Ankle Sprain

Re-Thinking the “Common” Ankle Sprain

Eric Nussbaum, MEd, ATC, LAT Goals of this presentation:

•Review Anatomy/Biomechanics • Review current literature • Provoke critical thinking Facts:

• Ankle sprains are the most common injuries seen in athletics • Athletic trainers are pretty good at treating the traditional lateral sprain • Taping and bracing does a good job of supporting lateral laxity. Facts Continued:

• Less effective at recognizing and managing HAS – Predicting disability • Less effective at recognizing further injury Occasionally, we get fooled and need to re-evaluate our situation! Questions??????

• What really causes acute functional disability? • Is tenderness above the talocrural joint a significant finding? • Why is a 5-6cm tenderness measurement significant? • Do I know how to evaluate proximal injury? • If its not progressing what else could it be? • Based on a good clinical exam, can you predict how long a person will be out with an ankle injury with consistency and good reliability? TheThe secretsecret lieslies inin thethe understandingunderstanding ofof thethe anatomyanatomy andand biomechanicsbiomechanics ofof thethe ankleankle The “Ankle” Joint

• Widely viewed as a single joint • Actually a series of joints that are highly integrated • Inferior Tibio-Fibular Syndemosis • Talocrural Joint • Subtalar Joint • Transverse Tarsal Joint • Tarsometatarsal Joints • Metatarsophalangeal Joints ThingsThings toto consider:consider:

• Most congruent joint in body – Large weight bearing surface – Tibia/Fibula act like wrench gripping talus • Ankle classically hinge joint – Triplaner motion – Functions much like a torque converter – Consider the whole picture • Intact syndesmosis is key to ankle function – Functions like a wrench gripping a nut – 1mm of widening changes contact area by 42%, – Greatest effects seen in first 1mm – 2mm - 56% - Ramsey & Hamilton JBJS, 1976 BoneyBoney Anatomy:Anatomy: TheThe TibiaTibia

• Big, strong bone • Bares most of the weight • Some rotation FibulaFibula FunctionsFunctions DynamicallyDynamically

–– MovesMoves distally/distally/posteriorlyposteriorly ––2.42.4 mmmm withwith dorsidorsi/plantar/plantar flexionflexion --originorigin forfor musclesmuscles thatthat stabilizestabilize archarch ofof footfoot --RotatesRotates aroundaround verticalvertical axisaxis -DF – Lat Rot 3-5 deg -PF – Medially rotates 3-5 deg ––BearsBears 1/61/6 ofof BWBW •W/ intact IM

Lambert, JBJS, 1971 Changes to the syndesmosis with motion

Plantar Flexion: Fibula hugs talus to maintain lateral support PF Fibula adducts, migrates distally, and externally rotates Upward change in motion angle (y axis)

Dorsi Flexion Fibula abducts, is pulled proximally and internally rotates on perpendicular axis to accommodate wider talus. Downward change in motion angle DF InterosseusInterosseus MembraneMembrane

•• ConnectiveConnective TissueTissue •• ParallelParallel fibersfibers •• SweepSweep downwarddownward 1515-- 2020 degreesdegrees -More acute w/ wt bearing •• LoadLoad transmissiontransmission •• OriginOrigin forfor archarch stabilizersstabilizers ofof footfoot TalusTalus

•• TalusTalus largelarge weightweight bearingbearing surfacesurface 1111--1313 cmcm –– WiderWider anteriorlyanteriorly –– ConcaveConcave laterallylaterally • Distal fibula convex • Good boney congruity –– FitsFits likelike wrenchwrench andand nutnut DeltoidDeltoid LigamentLigament

• Strong, Flat, Triangulated Band • Superficial and deep • Ant/Mid/Post – Superficial resists eversion of hind foot – Mid portion (Tib/Nav) suspends spring lig, prevents inward displacement of talus – Deep – prevents valgus displacement of talus • Many view as key to ankle stability LateralLateral LigamentsLigaments

