Selected Podcast
Lateral Ankle Sprains (Acute and Chronic Instability)
R. James Toussaint M.D., discusses lateral ankle sprains, the prevalence of these injuries and the mechanics involved. He explains the difference between mechanical instability vs functional instability, when nonoperative and operative treatment are indicated and importantly, the return to play criteria for an ankle sprain during recovery phase and functional phase.
Featuring:
I earned my bachelor’s degree in economics from the University of Chicago. Then, I graduated with my medical degree from the New York University Grossman School of Medicine. I also pursued a residency in orthopaedic surgery at Harvard Medical School and a fellowship in orthopaedic surgery, with a focus on foot and ankle, at OrthoCarolina Foot and Ankle Institute in Charlotte, North Carolina.
In addition to teaching as a clinical associate professor at the University of Florida College of Medicine, I also practice at the UF Orthopaedics and Sports Medicine Institute. I became an orthopaedic surgeon because I enjoy body’s complex anatomy and I want to help my patients regain their mobility. I am constantly thinking of new ways to treat foot and ankle disorders, and I’ve published research articles about traumatic disorders to provide care in disaster situations. This is important to me, as I have experience treating victims of the 2013 Boston Marathon bombings and providing care in Haiti, my birth country, following the 2010 earthquake.
Something that patients should know about me is that I always consider the spectrum of nonoperative treatments first. But if surgery is necessary, I encourage patients to ask questions and engage in shared decision making so that they feel comfortable with their treatment choice.
Outside of medicine, I enjoy collecting art and visiting art museums, especially UF’s Harn Museum of Art. I used to compete as a collegiate wrestler and I compete in triathlons when time permits. In 2021, I became a co-owner of the North Carolina Courage, one of the clubs in the National Women’s Soccer League.
R. James Toussaint, M.D.
My name is R. James Toussaint, M.D., and I am the chief of the foot and ankle division in the department of orthopaedic surgery and sports medicine. As a surgeon, I specialize in the diagnosis and treatment of orthopaedic injuries, with a particular interest in degenerative, traumatic and sports-related foot and ankle disorders.I earned my bachelor’s degree in economics from the University of Chicago. Then, I graduated with my medical degree from the New York University Grossman School of Medicine. I also pursued a residency in orthopaedic surgery at Harvard Medical School and a fellowship in orthopaedic surgery, with a focus on foot and ankle, at OrthoCarolina Foot and Ankle Institute in Charlotte, North Carolina.
In addition to teaching as a clinical associate professor at the University of Florida College of Medicine, I also practice at the UF Orthopaedics and Sports Medicine Institute. I became an orthopaedic surgeon because I enjoy body’s complex anatomy and I want to help my patients regain their mobility. I am constantly thinking of new ways to treat foot and ankle disorders, and I’ve published research articles about traumatic disorders to provide care in disaster situations. This is important to me, as I have experience treating victims of the 2013 Boston Marathon bombings and providing care in Haiti, my birth country, following the 2010 earthquake.
Something that patients should know about me is that I always consider the spectrum of nonoperative treatments first. But if surgery is necessary, I encourage patients to ask questions and engage in shared decision making so that they feel comfortable with their treatment choice.
Outside of medicine, I enjoy collecting art and visiting art museums, especially UF’s Harn Museum of Art. I used to compete as a collegiate wrestler and I compete in triathlons when time permits. In 2021, I became a co-owner of the North Carolina Courage, one of the clubs in the National Women’s Soccer League.
Transcription:
preroll: The University of Florida College of Medicine is accredited by the Accreditation Council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMAP category one. Credit physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Joining me today is Dr. R James Toussaint. He's a clinical associate professor at the University of Florida College of Medicine in the Department of Orthopedic Surgery and Sports Medicine. And he's also the division chief of Foot and Ankle at UF Health Shands Hospital, and he's here to highlight lateral ankle sprains for us today. Dr. Toussaint, it's a pleasure to have you join us. Can you tell us a little bit about lateral ankle sprains, how common they are, and the mechanics involved to contribute to these injuries?
Dr R James Toussaint: So first of all, thank you for having me. It's a pleasure to be on your podcast. I would start off by saying that ankle sprains or lateral, ankle injuries, related to sprains are very common. The incidence is, relatively high, about 30,000 ankle sprains per day, is what you'll see in some of the literature. And about 40% of all athletic injuries, involve an ankle sprain. It's important to know that the most common reason for missed athletic participation is ankle sprains. And ankle sprains. the variety that we're speaking about today involve the low ankle sprain, which is about 90% of all ankle sprains, whereas a high ankle sprain is about maybe one to 10% of all ankle sprains.
