Hello, everyone. Welcome to the AOSSM Fit and Ankle On Demand webinar. My name is James Toussaint. I am Division Chief of Fit and Ankle at the University of Florida. Now, for this webinar, I will be talking to you about in-season management of ankle injuries. Now, this is a little bit about me and my educational background and training. I have no conflicts or relevant disclosures pertinent to this presentation. Here's our agenda. First, we'll talk about low lateral ankle sprains, followed by medial low ankle sprains. And then, subsequently, we'll dive into high ankle sprains and ankle fractures. Lateral ankle sprains are the most common reason for missed athletic activity. There are approximately 30,000 or more ankle sprains per year in the United States, and approximately 40% of those happen in athletes. The most common mechanism is an inversion injury to the plantar flexed foot. Both the ATFL and CFL are commonly involved in over 90% of ankle sprains. Low lateral ankle sprains are associated with a number of conditions. You're going to find that the patients may or may not have a subtle cable varus foot. You'll often have some ankle impingement and synovitis. There may be intraarticular pathologies, such as osteochondral defects. If you have patients that have tenderness over the lateral aspect of the ankle, look out for perineal tendon injuries. And then, of course, there may be associated fractures, such as a fifth metatarsal base fracture, as we have here. You may also find anterior calcaneoprocess fractures or lateral or posterior talus process fractures. On physical exam, you're going to find focal tenderness and swelling over the involved ligament. The anterior ankle drawer exam is a good way to test the ATFL. And then, to test the CFL, you'll want to do a tailored tilt test. Excessive ankle inversion compared to the contralateral side may be an indicator of an injury to the ATFL or CFL. And please don't forget that the ATFL is best tested in plantar flexion and CFL is best tested in slight dorsiflexion. All right, let's move on to imaging. Despite having an ankle sprain, you'll want to obtain an x-ray series in your athletes. This will include a standard ankle series, which involves an AP lateral and mortis view. You can also consider obtaining a full-length tibia and fibular view to make sure that you don't have a proximal fibular fracture, as you would see in a mesoneuve injury. An external rotation stress view is important. And look out for any asymmetry in the mortis, the medial clear space, tibial fibular clear space. A various stress view may be useful in diagnosing a CFL injury. In cases where the patient continues to be symptomatic over the, let's just say, six to eight weeks following an ankle sprain, and the patient continues to have pain, in these athletes, you'll want to get advanced imaging such as an MRI. In this case, the patient had a relatively benign x-ray. However, the MRI showed bony bruising and an OCD lesion over the lateral talar dome. So an MRI is useful for OCD lesions and associated soft tissue injuries, such as perineal tendon injuries or ligamentous injuries. When it comes to treatment, in many cases, the athlete who sustains an ankle sprain during play can often return to competition with a lace-up ankle brace or taping. After the game or the competition, you want to institute rice therapy, so rest, ice compression, elevation, followed by an appropriate rehab protocol. This will often involve proprioceptive training. As a good rule of thumb, if the patient is able to do multiple single leg hops, maybe 10 to 15, with no difficulty, that can usually indicate an ability to return to play. Surgery is reserved for chronic instability or failed primary repair of the lateral ankle ligaments. If possible, the ideal time for surgery is post-season, and my surgical preference is to perform an ankle scope to look out for intraarticular pathology. This will be followed by an anatomic repair of both the ATFL and CFL. I'll often augment my repair with something like the Ardalan flex band or an internal brace. Now we're going to move on to the low medial ankle sprains. This injury is much less common than the lateral ankle sprain. Less than 10% of ankle sprains are involving the medial structures. The most common mechanism includes a forced eversion on a dorsiflexed foot that leads to a deltoid ligament injury. The injury mechanism requires a significant amount of energy, so recovery for your athlete may be difficult, and you'll find that the time to return to play is extended when compared to a standard lateral ankle sprain. There are a number of associated conditions that you'll find with a low medial ankle sprain. This will include pes planus, ankle impingement and synovitis similar to a lateral ankle sprain, and you'll often find intraarticular pathology such as an OCD lesion. The syndesmosis, the spring ligament and posterior tibial tendons could also be injured in this mechanism, and some fractures that you have to look out for are fractures of the fibula or the medial malleolus, for example, an avulsion injury to the medial malleolus. On a physical exam, you're going to find that there may be some focal tenderness and swelling over the involved deltoid ligament, spring ligament or posterior tibial tendon. The provocative tests that you might want to employ are the eversion stress test. The way you perform this is you'll have the patient sit down with his knee flexed to 90 degrees. You're going to stabilize the distal tibia with one hand, grab the calcaneus in the other, and while maintaining the ankle in neutral position, you want to apply an abduction force to the calcaneus to tilt the talus. If there's an increased amount of tailored tilt compared to the contralateral side or pain over the deltoid, then this is considered a positive test. The external rotation stress test is also employed. Frequently we'll do that in the operative room setting, but you can also do this in the clinic setting. The issue here is that although when you're doing the external rotation stress test, you are stressing the deltoid, but you may also be stressing the