Pathophysiology

Two types of injuries cause an ankle sprain. The most common is the inversion injury, in which the foot plantar flexes and internally rotates as the ankle inverts. The “roll” of the ankle injures the lateral ligaments and can also cause a lateral avulsion fracture. The less common eversion injury occurs when the ankle sustains an external rotation mechanism. Eversion stress injures the medial structures of the ankle, damaging the deltoid ligament or the syndesmosis.

Clinical Presentation

The most common presentation of an ankle sprain is a swollen and painful joint. Ecchymosis and decreased range of motion are generally present. In many instances, weight bearing causes pain; some patients are unable to bear any weight on the affected joint.

In obtaining the history, it is important to determine whether the patient heard any audible sounds at the time of injury. An audible “snap” or “pop” indicates the potential for a more serious injury. Immediate swelling or ecchymosis raises the index of suspicion for a fracture or substantial amount of joint involvement. Patients also commonly report a sensation of lightheadedness, nausea, or diaphoresis immediately after the injury.

Physical Examination

With a sprain, the ankle joint is often swollen and ecchymotic, and the edema can create an illusion of deformity. Limited active and passive motion and point tenderness at the site of injury are common. Joint laxity is present in more severe sprains. Muscle spasm often prevents accurate testing of strength and stability. If the injury is not acute, swelling and ecchymosis at the lateral aspect of the foot and the toes are common. With severe ankle sprains, tenderness may extend up the extremity. The entire lower limb should always be palpated.

Diagnostics

Although guidelines for radiography are controversial, plain radiographs are recommended for severe injuries, especially when instability is present or fracture is suspected. An x-ray study of the lower leg should also be performed if there is tenderness at the fibular head to rule out fracture. With less severe injuries, radiographs can be used to exclude an avulsion injury. More extensive radiologic examinations, such as stress films or computed tomography (CT) or magnetic resonance imaging (MRI) scans, are considered in consultation with an orthopedic surgeon, especially preoperatively.

Differential Diagnosis

Ankle injuries range from simple strains to severe injuries. The possibility of associated fibula fracture, stress fracture, avulsion fracture, or dislocation should be considered. Bursitis and tendinitis should be included in the differential diagnosis, especially if no distinct injury is recalled. Osteoarthritis, rheumatoid arthritis, and gouty arthritis are also common causes of ankle pain and swelling, especially in the older adult.

Management

The severity of the sprain dictates the management (see Table 171-1). Rest and protection, ice, compression, and elevation (RICE) are key first steps in providing pain relief and limiting swelling. Nonsteroidal anti-inflammatory drugs (NSAIDs) can help with pain management and may allow faster rehabilitation, although they can be associated with gastrointestinal (GI) side effects and in older adults should be used cautiously because of cardiovascular and renal concerns.² Topical NSAID gels are very effective at reducing pain and swelling and improving function in grade 1 and 2 sprains.³ Thromboembolic deterrent (TED) hose provide support to the entire lower limb, aid in circulation, and are less bulky than ankle splints or braces for grade l and 2 sprains. Casting for 10 to 14 days has been shown to be effective in grade 3 sprains.² Semirigid supports used after the acute injury has resolved may protect from subsequent sprains. All sprains require rehabilitation to restore the ankle to a stable and pain-free state. It is important for patients to understand that the treatment and recovery process will take weeks. Rehabilitation should begin as soon as possible after the injury and should include range-of-motion and strengthening exercises.^4,5 Even a severely swollen ankle can be mobilized with the simple exercise of “writing the alphabet” (active range of motion) with the affected foot. A program of active and passive resistive exercises progresses as range of motion and strength improve.

Ankle sprains can recur within the first month if the ankle has not been fully rehabilitated. Grade 2 and 3 sprains carry with them an increased risk of joint instability and traumatic arthritis. Recurrent sprains, which result in chronic instability, may require surgical repair.⁵ A weak ankle joint is at risk for fracture when it is stressed.

Indications for Referral or Hospitalization

Fractures, dislocations, or subluxations and grade 3 sprains require an orthopedic referral. Physical therapy may also be indicated to promote rehabilitation and a safe return to sports or work-related activities.

Patient and Family Education

Patients need to understand the importance of RICE as well as the necessity of preventing weight bearing on the injured ankle. Patients and family members should also be instructed in medication doses and side effects, proper elastic bandage wrapping technique, cast care, and crutch use. The recuperative process and the risk of recurrence also require explanation.

Pathophysiology

Achilles tendinopathy can occur in both adolescents and adults in both traumatic and nontraumatic settings. Aging, improper training, running up hills, or wearing shoes with soles that are too rigid can also contribute to the development of Achilles tendinopathy. Shoes or boots with a high back can irritate the tendon, causing pain and inflammation. Wearing of shoes with heels that maintain plantar flexion (high heels) for long periods can cause the tendon to shorten. Changing to flat or running shoes then increases stress on the tendon, causing pain. On occasion, Achilles tendinitis is caused by an anatomic abnormality, such as excessive foot pronation or tight hamstrings or gastrocnemius muscles.^6,7

Clinical Presentation

Patients with Achilles tendinopathy may have intermittent symptoms and may describe a pain that subsides during exercise but increases in severity while at rest. Pain can be located in the heel (insertional tendinopathy) or along the length of the tendon (tendinosis). Morning stiffness or severe pain on climbing stairs is also common. Most patients have an abnormal gait. Some limp, and some walk on their toes to avoid the heel-strike phase of walking.

Physical Examination

Localized swelling may be present around the tendon. There may be a bony prominence at the heel known as a Haglund deformity. Pain is often worse in the morning or after a period of inactivity and aggravated by shoe pressure. A palpable nodule, inflammatory signs, and crepitus may be present in severe or chronic cases.⁷

Diagnostics

Radiologic or laboratory tests are usually unnecessary, but the appropriate diagnostic tests should be guided by the history. Ultrasound is inexpensive and noninvasive and can be used to rule out rupture of the tendon. MRI is the gold standard but may not be needed in mild or straightforward cases. MRI is usually done if surgical intervention is a consideration.

Differential Diagnosis

Achilles tendinopathy causes primarily heel pain. Heel pain has varied causes. Retrocalcaneal bursitis, infection, fracture, plantar fasciitis, and partial tendon rupture should be considered in the differential diagnosis of Achilles tendinopathy. Posterior calf pain can also be caused by muscle strain, bruising, or thromboembolic disease.⁸

Management

Treatment of the acute phase of Achilles tendinopathy begins with the cessation of all sports activities and exercise. Tendon rest is imperative to avoid further injury. Severe inflammation may respond best to immobilization in a boot or cast. Crutches and partial weight bearing may be indicated. NSAIDs, either oral or topical, and an ice massage for 20 minutes three or four times a day help decrease inflammation and pain.⁹ A simple shoe insert that raises the heel approximately 2 cm ( inch) also helps ease strain on the tendon. In more severe or chronic cases, ultrasound is an adjunct therapy used by physical therapists. Regular follow-up visits to assess progress and to discourage the patient from returning to activity prematurely are necessary. Resolution of acute tendinopathy can take 8 weeks or longer.⁷ A program of stretching and strengthening begins when pain and swelling have subsided. Many patients can recover fully with exercise alone.¹⁰ To prevent recurrence or rupture, it is essential that patients do stretching exercises before engaging in any exercise.

Severe cases unresponsive to conservative treatment may benefit from surgical debridement. In rare cases, tendon transplant to augment the strength of the damaged tendon may be necessary.¹¹