Ankles - are you thinking laterally?

Lateral ankle sprains make up a large portion of our workload as Therapists and in a Society of Sports Therapists Twitter poll, came out as the number one injury that Sports Therapists see (46%).

I am sure that you will agree that they can be difficult to assess.

During my time practicing I can remember two specific occasions when patients presenting with lateral ankle sprains had suffered a fracture despite negative ottawa ankle rule testing in the clinical environment and atypical mechanisms of injury. Only upon further imaging were the fractures visible.

I promise that if you read the two ankle consensus papers by Gribble et al. (2016) and Delahunt et al. (2018) then you will feel more equipped to assess and treat this common injury.

Read on...

Gribble et al. (2016) reported that lateral ankle sprain was the most prevalent injury in the active population and could lead to chronic ankle instability resulting in reduced physical activity and quality of life. There is also an increased risk of osteoarthritis. There is a need to address sensorimotor and arthrokinematic deficits within rehabilitation as well as restoration of the soft tissue.

'Lateral ankle sprains can lead to chronic ankle instability resulting in reduced physical activity and quality of life.'

Delahunt et al. (2018) further highlighted the risk of lateral ankle sprain being as high as 70% in a persons lifetime. Although the direct cost to healthcare is relatively low (£135), there is a high reinjury rate.The mechanism is of inversion/internal rotation irrespective of sagittal plane displacement. It is still advised that Ottawa ankle rule testing is the most accurate way of ruling out fracture, with a pre-test probability of fracture being 15%, and a post-test probability of <1% with negative Ottawa tests.

'The mechanism is of inversion/internal rotation irrespective of sagittal plane displacement.'

Special testing:

Anterior drawer SN0.96 and SP0.84

Anterior ligament palpation for syndesmosis SN0.92

Squeeze test SP0.88

The indicated assessments include figure 8 measurement for swelling, SEBT, weight-bearing lunge, handheld dynamometer, BESS and foot lift tests.

I hope that this has give you some food for thought and has made you clinically reason your assessment...

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References:

DELAHUNT, E., BLEAKLEY, C.M., BOSSARD, D.S., CAULFIELD, B.M., DOCHERTY, C.L., DOHERTY, C., FOURCHET, F., FONG, D.T., HERTEL, J., HILLER, C.E., KAMINSKI, T.W., MCKEON, P.O., REFSHAUGE, K.M., REMUS, A., VERHAGEN, E., VICENZINO, B.T., WIKSTROM, E.A., GRIBBLE, P.A. 2018. Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium. British Journal of Sports Medicine.

GRIBBLE, P.A., BLEAKLEY, C.M., CAULFIELD, B.M., DOCHERTY, C.L., FOURCHET, F., FONG, D.T-P., HERTEL, J., HILLER, C.E., KAMINSKI, T.W., MCKEON, P.O., REFSHAUGE, K.M., VERHAGEN, E.A., VICENZINO, B.T., WIKSTROM, E.A., DELAHUNT, E. 2016. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine. 0, p.1-13.

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