Medial Mnkle Sprains 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