lateral Ankle Sprains PhysicalPhysical ROM indicative of return timeROM indicative of return time Swelling localized at firstSwelling localized at first TendernessTenderness StabilityStability RadiographsRadiographs
- 13. Anterior Drawer TestAnteriorDrawer Test
- 14. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle
- 15. Talar Tilt TestTalarTilt Test
- 16. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle
- 17. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle Acute Lateral Ankle SprainsAcute Lateral Ankle Sprains Differential DiagnosisDifferential Diagnosis FracturesFractures OLTOLT Stress fracturesStress fractures Midfoot injuriesMidfoot injuries Peroneal tendonsPeroneal tendons
- 18. Basic Helpful TestsBasicHelpful Tests Plain x-rays: get good ankle and footPlain x-rays: get good ankle and foot films; stress testing of ligamentsfilms; stress testing of ligaments CT scans (for subtle fractures, OCDs)CT scans (for subtle fractures, OCDs) MRIs (for soft tissue, intraosseous)MRIs (for soft tissue, intraosseous) For the most part, I find ultrasound hard toFor the most part, I find ultrasound hard to interpret, and bone scans too nonspecificinterpret, and bone scans too nonspecific (unless metal is present, rendering MRI(unless metal is present, rendering MRI difficult to interpret.)difficult to interpret.)
- 19. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle Acute Lateral Ankle SprainsAcute Lateral Ankle Sprains GradesGrades I - Stretch w/o macroscopic tearingI - Stretch w/o macroscopic tearing II - Torn ATFL, intact CFLII - Torn ATFL, intact CFL III - Entire complexIII - Entire complex
- 20. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle Acute Lateral Ankle SprainsAcute Lateral Ankle Sprains TreatmentTreatment I and III and II RICERICE BracesBraces Early ROM, stretching, strengthening, proprioceptionEarly ROM, stretching, strengthening, proprioception IIIIII ControversialControversial Cast for one week then progressCast for one week then progress
- 21. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle Acute Lateral Ankle SprainsAcute Lateral Ankle Sprains Return to Play?Return to Play? Painless smooth ROMPainless smooth ROM 80% strength to uninjured side80% strength to uninjured side Ability to hop on one footAbility to hop on one foot Sprint and cut drills without hesitationSprint and cut drills without hesitation Position simulated activitiesPosition simulated activities
- 22. Athletic Injuries ofthe Foot and AnkleAthletic Injuries of the Foot and Ankle Acute Lateral Ankle SprainsAcute Lateral Ankle Sprains Surgery indicated for chronic problems orSurgery indicated for chronic problems or instabilityinstability
- 23. ArthroscopyArthroscopy MRI is extremelyimportant to R/OMRI is extremely important to R/O tendinous, extraarticular and intraosseoustendinous, extraarticular and intraosseous lesions.lesions. Stress testing under anesthesia with fluoroStress testing under anesthesia with fluoro is accurate and helpfulis accurate and helpful Arthroscopy best evaluates cartilageArthroscopy best evaluates cartilage status, OCDs, loose bodies, anteriorstatus, OCDs, loose bodies, anterior impingement lesionsimpingement lesions
- 24. ANKLEANKLE INSTABILITYINSTABILITY LATERAL ANKLE ANDLATERALANKLE AND SUBTALARSUBTALAR
