scholarly journals Characterization of Ankle Kinematics and Constraint Following Ligament Rupture in a Cadaveric Model

2019 ◽  
Vol 141 (11) ◽  
Author(s):  
Bardiya Akhbari ◽  
Matthew H. Dickinson ◽  
Ednah G. Louie ◽  
Sami Shalhoub ◽  
Lorin P. Maletsky
Keyword(s):  
Internal Rotation ◽  
External Rotation ◽  
Training Data ◽  
Ankle Injuries ◽  
Ankle Sprains ◽  
Ligament Rupture ◽  
Ankle Kinematics ◽  
Posterior Translation ◽  
Ankle Mobility ◽  
And Inversion

Ankle sprains are a common injury that may need reconstruction and extensive physical therapy. The purpose of this study was to provide a description of the biomechanics of the ankle joint complex (AJC) after anterior talofibular (ATFL) and calcaneofibular (CFL) ligament rupture to better understand severe ankle injuries. The envelope of motion of ten cadaveric ankles was examined by manual manipulations that served as training data for a radial basis function used to interpolate ankle mobility at flexion angles under load and torque combinations. Moreover, ankle kinematics were examined, while tendons were loaded to identify how their performance is altered by ligament rupture. The increased force required to plantarflex the ankle following ligament rupture was measured by calculating the load through the Achilles. Following ATFL injury, the largest changes were internal rotation (5 deg) in deep plantarflexion and anterior translation (1.5 mm) in early plantarflexion. The combined ATFL and CFL rupture changed the internal/external rotation (3 deg), anterior/posterior translation (1 mm), and inversion (5 deg) throughout flexion relative to the isolated ATFL rupture. Moreover, the Achilles' load increased by 24% after the rupture of ligaments indicating a reduction in its efficiency. This study suggests that if patients demonstrate primarily an increased laxity in internal rotation, the damage has solely occurred to the ATFL; however, if the constraint is reduced across multiple motions, there is likely damage to both ligaments. Higher loads in the Achilles suggest that it is overloaded after the injury; hence, targeting the calf muscles in rehabilitation exercises may reduce patients' pain.

scholarly journals Displacement of Sequential Syndesmotic Ankle Injuries Assessed by a 3D Weightbearing CT

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0012
Author(s):  
Arne Burssens ◽  
Nicola Krähenbühl ◽  
Hannes Vermue ◽  
Nathan Davidson ◽  
Maxwell Weinberg ◽  
...  
Keyword(s):  
External Rotation ◽  
Imaging Techniques ◽  
Pearson Correlation ◽  
Ankle Injuries ◽  
Deltoid Ligament ◽  
3D Analysis ◽  
Anatomical Landmarks ◽  
Posterior Translation ◽  
2D Imaging ◽  
Weightbearing Ct

Category: Ankle Introduction/Purpose: Syndesmotic ankle injuries are challenging to diagnose, since current 2D imaging techniques try to quantify a 3D displacement. Therefore, our aim was two-fold: to determine displacement of sequential syndesmotic ankle injuries under various amounts of load using a 3D weightbearing CT (WBCT) and to assess the relation with current 2D imaging. Methods: Seven paired male cadaver specimens were included (tibia plateau to toe-tip) and mounted into a custom-built frame. WBCT scans were obtained after different patterns of load (0 kg or 85 kg) were combined with torque (0 Nm or 10 Nm external rotation). These conditions were repeated after each ligament condition: intact ligaments, sequential sectioning of the anterior inferior tibiofibular ligament (AITFL), deltoid ligament (DL), and interosseous membrane (IOM). CT images were segmented to obtain 3D models. These allowed quantification of displacement based on the position of computed anatomical landmarks in reference to the intact position of the fibula. A correlation analysis was performed between the 2D and 3D measurements. Results: The effect of torque caused significant displacements in all directions (P<0.05), except for shortening of the fibula (P>0.05). Weight caused a significant lateral (mean=-1.4 mm, SD=1.5) and posterior translation (mean=-0.6 mm, SD=1.8). The highest displacement consisted of external rotation (mean=-9.4°, SD=6.5) and posterior translation (mean=6.1 mm, SD=2.3) after IOL sectioning combined with torque (Fig. 1). Pearson correlation coefficients were moderate (range 0.31-0.51, P<0.05). Conclusion: Torque demonstrated superiority over weight in detecting syndesmotic ankle instability after 3D analysis. The clinical relevance of these findings can improve diagnosis by incorporating rotatory platforms during imaging and treatment strategies by providing appropriate stabilization against rotation.

