Society for Adolescent Health and Medicine Sports Medicine Workshop March 10, 2017 Albert C. Hergenroeder, M.D. Keith Loud, M.D

Ankle Injuries: Diagnosis and Management

Goal The audience will understand the diagnosis and management of common ankle injuries

Objectives The audience will be able to discuss: The two most common mechanisms of ankle injuries The key physical examination findings in examining the acutely injured ankle Explain the Ottawa Rules regarding indications for xrays Outline the acute treatment program

Mechanism of ankle sprains Inversion 85% of those that present to EC (Brostrom 1966) Eversion More likely associated with fracture Low index of suspicion for xray There is a 3rd mechanism: “Don’t remember”

Physical examination Inspection Active ROM x 6 Resisted ROM x 6 NV/Gait Active ROM x 6 Resisted ROM x 6 Provocative tests Palpation Functional tests http://youtube.com/watch?v=5uablQftMP0

Active ROM Dorsiflexion (extension) Plantarflexion (flexion) Then each with inversion and eversion

Resisted ROM x 6 Dorsiflexion Inversion Eversion Plantarflexion

Anterior drawer Positive test indicates tear of ATFL and CFL

Palpation Lateral joint line/lateral malleolus Base of fifth metatarsal Medial joint line/medial malleolus Navicular Proximal fibula Anterior joint line/talus

Functional testing

Ottawa Rules for obtaining ankle xray series (Steill 1993) Pain in the malleoli and > 1 of following Inability to walk pain free immediately after the injury or take 4 steps in the EC Or, tenderness at the tip of the malleoli

Ottawa Rules for obtaining foot xray series (Steill 1993) Pain in the midfoot (navicular, cuboid, cuneiforms), anterior talus, base of 5th, and The inability to bear weight, or Point tenderness over navicular, base of 5th, cuboid

Tibiofibular syndesmosis injury More serious Eversion is a risk factor Tender proximal to anterior joint line Squeeze test

Treatment The Goal is to limit disability

Initial treatment RICE Rest Ice Compression Elevation Analgesia

Injuries while using crutches Estimated 15,849 injuries to < 19 yo in the US, 1991 – 2008 National Electronic Injury Surveillance System Reported to ED 8,800 LE, 3,800 UE, 1,600 head Barnard 2010

Wearing stirrup for a year lowers risk of respraining ankle RCT, male professional soccer players For those with previous history of ankle sprain, wearing the orthosis was associated with a 5-fold reduction in the incidence rate in the next year, compared to those with previous injuries who did not wear the orthosis. Surve 1994

Initial rehabilitation exercises Relative rest Start as soon as possible Stretching Strengthening Get off crutches asap

Day # walk jog 1, 2 5 3, 4 10 5, 6 15 7, 8 20 9, 10 5, 10 11, 12 5, 5 13, 14 10%/week

Gradual return to play guidelines associated with ↓ LE reinjury rate Male, amateur soccer players Norway, RCT 10 return to play: jog > figure of eight > zig-zag jog, jog with 90° turns, jog with 180° turn, jog with 360° turns > ball drills > shooting, jumping, sprinting > team training > match play 11% reinjury rate intervention vs 29% cont Hagglund 2008

Summary 2 common mechanisms PE findings Inversion, eversion NV first Active, resisted ROM; provocative tests Functional tests

Summary (cont’d) Ottawa rules for ankle Initial rehab – RICE, analgesia Start pain free rehab asap

Summary (cont’d) Functional rehab Walk-jog > figure of 8 >sports Air stirrup for 6 months Some evidence for preventive, preseason programs

Thank you! alberth@bcm.edu Text xxx00.#####.ppt 10/31/2017 12:56:14 AM