• Help to control talar rotation/tilt • ATFL part of capsule • CFL crosses STJ – Extra capsular – Thicker – Cord like • PTFL least injured – Runs almost horizontally from fossa of inner aspect of tip of fibula to post tubercle of talus

• Ant/post capsule thinner then Lat/Med Ligaments Stress on Lateral Ligaments

• Motion w/ DF/PF occurs at Tibiotalar JT • ATFL/CFL work together in synergistic fashion throughout ROM • Inverse loading patterns – ATFL greatest stress w/ PF/Sup + axial load – CFL greatest tension w/ DF/Sup + compressive load * patterns accentuated by Sup • Axial load didn’t affect CFL tension, – Magnified ATFL tension w/ comp loading » Bahr R, Knee Surg Sports Trauma, 1998 SyndesmosisSyndesmosis

• Proximal Joint – Maintains Proximal integrity • Interosseus Membrane • Distal Joint – Convex distal medial fibula – Concave distal lateral tibia – Key to ankle function! LigamentsLigaments ofof SyndesmosisSyndesmosis

• Flattened bands of fibrous tissue

• No difference in stiffness between Tibiofibular ligaments and Deltoid *Beumer Foot and Ankle Int 2003 May

• Anterior Tibiofibular – Triangular in shape • Posterior Tibiofibular – Quadrangular in shape – Superficial / Deep fibers – Deep contain Fibrocartilage • Inferior transverse SyndesmoticSyndesmotic LigamentsLigaments Continued:Continued:

• Interosseus Ligament – Frequently not appreciated – Perpendicular fibers – Triangulated Transition – Cobweb like projections – Acts like a spring - 5-6cm from tip of fibula - Key stabilizing structure - Most proximal structure of syndesmosis - Key stabilizer of syndesmosis Interosseus Ligament CrossCross SectionalSectional EvaluationEvaluation

• Plastinization Study – 20 ankles – 1.6 mm cadaver slices • Clear Space – 4 mm • Prox Jt more posterior, (to sagital plane) Distal Jt more Anterior • Fibula crosses lower leg from postero- prox to antero- distally • Direct correlation between depth/length does exist – Deeper = bigger – Flatter = smaller • May predispose to injury • Variety in height of syndesmosis M-C Sora, Clin Anatomy, 17:513, 2004 Synovium

• Protrudes proximally and resembles a meniscus • Smooth and glistening • containing small vessels and nerves

– Sabacinski J Am Pod Med Assoc 1990 Synovial Recess

• Connects w/ ankle joint proper • Extends into syndesmosis • Since it contains small vessels and nerves Could it be subject to inhibitory shut down? - Swelling - Stimulation of mechanoreceptors - Pain inhibition Figure 10a: (a) Coronal fat-saturated fast spin-echo T2-weighted MR image (4000/60; matrix, 256 x 256; number of signals acquired, two; echo train length, 10; field of view, 12 cm) and (b-d) photomicrographs of distal tibiofibular syndesmosis of cadaveric ankle specimen

Kim, S. et al. Radiology 2007;242:225-235

• This thickening not found in all ankles • Does it develop as a result of syndesmotic injury? • Is it really synovium? It resembles a meniscus. Cadaveric Study of the Syndesmosis by Nussbaum & Gatt Submitted for publication ‘07

• Identify what structures are found at 5- 6 cm • Better understand the structures of the syndesmosis • 13 embalmed Human Ankles • Removed all superficial Soft tissue WhatWhat isis atat 66 cm?cm?

6 cm

Top edge of syndesmosis - Point where IMembrane begins - Triangular ligament - Draves * Most proximal portion of syndesmosis Interosseus Ligament Let’s go to the video tape! Strength of IL

• IL significantly stiffer then DATFL – (234+/-122 N/nm vs 162+/- 64 N/nm) • Mean Failure greater – (822+/- 298 vs 625 +/- 255N) • Plays and important role in stability of the ankle • Fiberous matrix • Pyramid in shape

Hoefnagels, Foot Ankle Int May 2007;28(5) StrengthStrength ofof thethe Ligaments:Ligaments:

