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      Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm

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          Abstract

          Acute ankle injuries are among the most common injuries in emergency departments. However, there are still no standardized examination procedures or evidence-based treatment. Therefore, the aim of this study was to systematically search the current literature, classify the evidence, and develop an algorithm for the diagnosis and treatment of acute ankle injuries. We systematically searched PubMed and the Cochrane Database for randomized controlled trials, meta-analyses, systematic reviews or, if applicable, observational studies and classified them according to their level of evidence. According to the currently available literature, the following recommendations have been formulated: i) the Ottawa Ankle/Foot Rule should be applied in order to rule out fractures; ii) physical examination is sufficient for diagnosing injuries to the lateral ligament complex; iii) classification into stable and unstable injuries is applicable and of clinical importance; iv) the squeeze-, crossed leg- and external rotation test are indicative for injuries of the syndesmosis; v) magnetic resonance imaging is recommended to verify injuries of the syndesmosis; vi) stable ankle sprains have a good prognosis while for unstable ankle sprains, conservative treatment is at least as effective as operative treatment without the related possible complications; vii) early functional treatment leads to the fastest recovery and the least rate of reinjury; viii) supervised rehabilitation reduces residual symptoms and re-injuries. Taken these recommendations into account, we present an applicable and evidence-based, step by step, decision pathway for the diagnosis and treatment of acute ankle injuries, which can be implemented in any emergency department or doctor's practice. It provides quality assurance for the patient and promotes confidence in the attending physician.

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          Most cited references 176

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          The effect of a proprioceptive balance board training program for the prevention of ankle sprains: a prospective controlled trial.

          Ankle sprains are the most common injuries in a variety of sports. A proprioceptive balance board program is effective for prevention of ankle sprains in volleyball players. Prospective controlled study. There were 116 male and female volleyball teams followed prospectively during the 2001-2002 season. Teams were randomized by 4 geographical regions to an intervention group (66 teams, 641 players) and control group (50 teams, 486 players). Intervention teams followed a prescribed balance board training program; control teams followed their normal training routine. The coaches recorded exposure on a weekly basis for each player. Injuries were registered by the players within 1 week after onset. Significantly fewer ankle sprains in the intervention group were found compared to the control group (risk difference = 0.4/1000 playing hours; 95% confidence interval, 0.1-0.7). A significant reduction in ankle sprain risk was found only for players with a history of ankle sprains. The incidence of overuse knee injuries for players with history of knee injury was increased in the intervention group. History of knee injury may be a contraindication for proprioceptive balance board training. Use of proprioceptive balance board program is effective for prevention of ankle sprain recurrences.
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            A systematic review on ankle injury and ankle sprain in sports.

            This article systematically reviews epidemiological studies on sports injury from 1977 to 2005 in which ankle injury was included. A total of 227 studies reporting injury pattern in 70 sports from 38 countries were included. A total of 201,600 patients were included, with 32,509 ankle injuries. Ankle injury information was available from 14,098 patients, with 11 847 ankle sprains. Results show that the ankle was the most common injured body site in 24 of 70 included sports, especially in aeroball, wall climbing, indoor volleyball, mountaineering, netball and field events in track and field. Ankle sprain was the major ankle injury in 33 of 43 sports, especially in Australian football, field hockey, handball, orienteering, scooter and squash. In sports injuries throughout the countries studied, the ankle was the second most common injured body site after the knee, and ankle sprain was the most common type of ankle injury. The incidence of ankle injury and ankle sprain was high in court games and team sports, such as rugby, soccer, volleyball, handball and basketball. This systematic review provides a summary of the epidemiology of ankle injury in sports.
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              Syndesmosis sprains of the ankle.

              A retrospective review of the clinical records and radiographs of 1344 ankle sprains occurring over a 41-month period at the United States Military Academy was performed. The incidence and severity of these sprains did not differ significantly from other studies with the exception of those injuries involving the tibiofibular ligaments. Those patients sustaining incomplete injuries to the ankle syndesmosis had a recovery time of almost twice that of those patients with severe (3rd degree) ankle sprains (55 vs. 28 days). Eight of 13 patients with 10 of 15 incomplete syndesmosis injuries were available for follow-up examination and radiographs at an average time of 20 months postinjury (range of 7-39 months). All patients with this injury had a positive "squeeze test" (compression of the fibula to the tibia at mid-calf) at the time of initial examination. Nine of 10 patients developed ossification of the syndesmosis in follow-up radiographs. None of these patients had developed chronic ankle instability, loss of motion, or arthritic changes of the joint at the time of final followup.
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                Author and article information

                Journal
                Orthop Rev (Pavia)
                Orthop Rev (Pavia)
                OR
                OR
                Orthopedic Reviews
                PAGEPress Publications (Pavia, Italy )
                2035-8164
                2035-8237
                14 December 2011
                02 January 2012
                : 4
                : 1
                Affiliations
                Munich University Hospital, Dept. Trauma Surgery - Innenstadt Campus, Ludwig-Maximilians-University, Munich, Germany
                Author notes
                Correspondence: Hans Polzer, Department of Trauma Surgery-Innenstadt Campus, Munich University Hospital, Ludwig-Maximilians-University, Munich, Germany. Tel. +49.0.89.5160.2511 - Fax: +49.0.89.5160.5482. E-mail: hans.polzer@ 123456med.uni-muenchen.de

                Contributions: HP, study conceiving, data collection, analysis and interpretation, manuscript writing; KGK, study conceiving, designing and coordinating, manuscript drafting; WCP, data analysis and interpretation, manuscript revising; FH, data acquisition, manuscript drafting; BO, manuscript drafting; WM, study designing, data interpretation, manuscript revising; SG, study conceiving and designing, data analysis and interpretation, manuscript revising.

                Conflict of interest: no sources of funding were used in the preparation of this article. The authors have no competing interest to report.

                Article
                or.2012.e5
                10.4081/or.2012.e5
                3348693
                22577506
                ©Copyright H. Polzer et al., 2012

                This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).

                Licensee PAGEPress srl, Italy

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                Orthopedics

                ankle injury, ankle sprain, evidence based algorithm, diagnosis, treatment.

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