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High Ankle Sprains

What is a high ankle sprain?

A high ankle sprain is an injury to the distal tibiofibular syndesmosis. The syndesmosis includes structures such as the anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament (PITFL), interosseous ligament (IOL), inferior transverse ligament, and interosseous membrane (IOM). These are highlighted in the figure below.

Figure 1: the distal tibiofibular syndesmosis

These injuries are typically associated with high-speed collisions or injuries where the foot is forcefully externally rotated while in a dorsiflexed positon. Other ankle ligaments may be injured concurrently, and it can occur with or without associated fractures.

Why is it important to recognize this injury?

High ankle sprains should be differentiated from the more common collateral ligament ankle sprains, because management and prognosis are different. In the absence of associated fractures, these injuries may be easily missed on imaging and exam, and can be associated with prolonged recovery and chronic pain.

How do you diagnose a high ankle sprain?

History: suspect high ankle sprain if the mechanism is one of forced external rotation of a dorsiflexed foot, or a collision. Pain is usually diffuse, and worse with walking up hills, pivoting, or doing single leg heel raise.

Physical exam:

  • Start with a general ankle exam to rule out other concurrent injuries. This may include an examination of the collateral ligaments, as well as determining the need for imaging with the Ottawa Ankle Rule (http://www.theottawarules.ca/ankle_rules)
  • The following maneuvers are specific to syndesmotic injuries:
    • Crossed leg test (https://youtu.be/Qb-euOa57TE): in sitting position, ask patient to cross their affected leg over the other leg with the distal third of fibular resting on the opposite knee. Apply down-ward pressure over the medial knee of the painful leg. Positive test is reproduction of pain in the ankle.
    • Fibular translation test (https://youtu.be/W3SHqKqkK14): stabilize tibia with one hand, then grasp fibular with other and attempt to translate it anterior or posterior. A painful soft end point with greater than 2 to 3 mm of translation, or increased translation compared to contralateral side is a positive examination.
    • Tibiofibular squeeze test (https://youtu.be/ANgWSz0UoDg): Squeeze the fibular and tibia together using the palms. Pain at syndesmosis is a positive exam.
    • Dorsiflexion external rotation stress test (https://youtu.be/s53uzyUv0bc): Dorsiflex the foot while applying an external rotation force. Pain is a positive test.
    • Stabilization tape test: patient is asked to do dynamic movements including walking, heel and toe walking, single legged heel raise, and standing pivot. Then the ankle is tightly taped in a circumferential fashion just above the ankle joint, and patient is asked to repeat the movements. Positive test is reduction of pain with taping.
    • Direct palpation – tenderness along the anterolateral joint line and proximal compared to typical sprain. Tenderness on palpation may extend proximally along the fibula.

Imaging: Standard lower extremity weight-bearing x-rays (AP and mortise views) may show increased tibiofibular clear space (normal < 6mm), decreased tibiofibular overlap (normal > 6mm on AP view, > 1 mm on mortise view), and increased medial clear space (normal < 4mm). See Figure 2 for reference. Optional stress views (external rotation stress or gravity stress views) may help assess for ankle stability.

Figure 2: Radiographic features of a normal ankle. Image from Orthobullet and altered to include labels (https://www.orthobullets.com/foot-and-ankle/7029/high-ankle-sprain-and-syndesmosis-injury)

CT/MRI are more sensitive and specific but are often not required to make the diagnosis – they should be considered for operative planning or if high suspicion and plain radiographs are normal.

Management:

Without gross instability, high ankle sprains should be treated non-operatively. In contrast to the more common lateral ankle sprains, syndesmotic injuries should be immobilized initially, and patient made non-weight bearing. The immobilization and non-weightbearing phase may be up to 2-3 weeks (or shorter if milder injuries), followed by protected weightbearing in a CAM boot and physiotherapy rehabilitation. High ankle sprains may take over a month to heal.

Surgical indications include unstable ankle on stress views, presence of associated fractures, and failure of conservative therapy.

Summary:

High ankle fractures are syndesmotic injuries that can occur with or without a concurrent fracture and should be suspected when the mechanism is forced external rotation of a dorsiflexed foot or collision. It should be differentiated from a collateral ankle ligament sprain because management and prognosis are different. These injuries should be initially treated with a period of immobility and non-weightbearing, and slowly progress to functional rehabilitation.

