Ankle Injuries - Athletes Sports-Medicine

Ankle injuries - Athletes

Sports-Medicine

Ankle-Injury

Lateral Inversion Sprain

Medial Eversion Sprain

Syndesmosis Sprain

Achilles Tendon Rupture

Other Ankle Injury Classifications

Sports-Medicine

Ankle-Injury

One of the most common types of injuries occurring during sports events is that of ankle injuries. The ankle is susceptible to injury in practically every sport that exists. "There is a broad spectrum of intra- and extra-articular pathologies that may result in chronic pain and loss of function after an ankle sprain in an athlete. Multiple concurrent intra- and extra-articular pathologies are common. The complex anatomy in the ankle and foot may result in overlap of the clinical features of these various conditions. Contemporary imaging modalities facilitate accurate diagnosis and appropriate and timely management. This review focuses on the particular mechanisms of injury in individual sports, the imaging manifestations of ankle ligament injuries, posttraumatic ankle synovitis, meniscoid lesions, soft-tissue impingement, and ankle joint chondral and osteochondral lesions, with an emphasis on their clinical relevance in athletes." (Uyar et al. 2004) The objective of this work is to research and explore ankle injuries and possible preventative measures that would effectively end losing athletes due to injuries of the ankle.

Sports-Medicine

Ankle-Injury

Objective

The objective of this work is to research and explore ankle injuries and possible preventative measures that would effectively end losing athletes due to injuries of the ankle.

Introduction

Athletic coaches, trainers and athletes alike know that sustaining an injury during the course of a competitive sport, or in practice is a reality that practically every athlete will deal with varying degrees of injury experienced. Many athletes have had their athletic career vanish in a moment of an injury occurring that affects them the rest of their life, rendering them incapable to participate I the athletic career they had hoped to pursue. One of the most common types of injuries occurring during sports events is that of ankle injuries. The ankle is susceptible to injury in practically every sport that exists.

Literature Review

In the work entitled 'Long-Term Outcomes of Inversion Ankle Injuries' stated is that: "Ankle Sprains are common sporting injuries generally believed to be benign and self limiting. However, some studies report a significant proportion of patients with ankle sprains having persistent symptoms for months or even years." (Barnsley et al. 2005) This work reports a study conducted toward the determination of "the proportion of patients presenting to an Australian sports medicine clinic who had symptoms after a sports-related inversion ankle sprain." (Barnsley et al. 2005) In the study the control group that was matched as to age and sex. Data collection was via interview/surveys with questions related to current ankle symptoms, disability related to ankle injury and present health status.

The mean age of the 19 patients in the study was 20 (range 13-28). Twelve male patients (63%) with follow-up averaging 29 months. Out of the 19 patients only five (26%) had fully recovered and had no pain, swelling, giving way, or weakness reported at the follow-up. This study states that findings are that: "Most patients who sustained an inversion ankle injury at sport and who were subsequently referred to a sports medicine clinic had persistent symptoms for at least two years after their injury. This reinforces the importance of prevention and early effective treatment." (Barnsley et al. 2005)

Stated in the work entitled 'Closed poste medial dislocation of the tibiotalar joint without fracture in a basketball player' is: "There is a broad spectrum of intra- and extra-articular pathologies that may result in chronic pain and loss of function after an ankle sprain in an athlete. Multiple concurrent intra- and extra-articular pathologies are common. The complex anatomy in the ankle and foot may result in overlap of the clinical features of these various conditions. Contemporary imaging modalities facilitate accurate diagnosis and appropriate and timely management. This review focuses on the particular mechanisms of injury in individual sports, the imaging manifestations of ankle ligament injuries, posttraumatic ankle synovitis, meniscoid lesions, soft-tissue impingement, and ankle joint chondral and osteochondral lesions, with an emphasis on their clinical relevance in athletes." (Uyar et al. 2004)

The long-term debilitating effect of an undiagnosed ankle injury is stated in the work entitled 'Traumatic foot and ankle injuries in the athlete': "Unrecognized and inappropriately managed foot and ankle injuries can lead to significant long-term functional disability. As many of the above injuries are frequently diagnosed late or not even considered because of the benign appearance of the foot or radiograph, it behooves the sports medicine physician to carefully assess the foot and obtain appropriate radiographs, including stress views as needed.

Although quick return to athletic play is among the goals of treatment for the elite athlete, this must be tempered by the fact that certain injuries require significantly greater time for complete recovery. A functional rehabilitation program is the best means to rapidly return the player to competition and while prolonging the athletic career." (Title & Katchis, 2004)

The work entitled 'Stress fractures of the foot and ankle' states: "When developing a treatment plan for the runner, the sports medicine physician must keep the athlete informed as to the nature of the injury and the necessity of the treatment. A fitness plan must be developed with the runner to ensure that strength, flexibility, and cardiovascular conditioning are maintained during this period. Ideally the physician should develop this plan with the runner and not dictate the type of activity that is used to obtain these goals." (Haverstock, 2001)

Wilkerson (1992) states in the work entitled "Ankle Injuries in Athletes" that "the most frequent cause of physician evolution in a sports-oriented environment" is that of ankle injuries. Further stated is "With a detailed history, physical and radiographic examination to avoid missing underlying pathology, the primary care physician can diagnose and treat the majority of ankle injuries. Occasionally, stress radiographs, arthograms, or magnetic resonance imaging (MRI) is needed.

