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Ankle Injuries & Pathology

Ankle sprains & instability: epidemiology, mechanisms, progression to LAI/osteoarthritis, and surgical decision-making framework.

Overview

Osteochondral lesions of the talus typically arise as late sequelae of ankle trauma, complicated by the bone's limited capacity for repair [1]. While ankle fractures may induce tibiotalar instability, they generally yield favorable outcomes when managed appropriately via surgical or nonsurgical pathways [2]. In acute settings, the Ottawa ankle rule demonstrates high sensitivity for excluding fractures in adults and can correctly predict fracture likelihood when present, though lower specificity rates increase the risk of false positives [4].

Management strategies vary by patient demographic and pathology. Pediatric athletes frequently sustain ankle injuries due to underlying abnormalities; acute sprains are typically treated nonsurgically with immobilization and rehabilitation, whereas chronic pathologies may require surgical intervention [7]. For lateral ankle sprains in athletes, functional nonsurgical management is the preferred approach [8]. Regarding stable ankle fractures, non-surgical treatment does not increase reoperation rates due to non-union [11]. In cases of osteochondral lesions of the posteromedial talar dome, anterior ankle arthroscopy facilitates successful microfracture procedures, provided no combined posterior pathology necessitates alternative surgical intervention [10].

Diagnostic and outcome assessment tools include the SEFAS, which is designed for a range of foot disorders including ankle fractures and possesses the best measurement properties in this specific population [17]. Surgical decision-making for instability requires careful anatomical consideration of the posteromedial neurovascular bundle to minimize injury risk [3]. Deltoid ligament repair or reconstruction is indicated only in patients reporting instability or those with peroperatively demonstrated medial instability and ligament pathology [30]. For multiligamentous injuries, arthroscopic repair of all injured ligaments offers the best potential outcomes, yielding clinical results similar to isolated lateral ligament injury treatment at two-year follow-up [15]. Finally, meta-analyses of isolated Weber B fractures do not currently support a definitive recommendation for conservative treatment over surgical intervention [31].

Anatomy & Pathophysiology

Osseous

Osteochondral lesions of the talus typically present as late sequelae of ankle trauma, occurring in a bone with limited intrinsic capacity for repair [1]. Rotational ankle fractures encompass a spectrum ranging from simple injuries with minimal long-term effects to complex injuries resulting in severe sequelae [5]. While multiple bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults, ankle fractures specifically may result in tibiotalar instability [2, 6]. In the majority of patients with ankle osteoarthritis, the average tibiotalar alignment is varus regardless of the underlying etiology [14].

Ligamentous

Although isolated lateral ligament ankle injury is less common than generally believed, arthroscopic repair of every injured ligament provides the best potential outcomes for treating ankle instability [9, 15]. Both open and arthroscopic anterior talofibular ligament (ATFL) repairs have achieved statistically significant improvements in functional outcomes and effectively addressed functional and mechanical ankle instability [20]. The collateral ligaments of the human ankle contain four typical types of mechanoreceptors, with Pacinian corpuscles being predominant within all complexes [45]. The primary function of these ankle collateral ligaments is to sense joint speeds during motion [45].

Vascular & Neural

Anatomic characteristics of the posteromedial neurovascular bundle must be considered during ankle surgery to reduce the risk of injury to the medial neurovascular bundle [3]. The posteromedial approach to the ankle is a safe technique that enables good visualization and reduction of individual fracture fragments with promising early outcomes [27].

Diagnostic & Kinematic Considerations

Application of the Ottawa ankle rule is highly sensitive for predicting the likelihood of ankle fractures when present, though it exhibits lower specificity rates that increase the likelihood of false positives [4]. Current radiological parameters remain insufficient to differentiate mild inherent anatomical asymmetry from malreduction of the syndesmosis [35]. Anterior ankle arthroscopy allows for the successful performance of the microfracture procedure for osteochondral lesions of the posteromedial talar dome, unless combined pathology necessitates surgical intervention on the posterior ankle [10]. Functional nonsurgical management is supported as the preferred method for lateral ankle sprains [8].

Classification

Osteochondral Lesions: Osteochondral lesions of the talus are usually late sequelae of ankle trauma [1].

Ankle Fractures: Ankle fractures may result in tibiotalar instability [2] but typically have good outcomes when appropriately managed either surgically or nonsurgically [2]. Rotational fractures of the ankle range from simple injuries with minimal long-term effects to complex injuries with severe sequelae [5]. Multiple, various-stage bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults [6].