•• DistalDistal PosteriorPosterior TibiofibularTibiofibular LigamentLigament isis strongeststrongest andand lessless frequentlyfrequently injuredinjured – Accounts for 43% of restraint •• DistalDistal AnteriorAnterior TibiofibularTibiofibular LigamentLigament – Accounts for 35% of restraint – Most frequently injured •• InterosseusInterosseus membranemembrane – 22% – Didn’t add to resistence of diastasis

Oglivie-Harris, DJ –”Disruption of Ankle Syndesmosis – Biomechanical Study of Ligamentous Restraints” – Arthroscopy1994;10:558 FromFrom thethe Literature:Literature:

• Ankle joint is inherently stable under load even in the absence of lateral ligaments – Tochigi et al, Foot Ankle Int 2000

- Axial load resulted in 91% increase in torque to failure with inversion testing. - As axial load increases, contact w/ articular surfaces plays a greater role. - Anatomy of talus/tibial plafond tend to force external rotation with an axial load - Cawley P, Foot Ankle 1991 Oct LockedLocked JointsJoints == RigidRigid LeverLever AnkleAnkle MotionMotion • Primarily in Sagital plane – DF – 15-20 deg – PF – 45-55 deg • Most stable in DF – (Closed packed) • Some slight talar ext rotation w/ DF – 5-6 deg – Pronates slightly w/ DF • Similar internal rotation w/ PF – As result of conical and wedge shape – Also slightly supinates – Posteriorlateral wedging of talar trochlea • Amt increases w/ PF

Sarafin, Anatomy of Foot & Ankle,1993 AnkleAnkle MotionMotion Continued:Continued:

• Triplanar Motion • Inversion/Eversion, Pronation/Supination – Primarily at STJ • 50% - Stephens, Foot Ankle 1992 – Normal ST Inversion 20-30 deg – Normal eversion 5-15 deg • 100 Deg total motion Tibiotalar Jt vs Subtalar Motion

• 10 deg DF – 20 deg PF – All motion tibiotalar - Supination - Ratio of STJ motion to Tibiotalar motion -3 : 1 - Internal to External Rotation -4 :1 - Virtually no flexion motion occurs in STJ

- Implications for reconstructions - Reconstruct CFL, crosses STJ lose motion/function - Bahr R, Knee Surg Sports Trauma 1998

- Inman’s Concept – STJ = Oblique hinge joint Subtalar Injury w/ inversion

• Look for tenderness over STJ • Frequently injured – Less frequently appreciated – >50% of inversion sprains • Togichi, FAI, 1998 Injury to Calcaneocuboid ligament

• Look for tenderness over ligament – Under scallop muscle – Ext Dig Brevis • Pain w/ MidFt rotation Questions:Questions:

• Can inversion injure the syndesmosis? – Traditionally thought hyperpronation (DF/EXT Rot) – HAS Incidence in literature 1-20% – Severe Inversion can injure mortise, though classically DF/Ext Rot • Hopkinson • Is there a Lateral injury progression? – Could increased talar tilt, allow talus to act like fulcrum against fibula? • Are there varying degrees of injury to the syndesmosis? Proximal Tenderness as it Relates to Functional Disability of Ankle Sprains; Grading the High Ankle Sprain

Eric Nussbaum, MEd, ATC, LAT Hillsborough High School, Hillsborough, NJ Charles Gatt, MD UMDNJ-RWJ Department of Orthopedics Hypothesis:

• The extent of tenderness above the ankle joint proper is directly related to functional disability, despite the existence of lateral ligament injury. • Proximal tenderness is a common finding with lateral ankle injury. • Utilization of a tenderness measurement and single leg hop testing can aid in predicting time lost from sports from HAS. • The extent of HAS can be graded by severity of injury based on height of tenderness, inability to hop and radiographic findings.. Methods • Prospective Cohort Study • Consecutive high school athletes who sustained an acute ankle injury during a 4 year period of time at a large high school in New Jersey were evaluated by athletic trainer and or team physician. • Athletes were allowed to return to sporting activity when they could pass a single leg hop test x 10 and functional testing. Supportive taping and or bracing was utilize for return to sporting activity. • Time out of sports was noted and correlated with type of ankle injury. • Figure 3: Injury vs Lateral Laxity

