The Ankle Sprain: Not So Benign in the Young and Middle-aged Athlete

Objectives: Ankle sprains are one of the most common musculoskeletal injuries occurring in general population and athletes. Complete and accurate diagnosis of all injuries sustained during an ankle sprain is critical to control healthcare costs and prevent long-term effects. The purpose of this study was to determine the incidence of concomitant ankle pathology identified on MRI in a consecutive series of patients with acute ankle pain following ankle sprain. Methods: Methods: Patients who reported ankle pain for three months or less and presented to a subspecialty fellowship trained orthopaedic sports medicine practice. Patients were included with ankle pain, if the chart review revealed clinical diagnosis of ankle pain or sprain at the time of their first visit and were all sent immediately if they didn’t have an MRI of their ankle. Patients were excluded if a displaced fracture was identified on x-ray evaluation on the day of the first visit. All MRIs were read by the same musculoskeletal-trained radiologists at the time of imaging. Sprains were classified as mild, moderate, or severe on MRI. A mild ankle injury was defined as an injury to the ATFL or CFLA. A level moderate was an injury to the ATFL and other lateral ligaments. A level severe was a medial injury or a medial and lateral injury. Results: 166 patients met the inclusion criteria (87 female, 79 male). The mean age of patients was 34 ± 17 years. The median length of time between injury and the first office visit was 5 days (range 1 to 90). The median time from injury to MRI was 8.5 days (range 1 to 241). On first visit, diagnosis revealed 104 had lateral ankle sprain, 28 had medial ankle sprain, 20 had medial and lateral ankle sprain. The remaining 14 patients had chief complaints surrounding the midfoot or heel. On MRI, there were 23 mild sprains, 44 moderate sprains, and 47 severe sprains (12 medial alone and 35 medial and lateral). Injuries identified on MRI are shown in Figure 1. The most common concomitant injury was bone contusion. Location of bone contusions are shown in Figure 2. Fifty-two ankles did not show any ligament damage. Fourteen had chief complaints related to lateral ankle sprain, 11 medial ankle sprain, 3 medial and lateral sprain, 2 midfoot injury and 2 heel injuries. Fractures were seen in 8 ankles. These included non-displaced fractures of the anterior process of the calcaneus, the distal tibia, distal fibula and the calcaneus posteriorly and inferiorly. In addition, there were stress fractures of the calcaneus, calcaneal, talus with stress reaction in the cuboid, and mid-tibial diaphysis. One patient had bony exostosis or osteochondroma arising from distal tibia. Conclusions: Conclusion: A high incidence of concomitant injury associated with even mild ligamentous injuries suggesting an ankle sprain was noted in this cohort of patients. MRI is a powerful imaging modality but not utilized commonly in the treatment of ankle sprain due to cost and limited availability of resources. We believe these findings support the increased usage of MRI for patients with acute ankle pain especially in those who continued to have pain. MRI is a necessary component of the work-up of every painful ankle to avoid long-term sequalae, misdiagnosis, and managed patient expectations to allow for return of activities of daily living and sports