- 25. CHRONIC INSTABILITYCHRONIC INSTABILITY DYNAMICVS STATICDYNAMIC VS STATIC FEELING OF “GIVING WAY”FEELING OF “GIVING WAY” SORENESS AND RECURRENTSORENESS AND RECURRENT EFFUSIONSEFFUSIONS
- 26. WORKUP FOR CHRONICWORKUPFOR CHRONIC INSTABILITYINSTABILITY AWAKE STRESSAWAKE STRESS TESTING (CLINICTESTING (CLINIC AND X -RAY)AND X -RAY) POINTPOINT TENDERNESSTENDERNESS OVEROVER LIGAMENTSLIGAMENTS MRIMRI
- 27. TALAR TILT TESTINGTALARTILT TESTING ANKLE NEUTRAL OR SLIGHTLYANKLE NEUTRAL OR SLIGHTLY PLANTAR FLEXEDPLANTAR FLEXED VARUS STRESS APPLIED AT CCVARUS STRESS APPLIED AT CC JOINTJOINT 9-10 DEGREES = + STRESS TEST9-10 DEGREES = + STRESS TEST 3-5 DEGREES SIDE VS SIDE = +3-5 DEGREES SIDE VS SIDE = +
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- 29. Talar Tilt TestTalarTilt Test
- 30. ANTERIOR DRAWER TESTANTERIORDRAWER TEST ANKLE IN SLIGHT PLANTARANKLE IN SLIGHT PLANTAR FLEXIONFLEXION AVOID FALSE NEGATIVE FROMAVOID FALSE NEGATIVE FROM DELTOIDDELTOID 9-10 MM = + TEST9-10 MM = + TEST 3-5 MM SIDE VS SIDE = + TEST3-5 MM SIDE VS SIDE = + TEST
- 31. Anterior Drawer TestAnteriorDrawer Test
- 32. SUBTALAR INSTABILITYSUBTALAR INSTABILITY 10%OF ANKLE SPRAINS10% OF ANKLE SPRAINS POSITIVE BRODENS VIEWPOSITIVE BRODENS VIEW STRESS SIDE VS SIDESTRESS SIDE VS SIDE (DEGREES NOT DEFINED)(DEGREES NOT DEFINED)
- 35. Treatment AlgorithmTreatment Algorithm RehabilitationRehabilitation Failureor suspected pathology proceed toFailure or suspected pathology proceed to MRIMRI Failure and known pathology proceed toFailure and known pathology proceed to operative approachoperative approach EUA and arthroscopyEUA and arthroscopy Proceed to secondary proceduresProceed to secondary procedures Delay or same dayDelay or same day
- 36. EVALUATION UNDEREVALUATION UNDER ANESTHESIA(EUA)ANESTHESIA (EUA) STRESS TESTING (LATERALSTRESS TESTING (LATERAL TILT, STRESS BRODENS,TILT, STRESS BRODENS, ANTERIOR DRAWER)ANTERIOR DRAWER) ANKLE TESTING COMPUTERANKLE TESTING COMPUTER ASSISTED (HOLLIS)ASSISTED (HOLLIS)
- 39. Treatment OptionsTreatment Options ForForsubtle,subtle, dynamicdynamic instability:instability: peroneal strengthening, lateral heelperoneal strengthening, lateral heel flare and supportive deviceflare and supportive device ForFor failures of conservative treatmentfailures of conservative treatment andand staticstatic instability:instability: Non-Anatomic Repairs with PeroneusNon-Anatomic Repairs with Peroneus brevusbrevus Anatomic Repairs of lateral ligamentsAnatomic Repairs of lateral ligaments
- 40. OPTIONS OF REPAIROPTIONSOF REPAIR METHODMETHOD ANATOMIC ( MODIFIEDANATOMIC ( MODIFIED BROSTROMBROSTROM, USUALLY WITH N., USUALLY WITH N. GOULDGOULD EXTENSOREXTENSOR RETINACULUM REINFORCEMENT)RETINACULUM REINFORCEMENT) NON ANATOMIC (NON ANATOMIC (CHRISMAN-CHRISMAN- SNOOKSNOOK))
- 41. TIMING OF REPAIRTIMINGOF REPAIR Often delay 10-14 days to allowOften delay 10-14 days to allow for the tissue to dry outfor the tissue to dry out Immediate repairImmediate repair Depends on the time ofDepends on the time of arthroscopyarthroscopy
- 42. CHRISMAN-SNOOKCHRISMAN-SNOOK 1/2 PERONEUS BREVUSTHRU1/2 PERONEUS BREVUS THRU TALUS, FIBULA AND CALCANEUSTALUS, FIBULA AND CALCANEUS 20% LOSS OF INVERSION20% LOSS OF INVERSION (SUBTALAR AND ANKLE)(SUBTALAR AND ANKLE) BEST REPAIR OF NON ANATOMICBEST REPAIR OF NON ANATOMIC