Biomechanical Analysis of Glenohumeral Internal Rotation Deficit in a Cadaveric Model

2010 ◽  
Author(s):  
Akash Gupta ◽  
Jeffrey Gates ◽  
Michelle H. McGarry ◽  
James E. Tibone ◽  
Thay Q. Lee
Keyword(s):  
Internal Rotation ◽  
Clinical Decision Making ◽  
Glenohumeral Joint ◽  
External Rotation ◽  
Clinical Decision ◽  
Biomechanical Analysis ◽  
Glenohumeral Internal Rotation Deficit ◽  
Posterior Translation ◽  
Throwers Shoulder ◽  
Cadaveric Model

Overhead throwing athletes have been shown to develop adaptive changes in humeral rotation to allow for higher throwing velocities. This manifests as an increase in humeral external rotation and a decrease in internal rotation, which is called glenohumeral internal rotation deficit (GIRD). The percentage of GIRD that significantly affects glenohumeral joint kinematics is not known. The objective of the study was to create a throwers shoulder model with fixed percentages of GIRD to determine at which point kinematic changes start occurring. The results showed that there was a significant decrease in posterior translation starting at 10% GIRD. With inferior translational loads, significantly less inferior translation starts occurring at 20% GIRD. The humeral head apex position at maximum external rotation moves superiorly, posteriorly and laterally, with significant changes in the superior direction occurring with 10% GIRD onwards. Overall, significant kinematic changes begin at 10% GIRD and this should be taken into account for clinical decision-making as to when intervention is necessary.

scholarly journals Restoration of Tibiofibular Kinematics with a Tricortical Screw or Suture Button Fixation After Syndesmotic Ankle Injuries

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0000
Author(s):  
Conor Murphy ◽  
Thomas Pfeiffer ◽  
Jason Zlotnicki ◽  
Volker Musahl ◽  
Richard Debski ◽  
...  
Keyword(s):  
Screw Fixation ◽  
External Rotation ◽  
Tracking System ◽  
Optical Tracking ◽  
Ankle Injuries ◽  
Suture Button ◽  
Tibiofibular Ligament ◽  
Cortical Screw ◽  
Significant Difference ◽  
Posterior Translation

Category: Ankle, Sports, Trauma Introduction/Purpose: Anterior inferior tibiofibular ligament (AITFL), Posterior inferior tibiofibular ligament (PITFL) and Interosseous membrane (IOM) disruption is a predictive measure of residual symptoms after ankle injury. In unstable injuries, the syndesmosis is treated operatively with cortical screw fixation or a suture button apparatus. Biomechanical analyses of suture button versus cortical screw fixation methods show contradicting results regarding suture button integrity and maintenance of fixation. The objective of this study is to quantify tibiofibular joint motion in syndesmotic screw and suture button fixation models compared to the intact ankle. Methods: Five fresh-frozen human cadaveric specimens (mean age 58 yrs.; range 38-73 yrs.) were tested using a 6-degree-of- freedom robotic testing system. The tibia and calcaneus were rigidly fixed to the robotic manipulator and the subtalar joint was fused. The full fibular length was maintained and fibular motion was unconstrained. Fibular motion with respect to the tibia was tracked by a 3D optical tracking system. A 5 Nm external rotation moment and 5 Nm inversion moment were applied to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. Outcome variables included fibular medial-lateral (ML) translation, anterior-posterior (AP) translation, and external rotation (ER) in the following states: 1) intact ankle, 2) AITFL transected, 3) PITFL and IOM transected, 4) 3.5 mm cannulated tricortical screw fixation, 5) suture button fixation. An ANOVA with a post-hoc Tukey analysis was performed for statistical analysis (*p<0.05). Results: Significant differences in fibular motion were only during the inversion moment. Fibular posterior translation was significantly higher with complete syndesmosis injury compared to the intact ankle at 0°, 15°, and 30° plantarflexion and the tricortical screw at 15° and 30°. Significantly higher fibular posterior translation was observed with the suture button compared to the intact ankle at 15° and 30 plantarflexion and to the tricortical screw at 15°. ER was significantly increased with complete injury compared to the tricortical screw at 0° and 30° plantarflexion. The suture button demonstrated significantly greater ER at 0° plantarflexion and 10° dorsiflexion compared to the intact ankle. The only significant difference in ML translation exists between the tricortical screw and complete injury at 30° plantarflexion. Conclusion: The suture button did not restore physiologic motion of the syndesmosis. It only restored fibular ML translation. Significant differences in AP translation and ER persisted compared to the intact ankle. The tricortical screw restored fibular motion in all planes. No significant differences were observed compared to the intact ankle. These findings are consistent with previous studies. This study utilized a novel setup to measure unconstrained motion in a full length, intact fibula. Physicians should evaluate AP translation and ER as critical fibular motions when reconstructing the syndesmosis with suture button fixation.