The low ankle sprain is, again, the common variety. It usually happens when, the person twists their ankle in an inversion type injury, meaning that the foot goes medial and the rest of the leg goes relatively lateral to that. And the ligaments that are injured would be the ATFL and CFL ligaments. There's another ligament down there called the PTFO, but that's rarely involved,
Melanie Cole (Host): Well, thank you so much for that. So then, Dr. Troussaint, in what sports are you seeing them the most frequently? I'd like you to speak to patients and to other providers and even to coaches so that they can look out for these kinds of injuries.
Dr R James Toussaint: To be fair, just about any, sport can result in an ankle sprain. You're most commonly see them with the indoor court type sports such as volleyball or basketball. But you also see these injuries in dancers or football players, even, baseball players can result in ankle sprains. So again, it's very common.
Melanie Cole (Host): So then let's talk about mechanical instability versus functional instability. I'd like you to speak about clinical history, the characteristics of this type of sprain. Speak about what you do with the patient when this happens?
Dr R James Toussaint: So first the patient would come in complaining of pain with weight bearing. They may or may not be able to weight bear. You'll often see some swelling and bruising, ecchymosis. The ecchymosis may be over the medial or the lateral aspect of the ankle. most commonly the discomfort that they'll, complain about is over the lateral aspect. But because of a contra crew type injury where, let's say the talus abuts the medial maliolis, they may have discomfort even on the medial side of the ankle. Sometimes the patient will experience some catching or popping sensation, and you'll see that, related to recurrent sprains, recurrent instability.
And it's important to distinguish, let's say, the subtle versus the gross instability patterns. Recurrent instability is only in about 20% of patients. Most patients, let's say over 80% of patients will have an isolated ankle sprain that gets adequately rehabbed. But if it's not adequately rehab, then it may result in chronic or recurrent instability. And the chronic or recurrent instability pattern is one in which the ankle, is just not trustworthy anymore. So whereas the patient with the acute variety, will have an ankle sprain and then not have any, further issues.
The chronic or recurrent instability pattern. the patient will have, the loss of ligamentous integrity and that type of patient will then have a scenario whereby small, and low impact activities such as, walking and maybe stepping on a pebble or a tree root will lead to an ankle sprain. And so those are the, issues that you want to address surgically, and I know we'll get to that, a little bit later on. But during my workup, we'll do a history. We'll get an idea of where the location of the discomfort is or duration. Some of the modifiers, things that make it better or worse, the intensity, if they've had any history of trauma, if they have any comorbidities.
Some patients may have ligamentous laxity that puts them at risk for ankle sprains or sprains of any joint. And then, we can move on to the physical exam. So the moment that I walk into the room, I'm already taking a note and taking stock of what I see. I'm looking at the ankle of high foot alignment, and then I'll evaluate the motion of the ankle, the motion of the foot, the alignment of the foot, as I mentioned. Obviously we'll look at the motor and neurovascular exam. We'll find out any focal tenderness. There are some, things that you would do in the physical exam, that are, gonna elicit, instability.
And we will check for ligamentous laxity with an interior drawer exam or a tailored tilt test that's gonna test the ATFL and CFL. And beyond that, we'll get some x-rays. The x-rays tend to be weight bearing films. Sometimes I'll have a stress view and the stress view will look at, the rotation, of the ankle. We'll look at the, width of certain, joints. And then, we may, move on to treatment options. Rarely do you need an MRI, but an MRI can be necessary if the symptoms are chronic or persistent, or if we're looking out for additional pathology.
Melanie Cole (Host): Well, thank you for that. So then start with some non-operative treatment modalities once you've determined what's going on, and you can even speak about the National Athletic Trainers Association's guidelines for treating, and then we'll talk about prevention for sure, Dr. Troussaint, but I'd like you to speak about non-operative first. What might you try conservative measures and then segue into surgical options?
Dr R James Toussaint: The first line treatment, certainly involves non-surgical treatment. So that's the first line option. And that's generally involving rest, ice, compression and elevation. We may consider a short period of immobilization in a cast or a boot. And in some cases that would, even involve non-weight bearing for a week or two as the discomfort subsides. Following this, physical therapy is extremely. You wanna start physical therapy as soon as possible or as early as can be tolerated. Early motion exercises is where we start, and then we can progress through some strengthening. It would certainly involve propioception and activity specific exercises.
