High ankle sprain

High ankle sprain
High ankle sprain
Other names	Syndesmotic ankle sprain, syndesmotic ankle injury
Specialty	Orthopedics

Last updated May 18, 2023

A high ankle sprain, also known as a syndesmotic ankle sprain (SAS), is a sprain of the syndesmotic ligaments that connect the tibia and fibula in the lower leg, thereby creating a mortise and tenon joint for the ankle. High ankle sprains are described as high because they are located above the ankle. They comprise approximately 15% of all ankle sprains.^[1] Unlike the common lateral ankle sprains, when ligaments around the ankle are injured through an inward twisting, high ankle sprains are caused when the lower leg and foot externally rotates (twists out).

Mechanism

The ankle joint consists of the talus resting within the mortise created by the tibia and fibula as previously described. Since the talus is wider anteriorly (in the front) than posteriorly (at the back), as the front of the foot is raised (dorsiflexed) reducing the angle between the foot and lower leg to less than 90°, then the mortise is confronted with an increasingly wider talus. The force is heightened when the foot is simultaneously forced into external rotation (turned outward). This chain of events may occur when the front of a hockey player's skate strikes the boards and the foot is forced outward. It may also occur in football, for example, when a player is on the ground with their leg behind them, the foot at right angles, and a rotational force is suddenly applied to the heel, as when someone falls on their foot. Overall, the most common mechanism is external rotation and may occur with sufficient rapidity that the actual mechanism is unrecognized.^{[ citation needed ]}

In this sequence of events, the most vulnerable structure is the anterior inferior tibio-fibular ligament, uniting the lower end of the tibia and fibula and playing an important role in the maintenance of the mortise. The injury to this ligament may vary from simple stretch to complete rupture. Some restraint to further injury is offered by the structures on the inside of the ankle, the medial malleolus and the medial collateral ligament. However, should these structures fail, then the force will be transmitted beyond the anterior inferior tibiofibular ligament to the strong membrane that holds the tibia and fibula together for most of their length. This force may then exit through the upper end of the fibula, creating a so-called Maisonneuve fracture.^{[ citation needed ]}

Diagnosis

Those who sustain high ankle sprains usually present with pain in the outside-front of the leg above the ankle, with increased discomfort when twisting (external rotation) is applied. In some cases, the diagnosis is only made after treatment for the more common, lateral, ankle sprain fails.^[2] Diagnosis may also be delayed because swelling is usually minor or nonexistent and the true nature of the injury unappreciated.^[3] A variety of diagnostic tests have been described such as the 'squeeze' (compressing the tibia and fibula above the midpoint of the calf), 'dorsiflexion with compression' (patient dorsiflexes the foot while the examiner compresses the internal and external malleolus), and 'external rotation' (patient sits with leg dangling and ankle at 90° and external rotation then applied to the foot) etc. None of them performs sufficiently well to allow diagnosis to be made on the basis of a single test,^[4] and is usually made by combining multiple tests supplemented with appropriate imaging when indicated. Plain radiographs, Ultrasound ^[5] or MRI may be used for diagnosis.

In the case of X-rays, demonstration of widening of the tibia and fibula 'mortise', a fracture of the medial malleolus, or a Maisonneuve fracture, will indicate an unstable or potentially unstable injury. However, 'normal' x-rays do not exclude significant ligament injury, and in one study, the ratio of diagnostic X-ray to known syndesmotic injury was only one in 17. By contrast, ultrasound may permit the injury to be visualized while the mortise is being stressed.^[5] Consequently, a diagnostic modality such as ultrasound or magnetic resonance imaging (MRI)^[4] that demonstrates the ligament itself may be helpful, if clinical suspicion remains.^[6]

Treatment

Treatment depends on severity and convalescence may be as short as a few days or as long as six months.^[7] Rest, icing, compression, and elevation is often recommended.^{[ citation needed ]}

Two important issues should be addressed early. First, a determination of whether the ankle is stable or unstable. This is usually answered by clinical assessment together with results of the imaging modalities previously described. In the case of suspected instability, specialist referral is indicated as surgery and some form of internal fixation may be an option, if not a requirement.^[8] Second, a decision of degree of weight bearing, if any, to be permitted. The answer to this is partly related to stability, partly to the clinical estimate of ligament injury together with imaging findings, and partly related to discomfort when weight bearing. The final decision is largely individualized depending on the circumstances.^[8]

