Acute Ankle Inversion Injury

Subjective Examination

Important to obtain mechanism of injury - usually occurs when walking or running on uneven surface, or when pushing off laterally from an acute cutting movement

Use the OTTAWA Ankle rules and OTTAWA Foot rules (designed for emergency department originally) to determine if x-ray is required.  6 cm up the lateral or medial side of the lower leg from the malleoli, or unable to weight bear determines if ankle x-ray required.  If tender over navicular or base of 5th metatarsal, or unable to weight bear determines if foot series x-ray is required.

Acute management

PRICER - recent evidence shows compression to be the most important factor over the first 24-72 hours

Objective Examination

Palpation:

ATFL, CFL, anterior portion of the deltoid ligament

Anterior joint line (talus)

Peroneal tendons as they pass posterior to the lateral malleolus (longus and brevis)

Peroneal tertius as it passes anterior to the lateral malleolus, inserting onto the base of the 5th metatarsal

Tibialis posterior, FHL and FDL as they pass posterior to the medial malleolus

ROM

DF/PF/IV/EV (NWB)

Standing DF lunge when tolerated (compare to other side with %)

Supination/Pronation to eliminate midfoot injury

Strength testing

Resisted isometric tests

Bilateral heel raises as tolerated (testing peroneals in a more functional manner - if weight bearing on the lateral border, could be lengthened and weak peroneals (and/or tight tibialis).  Also look for toe grabbing which is often a compensatory thing for poor balance.

Balance

If SLS is 30 secs +, the test is too easy and so progression to the 3 point star test is merited.  The patient has 3 attempts at each of the 3 points and the best reading is taken for each point.  Use this as an outcome measure.

Ligament testing:

1. Anterior drawer test (PA glide of the talus) - compare with other side.  If excessive movement, you are suspecting rupture to the ATFL and possibly anterior fibres of deltoid lig.  If the ankle has excessive movement, but is mainly moving into inversion, then it is likely that the ATFL is the main injured ligament.

2. Talar tilt test - looking for excessive laxity at the CFL ligament

Ligament grading:

Grade I: No laxity on stability testing, tenderness over ATFL = microtrauma

Grade II: Laxity on ligament testing with anterior drawer and/or talar tilt, with end feel

Grade III: Laxity in the absence of end feel

Prognosis/Healing Times

Grade I: 2-4 weeks

Grade II: 4-6 weeks

Grade III: 6-8 weeks

TREATMENT


1. Aim to improve ROM within comfortable ranges


ROM can be limited in the early stages by swelling, increased muscle tone and possible joint subluxation. Starting with gentle dorsiflexion and plantar flexion slides in sitting, then progress to active inversion and eversion.  In order to reduce muscle tone, dry needling can be effective and is not likely to worsen the inflammation.  Mulligans MWM at the fibula (apply a posterior superior glide) can be effective in improving inversion/eversion ROM.  Maintain glide for the whole movement and complete 3 x 6-10 repetitions.  In order to improve dorsiflexion range, the MWM can also be effective.  In supine, use your anterior thigh to support the sole of the patient's foot.  Using one hand, apply an AP glide to the talus, whilst using the other hand to support under the calf.  Ask the patient to actively DF as you maintain the AP glide throughout the movement.  Ask the patient to relax as you keep the AP glide on during the return to neutral.


2. Re-activate the peroneals (excessive tone as a protective response to injury)


In sidelying, ask the patient to PF the EV against gravity.  Ensure toes are switched off and can palpate the peroneal tendons during the movement to ensure correct activation.  5x10 reps in one session per day


3. Improve balance as early as possible


Standing on one leg, with soft knee to activate gluts and quads, and core muscles switched on.  Encourage the patient to stand for as long as possible, resting when getting uncomfortable.  If too easy, progress to star excursion test


4. Function


Return to normal walking as soon as possible.  Mulligan's fibula taping can be effective in improving range of motion and reducing pain.  Using hypo fix and rigid tape, apply tape at fibula, around the back of the achilles and attaching anteriorly, using a posterior-superior glide to the fibula when applying tape.


5. Endurance


Cycling (encourage pushing through the knee) or swimming (using a pull buoy until more comfortable)