scholarly journals Investigation of the Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In-situ Force

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0041
Author(s):  
Yuzuru Sakakibara ◽  
Atsushi Teramoto ◽  
Tomoaki Kamiya ◽  
Kota Watanabe ◽  
Toshihiko Yamashita
Keyword(s):  
External Rotation ◽  
Anatomic Reconstruction ◽  
Anterior Talofibular Ligament ◽  
Ankle Sprains ◽  
Principle Of Superposition ◽  
Initial Tension ◽  
Graft Tension ◽  
In Situ Force ◽  
Ankle Kinematics

Category: Basic Sciences/Biologics Introduction/Purpose: Ankle sprains are the most common sports injuries, and anterior talofibular ligament (ATFL) injury comprised 85% of all ankle sprains. Most patients recover with conservative treatment, but 20% of them progress to chronic ankle instability. Some studies have reported that anatomic reconstruction using a tendon graft is one of the best procedures to restore the ankle to its condition before symptom development. However, the effect of initial graft tension during ATFL reconstruction is still unclear. Therefore, the objective of this study was to investigate the effect of the initial graft tension during ATFL reconstruction. Methods: Eight fresh-frozen cadaveric ankle specimens were subjected to passive plantarflexion (PF)-dorsiflexion (DF) movement from 15° DF to 30° PF using the 6-degree-freedom robotic system. In addition, 60 N of anterior-posterior load, 1.7 Nm of inversion-eversion (IV-EV) torque, and 1.7 Nm of internal-external rotation (IR-ER) torque were applied to the ankle. During testing, 3-dimensional paths of the ankle were recorded simultaneously. Furthermore, in-situ forces of the ATFL and reconstructed graft were calculated using the principle of superposition. A repeated experiment was designed with the intact condition (intact), ATFL transection, and ATFL reconstruction with four different initial graft tensions (10 N, 30 N, 50 N, and 70 N). Results: AP laxity, IV-EV laxity and IR-ER laxity with ATFL transection was significantly greater than those with intact. In ATFL transection, the talus was significantly translated anteriorly with inversion and internal rotations under passive PF-DF motion compared with intact. Kinematic patterns and laxity in ATFL reconstruction with initial tension of 10 N and 30 N almost imitated intact, but in ATFL reconstruction with initial tension 70 N, the talus was significantly translated with external rotation compared with intact. As the initial graft tension during ATFL reconstruction increased, in-situ force of the reconstructed graft tended to increase during PF-DF motion. In-situ force of the reconstructed graft tension was significantly greater with initial tensions of 50 N, and 70 N than with intact during PF-DF motion (Figure 1). Conclusion: ATFL deficiency altered ankle kinematics and laxity. Although the optimal initial graft tension during ATFL reconstruction might restore ankle kinematics and laxity, excessive initial graft tension caused abnormal kinematics and laxity. Furthermore, the reconstructed graft tension increased as the initial tension increased. Initial tension during ATFL reconstruction has the important effect of imitating the normal ankle condition. We suggest that over-tensioning during ATFL reconstruction should be avoided in order to imitate the conditions of a normal ankle.