Ligamentous Injury: Functional nonsurgical management is supported as the preferred method for lateral ankle sprains in athletes [8]. Isolated lateral ligament ankle injury is not as common as is believed [9], whereas avulsion fracture of the lateral ankle ligaments in cases of severe inversion injury is more common than previously believed [18].

Pediatric Pathology: Acute ankle sprains in pediatric athletes are typically treated nonsurgically with immobilization and rehabilitation [7]. Chronic ankle pathologies in pediatric athletes may require surgical management [7].

Classification Systems: The DAFC system offers a reliable and comprehensive framework for ankle fracture classification [37] and provides prognostic insights regarding dislocation and posterior malleolus involvement [37]. The SEFAS has the best measurement properties for a range of foot disorders including ankle fractures [17].

Other Considerations: Outcome assessment tools and injury phenotypes are integrated into the broader management of ankle pathology, with specific systems like the DAFC and SEFAS guiding classification and measurement respectively [17, 37].

Clinical Presentation

Osteochondral lesions of the talus typically present as late sequelae of ankle trauma [1]. Correct early diagnosis is critical given the talus's functional significance and limited repair capacity [1]. While anterior ankle arthroscopy successfully facilitates microfracture for lesions of the posteromedial talar dome in most cases, it may prove insufficient if combined posterior pathology necessitates intervention [10].

Rotational fractures represent common injuries ranging from simple presentations with minimal long-term effects to complex cases with severe sequelae [5]. Ankle fractures frequently result in tibiotalar instability [2]. The Ottawa ankle rule demonstrates high sensitivity for predicting the likelihood of ankle fractures, though lower specificity rates increase the risk of false positives [4]. Clinical examination alone is insufficient to detect syndesmotic injuries in acute ankle sprains [19].

Pediatric Considerations: Ankle injuries are common in pediatric athletes and often stem from underlying abnormalities [7]. Acute sprains in this population are typically managed nonsurgically with immobilization and rehabilitation [7], yet they frequently result in a high incidence of chondral avulsion fractures [26]. Radiography may be inadequate for accurately diagnosing these chondral avulsion fractures [26]. Conversely, chronic ankle pathologies in pediatric athletes may require surgical management [7].

Stress Injuries: Multiple bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults [6]. In adolescent recreational dancers, stress fractures of the distal tibial physis are rare but should be entertained given the insidious onset of pain [12].

Chronic Pathology and Alignment: Functional nonsurgical management is the preferred method for lateral ankle sprains in athletes [8], although isolated lateral ligament injuries are less common than believed [9]. In the majority of patients with ankle osteoarthritis, average tibiotalar alignment is varus regardless of etiology [14]. Pathology of Kager's fat pad should be considered when investigating posterior ankle pain [24].

Prognosis and Recovery: Prognostic factors for full recovery after initial ankle sprain are inconsistent. Young age, low activity level, low-grade injury, good functional status, good neuromuscular function, and the absence of associated injuries are all linked to better recovery [25]. However, associated injuries may delay return to sport following acute lateral ligament repair in professional athletes [13], and symptoms may persist despite a return to the same level of competition [13].

Investigations

Plain radiography: The Ottawa ankle rule demonstrates high sensitivity for predicting ankle fractures, though lower specificity increases the likelihood of false positives [4]. While ankle fractures typically yield good outcomes with appropriate management, they may result in tibiotalar instability [2]. Radiography remains inadequate for accurately diagnosing chondral avulsion fractures in children with acute ankle sprains, despite these injuries occurring frequently in that population [26]. Furthermore, current radiological parameters are insufficient to differentiate mild inherent anatomical asymmetry from syndesmotic malreduction [35].

MRI: MRI is indispensable for evaluating deeper complex structures, such as the superficial deltoid ligament (SDM) and fracture lesions, in ankle injuries [40]. Enhanced ankle MRI is useful and important for predicting the nature of cystic osteochondral lesions [39]. Osteochondral lesions of the talus are usually late sequelae of ankle trauma, and their early diagnosis is critical due to the talus's functional significance and limited repair capacity [1]. Anterior ankle arthroscopy allows successful microfracture for posteromedial talar dome lesions unless combined pathology requires posterior intervention [10]. In contrast, MRI findings of varying injury grades in calf muscle strain injuries do not significantly correlate with final functional outcomes [16].

