How to assess lateral ankle sprain and its risks of chronic instability?

By Jehan de Chaillé

This blog article is the result of reading several scientific articles and then writing their synthesis. It does not claim to create knowledge but to optimize the evaluation and management of an often neglected acute ankle sprain.

How to assess lateral ankle sprain and its risks of chronic instability?

Current Recommendations for Lateral Ankle Sprain

What is acute lateral ankle sprain?

Acute lateral ankle sprain is the most common injury in sports and among the general population. Every day, around 6,000 cases are recorded in France, an underestimated figure since it only takes into account incidents treated in emergencies. This injury is particularly prone to recurrence and can lead to persistent symptoms and chronic ankle instability (CCI).

Why is better ankle sprain management needed?

A study carried out in 2010 found that the knowledge of members of the Irish Society Of Chartered Physiotherapists (ISCP) about lateral ankle sprain and CCI ( chronic ankle instability ) was insufficient. The treatments applied were often too standardized and did not take into account the need for a personalized approach, adapted to the specific deficits of each patient.

What is the 2019 International Ankle Consortium proposal?

In 2019, 14 ankle experts published a Delphi study entitled "Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 - Consensus statement and recommendations of the International Ankle Consortium" . They have standardized a diagnostic approach for traumatic ankles, which includes analysis of the mechanism of injury and evaluation of the bones and ligaments of the joint. This approach aims to improve the understanding and treatment of ankle sprains.

What is ROAST and what does it consist of?

ROAST (Rehabilitation-Oriented ASsessmenT) is a major innovation resulting from the collaboration of experts. This is an assessment method designed to identify mechanical and sensorimotor deficiencies in traumatic ankles in their acute phase. This tool aims to detect the risks of developing chronic ankle instability early, thus allowing more targeted and personalized care.

How to improve the management of acute lateral ankle sprains?

The key to improving the treatment of acute lateral ankle sprains lies in adopting a personalized diagnostic and therapeutic approach , based on the recommendations of the International Ankle Consortium and the use of ROAST. It is essential that clinicians update their knowledge and adapt their practices to offer patients the best possible care.

How to assess Acute Lateral Ankle Sprain?

Initial clinical assessment at subject presentation

Understanding the mechanism of injury

It will allow the affected tissues to be suspected.

Succinctly, the clinician must have in mind damage to the lateral ligaments if the subject describes a rapid mechanism of supination of the foot block, added or not to an internal rotation movement of the same region under the tibiofibular complex, whatever the position. of the foot in the sagittal plane.

Furthermore, the idea of an injury complicated by damage to the ankle syndesmosis must exist in the practitioner's reasoning. The mechanisms are less obvious, but currently publications describe injury mechanisms in external rotation of the foot under the malleolar clamp, supination of the talus in the clamp and excessive dorsiflexion in the sagittal plane.

Existence of antecedent

As the risk of recurrence is high, if the subject has already suffered one or more sprains, it is highly likely that it is new. Furthermore, the existence of a history increases the risks of the presence of associated mechanical and sensorimotor deficiencies which it is important to target in order to manage them.

Load capacity

It is part of the Ottawa rules. Both at the time of the trauma and when the subject presents himself, he must be able to support 4 steps. If this is not the case, the clinical probability of a fracture is high.

Bone assessment

According to the Ottawa rules, the presence of an malleolar fracture must be ruled out by combining the absence of malleolar pain reported by the subject with the absence of pain on palpation of the posterior slices of the malleoli over a height of 6 cm.

Ligament assessment

It is necessary to look for the different elements affected, or even to check whether they are completely broken.

The anterior talofibular ligament (ATFL) which is bi-fasciculated (an upper portion, and a more inferior portion) will be stressed by precise palpation during which the reproduction of pain recognized by the patient will be sought. Also stressed by a mechanism of supination and internal rotation of the foot, during which pain recognized by the patient will be sought. Its complete rupture will be identified by the Anterior Drawer Test (the fact that it is bi-fasciculated merits that this test be carried out with the talocrural joint in plantar flexion of approximately 10-20° for the upper portion, and with plantar flexion of approximately 45°-60° for the lower portion). The literature shows that it is the most sensitive and specific maneuver, that it is more reliable 4 to 6 days post-traumatic, and that the absence of sulcus in this test greatly reduces the risk of complete rupture. Depending on the teams, it is practiced in different positions (sitting at the edge of the table, in strict decubitus with the foot extended, in the decubitus position with the knee bent and the foot on the plane, etc.).*

The calcaneofibular ligament is subcutaneous and easily palpable. The reproduction of the patient's known pain upon palpation as well as the application of mechanical stress by dorsiflexion and internal rotation of the foot indicates damage to this means of union. Compared to the opposite side, significant laxity during internal rotation of the rear foot in maximum dorsiflexion increases the probability of a complete rupture.

