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Key Features

Essentials of Diagnosis

  • Mechanism is usually inversion and plantarflexion.

  • Swelling and pain in the ankle over the ligament.

  • Bruising over the ankle.

General Considerations

  • When a ligament is overloaded, tearing occurs. These injuries are graded on a scale of 1–3. Grade 1 injury is a stretch without instability; grade 2 is a partial tear with some instability; and grade 3 is a total disruption of the ligament with instability of the joint. The ankle has three lateral ligaments (anterior talofibular, calcaneofibular, and posterior talofibular) and a medial deltoid ligament. Inversion of the foot generally damages the anterior talofibular ligament, whereas eversion injures the deltoid ligament. Lateral ankle sprains are far more common than medial ankle sprains because the deltoid ligament is stronger mechanically than the lateral ligaments. However, medial ankle sprains may have more severe complications, including syndesmotic tearing and instability of the ankle joint requiring surgical stabilization. High ankle sprains involve injury to the tibiofibular syndesmosis, a movable connection in which the adjacent tibia and fibula bones are bound together by ligamentous structures. The syndesmosis supports the integrity of the ankle mortise joint. The ankle mortise is defined as the bony arc formed by the tibial plafond, the medial and lateral malleoli, and the roof of the talus. The mortise provides the wide range of flexibility and motion of the ankle, but its injury causes instability and pain. Syndesmotic injuries do not typically require surgery but do involve longer healing times than low-grade medial or lateral ankle sprains.

  • High-ankle sprains (a.k.a. syndesmotic injuries) occur most commonly with dorsiflexion and external rotation.

Clinical Findings

Symptoms and Signs

  • Swelling

  • Bruising

  • Pain

Differential Diagnosis

  • Injuries to the fifth metatarsal

    • Can occur with an inversion mechanism

    • Localized swelling and tenderness over the base of the fifth metatarsal is present

    • Fractures at the base of the fifth metatarsal can be divided into avulsion, Jones, and diaphyseal fractures

  • Fractures of the tibial epiphysis, malleoli, fibula, talar dome, or calcaneus


  • Diagnostic testing should be done when a bony injury is suspected

  • Obtaining radiographs is especially important when evaluating skeletally immature athletes who are more prone to growth plate injury

  • The adult Ottawa Ankle Rules

    • Used to determine whether obtaining x-rays are necessary

    • Appear to be reliable in patients older than 5 years

  • Additional indications to obtain radiographs in young athletes

    • Tenderness over the malleoli

    • Tenderness beyond ligament attachments

    • Excessive swelling

  • Medial ankle swelling, tenderness, and bruising warrant ankle three-view radiographs (anteroposterior, lateral, mortise) to evaluate asymmetry and instability of the ankle mortise

  • High-ankle sprains require

    • Radiographs

    • The syndesmotic squeeze test

    • The Kleiger test (external rotation of the foot in dorsiflexion)


  • Fractures and instability of ...

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