Ankle Sprains, Medial
Daniel C. Herman, MD, PhD, FAAPMR, FACSM, CAQSM
Giorgio A. Negron, MD
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Injury to the deltoid ligament complex of the medial ankle occurs when the foot is forced into eversion and external rotation.
Medial ankle sprains are less common than their lateral counterpart due to the vast strength of the deltoid ligament:
Deltoid ligament complex is composed of four superficial and two deep components (1).
Grade I sprain results from mild stretching of the deltoid ligament with microscopic tears (1). Patients have mild swelling and tenderness. There is no joint instability on exam, and the patient is able to bear weight and ambulate with minimal pain. Owing to their benign nature, these injuries are not seen frequently in the office.
Grade II sprain is a more severe injury involving an incomplete tear of the deltoid ligament. Patients have moderate pain, swelling, tenderness, and ecchymosis. There is mild to moderate joint instability on exam with some restriction in the range of motion and loss of function. Weight-bearing and ambulation are painful.
Grade III sprain involves a complete tear of the deltoid ligament. Patients have severe pain, swelling, tenderness, and ecchymosis. There is significant mechanical instability on exam and significant loss of function and motion. Patients are unable to bear weight or ambulate.
May progress to chronic ankle instability (constant sensation of ankle “giving away”) if lingering symptoms persist a year after initial ankle sprain (2)
Synonym(s): medial ankle sprain, deltoid ligament sprain
Previous ankle sprain
High-risk sports, including football, basketball, and long jumping
Valgus-flat foot deformity (3)
Low arch of the foot (i.e., pes planus)
Dysfunction of the spring ligament
Dysfunction of the posterior tibialis
Extreme fatigue of peroneus (fibularis) longus muscle
COMMONLY ASSOCIATED CONDITIONS
Syndesmosis disruption (3)
Fracture of the fibula and/or tibia
Avulsion fracture of the medial malleolus
Bimalleolar and trimalleolar fracture
Severe lateral ligament injury
Spring ligament injury
Posterior tibial tendon injury
Flexor hallucis longus injury
Posterior tibial and/or saphenous nerve traction injury
Mechanism of injury: Athletes typically report an off-balanced, pronated foot landing, which leads to forced external rotation, abduction, and eversion.
Alternate mechanism includes supination and excessive external rotation of the ankle (3).
Should inquire about previous ankle injury and history of “giving way.” This would suggest that there is an acute injury superimposed on chronic ankle instability.
Signs and symptoms include:
Medial ankle pain.
Swelling on the medial aspect of the ankle.
Ecchymosis around the medial aspect of the ankle.
Sensation of a “pop.”
Inability to walk.
Physical examination includes:
Evaluation of the ability to bear weight.
Careful palpation to identify tender structures.
Determination of tenderness over the deltoid ligament.
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