It is absolutely necessary to check the integrity of the syndesmosis , especially when a patient describes a mechanism of injury involving forced dorsiflexion coupled with internal rotation of the leg/external rotation of the foot creating supination of the talus in the clamp. bi-maleolar. For this, palpation of the means of passive unions and the squeeze test are respectively the most sensitive test and the most specific test. So in the case where both are positive, the risk of damage to the syndesmosis ligaments is very high. We can add stress to the syndesmosis by applying forced dorsal flexion of the talocrural joint coupled with external rotation of the foot (sometimes called Kleiger test, or external rotation test), compared to the opposite side. Reproduction of pain? Laxity? Raising syndesmosis damage can be a red flag.

We also find in the literature that it is necessary to couple these orthopedic tests with the presence or absence of various associated symptoms (localization of pain, supramalleolar edema).

What are the steps to identify and track mechanical and sensorimotor deficiencies?

During the acute phase of the ankle sprain, it was supported by this group of experts that vigilance with regard to deficiencies would constitute an effective means of identifying injured people who could drift towards CCI and thus of preventing them. For this, it is proposed to monitor and evaluate several criteria which are all found in populations suffering from CHF.

Pain

Do not hesitate to ask subjects to self-assess their pain. During rehabilitation, it must decrease. In addition to evaluating the intensity, it is possible to evaluate its impact in everyday life (see below).

Edema

The presence of edema will cause an alteration of somatosensory information transmitted to the central nervous system. This then triggers a process of “arthrogenic muscle inhibition” which will alter the stability and performance of the joint. A quick way to monitor the progress of edema is to perform the “Figure 8”. Monitoring the state of the edema will then make it possible to make therapeutic rehabilitation decisions and monitor its effectiveness. Given the AMI, imposing unipedal balance or change of direction exercises on a subject could, for example, be a factor in early recidivism.

Joint amplitude

The range of motion most impacted by lateral ankle sprains is visibly dorsiflexion. A good way to monitor your progress will be to set up the weight-bearing lunge test which is simple and quick. In the same way, the evolution of joint range of motion will make it possible to determine the effectiveness of the treatment and to guide its progression. A lack of progress will cause us to adopt another attitude and could even push us to reorient ourselves, for example.

Arthokinematics

If the amplitude of dorsiflexion is limited, the kinematics of the talus in its antero-posterior sliding capacities may be to blame. It should then be evaluated using the Posterior Talar Glide Test. If this test is negative, other potential causes of reduced dorsiflexion should be investigated, particularly with the sensations reported by the patient (involvement of the midfoot joints, posterior impingement, flexor hallucis longus, etc.)

Muscular force

It is advisable to measure the strength of the ankle muscles, since good protection of the joint is possible thanks to the recruitment of the musculo-tendinous units thanks to the rigidity generated. The literature has identified muscle weakness in the talocrural region in a population with CHF. Please note, manual assessment of isometric force is not reliable. It is absolutely necessary to use adequate equipment, such as isokinetic dynamometer (but very expensive and present mainly within specialized structures) or manual dynamometers. It is also advisable to measure the strength of the hip muscle groups since losses of proximal strength have also been noted.

Static postural balance

By the Balance Error Scoring System and the Foot Lift Test.

Dynamic postural balance

By the Star Excursion Balance Test.

Walking observation

Poor positioning of the lower limbs and walking techniques are found in populations suffering from CHF. These positions and techniques would be involved in a very high rate of recurrence during walking, particularly during the load/discharge transition phases.

Physical activity level

Estimate the level of physical activity before the injury and at the time of assessment. This can help to develop a personalized program and aim for coherent objectives but also to determine where the patient is and if the support is correct. For this, the Tegner questionnaire is proposed.

Self-assessment tools

Self-assessment makes it possible to improve care and build better quality follow-up. It is recommended to use the Foot and Ankle Disability Index and the Foot and Ankle Ability Measure to monitor changes in ankle function. There are statistics referring to subjects suffering from CHF, characterizing the functional impact and the disability experienced.

Conclusion

Adopting a personalized diagnostic and therapeutic approach, based on a comprehensive assessment and careful monitoring of mechanical and sensorimotor impairments, is essential for optimal recovery from acute lateral ankle sprains and avoiding chronic ankle instability. A commitment to continuing education and adaptation of clinical practices is necessary to improve patient outcomes.

To find out more about the ankle, discover our training “ The traumatic ankle ” with Massamba M’baye & Romain Tourillon

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