For those out there who aren't familiar with proprioception, proprioception involves basically retraining. Your nerves to give you an idea of where your joint or body parts are in space and that helps to prevent further ankle injuries in the future. For high risk activities or for the athletic type out there, you'll, consider an ankle brace, especially once the rehab gets going in an earnest manner. And again, the ankle brace will help limit the risk of, re. I would say, the important takeaway here is that early functional rehab allows for the quickest return to physical activity. The question that I often get is, when can I return to sport?
And that's highly dependent on the grade of the sprain, whether or not there are associated injuries and the compliance with rehab. But as a rule of thumb, a grade one or a grade two type of ankle sprain, the person should be able to get back to activity or sport within the first two weeks, a grade three type of injury, maybe three or four weeks. And if there's a high ankle sprain, although this is not the topic of this talk, but if there's associated high ankle sprain, it's six to eight weeks.
And if the high ankle sprain needed surgery, The athlete isn't getting back to sport until the next season, so it's a season ending injury. Again, prevention is gonna involve bracing, maybe a semi rigid orthosis. Patients that have some sort of malalignment of their foot, the cable, various foot. So the foot with a high arch is not gonna necessarily need an arch support. The arch is already high. I would recommend a brace with a lateral hind foot wedge, and a four foot wedge with a first meta recess. Again, this is a type of orthosis that's going to diminish or another word is to correct deformity or at least accommodate it.
And again, back to physical therapy. Physical therapy is not a, short term thing. I would say it's season long program. And that's gonna involve the strengthening and proprioseptive exercises that we talked about
Melanie Cole (Host): Dr. Troussaint, when would you consider neurovascular compromise if they've done rehabilitation of this lateral ankle sprain? They've done all of that, and you spoke about criteria for return to play, so I'm glad you did that, because then I didn't have to ask you that question, so that was awesome. But when do you consider that something else might have?
Dr R James Toussaint: If over the course of a few months, let's just say six to eight weeks, and the pain persists, then what I would typically do is obtain a more advanced imaging, such as an MRI. With the MRI, I'm looking for additional pathology, and the additional pathology could be tendon injury such as the perineal tendons, and those are located over the lateral aspect of the ankle and HD foot. There may be an associated osteochondral injury where there's, let's just say a defect within the tailor dome or on the tibial poufant. There's also the possibility of a high ankle injury, such as a Sysdomontic injury. Other things to consider are, fractures. So a fracture of the base of the fifth metatarsal or the anterior calkino process.
And so with patients that have persistent discomfort and pain despite physical therapy over the past six to eight weeks, then an MRI is used to rule out some of these additional pathologies. One thing to keep in mind is for patients that have persistent pain, we may also want to consider a stretch neuropraxia. So the stretch neuropraxia involves a stretch injury of the superficial perineal. Because of the mechanism of the injury, the nerve has been stretched and that could lead to burning or pain or even CRPS, over the injured extremity. So these are all things to keep in mind for patients that have, persistent pain and discomfort despite doing everything right non-operatively.
Melanie Cole (Host): Dr. Toussaint this is such an informative podcast, so please wrap up for us. What would you like other providers, patients, coaches, anybody involved with sports that could, you know, or even daily activities that could cause these kinds of ankle sprains prevention summary. What would you like as your final takeaway message?
Dr R James Toussaint: I would love for all of the providers and patients out there to know that, ankle sprains by and large can be treated non-surgically. but for the patient that ends up with persistent pain and discomfort and recurrent instability over the course of, let's say two months from the date of injury. Then an MRI is necessary, and then a referral to an orthopedic surgeon such as myself is the appropriate way to go. And at that point I would review the MRI and determine what type of surgical treatment may be necessary.
Melanie Cole (Host): Thank you so much, Dr. Toussaint, for joining us today and really sharing your incredible expertise. To refer your patient or to listen to more podcasts from our experts, please visit ufhealth.org/medMatters, and that includes today's episode of UF Health Med EdCast with UF Health Shands Hospital. For updates on the latest medical advancements, breakthroughs, and research, please follow us on your social channels. I'm Melanie Cole.
preroll: The University of Florida College of Medicine is accredited by the Accreditation Council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMAP category one. Credit physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Joining me today is Dr. R James Toussaint. He's a clinical associate professor at the University of Florida College of Medicine in the Department of Orthopedic Surgery and Sports Medicine. And he's also the division chief of Foot and Ankle at UF Health Shands Hospital, and he's here to highlight lateral ankle sprains for us today. Dr. Toussaint, it's a pleasure to have you join us. Can you tell us a little bit about lateral ankle sprains, how common they are, and the mechanics involved to contribute to these injuries?