syndesmosis as well. In a similar fashion to the lateral ankle sprains, you'll want to obtain your standard weight-bearing imaging, AP lateral and mortise of the ankle. Look out for medial clear space widening, an external rotation stress view to look out for, again, any asymmetry in the joint. You might want to compare to the contralateral side. An MRI, an MRI is a good modality in this situation. You'll want to obtain an MRI if pain persists for six to eight weeks following a sprain. It'll be useful to evaluate for OCD lesions or associated soft tissue pathology. In this case, the patient's deltoid is disrupted. There should be some dark fibers within the medial aspect of the ankle as denoted in this red circle. Treatment in this case is similar to lateral ankle sprains. In many cases, the athlete can return to play with a lace-up brace or taping during their competition. However, after competition, they will require a period of immobilization for a few weeks. This will include a RICE protocol followed by rehab and specifically proprioceptive training. Inline running can start at around four weeks time, and you want to avoid cutting or sport-specific exercises until their ability to do inline running is normal. Just recall that the patient may be symptomatic for months given that the low medial ankle sprain requires a lot more energy and thus there'll be a lot more soft tissue trauma. There is some controversy that exists for surgical treatment of the deltoid. I do prefer to repair the deltoid if it's disrupted in the setting of an unstable ankle injury. This will involve an ankle arthroscopy for a debridement and to look out for any intra-articular pathology, and then I will follow that with an anatomic repair of the deltoid ligament using suture anchors. Okay, and now on to high ankle sprains. High ankle sprains are found in approximately 13% of ankle fractures, but only 1% of all ankle sprains without a fracture. The high ankle sprains unfortunately will result in more time missed away from competition when compared to the standard low ankle sprain, and this is because it requires a lot more energy to sustain this injury. It occurs with a forceful external rotation force on the foot and ankle while the leg is planted. There are a number of associated conditions such as peroneal tendon injuries, associated fractures, most commonly a Weber C, but it can also happen in Weber B type ankle fractures. You may find a fifth metatarsal base fracture, anterior process of the calcaneus, or a tailored process fracture. The associated injuries may also include a deltoid ligament injury and intra-articular pathologies such as OCD lesions and loose bodies. Moving on to the physical exam for high ankle sprains, palpation is key. You'll want to palpate the syndesmosis. That's an excellent indicator of the ability to return to play if the patient is non-tender with a syndesmosis, then you're in good shape. The squeeze test is good in that it gives you an idea of the level of the injury, so compression of the tibia and fibula at mid-calf level causes pain at the syndesmosis. An external rotation stress test, as we mentioned earlier, if there's pain over the syndesmosis with external rotation and dorsal flexion of the foot, then this is a positive finding. Just be aware that it may indicate a deltoid ligament injury as well. Syndesmotic injuries are notoriously difficult to assess on x-rays, although there's still a lot of information that you can wean out of your standard views. So, if possible, you'll want to obtain weight-bearing views of the extremity, AP, lateral, and mortise views of the ankle. In this case, you certainly want to obtain full-length tibia and fibula views to assess for a maisonneuve injury. The external rotation stress view and gravity stress views allow you to assess for any asymmetry or widening within the joint. In this case, this person has a posterior malleolus fracture. A posterior malleolus fracture is extremely difficult to sustain in isolation, so an axial CT scan was also obtained. And here you can see not only does this patient have a posterior malleolus fracture, but there's a flex sign in the anterolateral aspect of the tibia, which is indicative of a syndesmotic injury. Treatment for syndesmotic injuries depends on whether or not the syndesmosis is stable. You may want to consider non-operative treatment if the syndesmosis is stable and well-reduced. The treatment protocol will include a period of immobilization, approximately two weeks of non-weight-bearing, followed by a RICE protocol. The patient can then proceed to full weight-bearing when they can tolerate weight-bearing with minimal discomfort. You'll want to begin proprioceptive training relatively quickly after that, and sport-specific training and drills begin when the athlete can comfortably jog in a straight line and hop with minimal discomfort. Full recovery, as I've noted here, can vary substantially among different athletes, with various research suggesting a few months until a return to play can be even recommended. When it comes to operative treatment of high ankle sprains, you'll want to consider this in cases where the athlete is symptomatic with an unstable injury or a malreduced syndesmosis, as you may see on an x-ray or advanced imaging, such as an MRI or CT scan, at which point the patient will require surgical fixation. The different ways that you can fix this include rigid versus dynamic fixation. Dynamic fixation has been shown to have a lower complication rate, faster return to sport, and a lower need for hardware removal. However, a meta-analysis was done that showed no difference in clinical outcome and malreduction rate. So, I can say in my hands, I will commonly do an arthroscopic evaluation and debridement of the joint, and then I will employ dynamic fixation through a four-hole plate. The two x-rays, the one on the left and on the right, show two different ways to fix the syndesmosis. However, at this point, I do know that for a lot of the athletes, we're using the dynamic fixation, but I would defer to the surgeon and their specific practice habits to determine what is