Ankle Sprains, Medial
Anne S. Boyd
Jason Wander
BasicsDescription
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Injury to the deltoid ligament complex of the medial ankle occurs primarily from a pronation/external rotation injury of the foot.
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Grade I sprain results from mild stretching of the deltoid ligament with microscopic tears (1). Patients have mild swelling and tenderness. There is no joint instability on exam, and the patient is able to bear weight and ambulate with minimal pain. Owing to their benign nature, these injuries are not seen frequently in the office.
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Grade II sprain is a more severe injury involving an incomplete tear of the deltoid ligament. Patients have moderate pain, swelling, tenderness, and ecchymosis. There is mild to moderate joint instability on exam with some restriction in the range of motion and loss of function. Weight bearing and ambulation are painful.
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Grade III sprain involves a complete tear of the deltoid ligament. Patients have severe pain, swelling, tenderness, and ecchymosis. There is significant mechanical instability on exam and significant loss of function and motion. Patients are unable to bear weight or ambulate.
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Synonym(s): Medial ankle sprain; deltoid ligament sprain
Epidemiology
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Isolated deltoid ligament injuries are rare and constitute <10% of all ankle sprains (2).
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Deltoid ligament sprains are often accompanied by a lateral malleolar fracture and/or syndesmotic injury (2).
Risk Factors
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Previous ankle sprain
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High-risk sports, including football, basketball, and long jumping
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Low arch of the foot
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Dysfunction of the posterior tibialis
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Extreme fatigue of peroneus (fibularis) longus muscle
General Prevention
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Ankle braces and taping both appear to be somewhat effective, but braces appear to be superior to taping (1).
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Proprioceptive training appears to be equally effective in primary and secondary prevention of ankle injuries (3).
Commonly Associated Conditions
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Syndesmosis sprain
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Fracture of the fibula and/or tibia
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Avulsion fracture of the medial malleolus
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Severe lateral ligament injury
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Posterior tibial tendon injury
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Flexor hallucis longus injury
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Posterior tibial and/or saphenous nerve traction injury
DiagnosisHistory
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Athlete reports an eversion, external rotation injury with the foot abducted/pronated.
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Should inquire about previous ankle injury and history of “giving way.” This would suggest that there is an acute injury superimposed on chronic ankle instability.
Physical Exam
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Signs and symptoms include:
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Medial ankle pain
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Swelling on the medial aspect of the ankle
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Ecchymosis around the medial aspect of the ankle
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Sensation of a “pop”
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Inability to walk
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Physical examination includes:
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Evaluation of the ability to bear weight
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Careful palpation to identify tender structures
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Determination of tenderness over the deltoid ligament
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A check for tenderness over the anterior syndesmosis ligament, lateral ankle, and fibula (distal and proximal)
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A check of posterior tibial tendon function with resisted inversion
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A check of extensor hallucis longus tendon function with resisted extension of the great toe
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A check of range of motion of the ankle joint
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A check of flexor hallucis longus tendon function with resisted flexion of the great toe
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A squeeze test and external rotation test to rule out syndesmotic injury
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A valgus talar tilt test to determine the stability of the deltoid ligament; this is done with passive eversion of the ankle.
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Diagnostic Tests & Interpretation
Imaging
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Anteroposterior, lateral, and mortise views of the injured ankle are essential to rule out fracture (60% of patients with a deltoid rupture have an associated avulsion fracture of the medial malleolus, syndesmotic injury, or a fibular fracture).
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>3 mm of medial clear space between the lateral border of the medial malleolus and the medial border of the talus at the level of talar dome is abnormal and suggestive of a medial ankle sprain.
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Consider a valgus talar tilt stress radiograph to assess for significant instability and possible surgical treatment: >10 degrees difference in abduction tilt of the talus compared with opposite ankle is abnormal (perform this test only if there are no associated fractures).
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Consider MRI if the extent of deltoid ligament rupture is unclear (partial vs complete), and surgical treatment is being considered.
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In the setting of acute injury, MRI has no advantage over plain x-ray (1).
Differential Diagnosis
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Syndesmosis tear or sprain
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Posterior tibial tendon tear or subluxation
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Flexor hallucis longus tendon tear or sprain
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Distal tibia fracture
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Osteochondral fracture of the talar dome
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Fracture of the calcaneus
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Fracture of the lateral process of the talus
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Medial ankle sprain with associated proximal fibular fracture (Maisonneuve fracture)
P.27
TreatmentPre-Hospital
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Prevent/reduce inflammation and swelling with rest, ice, compression, and elevation (RICE protocol).