Yuhao Shi, MD

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

References1,2:

1.           Wake, J. & Martin, K. D. Syndesmosis Injury From Diagnosis to Repair: Physical Examination, Diagnosis, and Arthroscopic-assisted Reduction. J. Am. Acad. Orthop. Surg. 28, 517–527 (2020).

2.           High Ankle Sprain & Syndesmosis Injury – Foot & Ankle – Orthobullets. https://www.orthobullets.com/foot-and-ankle/7029/high-ankle-sprain-and-syndesmosis-injury.

Patellofemoral Pain – A common cause of anterior knee pain

Patellofemoral (PF) pain is a common cause of anterior knee pain in young adults and adolescents. This is described as knee cap pain that is worsened by activities that load onto a flexed knee. These include squatting, stairs, hiking, and running.1,2

The patella acts as a lever which helps extend the knee.1 The patella moves within the trochlear groove of the femur during leg extension and flexion. PF pain is thought to be due to incorrect tracking of the patella.3 More specifically, in PF pain, the patella tracks laterally.

Risk Factors for developing PF pain1

  • Activities including running, squatting, stairs (rapid increase in activities/training)
  • Dynamic valgus (caving in of knees)
  • Female sex (increased Q angle)
  • Foot abnormality (eversion and pes pronatus)
  • Sudden increase in activity level
  • Patellar instability
  • Quadriceps weakness

Diagnosis of this condition is made on a combination of history and physical examination findings. On history, the cardinal feature is that pain around and behind the knee cap is worse during weight-bearing knee flexion activities. Patients may also complain of worsening of their pain after a prolonged period of sitting with the knee flexed (on a plane, in a movie theatre).2

On physical exam, pain with squatting is most sensitive for PF diagnosis.2 Other tests, such as the patellar grind test, apprehension test, and tilt tests, have low diagnostic yields. These do not present with joint swelling, and range of motion is preserved.2

Imaging is not required for the diagnosis of PF pain.1 Radiographs should be obtained in cases where the diagnosis is not clear, or when the patient does not respond to first-line treatment options.2

The treatment of PF pain includes rest, activity modification, and physical therapy. The key is to work on and correct the underlying causes of the pain. This may include avoiding repetitive activities, assessing footwear, and most importantly addressing hip and knee muscular imbalances that cause the knee cap to track incorrectly. Patients should begin with a structured physiotherapy program to help correct imbalances.2 In some cases, foot orthotics can be considered to help with leg alignment and reduce pain in the short term.4 Bracing and taping techniques, while not fully supported by evidence, can help patients during periods of activity by stabilizing the patella.3

Sonam Maghera, MD, BMSc

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn-Lise Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

1.    Gaitonde DY, Ericksen A, Robbins RC. Patellofemoral Pain Syndrome. Am Fam Physician. 2019;99(2):88-94.

2.    Crossley KM, Callaghan MJ, Linschoten R van. Patellofemoral pain. Br J Sports Med. 2016;50(4):247-250.

3.    Jin J, Jones E. Patellofemoral Pain. JAMA. 2018;319(4):418-418.4.         Collins NJ, Barton CJ, Middelkoop M van, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018;52(18):1170-1178.

Multidirectional Instability (MDI) of the Shoulder

What is MDI?

Multidirectional Instability is a condition of the shoulder characterized by recurrent symptomatic subluxation or dislocation of the glenohumeral joint in more than 1 direction. It is more common between the age of 12 and 35, with a slight female predominance. Typically, MDI occurs in the absence of macrotrauma, and is thought to be caused by a combination of ligamentous laxity, presence of redundant joint capsular tissue, and repetitive use.

It is more common in patients with generalized joint laxity, with or without congenital disorders such as Ehlers-Danlos or Marfan syndrome. It may also be associated with repetitive overhead activities such as in swimmers, gymnasts, volleyball players, and weightlifters.

Occasionally MDI can be caused by a major traumatic event, such as in the case of a labral tear. However, in these traumatic cases, the prognosis and treatment considerations are different – the patient usually does well by surgically addressing the structural lesion (e.g. labral tear).

The rest of this article will focus mostly on atraumatic MDI.

Figure source: https://orthoinfo.aaos.org/en/diseases–conditions/chronic-shoulder-instability/

How does MDI present? And how do you diagnose it?

MDI presents on a spectrum ranging from vague shoulder pain without perceived instability to daily occurrences of symptomatic subluxations and frank dislocations with activities. The focus of the history and exam is to identify instability of the shoulder in more than 1 plane.

