Ligamentous Injuries and the Risk of Associated Tissue Damage in Acute Ankle Sprains in Athletes

SLR - March 2015 - Jessica Olson

Reference: Roemer FW, Jomaah N, Niu J, Almusa E, Roger B, D'Hooghe P, Geertsema C, Tol JL, Khan K, Guermazi A. Ligamentous Injuries and the Risk of Associated Tissue Damage in Acute Ankle Sprains in Athletes: A Cross-sectional MRI Study. Am J Sports Med. 2014 Apr 21;42(7):1549-1557.

Scientific Literature Review

Reviewed By: Jessica Olson, DPM
Residency Program: Grant Medical Center, Columbus, OH

Podiatric Relevance: Ankle sprains are a common lower extremity injury experienced by athletes. The anterior talofibular ligament (ATFL) is most commonly involved with these injuries as it the weakest ligament of the lateral ankle complex; however, the calcaneofibular (CFL), posterior talofibular (PTFL), ankle syndesmosis, peroneal, extensor, and flexor tendons, medial ankle ligament complex, talus, and tibia may also be injured depending on the mechanism and degree of sprain. The current gold standard for diagnosing ankle sprains is the physical exam coupled with plain radiography to evaluate for fractures and mortise alignment, neither of which have a high sensitivity or specificity for diagnosing soft tissue other structural injuries including osteochondral defects (OCD) often incurred with ankle sprains. This study advocates for the use of MRI as a diagnostic adjunctive in the management of acute ankle sprains in athletes, as MRI allows for more precise evaluation of the involved ligaments, tendons, and other structural injuries often associated with ankle sprains. Additionally, this study utilizes MRI to describe the structural injury patterns and the risk of associated structural injury in relation to injury pattern in athletes with ankle sprains. As foot and ankle specialists, it is imperative that these common athletic injuries be understood and evaluated thoroughly, as misdiagnosis can lead to misguided treatment, which can be especially detrimental in the athletic population.

Methods: Ankle MRI scans of 261 athletes following acute ankle sprain injury were evaluated for lateral ankle complex injury, syndesmotic ligament injury, medial ankle ligament injury, peroneal, extensor, and flexor tendon/retinacula injury, sinus tarsi ligament injury, joint effusion, and associated OCD of the talus and tibia, utilizing respective standard imaging and grading classifications. Data was obtained retrospectively via institutional records and reviewed by a single experienced musculoskeletal radiologist using the following inclusion criteria: registered athlete, referral MRI terms of “acute ankle sprain”, “sprain”, “twisting injury”, “syndesmosis”, “lateral ligaments”, and “ligament tear.

Results: Of the 261 ankle sprain MRIs reviewed, 88.1 percent (N= 230) were men with an average age of 22.5 +/- 4.5 years old (range, 14-39) who played soccer (N=221, 84.7%). Eighty-two percent (N=214) of the MRIs were obtained an average of 5.7 +/- 4.8 days (range, 1-26 days) post injury. Injury pattern results included: 40.2 percent (N=105) with no or low-grade lateral ligament injury with no syndesmosis injury, 39.5 percent (N=103) with complete ATFL injuries, with or without concomitant CFL or PTFL injury, but no syndesmotic injury, and 20.3 percent (N=53) had syndesmotic injuries with or without lateral ankle ligament injury. Associated structural injuries included: 14.6 percent (N=38) with sinus tarsi injury, 3.8 percent (N=10) with medial ligament injury, and less than 2 percent (N=3, N=4) with retinaculum or tendon involvement, respectively. Osseous involvement of the talus (44.1 percent, N=115), as well as tibial contusions (23 percent), were common, especially when associated with syndesmotic injury.

Conclusion: The results of this study on ankle MRIs in acute ankle sprains of athletes provides compelling evidence of the prevalence of partial to complete lateral ligament injuries (56 percent), syndesmotic injury with or without lateral ligament injury (20 percent), medial ligament injury (49 percent), and associated structural talar and tibial contusions (44 percent) with syndesmotic injury. Given these results, foot and ankle specialists should have heightened clinical suspicion for these associated injuries with ankle sprains. MRI imaging modality can be readily utilized in athletes presenting with these injuries to provide a comprehensive diagnostic evaluation and aid in appropriate post-injury management. Of note however, given the retrospective design of this study, it lacks clinical correlation to the MRI findings, clinical follow-up, and cannot be readily extrapolated to a nonathletic population, thus warranting follow-up studies to provide additional information.