Ultrasonography: Ultrasonography and magnetic resonance imaging exhibit a complementary relationship in the evaluation of ankle injuries [40]. Ultrasonography may be utilized as an imaging modality option for lateral ankle sprains in children [43]. However, the roles of both ultrasonography and MRI during the healing process after Achilles tendon rupture are limited due to a weak correlation with clinical findings [47].

Other Considerations: Clinical examination is insufficient to detect syndesmotic injuries in acute ankle sprains [19]. Pathology of the Kager's fat pad should be considered when investigating posterior ankle pain [24]. Anatomic characteristics of the posteromedial neurovascular bundle must be considered during ankle surgery to reduce injury risk [3]. Multiple, various-stage bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults [6]. Isolated lateral ligament ankle injury is less common than believed, whereas avulsion fractures of the lateral ankle ligaments in severe inversion injuries are more common than previously thought [9, 18]. In the majority of patients with ankle osteoarthritis, the average tibiotalar alignment is varus regardless of etiology [14].

Treatment

Non-Operative

Correct early diagnosis of osteochondral lesions of the talus is critical due to the functional significance of the talus and its limited capacity for repair [1], as these lesions are usually late sequelae of ankle trauma [1]. Acute ankle sprains in pediatric athletes are typically treated nonsurgically with immobilization and rehabilitation [7], and functional nonsurgical management is supported as the preferred method for lateral ankle sprains in athletes [8]. Functional treatment yields comparable results to operative treatment for ankle sprains [36], is associated with a lower cost [36], facilitates a faster return to work or sports [36], and is preferable in most cases of ankle sprains [36]. Non-surgical treatment of stable ankle fractures does not lead to an increase in reoperations caused by non-union [11]. A 7-day course of treatment with a ketoprofen patch is useful in benign ankle sprain and did not reveal unexpected adverse events [29]. Treatment of os trigonum syndrome begins with nonsurgical measures [46].

Operative

Indications: Surgical management is indicated for chronic ankle pathologies in pediatric athletes [7], symptomatic athletes with os trigonum syndrome requiring excision [46], and Achilles tendon partial tears recalcitrant to conservative treatment [41]. Operative intervention for ankle fractures is appropriate when anatomic reduction is required, as ankle fractures may result in tibiotalar instability [2]. While ankle fractures typically have good outcomes when appropriately managed either surgically or nonsurgically [2], the meta-analysis does not allow for a definitive recommendation of conservative treatment over surgical intervention for isolated Weber B ankle fractures [31]. Operative intervention for Achilles tendon partial tears is successful irrespective of the level of the injury (midportion or retrocalcaneal area) [41].

Surgical Approach / Technique: Anterior ankle arthroscopy allowed for the successful performance of the microfracture procedure in most cases of osteochondral lesions of the posteromedial talar dome [10], though this procedure may not be successful if there is a combined pathology necessitating surgical intervention on the posterior ankle [10]. The posteromedial approach to the ankle is a safe technique that enables good visualization and reduction of individual fracture fragments and has promising early outcomes [27]. Anatomic characteristics of the posteromedial neurovascular bundle should be kept in mind during ankle surgery to reduce the risk of injury to the bundle [3]. Arthroscopic treatment of ankle multiligamentous injuries provides similar clinical outcomes to the treatment of isolated lateral ligament injury at the 2-year follow-up [15], yet arthroscopic repair of each and every ligament that appears injured provides the best potential outcomes when treating ankle instability [15]. Open and arthroscopic ATFL repairs equally achieved statistically significant improvement in functional outcome and effectively addressed functional and mechanical ankle instability [20].

Adjuncts: The application of the Ottawa ankle rule is highly sensitive and can correctly predict the likelihood of ankle fractures when present, though lower specificity rates increase the likelihood of false positives [4]. MRI findings of varying injury grades did not significantly correlate with final functional outcomes in patients with calf muscle strain injuries in a non-athletic population [16].

Other Considerations: Rotational fractures of the ankle range from simple injuries with minimal long-term effects to complex injuries with severe sequelae [5]. Ankle injuries are common in pediatric athletes and often result from underlying abnormalities [7]. Associated injuries may delay return to sport following acute lateral ligament repair of the ankle in professional athletes, and symptoms may continue despite return to the same level of competition [13].