- 44. SPECIAL INDICATIONS FORSPECIALINDICATIONS FOR EXTRA ARTICULAR REPAIREXTRA ARTICULAR REPAIR EXCESSIVE WEIGHT ANDEXCESSIVE WEIGHT AND STRESSESSTRESSES FUSED SUBTALAR JOINTFUSED SUBTALAR JOINT ABSENT OR EXCESSIVELYABSENT OR EXCESSIVELY SHREDDED TISSUESSHREDDED TISSUES
- 45. ANATOMICANATOMIC RECONSTRUCTIONRECONSTRUCTION BROSTROM: DIRECT REPAIROF ATFLBROSTROM: DIRECT REPAIR OF ATFL AND CFLAND CFL KARLSSON: SUTURE INTO BONE ANDKARLSSON: SUTURE INTO BONE AND OVERSEWINGOVERSEWING GOULD: CFL, LATERALGOULD: CFL, LATERAL TALOCALCANEAL, ATFL, ANDTALOCALCANEAL, ATFL, AND REINFORCEMENT W EXTENSORREINFORCEMENT W EXTENSOR RETINACULUMRETINACULUM
- 46. BROSTROM - GOULDBROSTROM- GOULD TECHNIQUETECHNIQUE Place patient in semi-lateralPlace patient in semi-lateral Caution of the nerves that are easilyCaution of the nerves that are easily injuredinjured Inspect and debride the lateral gutter andInspect and debride the lateral gutter and peronealsperoneals Lateral gravity stress testLateral gravity stress test Foot parallel to floorFoot parallel to floor Heel neutral to mild valgusHeel neutral to mild valgus Gentle stress to assure laxity addressedGentle stress to assure laxity addressed
- 47. BROSTROM - GOULDBROSTROM- GOULD TECHNIQUETECHNIQUE
- 48. BROSTROM - GOULDBROSTROM- GOULD TECHNIQUETECHNIQUE
- 49. BROSTROM - GOULDBROSTROM- GOULD TECHNIQUETECHNIQUE
- 50. BROSTROM - GOULDBROSTROM- GOULD TECHNIQUETECHNIQUE
- 51. POST OPERATIVE REGIMENPOSTOPERATIVE REGIMEN CAST OR SPLINT 4 WEEKS NWBCAST OR SPLINT 4 WEEKS NWB BEGIN ACTIVE ROMBEGIN ACTIVE ROM PREsPREs PROPRIOCEPTIVE EXERCISESPROPRIOCEPTIVE EXERCISES RESUME NORMAL ACTIVITIESRESUME NORMAL ACTIVITIES
- 52. CHOICE OF REPAIRCHOICEOF REPAIR BROSTROM-GOULDBROSTROM-GOULD TESTSTESTS TIGHT INITIALLY, BUT RANGETIGHT INITIALLY, BUT RANGE OF MOTION IS NOT LIMITED--OF MOTION IS NOT LIMITED-- MAKING ITMAKING IT THE REPAIR OFTHE REPAIR OF CHOICECHOICE WHEN FLEXIBILITY ISWHEN FLEXIBILITY IS DESIREDDESIRED
- 53. CONCEPT OF THECONCEPTOF THE ANATOMIC REPAIRANATOMIC REPAIR REPAIRED INJURED TISSUESREPAIRED INJURED TISSUES HYPERTROPHY AND REGAINHYPERTROPHY AND REGAIN STRENGTH AND FLEXIBILITYSTRENGTH AND FLEXIBILITY WITH STRESS AND MATURITY.WITH STRESS AND MATURITY. THE REPAIRED TISSUES ARETHE REPAIRED TISSUES ARE IN THE ANATOMIC AXESIN THE ANATOMIC AXES
- 54. WHY REPAIR THEWHYREPAIR THE LIGAMENTS?LIGAMENTS? CONTINUAL FLAKING OFF OFCONTINUAL FLAKING OFF OF OSTEOCHONDRAL FRAGMENTSOSTEOCHONDRAL FRAGMENTS PAIN, SWELLING, GIVING WAYPAIN, SWELLING, GIVING WAY DEVELOPMENT OF ARTHRITISDEVELOPMENT OF ARTHRITIS
- 55. CONCERNS TO BEAWARE OFCONCERNS TO BE AWARE OF AT OR BEFORE SURGERYAT OR BEFORE SURGERY CONCOMITANT EXTRAARTICULARCONCOMITANT EXTRAARTICULAR (TENDINOUS) OR INTRAARTICULAR(TENDINOUS) OR INTRAARTICULAR PATHOLOGYPATHOLOGY VARUS HEEL OR VARUS HEEL STRIKEVARUS HEEL OR VARUS HEEL STRIKE 2° TO TIBIA VARA2° TO TIBIA VARA HYPERELASTICITYHYPERELASTICITY DAMAGE TO SUPERFICIAL PERONEALDAMAGE TO SUPERFICIAL PERONEAL OR SURAL NERVE BRANCHOR SURAL NERVE BRANCH
- 56. CONCLUSIONSCONCLUSIONS OVERALL THE OBJECTIVERESULTSOVERALL THE OBJECTIVE RESULTS ARE EXCELLENT WITH GOODARE EXCELLENT WITH GOOD STABILITY AND FLEXIBILITYSTABILITY AND FLEXIBILITY ATTENTION TO THE VARUS HEEL,ATTENTION TO THE VARUS HEEL, PRELIMINARY WORKUP, AND GRAVITYPRELIMINARY WORKUP, AND GRAVITY TEST HAS AVOIDED PERSISTENTTEST HAS AVOIDED PERSISTENT UNDETECTED PROBLEMS ORUNDETECTED PROBLEMS OR RECURRENCES.RECURRENCES.
