The Common Problem of Ankle Strain - Essay Example

Case discussion- Ankle Sprain Introduction Ankle is a joint in the lower limb which is formed by fibula, tibia and talus. Its purpose is to facilitate dorsiflexion and plantar flexion of the foot. The medial bony prominence of the ankle is called the medial malleolus and is formed by the tibia while the lateral malleolus is formed by the fibula. The joint’s stability is maintained by various ligaments and the arrangement of the bones. The ligaments on the lateral side of the ankle are anterior talo-fibular ligament, calcaneo-fibular ligament and the posterior talo-fibular ligament. The ligament on the medial side is the deltoid ligament (actually a ligament complex). Instability to the joint occurs whenever there is a fracture of any of the bones of the joint or when there is sprain. Sprain means damage to the ligament. It can be just stretching of the ligament or tearing or rupture of the ligament. Ankle sprains are the most common injuries to the ankle. In fact, they account for 85% of the injuries to the ankle (1). Most of the times the sprains are inversion sprains where the lateral ligaments are damaged.  This is because of the bony and soft tissue anatomy of the ankle and the fact that the lateral malleolus extends further inferiorly than the medial malleolus (2). Other types include syndesmotic sprains and eversion sprains. It is important to diagnose and treat ankle sprains appropriately to prevent symptoms of chronic instability like loss of motion, strength and proprioception (1). Sprains of the ankle account for 38-45% of all injuries in sports (1). It is more common in those who are less active and in the elderly (1). No sex predominance has been noted (1). In about 40% of those who have suffered ankle sprains, chronic instability is a sequel (1). Case history 19 year old James was brought to the emergency department on a Saturday morning at 4 am following injury to the right ankle as he tumbled over the steps while he was returning from a party. He looked intoxicated. On admission to the casualty, he was found to be in intense pain. Examination of the right ankle revealed moderate swelling at the joint with no external bruises and decreased movements at the joint. Pain was mainly localized to the lateral side. He could bear weight on that joint but with pain. Palpation ruled out the possibility of any fractures. There was no evidence of neurovascular compromise either. Past medical history was unremarkable. A diagnosis of grade-II ankle lateral ligament sprain was made in this patient. Ice with the help of ice bag was applied locally. The affected leg was elevated and rested on a pillow. Elastic bandage was applied to the ankle from the toes up to the middle of the calf and half an hour later blood circulation was checked in that limb. He was then discharged with an advice to apply ice and elevate the limb for the next 3 days, take rest for 2 weeks and lay the leg in immobilization during those 2 weeks. For simple movements he was advised to use clutches and not to bear weight on the ankle. He was also advised to go in for physiotherapy after 2 weeks to strengthen the muscles and improve joint stability. He was prescribed anti-inflammatory drugs for immediate pain relief. He was asked to come for follow up only if the pain persisted or the swelling did not subside. It is 6 months since the injury, and James is able to walk without limp and pain. Discussion Injury to the ankle occurs when sudden plantar flexion and inversion of the foot occurs (1). The clinical symptoms depend on the degree of damage to the ligaments and also associated fractures. Sudden rupture of the ligament is very painful and causes immense swelling. These symptoms also are seen in case of associated fractures. Based on the extent of injury to the ligaments, ankle sprains may be classified in to 3 grades as follows (1): Grade I:  There is only a stretch in the ligamentous structures. The degree of swelling is mild and weight bearing is possible. Grade II: There is tearing of the ligamentous structures, but it is incomplete. The degree of swelling is moderate. Weight bearing is accompanied with pain and mild instability is present. Grade III: There is at least one ligamentous structure that is ruptured completely. The swelling is severe. Weight bearing is not possible due to instability. Findings on physical examination include decreased movement at the joint, swelling, edema and ecchymosis (1). Weight bearing capacity and instability at the joint should be assessed. There are tests which determine the degree of instability at the joint. These include anterior drawer test, talar tilt test and squeeze test (1). During clinical evaluation, one must look for neurovascular complications and other associated conditions like arthritis, connective tissue disorders, diabetes, neuropathy and previous ankle sprain (1). This is because, these factors influence the prognosis. When there is a neurovascular compromise, the patient complains of cold foot and paresthesias (1). Radiographic evaluation may not be necessary in all cases of ankle injury (1). X-ray is recommended when fracture is suspected. Clinically, fracture is detected by palpating the posterior edge or tip of the medial or lateral malleolus, navicular or base of the fifth metatarsal bones (1). Tenderness along the base of the fifth metatarsal indicates avulsion of the peroneal brevis tendon (3). Pain on palpation and effusion along the talocrural joint line is suggestive of suspicion of an osteochondral talar dome lesion (3). This lesion may not be actually prominent in X-ray until 2 to 4 weeks (3). Inability to bear weight also prompts for X-ray evaluation (1). Infact, implementation