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Prevent further injury or worsening of current injury.
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Rest is achieved by limiting weight bearing by having patients use crutches or other assistive devices until they are able to walk with a normal gait.
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Ice or cold-water immersion is recommended for 15–20 min q2–3h for the 1st 48 hr or until swelling improves, whichever comes 1st.
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Compression to control and decrease swelling should be applied early, usually with an Ace wrap or stirrup brace. Compression should be supportive but not constrictive.
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The injured ankle should be kept elevated above the level of the heart to further alleviate swelling.
Additional Treatment
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Grade I sprain: Functional rehabilitation and possibly a splint or a brace, with the recognition that return to sports generally is more delayed (3–6 wks) than with a lateral sprain (1–3 wks)
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Grade II sprain: Same as grade 1, but in addition, may need a short period of immobilization in posterior splint or walking boot
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Grade III sprain: Treatment is controversial; requires immobilization (6–8 wks) or may need operative repair (see “Referral”).
Referral
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>4 mm of medial clear space on the mortise view
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Significant instability on reverse talar tilt stress radiograph or weight-bearing views
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Grade III injury may need operative repair to prevent long-term complications.
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Medial malleolus fracture
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Displaced lateral malleolus fracture
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Wound penetrating into the joint
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Uncertain diagnosis
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Patients with neurovascular compromise
Additional Therapies
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Functional rehabilitation is of great importance in aiding return to activity and preventing chronic instability. The exercises should begin as soon as the initial pain and swelling have subsided sufficiently to allow the patient to perform simple exercises and should continue until the patient has returned to pain-free activity (1)[A].
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Achilles tendon stretch
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Foot circles
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Alphabet exercises: While leg is stable, patient should use the great toe and foot to “write” the letters of the alphabet in the air.
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Isometric and isotonic plantar flexion, dorsiflexion, inversion, eversion, and toe curls
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Marble pickups (using toes)
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Heel walks
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Toe walks
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Circular wobble board
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Walking on different surfaces
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Walk-jog, jog-run
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During functional rehabilitation, it may be of benefit to use splints, braces, and taping to try to reduce instability, protect the ankle from further injury, and limit swelling.
Complementary and Alternative Medicine
Neither US therapy, low-level laser therapy, nor hyperbaric therapy appears to be effective in the treatment of medial ankle sprains (1)[B].
Ongoing CarePrognosis
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Pain decreases rapidly during the 1st 2 wks following injury.
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∼5–33% of patients report some pain after 1 yr.
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Healing rates vary widely among studies, with 36–85% of patients reporting full recovery over the 1st 3 yrs.
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Lack of proper rehabilitation contributes to recurrent and/or chronic ankle symptoms, complaints, and problems.
Complications
Deltoid ligament injury generally is a more serious injury than lateral ankle sprain and frequently is associated with concomitant injury to the lateral ligaments or fibula.
References
1. Maughan DL. Ankle sprain. In: UpToDate, Eiff P (Ed), UpToDate, Waltham, MA, 2009.
2. Clanton TO, Porter DA. Primary care of foot and ankle injuries in the athlete. Clin Sports Med. 1997;16:435–466.
3. McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med. 2006;34:1103.
Additional Reading
Birrer RB, Fani-Salek MH, Totten VY, et al. Managing ankle injuries in the emergency department. J Emerg Med. 1999;17:651–660.
Mei-Dan O, Kahn G, Zeev A, et al. The medial longitudinal arch as a possible risk factor for ankle sprains: a prospective study in 83 female infantry recruits. Foot Ankle Int. 2005;26:180–183.
CodesICD9
845.01 Deltoid (ligament), ankle sprain
Clinical Pearls
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An athlete may return to full activity once he or she is able to do a progressive rehabilitation program without pain and instability. Return to sports may be prolonged over several months depending on the degree of injury.
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To prevent future injuries, athlete should wear an ankle brace for sporting activities and complete rehabilitation.
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Untreated, severe sprain may result in chronic pain, instability, and the possibility of ankle arthritis.
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Effect of external ankle support on performance:
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Dependent on the specific brace or method (such as taping) used
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Decrease in performance ≤5%
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