Ankle sprains in the paediatric athlete

Question 1

How common are sports and other MSK complaints in the ED?

Answer 1

1. 8% of pediatric ED visits are for sports injuries

2. 41% of pediatric ED visits are for MSK complaints

Question 2

What are the most common MSK injuries?

Answer 2

1. Sprains 34%
2. Contusions 30%
3. Fractures 25%

Ankle injuries are the most common (20%)

Question 3

What ligaments stabilize the ankle laterally?

Answer 3

1. Anterior talofibular ligament (ATFL)
2. Calcaneofibular ligament (CFL)
3. Posterior talofibular ligament (PTFL)

Question 4

What ligament stabilizes the ankle medially?

Answer 4

Deltoid ligament emanating from the distal tibia

Question 5

What muscles provide dynamic stability?

Answer 5

1. Peroneus brevis laterally (everts the foot)

2. Tibialis posterior medially (inverts the foot)

Question 6

What is the most likely mechanism of injury?

Answer 6

Inversion of a plantar flexed foot

Question 7

What is the most commonly injured ankle ligament?

Answer 7

ATFL

Question 8

What are the Ottawa ankle rules?

Answer 8

An ankle X-ray series is only necessary if there is pain in the malleolar zone and any of the following:

1. bone tenderness at the posterior edge or tip of the lateral malleolus OR
2. bone tenderness at the posterior edge or top of the medial malleolus OR
3. inability to weight bear both immediately and in the ED

Question 9

What are the Ottawa foot rules?

Answer 9

A foot X-ray is only necessary if there is pain in the midfoot zone and any of the following:

1. bone tenderness at the base of 5th metatarsal OR
2. bone tenderness at the navicular bone OR
3. inability to bear weight both immediately and at the ED

Question 10

What are initial management goals?

Answer 10

1. Functional brace for 3-6m to protect the ankle from further injury
2. Relative rest with early mobilization
3. Ice pack for 15 min at a time 1-3 times per day x 36h
4. Compression and elevation - little evidence
5. NSAID

Question 11

What should be included in a supervised ankle rehabilitation program?

Answer 11

1. returning to normal ROM
2. strengthening the peroneal musculotendinous unit with resisted dorsiflexion, plantar flexion, eversion and inversion of the ankle using a rehab elastic band
3. optimizing flexibility of the calf muscles and Achilles tendon to faciltate a neutral and more stable position of the ankle by stretching the gastrocnemius, soleus, and Achilles tendon
4. proprioceptive rehabilitation with wobble boards and trampolines
5. bracing to provide extra support

Question 12

When should return to play occur?

Answer 12

In a stepwise fashion once ROM, strength, and proprioception have returned to normal and pain has resolved. Usually between 1-6 weeks. A brace should be worn for protection from further injury during the 1st 3-6m post injury.