of Ottawa rules has reduced unnecessary radiography (3). The Ottawa rules state that radiographs should be obtained to rule out fracture when a patient presents (within 10 days of injury) with bone tenderness in the posterior half of the lower 6 cm (2.5 in) of the fibula or tibia or an inability to bear weight immediately after the injury and in the emergency department; also, bone tenderness over the navicular bone or base of the fifth metatarsal is an indication for radiographs to rule out fracture of the foot (3). If indicated to get an X-ray as per these rules, then anteroposterior, lateral and mortise radiographs should be obtained after the initial physical examination (3). It is important to know the mechanism of injury. Lack of swelling with an eversion mechanism of injury associated with tenderness at the distal tibiofibular joint, may indicate a syndesmosis sprain (3). This type of sprain can be further confirmed with ‘squeeze’ test. Sophisticated investigations with CT scans or MRI are rarely required. Infact, they should be considered in those who remain symptomatic even after 6 weeks, to rule out talar dome lesions and in those with suspected displaced osteochondral fragment (3). Treatment depends on the degree of injury, presence of associated fractures and neurovascular compromise and general condition of the patient. In the emergency room treatment is mainly aimed at bringing down the pain and minimizing swelling (1). Application of ice, elevation of the foot above the level of the heart and compression with crepe wraps or elastic sleeves bring down swelling. Ice must be wrapped in a cloth or put in an ice bag and then applied. Each time it should be applied for at least 20 minutes. Also, between 2 applications, there must be a gap of at least half an hour to prevent frost bite. Ice decreases swelling by decreasing the increased blood flow to the region. The ankle must be wrapped all the way from the toes up to the top of the calf muscle. Care must be taken not to cut off the circulation to the foot. Immobilization is achieved with air splints, plastic braces or Velcro braces (1). Casting is rarely required. A study by Boyce and others (4) has shown that the use of an Aircast ankle brace for the treatment of lateral ligament ankle sprains produces a significant improvement in ankle joint function at both 10 days and one month compared with standard management with an elastic support bandage. The period of immobilization depends on the degree of injury and can range from 4 to 21 days (1). Rest is a very important aspect in the treatment of ankle sprains because it allows tissue healing. Care must be taken not to apply weight on the ankle. Crutches may be necessary for some days to prevent weight bearing. In some patients with moderate to severe injury, physical therapy in the acute phase with cryotherapy or electrical muscle stimulation may be recommended (1) to decrease the intense swelling and facilitate quick recovery. Anti-inflammatory medications will be necessary to reduce swelling and pain. After the period of immobilization, physiotherapy is required to strengthen muscles and restore stability of the joint. In fact, physiotherapy and rehabilitation are the most important aspects of management of ankle sprain to facilitate walking without limping or pain. Rehabilitation starts immediately after the acute phase, from the 4th day, and may last up to 2 weeks (1). Exercises advised during this phase are those that increase the range of movements like inversion and eversion at the joint, strengthening exercises, and proprioceptive and balance training (1). Surgical intervention is not necessary in most of the cases. It is indicated when fibulo-calcaneal ligament is torn or when there is an unstable fracture (1). Some orthopedicians recommend surgical intervention in grade III and above sprains (2). In most of the cases, follow up may not be necessary until and unless swelling continues or there is persistent pain even after 2 weeks. Since ankle sprains are very common among athletes, it is useful to advise them regarding prevention to prevent unnecessary morbidity and medical expenditure. The prevention strategies include use of ankle braces and advocation of multifaceted ankle sprain prevention programmes (5). How far these are useful is still debatable. References 1. Rimando MP. Ankle Sprain. eMedicine from WebMD [online] 2007. [Cited 2007 Sep 23] from URL: http://www.emedicine.com/PMR/topic11.htm 2. Young CC. Ankle Sprain. eMedicine from WebMD [online] 2005. [Cited 2007 Sep 23] from URL: http://www.emedicine.com/SPORTS/topic6.htm 3. Wolfe MW, Uhl, TL, Mccluskey LC. Management of Ankle Sprains. American Family Physician [online] 2001. [Cited 2007 Sep 23] from URL: http://www.aafp.org/afp/20010101/93.html 4. Boyce SH, Quigley MA, Campbell S. Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace. Br J Sports Med 2005; 39:91-96. 5. Osborne MD, Rizzo TD Jr. Prevention and treatment of ankle sprain in athletes. Sports Med. 2003; 33(15):1145-50 Bibliography Boyce SH, Quigley MA, Campbell S. Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace. Br J Sports Med 2005; 39:91-96. Osborne MD, Rizzo TD Jr. Prevention and treatment of ankle sprain in athletes. Sports Med. 2003; 33(15):1145-50 Rimando MP. Ankle Sprain. eMedicine from WebMD [online] 2007. [Cited 2007 Sep 23] from URL: http://www.emedicine.com/PMR/topic11.htm Wolfe MW, Uhl, TL, Mccluskey LC. Management of Ankle Sprains. American Family Physician [online] 2001. [Cited 2007 Sep 23] from URL: http://www.aafp.org/afp/20010101/93.html Young CC. Ankle Sprain. eMedicine from WebMD [online] 2005. [Cited 2007 Sep 23] from URL: http://www.emedicine.com/SPORTS/topic6.htm Read More