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Evaluation of the painful foot is simplified because all aspects of the foot that may be designated as the site of pain by the patient are visible, palpable, and reproducible to the examiner. The tissue sites of pain in the foot are the joints, ligaments, tendons, or peripheral nerves. The mechanisms of pain and disability are elucidated by the patient in the history.

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The ankle essentially consists of the talotibial joint. The talus fits within the mortise formed by the malleoli of the tibia and the fibula, allowing primarily flexion and extension with limited lateral flexion on rotation. The talus allows no lateral or rotational movement within the mortise when dorsiflexed but allows some lateral motion when fully plantar flexed. It is in the plantar flexed position that the ankle sustains injury to its ligaments when there is excessive lateral rotatory movement upon the fixed foot.

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The ankle joint is made stable by its collateral ligaments. The ligaments on the medial side are the deltoid ligaments: anterior talotibial, tibionavicular, calcaneotibial, and posterior talotibial. Those on the lateral side are the anterior talofibular, calcaneofibular, talocalcaneal, and posterior talofibular. All ligaments are named according to the bones they connect and sustain injury when these bones are excessively separated from the sustained injury. The anterior talofibular ligament is the weakest and most frequently injured ligament (Figs. 33-1 and 33-2).

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Figure 33-2
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Medial (deltoid) collateral ligaments.

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A strain is a force, and a sprain is tissue damage from excessive strain. This damage may involve tearing of individual collagen fibers composing the ligament. The number and degree of sprain depends on the number and extent of the collagen fibers injured.

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Symptoms and Clinical Findings

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The history reveals the mechanism by which the ligamentous injury occurred. Local pain, tenderness, and swelling are common findings.

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Examination reveals the extent of swelling and tenderness. Mere edema implies minor sprain, whereas ecchymosis implies tearing, causing microhemorrhage and more severe injury.

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The examination will determine which ligament has been damaged and to what degree. The degree of inversion of the foot compared with the opposite side, using the same technique and moving the feet identically, reveals the degree of ligamentous injury. A complete tear allows excessive motion. A positive drawer sign implicates the posterior or anterior talofibular ligaments.

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Diagnosis is basically made by examination, but stress films may reveal talar tilt within the mortise. X-ray studies may also reveal an avulsion fracture when the lateral collateral ligaments have been excessively stressed.

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Treatment

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Treatment depends on the severity of the injury. Mild sprain (grade I) is an ...

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