• Degree of laxity 0 1st 2nd 3rd Total

• Type of Injury • A) Isolated Lateral Sprains 0 109 28 1 138 • • B) 5-6 cm of tenderness 4 24 87 4 119 • • C)B + STJ Sprain0720 9

• D) HAS ( > 6cm) 16 3 0 2 21

• E) IsoLat + STJ 0040 4

• F)Medial 5800 13

• G) Medial + Avulsion Fx2000 2

• H)Dorsal/Capsular5000 5

• I)Distal Fibular Boney0910 10

• Totals 32 160 122 7 321 Figure 4: Study Statistics: TOOS (days) Proximal Tenderness N Mean SD Min/Max p Value A) Isoated lateral, 138 .80 .67 0/2 (No prox tenderness)

B+C) <7 cm 128 5.60 1.44 3-10 .0019 D) > 6 cm 21 14 1.87 11-18 .0001 I) Boney Tenderness 10 11 2.37 8-15 .0001 -Distal Fib pain Results

1) Proximal Tenderness is associated w/ disability - 100% of proximally tender could not pass SLHT - Represented 95% of total that could not pass SLHT - Laterally lax and proximally tender longer TOOS (5.6 vs .8 days) 2) Definite variation in tenderness on clinical exam - 6cm as measured from tip of lateral malleolus key - Important border for severity of injury - TOOS 5.6 vs 14 days 3) Incidence of HAS more common then in current literature (159/321; 49%) 4) SLHT valid test for syndesmotic injury 5) HA Grading scale useful tool for clinicians Key Finding:

If the syndesmosis is injured, you see functional disability

• People w/ lateral laxity can hop, people w/ syndesmotic injury can’t! • Syndesmosis is key to ankle function MRI Study by Brown:

Studied MRI of 94 ankles w/ severe sprain – Syndesmotic injury seen in 63% • 23 Acute, 36 chronic – ATF seen in 74% of all sprains • 49 with syndesmotic injury; 21 without; p = 0.03 – The tibiofibular joint was incongruent in 33% • n = 31; 6/23 acute; 21/36 chronic; 4/35 no injury; p < 0.0001 - The tibiofibular recess (mean +/- SD) was 1.2 +/- 0.92 cm in acute cases, 1.4 +/- 0.57 cm in chronic cases, and 0.54 +/- 0.68 cm in cases with no syndesmosis injury (p < 0.0001) Brown KW, Am J Roent 2004 Jan;182(1) Assessment of Syndesmotic Injury

How do you best evaluate the syndesmosis?

– There isn’t much written in the Athletic Training Text Books! – Lacking consistency of exam results Study by Beumer “A biomechanical evaluation of clinical stress tests for syndesmotic ankle instability”

• Utilized displacement transducers • Fresh cadaver ankles • Sectioned ligaments • None of current tests could distinguish which ligaments were sectioned • Pain rather then displacement should be utilized as outcome measurement of tests

» Foot Ankle Int 2003 Apr;24(4):358-63 SpecialSpecial TestsTests

• Palpation: – Pain indicates injury/irritation • Oglivie-Harris

– Palpate for tenderness over DATF/PTF, pain radiating up interosseus membrane

– Depends on evaluators ability to find ligament/IM

– Most frequently positive test – • Alonso- JOSPT,1998 SpecialSpecial Tests:Tests:

• Dorsiflexion/External Rotation Stress Test – Kleiger Test – Doesn’t measure instability – If present indicative of injury/irritation- - • Oglivie-Harris-JARS, 1994 – Best inter-tester reliability – Alonso, JOSPT, 1998 SpecialSpecial TestsTests

•• SqueezeSqueeze TestTest – Compress at mid calf – Causes seperation of distal joint – • Teitz Foot Ankle Int,1998 – Least Positive Test, – + w/ Significant Inj – Alonso JOSPT, 1998 SpecialSpecial TestsTests Continued:Continued:

Maleolar Compression/Rebound Test

– Compress malleoli and look for pain with rebound – Hard, frequently very sore – Not well publicized Special Tests

• Wt Bearing w/ Active DF

– w/ manual compression of maleoli, digital inclinometer, scale – – + test if increased ROM w/ compression – + if decrease in end range pain – Moderately positive test (47%), fair reliability statistically – • Alonso, JOSPT, 1998 TendernessTenderness MeasurementMeasurement

Measurement from distal tip of fibula to most proximal point of pain on IM. • Measured in cm FunctionalFunctional Assessment:Assessment:

• Functional Testing – Inability to raise on their toes – Taylor • Raising on toes produces hindfoot inversion – Stress the syndesmosis! • Classic Complaint – Can’t push off • Inability to hop from toes x 10 • Great sideline test Xray •R/O Fx • Frank vs Latent Diastasis • No optimal parameter ProspectiveProspective EvaluationEvaluation ofof SyndesmoticSyndesmotic AnkleAnkle SprainsSprains WithoutWithout DiastasisDiastasis

American Journal of Sports Medicine January, 2001

Eric Nussbaum, MEd, ATC Timothy Hosea, MD Donald Kessler, MEd, ATC Brian Incremona, MD Shawn Sieler, MD Ronald Cody, PhD WhatWhat wewe found:found: EvaluationEvaluation

Functional disability - can not do single leg hop from toes x 10. 100% + Pain over AITF ligament 100% + Proximal pain; Tenderness measurement 100% + Absence of fracture *Consistent in all our subjects

Dorsiflexion/External Rotation Stress test was positive 55/60 Squeeze Test positive 20/60 Add two days to the formula But Wait!

There are other factors to consider! RadiographicRadiographic StudiesStudies

• Arthrogram • Bone Scan – Evaluation of chronic pain after ankle sprain • CT • MRI – Visualization of ligments – Cuts 3mm or less – Visualized on two or more sequences • Axial, Coronal at level of plafond – Wavy, absent – Better result w/ gadolinium • US Osteochondral Defects:

• More common on medial facet then lateral – More deep, less sympt • Suspect w/ chronic ankle pain/swelling • Lateral assoc. w/ inv/df, more likely displaced Canale-ST JBJS 1980 BoneBone BruisesBruises

• Not much written in literature • Don’t frequently get MRI’s acutely • They do occur • Talus, posterior medial tibia pain

Brown,KW – Am J Roentgenol; 182(1) 2004 - MRI study of 53 syndesmotic sprains - Evidence of Bone Bruise 24% acute, 4/36 chronic

Pinar, H – KSSTA, 1997; 5 (2) -MR w/ Gadolinium • 50% w/ injury to both ATF/CF • 16% isolated ATF sprains • More frequently Medial then lateral Talus Most common sites w/ inversion HeterotopicHeterotopic OscificationOscification

• High Incidence with syndesmotic injury – 9/10 – Hopkins – 60-90% in literature • Veltri; NFL combine – Mistreating lat sprains? • Chronic pain/disability • >6 weeks post Injury • Synostosis • Alters normal function - load transmission MoreMore AggressiveAggressive TreatmentTreatment DilemnasDilemnas

• Inject? – Injections have shown no advantage in speeding recovery – Many instances, prolongs recovery, HTO? – Chance for infection • Acute Screw Fixation – Dr. Jay Cox: Long time PSU Physician –Arthrogram – Overdrill fibula, togle screw into tibia – 2 surgeries, 4-5 week recovery Obviously there are varying degrees of HAS……

Is it possible to grade HA injury?

