Many years ago whilst working in the UK at Bath Rugby, a player of ours had been competing in a representative match in London.
During the game he twisted his foot/ankle and as a result was unable to continue playing.
Part of my brief at the time was to ring the rep players post match to discuss any injuries they may have incurred.
When I spoke with player X, he related to me that the medical staff thought he'd suffered a pretty bad ankle sprain and so they compressed and iced it immediately, gave him crutches and suggested he see me upon his return to Bath.
On the phone I asked him some very specific questions about his pain and swelling.
The feature that concerned me the most was how he described the amount of severe swelling and pain in his midfoot and forefoot.
He indicated that his ankle was not even that sore.
My initial fear was that he had suffered a LisFrancs injury.
I told him to keep icing, keep his foot elevated, take painkillers and under no circumstances bear weight on it until he heard from me again.
The next day he saw a Sports Physician and after his x-ray the doctor reported to me 'The split between his first and second metatarsal is big enough to drive a bus through!' He had indeed suffered a very severe LisFrancs injury, to the extent that after 18 months, two bouts of surgery and exhaustive rehabilitation, he failed to ever play again.
The ankle itself was fine.
So when a patient describes to us that they have suffered a typical inversion type of ankle injury, we need to exclude a number of other 'sinister' injuries that may coincide with a simple ATFL (lateral ligament) sprain.
These include; 1.
Syndesmosis injury (or high ankle sprain).
Characteristic feature being fibula pain that extends upwards from the anteriorinferior tibiofibular joint.
2.
Bifurcate ligament sprain.
Pain is centred around the midfoot near the cuboid bone.
3.
LisFrancs injury.
Pain centred around the 1st and 2nd metatarsals.
4.
Sinus tarsi injury.
Pain centred in the anterior part of the ankle, deep in the antero-lateral gutter.
5.
Subtalar joint injury.
These will often present weeks and months down the track as posterior ankle pain that increases with plantarflexion movements.
6.
Talar dome injury.
Pain internal within the ankle that causes repeat effusions of the ankle.
Physiotherapists in the suburbs do not have the same luxury as physiotherapists working in elite sport when it comes to diagnostic imaging.
Often our 'non elite' patients cannot afford MRI's and other expensive investigations.
So we are simply left up to our best clinical judgement.
However, simple ATFL ankle sprains (even severe Grade 3) should and will recover and be fully functional within six weeks if managed well.
However, if after six weeks a patient still has persistent ankle pain (particularly in the areas mentioned above) or has repeat ankle joint effusions other than the expected capsule synovitis, or pain that worsens with repeat impact, then you need to insist that they seek a specialist opinion for other 'sinister' pathologies.
The sequel of dysfunction that is a result of undiagnosed ankle injuries are numerous.
These include, but are not limited to; 1.
Persistent ankle stiffness, particularly dorsiflexion as measured in a knee to wall test.
2.
Poor proprioception due to the direct damage to the proprioceptive ligament of the ATFL but also due to the 'neural fog' that accompanies long term pain.
3.
Persistent ankle effusion, which we often see in the lateral and medial gutter of the ankle.
4.
Severe weakness in the extrinsic ankle muscles such as peroneals, tib post and flexor halluces longus, and also the proximal muscles such as the gluteals and abdominals.
5.
Acquired secondary compensations such as overpronation, reduced knee extension with walking and excessive hip and pelvic rotation.
During the game he twisted his foot/ankle and as a result was unable to continue playing.
Part of my brief at the time was to ring the rep players post match to discuss any injuries they may have incurred.
When I spoke with player X, he related to me that the medical staff thought he'd suffered a pretty bad ankle sprain and so they compressed and iced it immediately, gave him crutches and suggested he see me upon his return to Bath.
On the phone I asked him some very specific questions about his pain and swelling.
The feature that concerned me the most was how he described the amount of severe swelling and pain in his midfoot and forefoot.
He indicated that his ankle was not even that sore.
My initial fear was that he had suffered a LisFrancs injury.
I told him to keep icing, keep his foot elevated, take painkillers and under no circumstances bear weight on it until he heard from me again.
The next day he saw a Sports Physician and after his x-ray the doctor reported to me 'The split between his first and second metatarsal is big enough to drive a bus through!' He had indeed suffered a very severe LisFrancs injury, to the extent that after 18 months, two bouts of surgery and exhaustive rehabilitation, he failed to ever play again.
The ankle itself was fine.
So when a patient describes to us that they have suffered a typical inversion type of ankle injury, we need to exclude a number of other 'sinister' injuries that may coincide with a simple ATFL (lateral ligament) sprain.
These include; 1.
Syndesmosis injury (or high ankle sprain).
Characteristic feature being fibula pain that extends upwards from the anteriorinferior tibiofibular joint.
2.
Bifurcate ligament sprain.
Pain is centred around the midfoot near the cuboid bone.
3.
LisFrancs injury.
Pain centred around the 1st and 2nd metatarsals.
4.
Sinus tarsi injury.
Pain centred in the anterior part of the ankle, deep in the antero-lateral gutter.
5.
Subtalar joint injury.
These will often present weeks and months down the track as posterior ankle pain that increases with plantarflexion movements.
6.
Talar dome injury.
Pain internal within the ankle that causes repeat effusions of the ankle.
Physiotherapists in the suburbs do not have the same luxury as physiotherapists working in elite sport when it comes to diagnostic imaging.
Often our 'non elite' patients cannot afford MRI's and other expensive investigations.
So we are simply left up to our best clinical judgement.
However, simple ATFL ankle sprains (even severe Grade 3) should and will recover and be fully functional within six weeks if managed well.
However, if after six weeks a patient still has persistent ankle pain (particularly in the areas mentioned above) or has repeat ankle joint effusions other than the expected capsule synovitis, or pain that worsens with repeat impact, then you need to insist that they seek a specialist opinion for other 'sinister' pathologies.
The sequel of dysfunction that is a result of undiagnosed ankle injuries are numerous.
These include, but are not limited to; 1.
Persistent ankle stiffness, particularly dorsiflexion as measured in a knee to wall test.
2.
Poor proprioception due to the direct damage to the proprioceptive ligament of the ATFL but also due to the 'neural fog' that accompanies long term pain.
3.
Persistent ankle effusion, which we often see in the lateral and medial gutter of the ankle.
4.
Severe weakness in the extrinsic ankle muscles such as peroneals, tib post and flexor halluces longus, and also the proximal muscles such as the gluteals and abdominals.
5.
Acquired secondary compensations such as overpronation, reduced knee extension with walking and excessive hip and pelvic rotation.
Source...