more appropriate for their athletes. The post-op protocol will involve immobilization in a splint for a few weeks and then progressive weight-bearing is tolerated in a boot. The patient can begin Alter-G or pull work soon thereafter and return to sports when they pass their physical therapy testing. We should discuss some of the complications associated with surgery involving high and low ankle sprains. The patient may sustain delayed wound healing, nerve injury, recurrent instability. Joint stiffness may be seen in cases where there is an over-constraint from the repair or the augment device. The suture-type augmentations for lateral ankle sprains have been noted to have over-tightening, and so there are different ways to avoid that issue. There is less of that issue without the suture-type devices. The delay in return to play may also be secondary to associated injuries, so look out for some of those fractures that I mentioned earlier. These fractures, such as the anterior calcaneal process fractures, talus evulsion, lateral process of the talus, fifth metatarsal base, all of these may have a role to play in delaying your athlete. We're now going to move on to ankle fractures. These are less common than ankle sprains in the athlete, but more commonly will lead to missed athletic activity. They do require higher energy, so that results in more morbidity and a longer recovery. The mechanism usually involves a forced rotation of the foot and ankle. The associated conditions include deltoid ligament injuries, syndesmotic injuries, there'll be intraarticular pathologies such as loose bodies or OCD lesions, associated fractures such as the lateral talus process, evulsion injuries, medial malleolus, talus distal fibula. On the physical exam, it's important to reduce a dislocation. If you see one, the reduction should be done on the field as quickly as possible. You should note any skin compromise. Perform your motor, neuro, and vascular exam. Palpation should be performed last after you've gained the trust of the patient. We'll move on to imaging. You'll want to obtain a standard ankle series, AP lateral and mortis, and you'll also want to include a full-length tibia and fibula to assess for mesoneuve injuries. So the full-length tibia and fibulas will include the knee, and then you'll want to get additional x-rays of the foot, the AP and oblique of the foot to assess for any associated foot injuries. The lateral of the foot should be included in the lateral of the ankle. If possible, consider some stress views or imaging of the contralateral side if the original x-rays are equivocal. Advanced imaging can be key in this scenario, so a CT scan is great to assess for the fracture pattern and for preoperative planning. An MRI is useful to evaluate for associated soft tissue and cartilaginous pathology. In this case, this patient did end up having a proximal fibula fracture, which may have otherwise been missed if the imaging didn't include the full-length tibia and fibula. Various classification systems exist for ankle fractures, but treatment depends ultimately on whether the ankle fracture is stable or not. Non-operative treatment is reserved for stable patterns without evidence of syndesmotic injury. This would be, for example, a Weber A type of ankle fracture or perhaps a Weber B with no syndesmotic injury and minimal displacement. As mentioned earlier, ankle fractures tend to require a prolonged period of non-contact sport, so typically non-contact drills will begin around six weeks and the patient will progressively return to play based on them passing their physical therapy tests. Operative treatment is reserved for unstable injuries. The surgical preference is an arthroscopic evaluation. This is important to remove any loose bodies, to identify any OCD lesions, and to evacuate the hematoma. An anatomic joint reduction is your ultimate goal, and that should include repair of the deltoid and the syndesmosis. Postoperatively, the patient will be immobilized in a splint for two weeks and then begin active range of motion. Progressive weight-bearing is tolerated and a boot begins at around four to six weeks. In the meantime, physical therapy will begin at about two to four weeks. So return to play varies. The ankle fractures will vary in terms of the amount of disruption, both in the bony injury as well as soft tissue injury, and thus return to play varies drastically. The important thing here is that the patient will work closely with their athletic trainer and physical therapist to meet certain milestones and ultimately get back onto the field. This may not occur for over a year and ideally the patient can return to their pre-injury level of play, but they should be counseled that this may never happen. We should talk about ankle fracture complications. This list of complications can include nonunion, malunion, failure of fixation, particularly if the fixation is inadequate or insufficient. The patient may have wound healing problems and, of course, joint stiffness or synovitis. There are a few things to consider. Stress fractures. These may result in prolonged loss of playtime. Stress fractures can be very frustrating for both the clinician and for the athlete. Oftentimes, we may try to treat the stress fracture nonoperatively with a RICE protocol in a period of immobilization. You should consider a bone stimulator. However, the stress fractures, if they remain persistent, they may be better treated surgically. Medial malleolus avulsion and anterior colliculus fractures. They may appear benign. However, there are a number of studies that show that surgical treatment leads to quicker return to play. So, in cases where there's a medial malleolus avulsion or an anterior colliculus fracture, these are essentially injuries to the deltoid, and repairing the deltoid will lead to quicker return to play. Thank you, everyone. That's it for the presentation. I hope you take away some pearls regarding end-season management of ankle injuries. Thanks again. Thank you.

ankle injuries

lateral ankle sprains

medial ankle sprains

high ankle sprains

ankle fractures

in-season management