Will this help us to better predict disability? GradeGrade II HAS:HAS: TheThe ““LowLow –– HighHigh AnkleAnkle”” SprainSprain

• Pain above talocrural joint • Tenderness over AITF ligament • Tenderness length < 6cm • Mechanism primarily inversion • Associated w/ individuals w/ 2nd degree lateral laxity • Previous Hx of lateral ankle sprain • Functional disability – Can’t hop from toes • More common then previously thought LowLow HighHigh SprainSprain

• 5-7 day return • Treatment Dilemma – Can become chronically sore/swollen – Use Protocol or not??? – Aircast/Walking Boot/ALP? • Follow protocol –First 4 days –ALP helpful – Quicker functional return – Better long term results – Reduce incidence HTO Grading HAS Continued: (Ankle sprains w/ proximal tenderness) • Second degree – >6 cm of tenderness – If positive squeeze test add 2 days to recovery – days out = 5 + .93X(cm tenderness) • About 2 weeks utilizing protocol – No diastasis, OCD – DATFL/IL probably injured • Third degree – >6 cm prox tenderness – Diastasis or OCD on Diagnositc films – >12 cm Suspect diastasis – Longer disability – Surgical repair? An interesting Finding with Adolescent Athletes • 13 HS Athletes, all 15 years of Age – All skeletally immature – All expressed tenderness directly over distal fibula @ 5-7 cm of height – Not tender over DATFL – Inability to hop – Negative xray for fx – Suspected of Stress reaction/fracture – Disability avg 11 days (Range 8-15 days)

• Does IL act as fulcrum against fibula? • Most common location of fibular stress fx AnotherAnother FindingFinding

• In College FB – Avg 5 HAS /year (14 year review) – Utilize Prophylactic Taping/Bracing – Bigger, faster, higher impact • In HS – HAS not as common – LHAS much more common • As common as 48% of lateral ankle sprains exhibit tenderness. (5 year review of 378 sprains) – Minimal prophylactic taping/bracing TheThe BigBig Question:Question:

Taping and bracing does a great job minimizing the effects of lateral ankle sprains.

- DoesDoes tapingtaping oror bracingbracing thethe ankleankle preventivelypreventively inin thethe neutralneutral positionposition predisposepredispose itit toto syndesmoticsyndesmotic injury?injury?

-- DoDo thethe risksrisks outweighoutweigh thethe benefits?benefits?

* Needs further study and review TreatmentTreatment Tips:Tips:

• Start looking for syndesmotic injury with your normal exam. • Be alert for tenderness and functional disability! • Trust your findings and lock them up! – A little time in the beginning saves time in the end. • Posterior splint over boot – Non weight bearing key, boot too easy to walk – You can tell when they walk on the splint! AnkleAnkle LigamentLigament ProtectorProtector (ALP)(ALP)

• DJ Orthopedics • ALP Plus is very effective – Looks funky, works great – Controls medial lateral tilt of calcaneus/talus

– Minimizes hyper DF – Reduced Inv/ever greater than Aircast, rated more comfortable. – Gross, JOSPT,1992

– *I do not receive any financial compensation from DJ Ortho for pushing their brace! TipsTips Continued:Continued:

•• AchillesAchilles tapingtaping (posterior(posterior support)support) maymay bebe beneficialbeneficial – May help to limit dorsiflexion stresses •• OrthoticOrthotic oror archarch supportsupport may help – Muscles that support arch originate on fibula and IM and may be injured as well. – Propensity toward pronation w/ decreased wt bearing – Orthodic w/ ALP may be beneficial •• DonDon’’tt forgetforget thethe firstfirst ray!ray! – Stabilizing may help •• HeelHeel LiftLift maymay bebe beneficialbeneficial Answers to my original questions:

• Cause of functional disability? – Syndesmotic injury should be considered – If they can’t hop, consider injury • Significance of 5-6 cm? – Interosseus Ligament – Border to greater injury – Important stabilizer of syndesmosis • How do I evaluate it? – Know your anatomy! – Good palpation – Look for specific pain – Clinical tests Answers to Original Questions:

• Can you predict disability? – Good clinical/functional evaluation – Note syndesmotic involvement • Tenderness measurement • Single leg hop test • If it isn’t progressing the way it should what else could it be? – Work it up! - OCD, Bone Bruise/Occult Fx, syndesmosis Questions?Questions? Thank you!