The vast majority of ankle sprains can be treated with adhesive tape strapping or semirigid orthotics and nonsteroidal anti-inflammatory medication followed by rehabilitation. Key points of rehabilitation are control of pain and swelling acutely with nonsteroidal anti-inflammatories and RICE (rest, ice, compression, and elevation), then restoring normal range of motion, strengthening muscle groups, and retraining proprioception of the ankle joint." (Wilkerson, 1992)

Martin & Martin (2002) state the fact that "Sports play an integral part in the lives of many students, both male and female, making the need for sports medicine universal. The ratio of school-aged female to male athletes has increased from 1 in 27 athletes in 1972 to 1 in 3 today." Stated as well is the important factor as related by Martin & Martin (2002) as to bone strength: "Several factors make injuries to the immature skeleton different than those of the mature skeleton. Immature bone is less dense and more porous than adult bone due to the abundant vascular channels and lower mineral content. This accounts for the lower modulus of elasticity and bending strength found in the bones of growing athletes, resulting in fractures occurring after less significant trauma. The periosteum that surrounds the bone is thicker and stronger than that found in the adult. It is attached firmly in the metaphyseal and ephiphyseal regions of the long bones to help stabilize the physis. This thicker, stronger, more biologically active periosteum helps young bones heal quicker and more reliably than their adult counterparts. Growth plates (physes) located at the ends of the long bones (epiphyses) and at the insertion of certain muscle-tendon units (apophyses) may be subject to injury when exposed to excessive force. Damage to these specific physes can lead to temporary or permanent disturbances of growth." (Martin & Martin, 2002)

Ankle injuries are usually due to "excessive inversion" (Trojan & Mckeag, 1998) However, it is important to make the differentiation between a "simple inversion sprain and a potentially disabling injury."(Trojan & Mckeag, 1998) The method of assuring expedient diagnosis is through screening for any deformity and running tests specific to this type injury. Assessment is best performed during the "preswelling period on the sidelines" according to Trojan and McKeag (1998) The most common injury experienced by athletes is that of ankle sprains. Facts stated by Trojan & McKeag (1998) in relation to ankle injuries are: (1) Most involve injury to the lateral supporting ligaments from an inversion incident; (2). The risk of ankle injuries varies by sport; they make up 45% of all injuries in basketball, 31% in soccer, and 25% in volleyball; (3). In professional, college, and high school football, ankle sprains account for 10% to 15% of all time lost to injury. Yet these injuries are often minimized. (Trojan & Mckeag, 1998) The avoidance of "chronic ankle pain, laxity, or arthritis can be accomplished through "appropriate treatment." Ankle injuries are usually due to "excessive inversion" (Trojan & Mckeag, 1998) However, it is important to make the differentiation between a "simple inversion sprain and a potentially disabling injury."(Trojan & Mckeag, 1998) The method of assuring expedient diagnosis is through screening for any deformity and running tests specific to this type injury. Assessment is best performed during the "preswelling period on the sidelines" according to Trojan and McKeag (1998)

The avoidance of "chronic ankle pain, laxity, or arthritis can be accomplished through "appropriate treatment." The following table illustrates the differentiation in ankle injuries that exists:

Table 1. Useful Tests for Various Ankle Injuries

Injury Location

Specific Injury

Useful Test

Lateral

Inversion sprain

Lateral malleolus fracture

Osteochondritis dissecans

Peroneal tendon subluxation

Bifurcate ligament avulsion

Anterior drawer, talar tilt

X-ray as per Ottawa ankle rules

Mortise view ankle x-rays

Resisted dorsiflexion and eversion

X-rays

Medial

Medial ankle sprain

Medial malleolus fracture

Posterior tibialis tendon injury

Flexor hallucis longus tendinitis

Eversion stress

X-ray as per Ottawa ankle rules

Single heel-rise test

Resisted first-toe flexion

Posterior

Achilles tendon rupture

Os trigonum fracture

Thompson's

Weight-bearing lateral x-ray, tenderness on passive plantar flexion

Anterior

Syndesmosis sprain

Dorsiflexion injuries

Anterior tibialis tendon injury

Squeeze," external rotation

Side-to-side

Resisted dorsiflexion

Avulsion fracture, 5th metatarsal

Maisonneuve fracture

Palpation tenderness, foot x-rays

Palpation tenderness, fibula x-rays

Source: Trojan & Mckeag (1998)

Lateral Inversion Sprain

The lateral inversion sprain is sated to be "the most common ankle injury" accounting for approximately 85% of ankle sprains. The inversion injury will result in lateral ligaments being stretched and/or torn (generally from anterior to posterior)" (Trojan & McKeag, 1998. The following table illustrates how the physician grades the injury and reveals the prognosis as well:

Table 2. Grading of Lateral Ankle Sprains and Return to Play (11)

Grade

Anterior

Drawer Test

Talar Tilt

Test

Return to Play

Negative

1-10 dy

Increased laxity

Negative

2-4 wk

Positive

5-8 wk with optimal rehab

Source: Trojan & Mckeag (1998)

Treatment for lateral sprains are stated as being inclusive of "rest, ice, compression and elevation" along with assistance of crutches and pain and swelling medication as illustrated in the PRICEMMM Table below:

Protection with ankle bracing to prevent reinjury while ligament heals;

Rest for injured ankle until normal heel-toe gait is restored;

Ice on ankle to decrease swelling and relieve pain;

Compression as soon as possible to decrease swelling;

Elevation: the initial step for reducing swelling;

Medication: NSAIDs or acetominophen for pain relief;

Mobilization early on when pain free to expedite return to play; and Modalities: exercise and proprioception training to prevent reinjury.

Source: Trojan & McKeag (1998)

Medial Eversion Sprain

The medial eversion sprain is the type of sprains that wrestlers commonly deal with in. These types of sprains are not as common as lateral sprains with lateral sprains accounting for 85% of ankle sprains and eversion sprains accounting for 10% of ankle sprains. But, when a fracture does occur, 75% of the time it occurs on the medial side.

Syndesmosis Sprain

The Syndesmosis sprain is "postulated to be external rotation and hyperdorsiflexion" in nature as to the causal mechanism. Syndesmosis sprains account for between 1% and 11% of all ankle sprains and occurs more in contact sports. These sprains typically take longer to heal and recovery is 55 days instead of the 35 days allotted for a lateral sprain with a rating of grade 3. The bifurcate ligament injury usually happens due to "violent dorsiflexion, forceful plantar flexion, or direct trauma"(Trojan & McKeag, 1998) This type of sprain accounts for 19% of ankle inversion sprains.

Achilles Tendon Rupture

Achilles tendon rupture usually occurs in older athletes who are not conditions and in younger athletes that have been inactive due to another injury. The sensation is reported to be sharp pain in the Achilles and say it sounded like they were shot. Trojan & McKeag (1998) state of treatment in this injury that it is "controversial."..and that... "Casting is a reasonable option, especially if the tear is more than 2 cm from the calcaneal attachment. Surgery should be considered for the elite athlete to minimize the chance of rerupture."(Trojan & McKeag,1998)

Other Ankle Injury Classifications

Achilles tendon rupture usually occurs in older athletes who are not conditions and in younger athletes that have been inactive due to another injury. The sensation is reported to be sharp pain in the Achilles and say it sounded like they were shot. Trojan & McKeag (1998) state of treatment in this injury that it is "controversial."..and that... "Casting is a reasonable option, especially if the tear is more than 2 cm from the calcaneal attachment. Surgery should be considered for the elite athlete to minimize the chance of rerupture."(Trojan & McKeag,1998) Other sprains are the: (1) Peroneal Tendon Subluxation or Dislocation; (2) The Flexor Hallucis longus injury; (3) The Lateral Periostitis or 'Jumpers Ankle"; (4) Os trigonum injury; (5) Anterior tibialis tendon injury; and (6) Fractures which account for 15% of all ankle injuries among athletes. (Trojan & McKeag, 1998) The following table illustrates the diagnosis and care for varying types of ankle sprain and strain:

Table 4. Diagnosing and Managing Ankle Fractures

Site or Type

Characteristics and Findings

Treatment

Comments

Malleolus

Injuries that extend across an imaginary line drawn through the top of talar dome on AP x-ray considered unstable

Referral for unstable fxs; closed reduction, postreduction x-rays, casting and non-weight bearing for stable fxs

Epiphysis of tibia

Type 1 (Salter-Harris)

Localized swelling or minimal widening on x-ray

Casting for 2-4 wk

Be wary of "ankle sprain" in prepubescent patients since ligaments are stronger than physis at this age. Good to excellent healing for types 1-3; poor prognosis for types 4 and five.

Type 2

Metaphyseal fx into physis on x-ray

Closed reduction, long leg cast

Type 3

Epiphyseal fx into physis on x-ray

Referral to surgeon

Type 4

Fx through both metaphysis and epiphysis on x-ray

Referral to surgeon

Type 5

Narrowing of physis on x-ray

Referral to surgeon

Osteochondral

Weak ankles, crepitus, locking, deep pain, recurrent swelling

Casting if fragment not avulsed from talar dome; otherwise, surgical intervention

Often missed initially; may follow compression injury of talar dome.

Posterior tubercle of talus and os trigonum

Mechanism is severe plantar flexion of foot; patient has lateral posterior triangle pain; resisted eversion pain free; passive plantar flexion mimics symptoms

Short leg cast in 15° of plantar flexion for 4 wk; surgical excision occasionally

Occur in dancers, runners, soccer players.

Avulsion of fifth metatarsal

Inversion injury can avulse plantar aponeurosis from proximal tuberosity; produces tenderness at base of 5th metatarsal

Symptomatic care in cast shoe or hard shoe