Acute Ankle Injuries – Sprains, Strains & Fractures

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Dr Peter Lam

Ankle Sprains


  • Ability to weight bear
  • Mechanism of injury

Examination to exclude associated injuries

  • Proximal tibiofibular joint and full length of fibula (high ankle sprain)
  • Intra articular ankle pathology – chondral/osteochondral lesions
  • Anterior process of calcaneus
  • Base of 5th metatarsal

Ankle lateral ligament injury (low ankle sprain)

Low ankle sprain with large haematoma

  • Difficulty wt bearing
  • Avoid using boot for greater than 1-2 wks
  • Need to come out of boot several times per day to do gentle ankle DF stretches to prevent ankle stiffness
  • High risk of residual ankle stiffness – may need arthroscopic release

When to refer

  • If persistent instability despite 2-3 month course of physiotherapy i.e. unstable despite good peroneal strength and proprioception or good peroneal strength but unable to improve proprioception because of gross lateral ligament instability
  • Aim of surgery is to prevent articular damage to the ankle joint and the early development of medial compartment arthritis of the ankle

Surgery – lateral ligament reconstruction

  • Immobilise with Aircast stirrup brace or Aircast SP walker boot for 6 weeks post op – wear brace or boot whenever walking outside home
  • Commence physiotherapy 2 weeks post op

Special consideration in patients with ankle instability

  • Hindfoot varus deformity
  • Generalised ligamentous laxity

Syndesmotic ligament injury (high ankle sprain)

  • Wide spectrum ranging from mild stable injury to complete diastasis
  • Represents 1% of all ankle sprains (Hodgkinson F&A  1990)
  • May occur with or without lateral ligament injury (Scranton 2000)

Clinical features

  • Anterolateral ankle pain
  • Swelling much less prominent
  • Pain and swelling more localised than in low ankle sprains
  • Pain with push off
  • Pain with ankle dorsiflexion


  • Plain xray – The most reliable criterion for a syndesmotic injury is a tibiofibular clear space on the AP view of more than 6mm in adults (Pneumaticos SG et al  F&A Int  2002)
  • MRI scan

Natural history

  • Prolonged recovery time – twice as long as that of low ankle sprain
  • Residual symptoms such as stiffness

Stable – physiotherapy


  • Surgery with insertion of a Tightrope/Zip Tight.
  • No fracture – may weight bear as tolerated from week 2 to 6 week in a walker boot.
  • Fracture – non weight bearing for 6 week in a walker boot.
  • Out of boot and commence physiotherapy after 6 weeks
  • May start running when able to perform knee to wall within 2cm of contralateral ankle – usually after 10 weeks post op.

Chondral or Osteochondral injury

Clinical Features

  • Pain and swelling in ankle
  • Start up pain, pain worse with stairs
  • Localised joint line tenderness


  • Xray
  • MRI scan (Most useful investigation)


  • Physiotherapy
  • Surgery – arthroscopic debridement followed by physiotherapy
  • Day surgery procedure
  • Weight bear as tolerated and crutches for 1-3 days
  • Change of dressing after 5 days
  • Home stretching program after 5 days
  • Physiotherapy from 2 weeks

When to refer for surgery

  • If persistent pain despite 2-3 month course of physiotherapy

Anterolateral ankle soft tissue impingement (Meniscoid lesion)

  • May become painful following an ankle sprain
  • Synovitis
  • Meniscoid lesion – Thickening and scarring of the anterior inferior tibiofibular ligament

Clinical features

  • ankle effusion, anterolateral joint tenderness


  • physiotherapy, injection, arthroscopic debridement


When to refer for surgery

  • If persistent pain despite a 2-3 month course of physiotherapy and did not respond to a trial of corticosteroid injection into the ankle


  • Commence physiotherapy within 2 weeks post surgery to reduce post-surgical scarring as post-surgical scarring could lead to the development of similar symptoms.
  • Intensive home stretching program 10min 3x per day

Anterior ankle bony impingement

  • Recurrent ankle instability
  • Common in soccer, basketball, dancing

Clinical features               

  • anterior ankle pain
  • pain with squatting, running uphill or stairs
  • exacerbated by landings and take offs from jumps
  • tenderness with passive or active dorsiflexion of the ankle


  • xray – bony impingement
  • CT scan
  • MRI – helpful in excluding other ankle pathology


When to refer for surgery  

  • If persistent painful anterior bony impingement pain despite a 2 month course of physiotherapy and relative rest.
  • Corticosteroid injection usually helps transiently eg helps get football player through season for surgery during the off season.


  • Arthroscopic debridement
  • Commence physiotherapy 1 week post surgery to reduce post-surgical scarring as post-surgical scarring could lead to the development of similar symptoms.
  • Aggressive home stretching program is required to maintain the improvement in the ankle dorsiflexion range following removal of the anterior impingement spurs.
  • Surgery is NOT recommended for painless anterior bony ankle impingement

Anterior Process of Calcaneus fracture

  • Occurs when the foot is adducted and plantarflexed
  • It is an avulsion fracture of the bifurcate ligament

Clinical features

  • Pain and tenderness in region of sinus tarsi
  • Point of maximal tenderness is 2cm anterior and 1cm inferior to the ATFL


  • Aircast SP walker boot for 4-6 weeks followed by physiotherapy – boot off for shower, bed and to do gentle ankle range of motion exercises

Occasionally patient may develop persistent pain localized to the fracture site despite a trial of immobilization and physiotherapy. If this occurs then surgery to excise the fragment is required. If the fragment is large and there is a non union then open reduction and internal fixation may be required

Lateral Process of Talus fracture

  • Localised pain, swelling and bruising anterior to the lateral malleolus
  • Plain x ray may not show the fracture
  • Bone scan and CT scan for diagnosis
  • This fracture is frequently diagnosed late in patients with presumptive diagnosis of an ankle sprain but have chronic pain
  • If the fracture is undisplaced – Short leg non weight bearing cast or Walker boot for 6 weeks
  • If the fracture is displaced – surgery is required
  • Prognosis is guarded, as there is a significant risk of developing post-traumatic arthritis of the subtalar joint. This could occur within 12 months of the injury.

Base of 5th Metatarsal fracture

  • Treat symptomatically in an Aircast SP walker boot for 4-6 weeks followed by physiotherapy
  • Surgery is only required if there is significant displacement
  • Differential diagnosis – painful 5th metatarsal apophysis

Posterior ankle impingement from Os trigonum

  • Ununited posterolateral tubercle of the talus
  • Its incidence varies from 7-13%
  • Occurs bilaterally in 33-50% of cases
  • Often asymptomatic and the degree of symptom is unrelated to its size
  • May become symptomatic after lateral ligament sprain

Clinical Features

  • Posterolateral ankle pain
  • Pointe work and jumping
  • Tenderness
  • Posterior impingement test


  • Xray
  • CT scan
  • MRI scan

When to refer for surgery

  • If persistent posterior impingement pain despite a 2-3 month course of physiotherapy, relative rest +/- a trial of corticosteroid injection in the patient who do not have an os trigonum


  • Posterior ankle arthroscopy with excision of the os trigonum or the trigonal process
  • Post op rehab/physio is similar to anterior ankle scope
  • Return to barre class about 4-6 wks post op

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