A view from the emergency department – working up lateral ankle injuries from diagnosis to return to play

Ankle sprains affect anyone and everyone along the activity spectrum, from semi-professional players and athletes to weekend warriors and accidental injuries. There are over 300,000 ankle sprain presentations to ED annually in the UK (1), 85% of which, are accounted for by lateral ankle sprains.

Clinical Work Up

The mechanism of injury is a key factor in helping to unpick injury subtypes in the ED. These can be divided into lateral, medial, and high ankle sprains (Table 1).

Types of Sprains	Mechanism of Injury
Lateral Ankle Sprain	Inversion & Plantarflexion
Medial Ankle Sprain	Eversion
High Ankle Sprain	External rotation & dorsiflexion

 

When a case of LAS is suspected in ED, there are many important factors to consider when taking a history (Table 2).

Risk Factors for LAS

Extrinsic (2) Mechanism of injury? Awkward landing after a jump or did patient take direct impact to medial ankle? (3). Was the foot planted on the ground or inverted? Type of sport? Does the sport involve cutting, pivoting, jumping? Surface Type? Grass, artificial surface, or hard court? Competition Level? Elite sport or amateur athlete? Training load changes?

Intrinsic (2) Height? Taller athletes have a greater risk of injury The incidence of lateral ankle sprain is reported to be higher in female patients. Lower BMI may be associated with sustaining an initial ankle sprain, whereas higher BMI may have a role in persisting ankle issues. Previous ankle injuries? On the same side? could indicate chronically unstable ankle or inadequate rehabilitation? On the other side? could indicate a biomechanical cause? History of hypermobility? Beighton Score?

 Table 2: Risk Factors for Lateral Ankle Sprains

Grading a lateral ankle sprain can be challenging, however there may be features in the history that would point towards a higher grade of injury. This may include a combination of factors including participating in high energy contact sports and previous ankle injuries. 

Clinical Based Tests

The common clinical features presenting to the ED for a patient with a lateral ankle injury are shown in (Figure 1).

In ED, patients with LAS can be split into two main subgroups:

• Unable to weight bear following an injury

“For patients who can’t weight bear, a visual inspection and palpation using the Ottawa rule can help to rule in patients who need an X-ray. Additional screening tests, should also be performed to assess for syndesmosis, or high ankle injuries, in non-weight bearing patients – or those with bone disorders”

&

• Unstable ankle/ that keeps giving way

“For patients with unstable ankles, it is important to ask about functional or athletic demands, a history of previous ankle injury and special tests to palpate and assess the integrity of the lateral ankle ligaments. If a high-grade lateral ankle ligament injury is suspected, then follow up in a specialist SEM clinic may be needed to consider further imaging” (Figure 2)

On the ED shop floor, a quick screen using symptoms, special tests, and the single leg load test (Table 3), can help to determine which patients can be sent home without follow up. The single leg load test can be performed easily on the shop floor and being able to reach stage 3 or 4 is associated with not having a high-grade lateral ankle injury (4).

Stage 1	Difficulty in single leg standing
Stage 2	Able to single-leg stand
Stage 3	Able to single-leg heel raise
Stage 4	Able to single leg hop

 

 

If significant swelling, bruising or pain limits examination, then a repeat examination in 1 week in a specialist follow up clinic, may be advisable. This is based on the idea that as pain and swelling, reduce after the acute injury – the sensitivity and specificity of clinic-based tests improves (Table 4). Immobilisation may be considered in patients where a high-grade LAS, or syndesmosis injury is suspected, up until this review.

Structure	Test	Specificity	Sensitivity
Lateral Ankle
ATFL	Anterior draw	0.84	0.96 (5)
CFL	Talar tilt	0.75	0.67 (6)
PTFL	Posterior draw
Medial Ankle
Deltoid	Eversion stress	5 days post injury: 0.84	5 days post injury: 0.96
High ankle
Syndesmosis	Kleiger (external rotation)	0.85	0.20 (7)
Syndesmosis	Squeeze	0.94	0.30 (7)

Table 4: Sensitivity and specificity of common clinical tests of the ankle

What can a Sport and Exercise medicine clinics offer follow up patients from the ED?

• Repeat examination, in a follow up clinic – focussed on function and rehabilitation.
• Point of care ultrasound (with dynamic testing) to evaluate the ankle ligaments and assess ankle stability.

ATFL: https://vimeo.com/692781151 

CFL: https://vimeo.com/692781290

AITFL: https://vimeo.com/692783171

• Opportunity to establish early rehab goals and timeline of recovery.
• Referral for targeted imaging (US or MRI) – where required (Table 5).

	Advantages	Disadvantages
Ultrasound	Dynamic views may be obtained Cost effective Time-efficient (8)	Reliant on clinician expertise Reliant on equipment used
MRI	Particularly useful in chronic ankle instability or persisting symptoms Useful in concomitant injuries	Expensive Limited availability False-positive findings (3)

Table 5: Ultrasound vs MRI imaging for lateral ankle injuries

Conclusion

1. The single leg loading test, can be used as a screening test on the ED shop floor, to assess ankle function.
2. The sensitivity and specificity of ankle tests, improves after swelling and pain reduces from an acute injury.
3. Follow up in a specialist Sports medicine clinic from ED, can help to improve access to imaging and early rehabilitation

No competing interest and no relevant declarations.

Authors

Kos Desilva @DesilvaKos

Sports & Exercise Medicine department, Homerton University Hospital Foundation Trust, London, United Kingdom

Irfan Ahmed @Exerciseirfan

Sports & Exercise Medicine department, Homerton University Hospital Foundation Trust, London, United Kingdom

With thanks to:

Ultrasound video of the lateral ankle provided by Orca Resource & Peter Resteghini.

Orca Resource EdTech streaming platform provides a comprehensive series of high quality videos for the medical industry including musculoskeletal ultrasound

https://www.orcaresource.com

Dr. Peter Resteghini is a Consultant Physiotherapist & Musculoskeletal Sonographer based at Homerton Hospital NHS trust.

He is also the Course Director for the Postgraduate Certificate in Musculoskeletal Ultrasound (University of East London)

References

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