Dr R James Toussaint: So first of all, thank you for having me. It's a pleasure to be on your podcast. I would start off by saying that ankle sprains or lateral, ankle injuries, related to sprains are very common. The incidence is, relatively high, about 30,000 ankle sprains per day, is what you'll see in some of the literature. And about 40% of all athletic injuries, involve an ankle sprain. It's important to know that the most common reason for missed athletic participation is ankle sprains. And ankle sprains. the variety that we're speaking about today involve the low ankle sprain, which is about 90% of all ankle sprains, whereas a high ankle sprain is about maybe one to 10% of all ankle sprains.
The low ankle sprain is, again, the common variety. It usually happens when, the person twists their ankle in an inversion type injury, meaning that the foot goes medial and the rest of the leg goes relatively lateral to that. And the ligaments that are injured would be the ATFL and CFL ligaments. There's another ligament down there called the PTFO, but that's rarely involved,
Melanie Cole (Host): Well, thank you so much for that. So then, Dr. Troussaint, in what sports are you seeing them the most frequently? I'd like you to speak to patients and to other providers and even to coaches so that they can look out for these kinds of injuries.
Dr R James Toussaint: To be fair, just about any, sport can result in an ankle sprain. You're most commonly see them with the indoor court type sports such as volleyball or basketball. But you also see these injuries in dancers or football players, even, baseball players can result in ankle sprains. So again, it's very common.
Melanie Cole (Host): So then let's talk about mechanical instability versus functional instability. I'd like you to speak about clinical history, the characteristics of this type of sprain. Speak about what you do with the patient when this happens?
Dr R James Toussaint: So first the patient would come in complaining of pain with weight bearing. They may or may not be able to weight bear. You'll often see some swelling and bruising, ecchymosis. The ecchymosis may be over the medial or the lateral aspect of the ankle. most commonly the discomfort that they'll, complain about is over the lateral aspect. But because of a contra crew type injury where, let's say the talus abuts the medial maliolis, they may have discomfort even on the medial side of the ankle. Sometimes the patient will experience some catching or popping sensation, and you'll see that, related to recurrent sprains, recurrent instability.
And it's important to distinguish, let's say, the subtle versus the gross instability patterns. Recurrent instability is only in about 20% of patients. Most patients, let's say over 80% of patients will have an isolated ankle sprain that gets adequately rehabbed. But if it's not adequately rehab, then it may result in chronic or recurrent instability. And the chronic or recurrent instability pattern is one in which the ankle, is just not trustworthy anymore. So whereas the patient with the acute variety, will have an ankle sprain and then not have any, further issues.
The chronic or recurrent instability pattern. the patient will have, the loss of ligamentous integrity and that type of patient will then have a scenario whereby small, and low impact activities such as, walking and maybe stepping on a pebble or a tree root will lead to an ankle sprain. And so those are the, issues that you want to address surgically, and I know we'll get to that, a little bit later on. But during my workup, we'll do a history. We'll get an idea of where the location of the discomfort is or duration. Some of the modifiers, things that make it better or worse, the intensity, if they've had any history of trauma, if they have any comorbidities.
Some patients may have ligamentous laxity that puts them at risk for ankle sprains or sprains of any joint. And then, we can move on to the physical exam. So the moment that I walk into the room, I'm already taking a note and taking stock of what I see. I'm looking at the ankle of high foot alignment, and then I'll evaluate the motion of the ankle, the motion of the foot, the alignment of the foot, as I mentioned. Obviously we'll look at the motor and neurovascular exam. We'll find out any focal tenderness. There are some, things that you would do in the physical exam, that are, gonna elicit, instability.
And we will check for ligamentous laxity with an interior drawer exam or a tailored tilt test that's gonna test the ATFL and CFL. And beyond that, we'll get some x-rays. The x-rays tend to be weight bearing films. Sometimes I'll have a stress view and the stress view will look at, the rotation, of the ankle. We'll look at the, width of certain, joints. And then, we may, move on to treatment options. Rarely do you need an MRI, but an MRI can be necessary if the symptoms are chronic or persistent, or if we're looking out for additional pathology.
Melanie Cole (Host): Well, thank you for that. So then start with some non-operative treatment modalities once you've determined what's going on, and you can even speak about the National Athletic Trainers Association's guidelines for treating, and then we'll talk about prevention for sure, Dr. Troussaint, but I'd like you to speak about non-operative first. What might you try conservative measures and then segue into surgical options?