An alternative measure consists of H.E.M. (Healthy blood flow, Eliminate swelling and Mobility). This treatment suggests increasing healthy blood flow to the ankle, including immune cells required for healing. The treatment also suggests improving healthy range of motion, stability and strength in the ankle to aid in a full recovery. Recent research suggests that macrophages (immune cells responsible for muscle repair and growth) are necessary for muscle to grow back to its pre-injured state.^[9] The H.E.M. ankle rehab treatment suggests not icing the injury, and instead, following more proactive rehab techniques for recovery: "when ice is applied to a body part for a prolonged period, nearby lymphatic vessels begin to dramatically increase their permeability (lymphatic vessels are 'dead-end' tubes which ordinarily help carry excess tissue fluids back into the cardiovascular system). As lymphatic permeability is enhanced, large amounts of fluid begin to pour from the lymphatics 'in the wrong direction' (into the injured area), increasing the amount of local swelling and pressure and potentially contributing to greater pain."^[10]

Rehabilitation is important. A significant percentage of these sprains also involve medial and/or lateral ankle ligament injury and slow recovery and continuing symptoms are common.^[1] However, limiting external rotation to protect healing ligaments is a primary concern and can usually be achieved by short leg casts, walking boots, and custom orthoses. The degree of permitted weight bearing can be individualized dependent on tolerance and those with less injury are able to ambulate with full weight-bearing. Nevertheless, most use crutches to reduce the burden to some extent and those with more discomfort may be limited to "toe touch" on the affected side for one to two weeks. Some advocate the ability to climb and descend stairs with minimal discomfort as an indication to permit full, or at least progressive, weight-bearing.^[7] Early resistance exercise minimizes muscle atrophy and weakness and a variety of exercises—elastic bands, ankle weights, heel raise exercises—may be used in conjunction with a calf stretch. In the early stages, isometric strengthening and electrical stimulation will combat muscle atrophy and developing weakness.^{[ citation needed ]}

Related Research Articles

The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws and or nails.

<span class="mw-page-title-main">Human leg</span> Lower extremity or limb of the human body (foot, lower leg, thigh and hip)

The human leg, in the general word sense, is the entire lower limb of the human body, including the foot, thigh or sometimes even the hip or gluteal region. However, the definition in human anatomy refers only to the section of the lower limb extending from the knee to the ankle, also known as the crus or, especially in non-technical use, the shank. Legs are used for standing, and all forms of locomotion including recreational such as dancing, and constitute a significant portion of a person's mass. Female legs generally have greater hip anteversion and tibiofemoral angles, but shorter femur and tibial lengths than those in males.

In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia, and one between the femur and patella. It is the largest joint in the human body. The knee is a modified hinge joint, which permits flexion and extension as well as slight internal and external rotation. The knee is vulnerable to injury and to the development of osteoarthritis.

The tibia, also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates ; it connects the knee with the ankle. The tibia is found on the medial side of the leg next to the fibula and closer to the median plane. The tibia is connected to the fibula by the interosseous membrane of leg, forming a type of fibrous joint called a syndesmosis with very little movement. The tibia is named for the flute tibia. It is the second largest bone in the human body, after the femur. The leg bones are the strongest long bones as they support the rest of the body.

The fibula or calf bone is a leg bone on the lateral side of the tibia, to which it is connected above and below. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. Its upper extremity is small, placed toward the back of the head of the tibia, below the knee joint and excluded from the formation of this joint. Its lower extremity inclines a little forward, so as to be on a plane anterior to that of the upper end; it projects below the tibia and forms the lateral part of the ankle joint.

The ankle, or the talocrural region, or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joint. The movements produced at this joint are dorsiflexion and plantarflexion of the foot. In common usage, the term ankle refers exclusively to the ankle region. In medical terminology, "ankle" can refer broadly to the region or specifically to the talocrural joint.

A sprain, also known as a torn ligament, is an acute soft tissue injury of the ligaments within a joint, often caused by a sudden movement abruptly forcing the joint to exceed its functional range of motion. Ligaments are tough, inelastic fibers made of collagen that connect two or more bones to form a joint and are important for joint stability and proprioception, which is the body's sense of limb position and movement. Sprains can occur at any joint but most commonly occur in the ankle, knee, or wrist. An equivalent injury to a muscle or tendon is known as a strain.

