Definition
Simple sprain
- injury to ATFL
- will almost always get better in 6-8/52
Complex sprain
- associated injury
- suspect if patient slow to recover
- diagnose most things on MRI
Symptoms
Instability
- clinical diagnosis
- most will get better with appropriate physio
Pain
- if pain is present as well then consider other pathology
- isolated instability isn't usually painful
Causes
1. Soft tissue
- lateral gutter fibrosis
- Bassett's ligament (thicknened AITFL)
- meniscoid / ferkel lesion
2. Bony Injury
- OCD / loose body
- bone bruise
- fracture anterior calcaneum / lateral process / sustenaculum tali
3. Tendon / ligament
- deltoid
- peroneal dislocation / tears
- high ankle sprain / syndesmotic injury
- sinus tarsi syndrome
- Achilles tendonitis
DDx
Soft Tissue
1. Lateral gutter fibrosis
Ligament healing thicker than normal
- associated scar tissue
- initial injury seemed to get better
- ongoing pain and swelling over lateral ankle
Management
- arthroscopy and debride
- most will get better
2. Bassett's Lesion
Pathology
Primary injury to AITFL
- tear may produce laxity
- talar dome may extrude anteriorly in DF
AITFL
- normally thin and above level of ankle joint
- may become thickened and scarred causing lateral ankle pain and swelling
Diagnosis
Difficult to diagnose
- tender in syndesmosis & interosseous membrane
- positive squeeze test
Management
- arthroscopy and debride
- most will get better
3. Meniscoid Lesion
Definition
Scar tissue beginning in the lateral gutter
- extending across between tibia and talus
- looks like a meniscus
Management
- arthroscopy and debride
- most get better
Bony Injury
1. Fracture Anterior process of calcaneum
Pathology
Avulsion of the origin of the bifurcate ligament
- often missed if x-ray is in the wrong plane
Diagnosis
Suspect if tender over anterior calcaneus
- CT or more plain films
Management
- non-op for 6/12
- most will unite or get a painless fibrous nonunion
2. Fracture Lateral Process
Pathology
Eversion injury leading to lateral ankle pain
- tends to be larger than appears on plain x-ray
- often cause stiffness as involves STJ
Diagnosis
CT / MRI
Management
ORIF
- > 1cm
- displaced > 2mm
Small and comminuted
- excise
3. Fracture Sustenaculum Tali
Caused by impaction on medial malleolus as the talus internally rotates
Management
- usually treat non-operatively
4. Fractured Os peroneum
Pain distally over the CCJ
Management
- non-operative initially
- late excise
5. Bone bruise
Pathology
Oedema in bone usually medial talar body and medial malleolus
- initial injury settles
- get pain with resumption of activity
Diagnosis
MRI
Management
Usually settles in 6/12
5. Osteochondral fracture
Mechanism
- occur as the talus is inverted within the mortise
Pathology
Anterolateral
- caused by shear stresses as the lateral talus abuts the lateral malleolus
- tend to be smaller and generally do better
Posteromedial
- caused with medial ridge impacting the roof
- more significant injury
- tends to be larger with underlying necrotic bone
6. Loose Body
Tendon / Ligament
1. Deltoid Tear
Pathology
- severe injury / almost an ankle dislocation
- gross inversion of talus with distraction
- complete tear of lateral structures and tear of deltoid
- medial pain with lateral sprain
Management
Initially treat non-operatively
- may need debridement / repair
2. High Ankle Sprain
Pathology
Injury to AITFL
- point tenderness and swelling
Management
Exclude diastasis
Treat non-operatively
- will take 12 weeks
Can benefit from late debridement
3. Peroneal Dislocation
Pathology
Occurs with inversion while plantar flexed (strong contraction of peroneals)
- more common in cavus type feet
- usually not diagnosed at the time
Symptoms
Patient complaining of painful snapping or clicking on lateral ankle
- after ~ 1/12 get synovial lined pouch anterior to malleolus from chronic subluxation
- won't heal
Management
Operative
- surgery with repair &/or deepening of groove
- repair and augment with periosteal flap or slip of Tendo achilles
4. Peroneal Tear
Single or multiple longitudinal split
- associate with subluxation / dislocation
- associated with cavus feet
5. Sinus Tarsi Syndrome
Lateral ankle pain
- injury to interosseous ligament
- residual synovitis
Management
- HCLA
- excision of contents of sinus
6. Achilles tendonitis
Insertional tendonitis
Retrocalcaneal bursitis
Haglund' s deformity