Medial ankle sprains are usually caused by a sudden twisting, turning, or rolling inwards of the ankle. A medial ankle sprain can occur due to a fall or stepping awkwardly onto an uneven surface. It can also happen due to the wear and tear of the deltoid ligament.
Other Names
- Deltoid Sprain
- Medial Ligament Sprain
- Medial Ankle Complex Sprain
- Deltoid Ligament Injury
Causes
- General
- Medial ankle sprains are poorly described in the literature
- Isolated injury is unusual but does happen
- Involves excessive pronation, external rotation and/or abduction
- General
- Mechanism typically involves eversion (pronation) of the ankle
- Occurs while running and jumping
- Can also occur when someone steps on outside of a planted foot or ankle giving a medially directed force
- Other causes include landing on uneven surfaces, misstepping on stairs
Anatomic illustration of the deltoid ligament and other medial ligaments of the foot and ankle
- Distal Fibula Fracture
- Bimalleolar Fracture
- Maisonneuve Fracture
- Ankle Osteoarthritis
- Syndesmotic Sprain
- Osteochondral Defect
- Lateral Ankle Sprain
- Ankle Joint
- Synovial hinge joint
- Formed by articulation formed by the distal Fibula, distal Tibia and Talus
- Deltoid Ligament
- Stabilizes the medial ankle
Risk Factors
- General
- Male Gender[3]
- High competition levels
- Younger athlete
- Orthopedic history
- Previous ankle sprain
- Sports
- Football
- Basketball
- Long Jumping
- Rugby
- Soccer
- Biomechanical
- Pes Planus
- Dysfunction of the spring ligament
- Posterior Tibialis Tendon Dysfunction
- Extreme fatigue of peroneus longs muscle
- Fractures & Dislocations
- Distal Tibia Fracture
- Distal Fibular Fracture
- Talus Fracture
- Calcaneus Fracture
- Subtalar Dislocation
- Ankle Fracture (& Dislocation)
- Peroneal Subluxation
- Muscle and Tendon Injuries
- Peroneal Tendon Injuries
- Achilles Tendonitis
- Achilles Tendon Rupture
- Posterior Tibial Tendon Dysfunction
- Flexor Hallucis Longus Tendinopathy
- Ligament Injuries
- Lateral Ankle Sprain
- Medial Ankle Sprain
- Syndesmotic Sprain
- Chronic Ankle Instability
- Intersection Syndrome Foot
- Bursopathies
- Retrocalcaneal Bursitis
- Nerve Injuries
- Peroneal Nerve Injury
- Tarsal Tunnel Syndrome
- Arthropathies
- Osteoarthritis of the Ankle
- Osteochondral Defect Talus
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin’s Disease)
- Calcaneal Apophysitis (Sever’s Disease)
- Other
- Haglunds Deformity
- Posterior Ankle Impingement Syndrome
- Sinus Tarsi Syndrome
Symptoms
Clinical demonstration of the external rotation stress test[4]
- History
- Pain over medial ankle following an acute injury (eversion or pronation)
- Worse with ambulation, running, jumping
- Sensation of instability
- Physical Exam: Physical Exam Ankle
- Useful to follow Ottawa Ankle Rules
- There may be bruising, swelling
- Exaggerated valgus hindfoot with or without weight bearing
- Tender to palpation over medial malleolus
- Special Tests
- External Rotation Stress Test: With the foot at 90°, apply external rotation to the joint
- Abduction Stress Test:
- Eversion Test:
- Anterior Drawer Test Ankle: translate distal tibia posteriorly to evaluate for laxity
Diagnosis
Radiographs
- Standard Radiographs Ankle
- Findings (stable)
- Typically normal
- Findings (unstable)
- If complete, avulsion injury off of medial malleolus
- Widening on the medial clear space
- Lateral shift of talus
- Ottawa Ankle Rules
- Decision making rule can help determine if xray is necessary
- They are close to 100% sensitive (need citation)
- Consider Stress Radiographs Ankle
- Useful in acute injuries, not chronic
- Manual stress
- Gravity stress views may be just as good as manual[5][6]
Ultrasound
- Can be used to evaluate deltoid ligament
- Chen et al: useful to distinguish isolated lateral malleolus fracture from bimal equivalent[7]
MRI
- Can be used to distinguish partial vs complete tear
- Evaluate for other soft tissue injuries
Arthroscopy
- Not considered part of a diagnostic workup
Classification
- Grade I (mild)
- Injury: ligament fiber stretch without macroscopic rupture
- Clinically minor swelling, palpatory tenderness
- Hardly any functional loss
- No increased instability
- Grade II (moderate)
- Injury: partial ligament tear
- Moderate pain, swelling and palpatory tenderness
- Mild to moderate instability
- Moderate functional disability
- Grade III (severe)
- Injury: complete tear of the ligament and joint capsule rupture
- Severe bruising, swelling, and pain
- Significant loss of function and an increased instability
- Unable to bear weight and walk normal
Treatment
Nonoperative
- Indications
- Most cases
- In general, management mirrors Lateral Ankle Sprain
- Cessation of physical activity
- PRICE Therapy
- Tall Walking Boot
- Advance weight bearing as tolerated
- Physical Therapy
Operative
- Indications
- Complete deltoid tear (grade III, possibly grade II)
- Bimalleolar equivalent
- Technique
- Primary repair
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