On history the patient may report some of the following:

  • Sensation of subluxation or dislocation in anterior, inferior, or posterior direction
  • Anterior instability: pain or subjective instability associated with overhead activities where shoulder is abducted and externally rotated. Avoidance of overhead activities.
  • Posterior instability: pain or subjective instability with forward flexion and internal rotation (e.g. pushing open a door)
  • Inferior instability: pain or instability with carrying heavy items.

The physical exam involves the following components:

  • General shoulder exam looking at all pertinent elements such as AC joint, rotator cuffs, scapular motion, joint mobility, biceps function, etc.
  • Assess for generalized ligamentous laxity with the Beighton score (higher score = more ligamentous laxity)
    • Ability to hyperflex elbow or knee > 10 degrees (1 point per joint)
    • Thumb opposition to the ipsilateral forearm (1 point per side)
    • >90 degrees of small finger dorsiflexion (1 point per side)
    • Ability to place palms flat on the ground while bending at the trunk (1 point)
  • Special maneuvers for joint instability
    • Load and shift test (https://www.youtube.com/watch?v=txARar71h5E): stabilize the scapula with one hand. With the other hand, grab the humoral head and attempt to move it anteriorly or posteriorly. Greater translation of the humoral head indicates greater anterior/posterior laxity of the joint.
    • Sulcus sign (https://www.youtube.com/watch?v=vV7u2JtdYWI): with the patient relaxed and in sitting position, pull the arm inferiorly. A feeling of subluxation or appearance of a sulcus or concavity under the acromion is a positive sign for inferior instability
    • Anterior apprehension test (https://www.youtube.com/watch?v=hy7zgoEsbzQ): in supine position, abduct the arm to 90 degrees and add maximal external rotation. Positive test for anterior instability is pain or the fear of subluxation reported by the patient.
      • Relocation test(https://www.youtube.com/watch?v=JkO8nnWFIwM): repeat the apprehension test, but apply pressure at the anterior shoulder (force directed posteriorly). A positive test is reduction of patient’s pain or fear of subluxation.
    • Jerk test (https://www.youtube.com/watch?v=j_qG1MNOws8): in sitting position, place arm into flexion and internal rotation. While applying an axial force to the humerus, bring the arm into horizontal adduction. A positive test for posterior instability is the feeling of posterior subluxation or “clunk” as the humeral head glides over the glenoid rim.

Plain x-rays of the shoulder can be ordered to assess for position of humeral head, and for major glenoid or humeral osseous defects, but are often normal in MDI. MRI of the shoulder allows for assessment of capsuloligamentous structures and evaluation of redundancy of joint capsule. It also helps to rule out other structural lesions such as labral tears that could alter the course of management.

How do you treat MDI?

Most cases of MDI are treated initially with a comprehensive physiotherapy program. The rehabilitation program involves strengthening of rotator cuff and scapular stabilizing exercises to improve stability of the shoulder. An example of a rehabilitation program for MDI is the 6-stage program devised by Watson et al. Most patients respond well to non-surgical therapy.

At least 6 months of therapy should be attempted before considering surgical treatment. Surgical stabilization procedures should be customized for each patient, based on anatomic deficit and direction of symptomatic instability.

In summary, MDI is a condition of shoulder instability in more than one direction, leading to pain and recurrent subluxations. The majority of these patients should be managed with at least 6 months of shoulder rehabilitation program. Refractory cases may be addressed by surgical therapy to stabilize the joint. 

Yuhao Shi, MD

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

References1–4:

1.           Warby, S. A., Watson, L., Ford, J. J., Hahne, A. J. & Pizzari, T. Multidirectional instability of the glenohumeral joint: Etiology, classification, assessment, and management. J. Hand Ther. 30, 175–181 (2017).

2.           Longo, U. G. et al. Multidirectional instability of the shoulder: A systematic review. Arthroscopy – Journal of Arthroscopic and Related Surgery vol. 31 2431–2443 (2015).

3.           Best, M. J. & Tanaka, M. J. Multidirectional Instability of the Shoulder: Treatment Options and Considerations. Sports Medicine and Arthroscopy Review vol. 26 113–119 (2018).

4.           Watson, L., Warby, S., Balster, S., Lenssen, R. & Pizzari, T. The treatment of multidirectional instability of the shoulder with a rehabilitation program: Part 1. Shoulder and Elbow vol. 8 271–278 (2016).