ankle sprain - dutch clinical guidline

An ankle sprain was defined an incident in which the rearfoot was inverted or supinated and

resulted in a combination of swelling, pain, and time lost or modification of normal function for 1 day. 

To be included, subjects had to report a history of 1 ankle sprain and 2 episodes of ‘‘giving way’’ within the past 3 months.

Brostrom in his report on the frequency of the individual ligament ruptures stated that isolated ATFL

injury occurred in 66%. A combined tear of ATFL and CFL was reported in 20%. It is the combined injury of both ATFL and CFL,which is responsible for the development of chronic lateral ankle instability. 

Rupture of CFL alone is very rare as an isolated injury. The PTFL is seldom injured.

The common mechanism of injury of plantar flexion and inversion together, with its  lower maximum load to failure,accounts for the greater frequency of injuries to the ATFL

Mechanical instability is the 

objective measurement (either clinical or roentgenographic) where as functional instability, first described 

by Freeman et al. 

is the patients' subjective complaint of givingway in the ankle joint. 

Functional 

instability is the most common and serious residual 

disability after lateral ligament injuries of the ankle 

joint.

Tropp 

defined functional instability as a motion beyond voluntary control but not exceeding the

physiologic range of motion.

Symptoms

Patients with chronic lateral instability usually have a 

preceding history of significant acute inversion ankle 

injury.

Patients often describe a feeling of `giving

way' while the ankle is plantar flexed and internally

rotated. 

patients also complain of pain, intermittent 

swelling and recurrent ankle sprains.

The examination 

may reveal lateral tenderness but the most common 

and important tests for evaluation of instability are 

anterior drawer test and inversion stress test.

The examination

may reveal lateral tenderness but the most common 

and important tests for evaluation of instability are 

anterior drawer test and inversion stress test.

Anteriordrawertest

In a relaxed patient,anterior subluxation of talus can 

be easily demonstrated, with the  patient seated on a 

bench and the leg hanging off the end with the knee b

ent, tibia is stabilized with one hand while pulling the 

foot forward with the other hand behind the heel 

. 

The same can be performed with the patient 

lying supine.

Inversion stress test

Excessive inversion of the heel in plantigrade position. 

In patients with calcaneofibular disruption, pain or 

frank instability may be demonstrated by this test

RADIOGRAPHIC EVALUATION

Stress roentgenograms

Inversion stress view is an excessive talar tilt on an AP 

view of the ankle

Classification systemsfor lateral ankle sprains

Based on the anatomy

GradeI:ATFLsprain

GradeII:ATFLandCFLsprains

GradeIII:ATFL,CFLandPTFLsprains.

Based on the degree of injury to the ligament(s)

Grade1: ligament stretched

Grade2: ligament partially torn

Grade3: ligament completely torn

Based on the clinical signs and symptoms

Mild sprain: minimal functional loss,no limp,

minimal or no swelling point tenderness, pain with

reproduction of mechanism of injury;

Moderate sprain: moderate functional loss,unable to

toe rise or hop on injured ankle, limp when walking,

localized swelling,point tenderness;

Severe sprain: diffuse tenderness and swelling;

crutches preferred by patient for ambulation

Group1: nonathletic or older patient;functional

treatment*;

Group2:youngathlete.

 Type A: negative stress X-ray findings; treat

functionally;

 TypeB: positive tiboitalar stress X-ray findings

 

(talar tilt>15° ; anterior drawer>1cm);

 treatby surgicalrepair;

TypeC: subtalar instability; treat functionally

Dutch Clinical Guideline

Diagnosis: fracture is the main red flag. The Ottawa ankle rules (OAR) have been developed 

and seem accurate to rule out fractures and the  need for radiography after acute ankle inju-

ries. The gold standard for diagnosing lateral ankle sprain is delayed physical examination 

(4 to 5 days post t rauma), which is more reliable than physical examination within 48 h after 

trauma.

 Stress radiography, ultrasonography and MRI have no role in the routine examina-

tion, but can be useful in diagnosing associated injury (bone, chondral or tendon) when there is 

a suspicion of such injury. 

Treatment: in the first phase, use ice and compression in combination with rest and 

elevation. Non-steroidal anti-infl ammatory drugs (NSAIDs) have beneficial short-term out-

comes for acute ankle sprains. A short period of plaster immobilisation or similar rigid support 

facilitating a rapid decrease of pain and swelling can also be helpful in the acute phase.

Thereafter, functional treatment for 4 to 6 weeks is preferable to immobilisation.

Prevention: balance or neuromuscular training prevents recurrence of ankle injuries in 

athletes up to 12 months postinjury, is training activities and/or at home. The use of a brace and 

tape reduces the risk of re-injury in those who are active in sports.