1. Model Injuries Classroom Look At Ankle Sprains Stephen M. Pribut, DPM Clinical Assistant Professor of Surgery, GWUMCThursday, February 14, 13

2. Lateral Ankle Instability and Injury Overview Evaluation Treatment Intersection of mechanics & biologyThursday, February 14, 13

3. Overview 40% of all sport injuries Account for 25% of time lost in athletics 23,000 sprains per/day in the U.S. 10% of all ER visits in U.S. Lateral ankle injuries = 85% Medial ankle injury = 5% Syndesmosis = 10% Long term problems in up to 50%Thursday, February 14, 13

4. AnatomyThursday, February 14, 13

5. Sagittal Plane Axis of MotionThursday, February 14, 13

6. Peroneal Tendons Assist lateral stability Pulleys aid functioning Behind malleolus Around CuboidThursday, February 14, 13

7. Lateral Ankle Structures Affected Anterior Talo-Fibular ligament Calcaneo-bular ligament Posterior talo-bular ligament Anterior-inferior tibio-bular ligamentThursday, February 14, 13

8. Lateral Ankle Structures Affected (2) Peroneus brevis tendon Peroneus longus tendon Os peroneum 5th metatarsal base - fracture variant: Jones fracture Interosseus ligament tear Fibular fracture Osteochondral fracture of TalusThursday, February 14, 13

9. Peroneal TendonsThursday, February 14, 13

10. Examination & Assessment Look Symmetry, Color, Swelling Touch Temperature, texture, tenderness Move Range of motion, limitations, pain on motionThursday, February 14, 13

11. Anterior Draw Stress X-rayThursday, February 14, 13

12. Ottawa Ankle Rules Less than 15% of ankle injuries presenting to the ER have a fracture. Rules were set up for ankle and foot x-rays following ankle sprain Tenderness at distal 6 cm of the posterior aspect of medial or lateral malleolus Tenderness at tip of malleolus Inability to walk 4 steps Tenderness of base of 5th metatarsal or navicularThursday, February 14, 13

13. Thursday, February 14, 13

14. Long Term Prognosis Residual instability, pain and swelling can occur in 20% to 40% of patients after a Grade II lateral ankle sprain. Review articles & Lectures: Doug Richie, Jr., DPMThursday, February 14, 13

15. Immediate Treatment PRICE Protection Rest Ice (24h - 48h) (long term - adverse impact to nerves, skin, blood ow) Compression ElevationThursday, February 14, 13

16. Staged Recovery Immediate: PRICE minimize swelling, hemorrhage, inammation, pain Week 1 - 3: Protection collagen - proliferative phase (initially Type 3 collagen)Thursday, February 14, 13

17. Staged Recovery (2) Week 3+ Exercise & Rehabilitation Improvement in collagen maturation phase Graduated exercise programThursday, February 14, 13

18. Staged Exercises Range of motion ROM - all directions Alphabet painting with toes Theraband Wobble board Figure 8 runningThursday, February 14, 13

19. Wobble Board Training Muscle strength Balance Joint position sense / proprioceptionThursday, February 14, 13

20. Problems: Ankle Instability Mechanical Laxity Functional Subjective sensation of instabilityThursday, February 14, 13

21. Ankle Instability and Sensorimotor Decits Cutaneous Alpha Motor Receptors Neurons Articular Extrafusal CNS Receptors Muscle Fibers Tendon & Muscle Articular Gamma Motor Receptors Receptors NeuronsThursday, February 14, 13

22. Factors In Ankle Instability and Sensorimotor Decits Reex Reactions Walking Mechanics Postural Control Muscle Strength Running Mechanics Proprioception Jumping & Landing Passive Active Sensory MotorThursday, February 14, 13

23. Ankle Instability and Sensorimotor Decits Postural Running Reex Reactions Control Mechanics Muscle Walking Jumping & Proprioception Strength Mechanics Landing Passive Active Sensory MotorThursday, February 14, 13

24. Decits Proprioception = Primary Decit Improve balance Improve strength Peroneal tendon reex & responsivenessThursday, February 14, 13

25. Bracing Stability Proprioceptive feedbackThursday, February 14, 13

26. Early Stages AFO Cam walker Pneumatic walking boot Control of ankle and STJ Allows early ambulation with Grade II & Grade III injuryThursday, February 14, 13

27. Later Stage or Mild Injury Gauntlet (lace-up) - Swede-O Stirrup - semirigid plastic slabs 3 in 1 Airsplint sport - sleeve, stirrup, locking wrapThursday, February 14, 13

28. BracingThursday, February 14, 13

29. Brace SelectionThursday, February 14, 13

30. Smaller BracesThursday, February 14, 13

31. Brace Limitations Age considerations Balance in elderly Leg length differences Creation of new pains Smaller braces - dont t in all shoes Joint axis interactions Weight of braces and bootsThursday, February 14, 13

32. Other Lateral Injuries 5th metatarsal avulsion fracture Jones fracture Peroneus brevis tendon tear Peroneus longus tendinopathy Cuboid fractureThursday, February 14, 13