scholarly journals Active Ankle Circumduction to Identify Mobility Deficits in Subacute Ankle Sprain Patients

2018 ◽  
Vol 34 (1) ◽  
pp. 1-6 ◽  
Author(s):  
Clément Theurillat ◽  
Ilona Punt ◽  
Stéphane Armand ◽  
Alice Bonnefoy-Mazure ◽  
Lara Allet
Keyword(s):  
Ankle Sprain ◽  
Clinical Relevance ◽  
Graphical Representation ◽  
Plantar Flexion ◽  
Biomechanical Model ◽  
Optoelectronic Device ◽  
Clinical Exam ◽  
Ankle Kinematics ◽  
Ankle Mobility ◽  
And Inversion

Assessment of ankle mobility is complex and of clinical relevance after an ankle sprain. This study develops and tests a biomechanical model to assess active ankle circumduction and its reliability. The model was then applied to compare individuals’ ankle mobility between injured and noninjured ankles after a sprain episode. Twenty patients with subacute unilateral ankle sprain were assessed at 4 weeks and 10 weeks after the injury. They underwent a clinical exam and an ankle circumduction test during which the kinematics were recorded with an optoelectronic device. A biomechanical model was applied to explore ankle kinematics. Reliability of the ankle circumduction tests were good to excellent (ICC of 0.55–0.89). Comparison between noninjured and injured ankles showed a mobility deficit of the injured ankle (dorsiflexion = −27.4%, plantar flexion = −25.9%, eversion = −27.2%, and inversion = −11.6%). The model allows a graphical representation of these deficits in 4 quadrants. Active ankle circumduction movement can be reliably assessed with this model. In addition, the graphical representation allows an easy understanding of the mobility deficits which were present in all 4 quadrants in our cohort of patients with subacute ankle sprain.

External Rotation Ankle Injuries: Investigating Ligamentous Rupture

2009 ◽  
Author(s):  
Mark R. Villwock ◽  
Eric G. Meyer ◽  
John W. Powell ◽  
Roger C. Haut
Keyword(s):  
High Frequency ◽  
Failure Load ◽  
Sports Injuries ◽  
External Rotation ◽  
Experimental Studies ◽  
Soft Tissue Injuries ◽  
Ankle Injuries ◽  
Ankle Sprains ◽  
Severity Of Injury ◽  
Ankle Complex

Ankle sprains are one of the most common sports injuries [1], accounting for 10% to 15% of these injuries [2]. The severity of injury varies greatly and the player’s recovery time is related to the structures involved and their degree of damage. In contrast to the soft tissue injuries reported in many clinical studies on the ankle, experimental studies have typically generated a high frequency of bone fracture when the foot/ankle complex is externally rotated [3–5]. In a majority of these manuscripts, the cadaveric test specimens are of advanced or unknown age. These variables may substantially affect both the failure load and the mode of failure in the joint, since most ankle sprains occur in people under the age of 35 years [6].

scholarly journals Syndesmotic Behavior after Sequential Sectioning: Simulation of Ligamentous Ankle Injuries in Vitro

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0001
Author(s):  
Robin P. Blom ◽  
Kaj S. Emanuel ◽  
Markus Knupp ◽  
Inger N. Sierevelt ◽  
Gino M.M.J. Kerkhoffs ◽  
...  
Keyword(s):  
External Rotation ◽  
Lower Limbs ◽  
Ankle Injuries ◽  
Deltoid Ligament ◽  
Active Motion ◽  
Need For Treatment ◽  
Ligament Rupture ◽  
Fresh Frozen ◽  
Rotation Stress