Dr R James Toussaint: The first line treatment, certainly involves non-surgical treatment. So that's the first line option. And that's generally involving rest, ice, compression and elevation. We may consider a short period of immobilization in a cast or a boot. And in some cases that would, even involve non-weight bearing for a week or two as the discomfort subsides. Following this, physical therapy is extremely. You wanna start physical therapy as soon as possible or as early as can be tolerated. Early motion exercises is where we start, and then we can progress through some strengthening. It would certainly involve propioception and activity specific exercises.
For those out there who aren't familiar with proprioception, proprioception involves basically retraining. Your nerves to give you an idea of where your joint or body parts are in space and that helps to prevent further ankle injuries in the future. For high risk activities or for the athletic type out there, you'll, consider an ankle brace, especially once the rehab gets going in an earnest manner. And again, the ankle brace will help limit the risk of, re. I would say, the important takeaway here is that early functional rehab allows for the quickest return to physical activity. The question that I often get is, when can I return to sport?
And that's highly dependent on the grade of the sprain, whether or not there are associated injuries and the compliance with rehab. But as a rule of thumb, a grade one or a grade two type of ankle sprain, the person should be able to get back to activity or sport within the first two weeks, a grade three type of injury, maybe three or four weeks. And if there's a high ankle sprain, although this is not the topic of this talk, but if there's associated high ankle sprain, it's six to eight weeks.
And if the high ankle sprain needed surgery, The athlete isn't getting back to sport until the next season, so it's a season ending injury. Again, prevention is gonna involve bracing, maybe a semi rigid orthosis. Patients that have some sort of malalignment of their foot, the cable, various foot. So the foot with a high arch is not gonna necessarily need an arch support. The arch is already high. I would recommend a brace with a lateral hind foot wedge, and a four foot wedge with a first meta recess. Again, this is a type of orthosis that's going to diminish or another word is to correct deformity or at least accommodate it.
And again, back to physical therapy. Physical therapy is not a, short term thing. I would say it's season long program. And that's gonna involve the strengthening and proprioseptive exercises that we talked about
Melanie Cole (Host): Dr. Troussaint, when would you consider neurovascular compromise if they've done rehabilitation of this lateral ankle sprain? They've done all of that, and you spoke about criteria for return to play, so I'm glad you did that, because then I didn't have to ask you that question, so that was awesome. But when do you consider that something else might have?
Dr R James Toussaint: If over the course of a few months, let's just say six to eight weeks, and the pain persists, then what I would typically do is obtain a more advanced imaging, such as an MRI. With the MRI, I'm looking for additional pathology, and the additional pathology could be tendon injury such as the perineal tendons, and those are located over the lateral aspect of the ankle and HD foot. There may be an associated osteochondral injury where there's, let's just say a defect within the tailor dome or on the tibial poufant. There's also the possibility of a high ankle injury, such as a Sysdomontic injury. Other things to consider are, fractures. So a fracture of the base of the fifth metatarsal or the anterior calkino process.
And so with patients that have persistent discomfort and pain despite physical therapy over the past six to eight weeks, then an MRI is used to rule out some of these additional pathologies. One thing to keep in mind is for patients that have persistent pain, we may also want to consider a stretch neuropraxia. So the stretch neuropraxia involves a stretch injury of the superficial perineal. Because of the mechanism of the injury, the nerve has been stretched and that could lead to burning or pain or even CRPS, over the injured extremity. So these are all things to keep in mind for patients that have, persistent pain and discomfort despite doing everything right non-operatively.
Melanie Cole (Host): Dr. Toussaint this is such an informative podcast, so please wrap up for us. What would you like other providers, patients, coaches, anybody involved with sports that could, you know, or even daily activities that could cause these kinds of ankle sprains prevention summary. What would you like as your final takeaway message?
Dr R James Toussaint: I would love for all of the providers and patients out there to know that, ankle sprains by and large can be treated non-surgically. but for the patient that ends up with persistent pain and discomfort and recurrent instability over the course of, let's say two months from the date of injury. Then an MRI is necessary, and then a referral to an orthopedic surgeon such as myself is the appropriate way to go. And at that point I would review the MRI and determine what type of surgical treatment may be necessary.
Melanie Cole (Host): Thank you so much, Dr. Toussaint, for joining us today and really sharing your incredible expertise. To refer your patient or to listen to more podcasts from our experts, please visit ufhealth.org/medMatters, and that includes today's episode of UF Health Med EdCast with UF Health Shands Hospital. For updates on the latest medical advancements, breakthroughs, and research, please follow us on your social channels. I'm Melanie Cole.