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Ankle sprains are the commonest injury in sport and result in significant morbidity. There is increasing evidence in the literature to suggest that up to 40% of patients have ongoing disability and impairment after an ankle sprain. The concept of ankle sprain being a tear of the lateral ligaments in isolation is flawed. Since the introduction of ankle arthroscopy the presence of intra-articular pathology has been identified as a major cause of ongoing functional instability and pain.

Ankle sprains can result in permanent damage to:

· Articular cartilage: Tibial plafond and talar dome.

· Nerves: Direct blow traction RSD.

· Tendons: Peroneal tendon tibialis posterior tendon.

· Soft Tissues: Distal tibial fibular syndesmosis synovitis impingement lesions

· Bone: Fracture of the anterior process of the calcaneus snowboarders' fracture (lateral process talus) - Type II accessory naviculars.

Careful clinical re-evaluation of the injured ankle is indicated in all cases. The most common site for chondral lesions in the ankle is the medial aspect of the tibial plafond and talar dome. These lesions can be diagnosed clinically. A Bone Scan may be useful; however it can often be misleading in the evaluation of these injuries. MRI can miss up to 30% of chondral lesions in the ankle.

Investigation of a difficult ankle:

· X-rays: AP lateral internal and medial oblique views

· Technetium Scan with pinhole views (Bone Scan)

· CT Scan: Best if further evaluating fractures or bony injuries

· MRI: Useful where there is more than one problem, for example, fracture of the anterior process of the calcaneus in association with a chondral lesion of the ankle arising from an injury

Be aware that 17% of the population has asymptomatic tarsal coalitions which appear to become symptomatic following an ankle sprain. These patients often have restriction of subtalar movement on clinical examination.

The majority of patients with bad results following non-operative and operative intervention after an ankle sprain have a reflex sympathetic dystrophy or chronic regional pain type syndrome. The key to this condition is early recognition and treatment. Overall however, the prognosis is poor for these patients.

The literature reports an 85% chance of good or excellent results following arthroscopic ankle surgery. In the athlete this can mean a return to sport.

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