Category: Ankle, Trauma, Distal Tibiofibular Joint Introduction/Purpose: Ankle fractures are often associated with ligamentous injuries of the distal tibiofibular syndesmosis and the deltoid ligament. These injuries may predispose to instability, early joint degeneration and long-term ankle dysfunction. In the classic article of Boden it was made clear that injuries of the syndesmotic ligaments were of no importance in absence of a deltoid ligament rupture. Even in the presence of a deltoid ligament rupture, the interosseous membrane withstood lateralization of the talus in fixated fibula fractures up to 4.5 mm above the ankle joint. However, detection of ligamentous injuries and the need for treatment remain subject of ongoing debate. Syndesmotic injuries are often treated operatively by temporary fixation performed with positioning screws. But do isolated syndesmotic injuries need to be treated operatively at all? Methods: Ten fresh-frozen, exarticulated through the knee, human cadaveric lower limbs were tested under axial compressive loads of 50 and 700 N, simulating non-weightbearing and weightbearing conditions. All specimens were tested with different foot positions (plantigrade, dorsiflexion, inversion, eversion, and 10 Nm external rotational torque) during sequential sectioning of the syndesmotic ligaments and the deltoid ligament. We triangulated Boden’s classic findings with an active motion capture system (0.1 mm accuracy) to track the translations and rotations of the fibula relative to the tibia. Results: Isolated sectioning of the AITFL resulted in an increase of external fibula rotation up to 8.9 degrees (doubling the physiological 4.0 degrees) with an external rotation stress of 10 Nm in non-weightbearing conditions. However, weightbearing appeared somewhat protective, reducing the external rotation to 7.9 degrees. Sectioning of all syndesmotic ligaments with an intact deltoid ligament resulted in a syndesmotic widening of 0.9 mm in weightbearing conditions with a plantigrade foot. Dorsiflexion of the foot resulted in a significant increase of syndesmotic widening for all conditions of the syndesmotic ligaments. Sectioning of the deltoid ligament resulted in a significant increase of all fibula translations in all foot positions during weightbearing conditions. Conclusion: The results of our study have implications for common ligamentous ankle injuries and their treatment. In isolated syndesmotic injuries with a plantigrade foot, weightbearing seemed protective and limiting syndesmotic widening probably due to the saddle shape of the tibiotalar surface. Conservative treatment in a cast seems justifiable. External rotation stress causes the “open-book-phenomenon” in isolated AITFL injuries, especially in non-weightbearing conditions. Protection with cast or surgery is necessary. The deltoid ligament prevents lateralization of the talus but allows increased syndesmotic widening and external rotation of the fibula in dorsiflexion and external rotation stress due to the shape of the talus.

Effect of Shoe Stiffness on Injury Produced Under External Rotation of the Foot in Human Cadavers

2013 ◽  
Author(s):  
Keith D. Button ◽  
Mark A. Davison ◽  
Jerrod E. Braman ◽  
Maureen C. Schaefer ◽  
Roger C. Haut
Keyword(s):  
Ankle Sprain ◽  
External Rotation ◽  
Ankle Injuries ◽  
Upper Body ◽  
Deltoid Ligament ◽  
Ankle Sprains ◽  
Interosseous Ligament ◽  
Lateral Ankle ◽  
Human Cadavers ◽  
Anterior Deltoid

Ankle sprain is a common occurrence in sports, accounting for 10–30% of injuries 9. Injury to the lateral ligamentous complex occurs under excessive foot inversion and is known as a “lateral ankle sprain” 1. Injury to the anterior deltoid ligament (ADL), which consists of the tibionavicular ligament (TiNL) and the anterior tibiotalar ligament (ATiTL), is known as a “medial ankle sprain” 13. High ankle sprains occur in the distal tibiofibular syndesmosis, which is comprised of the anterior and posterior tibiofibular ligaments (ATiFL and PTiFL) and the interosseous ligament (IOL) 2. While approximately 85% of ankle sprains are lateral ankle injuries, syndesmotic (high) and medial injuries typically result in more time off the field. The mechanism of both high and medial ankle sprain is commonly ascribed to excessive internal rotation of the upper body, while the foot is planted on the playing surface.

scholarly journals Posterior Translation of the Fibula is a Critical Factor in the Stability of the Syndesmosis After Injury and Repair

