Lesson

History

The ankle is one of the most commonly injured joints in football. The injury mechanism provides an important clue to the diagnosis. The typical mechanism, for a more simple ankle sprain, involves inversion and plantar flexion. The ability to weight-bear following injury is very helpful for distinguishing been an ankle sprain and a fracture.

The following are some important considerations when taking the history of an athlete who has sustained an injury to his/her ankle.

Mechanism of injury
The mechanism of injury is one of the key considerations when assessing an injured ankle. Lateral ligament sprains (and acute peroneal tendon injuries) generally occur after an ankle inversion injury. Inversion may occur when cutting, running on uneven ground or landing on an opponent’s foot. Deltoid ligament injuries typically occur after ankle eversion. Syndesmosis injuries (also known as high ankle sprains) generally occur with forced dorsiflexion, forced external rotation of the foot, or after eversion of the talus. The majority of fractures about the ankle also occur with characteristic injury mechanisms.
Mechanical symptoms
Locking or catching may be indicative of a loose body, such as an unstable talar dome injury. This symptom may also be caused by dislocating peroneal tendons. A more general sense of “clicking and clinking” is a common complaint and is generally not significant.
Instability
A poorly rehabilitated ligamentous injury can cause recurrent instability. Symptoms of instability can also be due to an unstable cartilage injury (talar dome injury or loose body).
Pain
Pain felt about the posterior ankle with plantar flexion is strongly suspicious for posterior impingement. Similarly, pain or restriction felt anteriorly with dorsiflexion is suspicious for anterior impingement.
Apprehension
Apprehension with activity on uneven ground may imply a more significant (or poorly rehabilitated) ligamentous injury.
Swelling
Swelling in the acute setting is likely to relate to a haemarthrosis. Recurring swelling may be due to synovitis (most commonly following trauma). Swelling may also be a clue to intra-articular pathology like a talar dome chondral injury.
Past history of injury
A past ankle injury is a risk factor for further injury. Many players return to play far too soon after a sprain. Enquiring about the adequacy of treatment (have they done any strength or proprioception exercises) is important as this may be related to the new injury.
An inability to weight bear after an injury is an important clinical sign. As you will see this is part of the ‘Ottawa criteria’. If an athlete is unable to walk one should suspect a more significant injury and order an x-ray.

Dr Pieter D'Hooghe

Orthopaedic Surgeon