- 57. CONCLUSIONSCONCLUSIONS THE BROSTROM-GOULD TECHNIQUETHEBROSTROM-GOULD TECHNIQUE FOR LATERAL LIGAMENTFOR LATERAL LIGAMENT RECONSTRUCTION REMAINS OURRECONSTRUCTION REMAINS OUR PROCEDURE OF CHOICE FOR THEPROCEDURE OF CHOICE FOR THE UNSTABLE LATERAL ANKLE FOR ALLUNSTABLE LATERAL ANKLE FOR ALL AGES AND ALL SPORTS AT THISAGES AND ALL SPORTS AT THIS POINT IN TIMEPOINT IN TIME
- 58. Subtle Fractures MimickingSubtleFractures Mimicking InstabilityInstability Anterior Process of the calcaneusAnterior Process of the calcaneus Lateral Process of the talusLateral Process of the talus
- 59. Subtle Fractures MimickingSubtleFractures Mimicking InstabilityInstability Anterior Process of the calcaneusAnterior Process of the calcaneus Commonly over-lookedCommonly over-looked Pain located anterior to ligamentsPain located anterior to ligaments Small – exciseSmall – excise Large – ORIFLarge – ORIF
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- 62. Talus FracturesTalus Fractures LateralProcess FracturesLateral Process Fractures 24% of talus fractures24% of talus fractures Snowboarders fractureSnowboarders fracture Dorsiflexion, compression, and ext. rotationDorsiflexion, compression, and ext. rotation Serves as insertion point for many ligamentsServes as insertion point for many ligaments Often overlookedOften overlooked Involves fibula and calcaneusInvolves fibula and calcaneus
- 63. Talus FracturesTalus Fractures LateralProcessLateral Process FracturesFractures Confused with lateralConfused with lateral ankle sprainsankle sprains Evaluator needs toEvaluator needs to remain awareremain aware Seen on plain filmsSeen on plain films CT to determine sizeCT to determine size and typeand type
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- 66. Talus FracturesTalus Fractures LateralProcess FracturesLateral Process Fractures TreatmentTreatment Non-displacedNon-displaced 4 weeks SLC non-weight bearing4 weeks SLC non-weight bearing 2 weeks in SLWC2 weeks in SLWC DisplacedDisplaced Depends on sizeDepends on size Excise if to smallExcise if to small Fixate in large enoughFixate in large enough
- 67. ANKLE ARTHROSCOPYANKLE ARTHROSCOPY SYNOVITISSYNOVITIS PLICASPLICAS CHONDROMALACIACHONDROMALACIA CHONDRALANDCHONDRAL AND OSTEOCHONDRAL LESIONSOSTEOCHONDRAL LESIONS LOOSE BODIESLOOSE BODIES IMPINGMENTIMPINGMENT
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- 69. Osteochondritis dissecans oftheOsteochondritis dissecans of the talustalus Known as OCDs or OLTsKnown as OCDs or OLTs MRI shows marrow edema, and effect onMRI shows marrow edema, and effect on the surrounding bonethe surrounding bone CT gives a more accurate sizing of theCT gives a more accurate sizing of the lesionlesion Arthroscopy accurately defines the lesionArthroscopy accurately defines the lesion and determines therapeutic approachand determines therapeutic approach
- 72. Options of Treatmentfor OLTsOptions of Treatment for OLTs Microfracture/”picking” of lesions 1.0cm inMicrofracture/”picking” of lesions 1.0cm in diameter and smallerdiameter and smaller Retrograde drilling if cartilaginous surface intactRetrograde drilling if cartilaginous surface intact ORIF if there is adequate bone for appositionORIF if there is adequate bone for apposition Osteochondral grafting from the knee for largerOsteochondral grafting from the knee for larger lesions (mosaicplasty)lesions (mosaicplasty) Possible allografting for defects (rare)Possible allografting for defects (rare) Possible autogenous chondrocyte graftingPossible autogenous chondrocyte grafting (difficult access in the ankle)(difficult access in the ankle)
- 73. Mosaicplasty SeriesMosaicplasty Series Gould,Kirchner, Ramirez, Cain,Gould, Kirchner, Ramirez, Cain, Dugas, and FowlerDugas, and Fowler 15 cases 1999-200315 cases 1999-2003 12 medial, 2 lateral, 1 anterior12 medial, 2 lateral, 1 anterior Medial malleolar osteotomy, anteriorMedial malleolar osteotomy, anterior pyramid, or gouge techniquepyramid, or gouge technique 2 Brostrom-Gould procedures added2 Brostrom-Gould procedures added 13/15 good/excellent results13/15 good/excellent results
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- 78. Anterior Impingement LesionsAnteriorImpingement Lesions Usually anterolateralUsually anterolateral Usually soft tissue and may beUsually soft tissue and may be associated with lateral instabilityassociated with lateral instability May be bonyMay be bony All can be treated arthroscopicallyAll can be treated arthroscopically with ligament reconstruction added ifwith ligament reconstruction added if neededneeded..
- 79. Anterior Impingement LesionsAnteriorImpingement Lesions
- 80. Anterior Impingement LesionsAnteriorImpingement Lesions
- 81. Anterior Impingement LesionsAnteriorImpingement Lesions
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