2018 ◽  
Vol 6 (7_suppl4) ◽  
pp. 2325967118S0012
Author(s):  
Neel Patel ◽  
Thomas Rudolf Pfeiffer ◽  
Jan-Hendrik Naendrup ◽  
Conor Murphy ◽  
Jason Zlotnicki ◽  
...  
Keyword(s):  
Sagittal Plane ◽  
Screw Fixation ◽  
External Rotation ◽  
Tracking System ◽  
Optical Tracking ◽  
Ankle Injuries ◽  
Suture Button ◽  
Tibiofibular Ligament ◽  
Cortical Screw ◽  
Posterior Translation

Objectives: Anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM) disruption is a predictive measure of residual symptoms after an ankle injury. Unstable syndesmotic injuries are typically treated surgically with cortical screw or suture button fixation. Previous studies have shown contradicting findings regarding the effects of partial syndesmotic injuries and different surgical fixation methods on tibiofibular kinematics. Thus, the objective of this study was to quantify tibiofibular joint motion with sequential disruption of the syndesmosis and with syndesmotic screw and suture button fixation compared to the intact ankle. Methods: Nine fresh-frozen human cadaveric specimens (mean age 60 yrs.; range 38-73 yrs.) were tested using a six degree-of-freedom robotic testing system. The subtalar joint was fused and the tibia and calcaneus were rigidly fixed to a robotic manipulator, while complete fibular length was maintained and fibular motion was unconstrained. A 5 Nm external rotation moment and 5 Nm inversion moment were independently applied to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. Fibular motion with respect to the tibia was tracked by a 3D optical tracking system. Outcome variables included fibular medial-lateral (ML) translation, anterior-posterior (AP) translation, and external rotation (ER) in the following states: 1) intact ankle, 2) AITFL transected, 3) AITFL, PITFL, and IOM transected (complete injury), 4) 3.5 mm cannulated tricortical screw fixation, 5) suture button fixation. An ANOVA with a post-hoc Tukey analysis was performed for statistical analysis (*p < 0.05). Results: All significant differences in fibular motion between ankle states occurred during the inversion moment. An isolated AITFL injury caused significant increases in fibular posterior translation at 15° and 30° plantarflexion compared to the intact ankle. A complete syndesmotic injury caused significant increases in fibular posterior translation in all 4 ankle positions and in fibular ER at 0° flexion and 15° plantarflexion compared to the intact ankle. No significant differences were detected in fibular motion between an isolated AITFL injury and complete injury at any ankle positions. No significant differences existed between the tricortical screw fixation and the intact ankle. Significantly higher fibular posterior translation was observed with the suture button compared to the intact ankle at 0° flexion, 30° and 15° plantarflexion. (Figure 1) Conclusion: An isolated AITFL injury resulted in a significant increase in fibular posterior translation relative to the tibia, comparable to that a complete injury, especially in positions of plantarflexion. Current diagnostic protocols after injury focus on the evaluation of fibular ML translation. However, these findings show that it is important to also evaluate syndesmotic stability in the sagittal plane and at different ankle positions. Restoration of native tibiofibular kinematics is essential to prevent post-traumatic arthritis. Tricortical screw fixation was able to restore tibiofibular kinematics in all planes. However, suture button fixation was not able to restore tibiofibular AP translation, which suggests that physicians should critically evaluate fibular AP translation and individualize treatment of unstable ankle injuries when reconstructing the syndesmosis with suture button fixation. [Figure: see text]

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

2011 ◽  
Vol 4 (1) ◽  
pp. 5 ◽  
Author(s):  
Hans Polzer ◽  
Karl Georg Kanz ◽  
Wolf Christian Prall ◽  
Florian Haasters ◽  
Ben Ockert ◽  
...  
Keyword(s):  
External Rotation ◽  
Clinical Importance ◽  
Complex Iii ◽  
Ankle Injuries ◽  
Diagnosis And Treatment ◽  
Lateral Ligament ◽  
Evidence Based ◽  
Ankle Sprains ◽  
Level Of Evidence ◽  
Residual Symptoms

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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