Streamlining Ankle Assessments
Faraz Sethi – MSK Physiotherapist
‘It’s only a twisted ankle; ice it, strap it, a few ibuprofen pills and you can play this weekend mate’
If any clinician denies using the catchphrase above at some point in their career, then you might as well stop reading now!
Our impact
Following on from my last blog, I wanted to discuss the assessment of an acute ankle sprain and question; if we as clinicians are doing all that we can for our patients. According to the ROAST consensus statement by Delahunt et al (2019), 40% of individuals develop chronic ankle instability within the first year after their first ankle sprain.
Even though I think it’s a well-rounded paper, unfortunately the limitation is that all nine assessment criteria are focused on the pathophysiological response to an ankle sprain. I believe the icing on the cake would have been a 10th assessment criteria involving patients self-reported emotional status. Personal factors, such as self-efficacy, resiliency and anxiety may influence how an individual perceives their injury/recovery
It’s happened all too often!
As we know (or don’t know), the development of chronic ankle instability is a consequence of the interaction of mechanical and sensorimotor impairments that manifest following acute lateral ankle sprain injury. Brain, chain, ankle sprain!
Historically, we have relied on the mechanism of injury giving us our potential outcome predictions; Was it contact or non-contact? Was it an inversion or eversion injury? Was it a high or low ankle sprain? BLA BLA BLA...
Nevertheless, as with all injuries, we understand that there is a cascade of events that could influence a patients return to function whether that be gardening or playing squash. Ankle instability is underdiagnosed but still a very prevalent pathology that we need to understand unequivocally.
Assessment
Clinical history, check. Ottawa ankle rules, check. Potential red flags, check. Diagnostics, check. What next?
I am not for one second undermining the importance of age, previous history of ankle sprain or any other risk factors for that matter but I believe we desperately need a more streamlined approach. Once we have ruled out anything sinister, we need to listen to our patients as they are telling us the answers we need to help them. Besides, there is not much we an do as clinicians in the first few days apart from act as that pillar of support, reassurance and validate a patient’s pain experience.
The conundrum
I guess a more simplified way to assess an ankle sprain moving forward after the initial stages would be to ask ourselves the following questions;
- Is it an unstable ankle?
- Is it a weak ankle?
- Is it a stiff ankle?
The Unstable Ankle
‘Fuck sake Doc, I’ve rolled my ankle again!’
How do we differentiate between mechanical and functional instability? (Fig 1) With mechanical instability, we should be aware of pathologic joint laxity for example excessive talar tilt discrepancy or a prominent anterior draw. However, with functional instability, we know that sensorimotor and neuromuscular deficits accompany ligamentous injuries but mechanical instability is not necessarily present. Confused? Let me try and simplify it.
Both mechanical and functional instability are still impacted by the central nervous system as the neural pathways have been compromised. External influences like stress, bereavement or financial problems can heighten these neural pathway disturbances. A history of insecurity, feeling of instability and giving way is far more common in the diagnosis than demonstrable instability on physical examination or stress radiographs.
Fig 1 – Mechanical vs Functional Instability
The Weak Ankle
‘The ankle doesn’t feel right, it doesn’t… I feel it’s not attached to my leg’
Those recurrent ankle sprains that have been neglected in the past is what generally causes a weak ankle. That pseudo instability where we think our ankle will give way, roll or twist doesn’t allow our minds to fully engage in a particular movement pattern or take part in a particular sport.
Avoiding sensitive tissues can make a patient more sensitive, however exposing that weak ankle to different loads and stimulus will desensitize the weak ankle with all those mechanoreceptors or afferent neurons causing heightened activity at the brain matrix level. Again, it always goes back to the brain!
The Stiff Ankle
‘Getting going is really hard in the morning, feels like my ankle is like a bag of cement’
Ankle stiffness is probably the most difficult scenario we face during assessments especially in the chronic ankle. We are unsure if its guarding, true stiffness or some form of arthritic change. Most of these ankles would have tried copious amounts of rehab and other useful/useless adjuncts. If these fail then we may have to consider an arthritic ankle.
Global end stage arthritis can be effectively managed non surgically like the knee and hip by modifying activities and through patient education. The key to a successful outcome is to engage the patient in the decision making process. The brain being a powerful tool in this scenario also!
Algorithms and Guidelines
Deep breaths…
Research by Halabchi and Hassabi (2020), Wahnert et al (2013) and Polzer et al, (2012) looked at the clinical aspects and algorithmic approach to ankle sprains. I absolutely loathe algorithms that categorize patients in to a flowchart. I mean come on, patients deserve more. I agree, to rule out anything sinister, they can be useful but anything more than that they become a nuisance.
One model of ankle instability I do appreciate however, which considers the brain, chain ankle sprain connection is Hertel and Corbett’s (2019) model of chronic ankle instability. They look at both the environmental and personal factors of an individual that could impact the patho-mechanical, motor and sensory behaviors of the ankle joint and not vice-versa (Fig 2).
Fig 2 - Model of Chronic Ankle Instability
The ideal world
Currently, psychological influences are not well understood, nor is the application or implementation of treatment interventions to address psychological impairments. The American Psychological Association defined psychological deficit as, ‘the cognitive, behavior or emotional performance of any individual at a level that is significantly below, or less than adept than, the norm’ (Bain et al, 2021). Simply put, if the brain is not ready due to the peripheral factors that may be influencing the recovery, the individual will almost undoubtedly not be ready to return to the activity of their choice.
Take Home Message
- Algorithms are NOT the answer
- Consider the unstable, weak or stiff ankle?
- Ankles are still connected to people
- Be thorough with the clinical history…the patient is telling you the answer!
Thanks for reading,
Faraz
References
Delahunt E, Bleakley CM, Bossard DS, et al; Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium British Journal of Sports Medicine 2018;52:1304-1310.
Halabchi and Hassabi (2020) Acute Ankle Sprains in Athletes. Clinical aspects and algorithmic approach. World J Orthop 2020 Dec 18;11(12):534-558.
Dirk Wähnert, Niklas Grüneweller, Julia Evers, Anna C Sellmeier, Michael J Raschke and Sabine Ochman - An unusual cause of ankle pain: fracture of a talocalcaneal coalition as a differential diagnosis in an acute ankle sprain: a case report and literature review. BMC Musculoskelet Disord. 2013; 14: 111.
Hans Polzer, Karl Georg Kanz, Wolf Christian Prall, Florian Haasters, Ben Ockert, Wolf Mutschler, Stefan Grote. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm Orthop Rev (Pavia) 2012 Jan 2;4(1):e5. doi: 10.4081/or.2012.e5. Epub 2011 Dec 14.
Jay Hertel, Revay O Corbett - An Updated Model of Chronic Ankle Instability. J Athl Train. 2019 Jun;54(6):572-588. doi: 10.4085/1062-6050-344-18. Epub 2019 Jun 4.
