" 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...

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

Jones fracture

Tenderness at base of 5th metatarsal

Surgical screw fixation followed by non-weight-bearing cast

Common in basketball players and ballroom dancers

Lateral process of talus

Inversion injury; seen on mortise view but difficult to see on lateral view; bone scan or CT scan may help identify

Nondisplaced fxs: short leg cast for 6 wk, 4 wk non-weight bearing; displaced fxs: surgical intervention

Often missed for months because of proximity to lateral ligaments. Common in snowboarders.

Maisonneuve fracture

Eversion injury often associated with deltoid ligament sprain; pain and x-ray findings on proximal third of fibula; involves interosseus membrane

Referral for internal fixation

Often misdiagnosed; important to palpate entire fibula with eversion injuries.

Calcaneus

Extra-articular fx often from twisting forces; intra-articular fx often from fall from height; both involve pain with walking or inability to bear weight; CT can delineate two types

Extra-articular: non-weight-bearing cast; intra-articular: surgical referral

Extra-articular fxs often heal well.

Cuboid

Subluxation

Occurs during pronation; pain over lateral side of foot, often along sinus tarsi; pain is elicited by pressing on plantar aspect of cuboid in dorsal direction; running, cutting, jumping markedly increase pain

Repositioning cuboid by holding the forefoot with thumbs over plantar surface of cuboid and 'whipping' the foot into plantar flexion while thumbs push cuboid dorsally

Mostly seen in classical ballet dancers and distance runners.

Fracture

Uncommon but can occur with inversion and plantar flexion; mimics severe sprain or fx of anterior process of calcaneus

Short leg cast for nondisplaced fx; displaced fx requires surgery

Subtalar dislocation

Violent plantar flexion and inversion of foot produce medial dislocation; dorsiflexion and eversion lead to lateral dislocation; foot is deformed in both types

Reduction under general anesthesia

85% are medial. Neurovascular assessment is critical.

AP = anteroposterior, fx = fracture

Importance of the Study

The importance of this study is the addition of relevant compilation of information for the practical use of athletes, coaches and trainers in their response to ankle injury in terms of assessment and treatment of the injury for optimum healing capacity and minimal long-term damage.

Methodology

Methodology of this research has been through a review of relevant peer-reviewed literature that held as its' focus ankle injuries in athletes.

Findings & Implications of the Study

Findings of this study are stated to be that there is always a change of lessening or furthering damage done when an athlete sprains their ankle. It is critical that coaches and trainers, as well as the athletes themselves become knowledgeable in relation to the various types of ankle injuries that exist and the assessment, care and treatment of these injuries so as to not become disabled due to poor medical attention to the injury.

Summary & Conclusion

Ankle injuries are a fact of life and most particularly in relation to those that are high-school and college-athletes. The consideration is important to coaches and trainers as well because losing a promising athlete in mid-season or even at the season's end can be detrimental to the team and to the individual player. Furthermore the coach or trainer may have the burden of knowing that if proper medical care and follow-up care is not provided to the athlete that better care and quicker assessment and diagnosis could have been the difference between whether or not the athlete is able to play the sport professionally. As this study has demonstrated, the developing bones of young athletes very much so tend to undergo stress which leads to many differentiated ankle injuries. This work has further provided information in the assessment, treatment, and follow-up care of these types of ankle injuries. It is the belief of this researcher that there remain enough 'unknowns' to validate the necessity of further and more specific study being applied in this area of Sports-medicine.