Pott's fracture, also known as Pott's syndrome I and Dupuytren fracture, is an archaic term loosely applied to a variety of bimalleolar ankle fractures. The injury is caused by a combined abduction external rotation from an eversion force. This action strains the sturdy medial (deltoid) ligament of the ankle, often tearing off the medial malleolus due to its strong attachment. The talus then moves laterally, shearing off the lateral malleolus or, more commonly, breaking the fibula superior to the tibiofibular syndesmosis. If the tibia is carried anteriorly, the posterior margin of the distal end of the tibia is also sheared off by the talus. A fractured fibula in addition to detaching the medial malleolus will tear the tibiofibular syndesmosis. The combined fracture of the medial malleolus, lateral malleolus, and the posterior margin of the distal end of the tibia is known as a "trimalleolar fracture".

$Maisonneuve fracture Medical condition$

The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane. There is an associated fracture of the medial malleolus or rupture of the deep deltoid ligament of the ankle. This type of injury can be difficult to detect.

<span class="mw-page-title-main">Tibialis anterior muscle</span> Flexor muscle in humans that dorsiflexes the foot

The tibialis anterior muscle is a muscle in humans that originates along the upper two-thirds of the lateral (outside) surface of the tibia and inserts into the medial cuneiform and first metatarsal bones of the foot. It acts to dorsiflex and invert the foot. This muscle is mostly located near the shin.

A syndesmosis is a type of fibrous joint in which two parallel bones are united to each other by fibrous connective tissue. The gap between the bones may be narrow, with the bones joined by ligaments, or the gap may be wide and filled in by a broad sheet of connective tissue called an interosseous membrane. The syndesmoses found in the forearm and leg serve to unite parallel bones and prevent their separation.

The talus, talus bone, astragalus, or ankle bone is one of the group of foot bones known as the tarsus. The tarsus forms the lower part of the ankle joint. It transmits the entire weight of the body from the lower legs to the foot.

$Ankle fracture Medical condition$

An ankle fracture is a break of one or more of the bones that make up the ankle joint. Symptoms may include pain, swelling, bruising, and an inability to walk on the injured leg. Complications may include an associated high ankle sprain, compartment syndrome, stiffness, malunion, and post-traumatic arthritis.

A sprained ankle is an injury where sprain occurs on one or more ligaments of the ankle. It is the most common injury to occur in ball sports, such as basketball, volleyball, football, and racquet sports.

The lateral collateral ligament of ankle joint are ligaments of the ankle which attach to the fibula.

<span class="mw-page-title-main">Malleolus</span> Ankle bone protrusion

A malleolus is the bony prominence on each side of the human ankle.

$Trimalleolar fracture Medical condition$

A trimalleolar fracture is a fracture of the ankle that involves the lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia, which can be termed the posterior malleolus. The trauma is sometimes accompanied by ligament damage and dislocation.

$Crus fracture$

A crus fracture is a fracture of the lower legs bones meaning either or both of the tibia and fibula.

Posterolateral corner injuries of the knee are injuries to a complex area formed by the interaction of multiple structures. Injuries to the posterolateral corner can be debilitating to the person and require recognition and treatment to avoid long term consequences. Injuries to the PLC often occur in combination with other ligamentous injuries to the knee; most commonly the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). As with any injury, an understanding of the anatomy and functional interactions of the posterolateral corner is important to diagnosing and treating the injury.

Medial knee injuries are the most common type of knee injury. The medial ligament complex of the knee consists of:

References

1 2 Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC (1998). "Persistent disability associated with ankle sprains: a prospective examination of an athletic population". Foot Ankle Int. 19 (10): 653–660. doi:10.1177/107110079801901002. PMID 9801078.
↑ Ankle Syndesmosis Injuries – Orthogate – Improving orthopedic care, education and research with Internet technologies
↑ Syndesmotic Sprain – Wheeless' Textbook of Orthopaedics
1 2 Sman AD, Hiller CE, Refshauge KM (2013). "Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review". Br J Sports Med. 47 (10): 620–628. doi: 10.1136/bjsports-2012-091702 .
1 2 Mei-Dan O, Kots E, Barchilon V, Massarwe S, Nyska M, Mann G (May 2009). "A dynamic ultrasound examination for the diagnosis of ankle syndesmotic injury in professional athletes: a preliminary study". The American Journal of Sports Medicine. 37 (5): 1009–16. doi:10.1177/0363546508331202. PMID 19336613.
↑ Nielson JH, Gardner MJ, Peterson MG, Sallis JG, Potter HG, Helfet DL, Lorich DG (July 2005). "Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study". Clinical Orthopaedics and Related Research (436): 216–21. doi:10.1097/01.blo.0000161090.86162.19. PMID 15995444.
1 2 Williams GN, Allen EJ (November 2010). "Rehabilitation of syndesmotic (high) ankle sprains". Sports Health. 2 (6): 460–70. doi:10.1177/1941738110384573. PMC 3438867 . PMID 23015976.
1 2 Polzer H, Kanz KG, Prall WC, Haasters F, Ockert B, Mutschler W, Grote S (Jan 2012). "Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm". Orthop Rev (Pavia). 4 (1): e5. doi:10.4081/or.2012.e5. PMC 3348693 . PMID 22577506.
↑ Tidball JG, Wehling-Henricks M (2007). "Macrophages promote muscle membrane repair and muscle fibre growth and regeneration during modified muscle loading in mice in vivo". The Journal of Physiology. 578 (1): 327–336. doi:10.1113/jphysiol.2006.118265. PMC 2075127 . PMID 17038433.
↑ Meeusen R, Lievens P (1986). "The use of cryotherapy in sports injuries". Sports Medicine (Auckland, N.Z.). 3 (6): 398–414. doi:10.2165/00007256-198603060-00002. PMID 3538270.

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[Gerber-1] 1 2 Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC (1998). "Persistent disability associated with ankle sprains: a prospective examination of an athletic population". Foot Ankle Int. 19 (10): 653–660. doi:10.1177/107110079801901002. PMID 9801078.

[orthogate.org-2] Ankle Syndesmosis Injuries – Orthogate – Improving orthopedic care, education and research with Internet technologies

[3] Syndesmotic Sprain – Wheeless' Textbook of Orthopaedics

[Sman-4] 1 2 Sman AD, Hiller CE, Refshauge KM (2013). "Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review". Br J Sports Med. 47 (10): 620–628. doi: 10.1136/bjsports-2012-091702 .

[Mei-D-5] 1 2 Mei-Dan O, Kots E, Barchilon V, Massarwe S, Nyska M, Mann G (May 2009). "A dynamic ultrasound examination for the diagnosis of ankle syndesmotic injury in professional athletes: a preliminary study". The American Journal of Sports Medicine. 37 (5): 1009–16. doi:10.1177/0363546508331202. PMID 19336613.

[pmid15995444-6] Nielson JH, Gardner MJ, Peterson MG, Sallis JG, Potter HG, Helfet DL, Lorich DG (July 2005). "Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study". Clinical Orthopaedics and Related Research (436): 216–21. doi:10.1097/01.blo.0000161090.86162.19. PMID 15995444.

[Williams-7] 1 2 Williams GN, Allen EJ (November 2010). "Rehabilitation of syndesmotic (high) ankle sprains". Sports Health. 2 (6): 460–70. doi:10.1177/1941738110384573. PMC 3438867 . PMID 23015976.

[pmid22577506-8] 1 2 Polzer H, Kanz KG, Prall WC, Haasters F, Ockert B, Mutschler W, Grote S (Jan 2012). "Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm". Orthop Rev (Pavia). 4 (1): e5. doi:10.4081/or.2012.e5. PMC 3348693 . PMID 22577506.

[9] Tidball JG, Wehling-Henricks M (2007). "Macrophages promote muscle membrane repair and muscle fibre growth and regeneration during modified muscle loading in mice in vivo". The Journal of Physiology. 578 (1): 327–336. doi:10.1113/jphysiol.2006.118265. PMC 2075127 . PMID 17038433.

[pmid3538270-10] Meeusen R, Lievens P (1986). "The use of cryotherapy in sports injuries". Sports Medicine (Auckland, N.Z.). 3 (6): 398–414. doi:10.2165/00007256-198603060-00002. PMID 3538270.

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