ANKLE INJURIES Management

The sprained ankle, while best treated conservatively, must be treated thoroughly to prevent chronic pain or future arthritis. Clinically the presentation of sprains varies from a mild limp to severe handicap and inability to bear weight. The patient must therefore be treated according to the symptoms.

If ligament rupture is suspected, x-rays with the ligament under stress should be taken under anaesthesia in both the lateral and anteroposterior planes. Complete lateral ligament rupture is treated either conservatively – by immobilisation in a below-knee walking plaster cast followed by early mobilisation – or surgically.

Prolonged immobilisation is to be discouraged as it leads to muscle wasting and increased joint stiffness. There is improved healing of ligaments if movement is permitted.

In addition to facilitating the resolution of swelling and providing gait re- education, physiotherapists can assist the return of normal proprioception which will prevent recurrence of the injury. Proprioceptive exercises such as bouncing a ball while standing on one leg or balance board exercises have been shown to improve recovery and should be started as soon as possible.

Outcome In mild injuries, where the ATFL is stretched but not torn, full recovery is expected within two weeks.

For more severe injuries full recovery is expected in six to eight weeks in 70-90% of patients depending on the demands they place on their ankle. Surgical intervention within the first six weeks is thus rarely justified. Patients who fail to recover within six weeks require reassessment.

Patients with chronic instability often complain of the ankle giving way. A suction sign (visible dimpling on the anterolateral aspect of the ankle) is usually evident on performing the anterior draw test. Those who do not respond to physiotherapy may require surgery if they need a strong, stable ankle for work or sport.

Chronic pain often implies an incorrect diagnosis and assessment by a specialist

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is advisable. Investigations such as ankle arthroscopy, MRI and/or isotope scanning may be indicated to rule out differential diagnoses which include osteochondral ankle fractures, peroneal tendon disorders, peroneal nerve injury and soft tissue impingement of the lateral gutter (groove on outside of lateral malleolus). The cause of pain should be investigated before considering ligament repair for presumed instability.

Dr Peter Greenway is a full-time GP in Crawley, Sussex. He runs a private sports injury clinic in conjunction with a multidisciplinary team of physiotherapists and a sports physician. John Fairley, a senior physiotherapist at the clinic, developed the patient rehabilitation programme overleaf.

KEY POINTS

• Sprains of the ankle joint and particularly the lateral ligament are common and vary from minor sprains to complete ligament tears

• Inadequate management can lead to significant morbidity

• A careful history and examination is necessary in lateral ligament ankle sprain.

• X-ray according to the Ottawa Rules – to avoid wasted resources

• Appropriate management should lead to recovery within six weeks

• Patients with persistent pain or instability need further assessment by a specialist

ANKLE SPRAIN CLASSIFICATION & MANAGEMENT

The following grading system and corresponding management can be applied to ankle sprains affecting the lateral ligament complex.

Mild sprain with no instability 1 2 3

Presentation – In a mild sprain there is minimal functional loss, little swelling and often tenderness localised to the ATFL component only. There is no joint instability and the patient is able to weight-bear.

Treatment – Grade 1 sprains are normally adequately managed using the PRICE regimen.

Protect – Support to prevent further damage Rest for 24 – 48 hours Ice – a bag of semi-frozen peas is adequate (applied for 20 mins. max.every few hours) Compression – with double-layered elasticated support bandages Elevation – above the level of the waist.

These measures can be instituted by the GP and combined with a short course of oral analgesics and/or non-steroidal anti-inflammatory medication. A patient advice leaflet encourages patients to take an active role in their treatment.

Incomplete tear with mild instability

Presentation – Moderate or severe pain is experienced. There is moderate functional loss, difficulty in walking or inability to bear weight and the patient may require a stick or crutches. Swelling is present over the lateral ligament with associated tenderness over the ATFL and CFL components.

Treatment – Most Grade 2 sprains benefit from physiotherapy referral.

Patients have difficulty weight bearing and find it more comfortable to have the ankle supported by stirrup strapping. The potential benefits of physiotherapy are often overlooked in general practice. A rapid access policy (within 48 hours) for such injuries is strongly recommended to reduce the risk of the injury becoming chronic. Taping is often beneficial.

Ligament rupture with marked instability

Presentation – Ligament rupture in which there is marked functional loss. The patient is unable to bear weight and requires the use of crutches. There is usually substantial soft tissue swelling and tenderness. There is laxity on stressing the ligaments.

Treatment – In Grade 3 sprains specialist orthopaedic referral is required immediately with adjunctive physiotherapy.

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