Complications

Instability: Osteochondral lesions of the talus typically present as late sequelae of ankle trauma [1], while ankle fractures may result in tibiotalar instability [2]. Chronic ankle pathologies often necessitate surgical management [7]. Although isolated lateral ligament injuries are less common than believed, avulsion fractures of these ligaments in severe inversion injuries occur more frequently than previously thought [9, 18]. Repair or reconstruction of the deltoid ligament is reserved for patients reporting instability with peroperatively demonstrated medial pathology [30]. Associated injuries can delay return to sport following acute lateral ligament repair, and symptoms may persist even after returning to the same competitive level [13].

Trauma Sequelae: Complex ankle fractures carry severe sequelae [5], and long-term outcomes for distal tibial pilon fractures correlate with the severity of bone and soft-tissue injury as well as reduction quality [21]. Non-surgical treatment of stable ankle fractures does not increase reoperations due to non-union [11]. Multiple bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults [6], and bone bruises following sprains correlate with the severity of soft-tissue injury [42]. In dancers and gymnasts, stress fractures of the distal tibial physis should be considered despite their rarity [12].

Arthritis and Alignment: In the majority of ankle osteoarthritis cases, tibiotalar alignment is varus regardless of etiology [14]. Modern ankle arthroplasty implants demonstrate survivorship greater than 90% at short-term follow-up [23].

Other Considerations: The nature of life impact following ankle fractures extends beyond short-term pain into many areas of life [22]. In the National Basketball Association, games played and prior hip, hamstring, or quadriceps injuries are risk factors for ankle injuries, while physiologic burden factors like minutes per game and usage rate are associated with increased time loss [32]. Repair of chronic Achilles tendon rupture using two intratendinous flaps from the proximal gastrocnemius-soleus complex allows for defect bridging with minimal complications and good final outcomes [44].

Recovery

Light activity (weeks): Return to desk work, driving, and light activities of daily living is contingent on fracture stability and injury severity. While ankle fractures typically yield good outcomes with appropriate management, rotational variants range from simple injuries with minimal long-term effects to complex cases with severe sequelae [2, 5]. Non-surgical treatment of stable fractures does not increase reoperation rates due to non-union [11]. For benign ankle sprains, a 7-day course of ketoprofen patch treatment is useful and reveals no unexpected adverse events [29].

Full activity (months): Return to sport and manual work is influenced by injury complexity and associated pathologies. Associated injuries may delay return to sport following acute lateral ligament repair in professional athletes, and symptoms may persist despite returning to the same competitive level [13]. In the National Basketball Association, games played, prior history of hip, hamstring, or quadriceps injuries, minutes per game, and usage rate are risk factors for ankle injuries and increased time loss [32]. Multiple bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults, complicating the timeline for full activity [6].

Complete recovery / outcome plateau (months): Final functional outcomes stabilize based on the nature of the initial trauma and patient-specific factors. Osteochondral lesions of the talus are usually late sequelae of ankle trauma, necessitating early diagnosis due to the talus's limited repair capacity [1]. Long-term outcomes of distal tibial pilon fractures correlate with injury severity and reduction quality, with more severe fractures yielding poorer results [21]. Prognostic factors for full recovery after initial ankle sprain are inconsistent, though young age, low activity level, low-grade injury, good functional status, good neuromuscular function, and absence of associated injuries are linked to better recovery [25]. The impact of ankle fractures can extend beyond short-term pain into many areas of life [22].

Rehabilitation protocol: Management strategies vary by pathology. Ankle fractures may result in tibiotalar instability requiring surgical or non-surgical intervention [2]. Modern ankle arthroplasty implants demonstrate survivorship greater than 90% at short-term follow-up, influencing long-term rehabilitation goals [23]. MRI findings of varying injury grades in calf muscle strains do not significantly correlate with final functional outcomes, suggesting imaging alone may not dictate rehabilitation intensity [16].

Functional milestones: Outcome trajectories are defined by the specific injury type and patient demographics. Young age, low activity level, low-grade injury, good functional status, good neuromuscular function, and no associated injury are linked to better recovery after initial ankle sprain [25]. Games played and prior history of hip, hamstring, or quadriceps injuries were found to be risk factors for ankle injuries in the National Basketball Association [32].

Other Considerations: Clinicians must account for the functional significance of the talus and its limited capacity for repair when diagnosing osteochondral lesions early [1]. The nature of life impact following ankle fractures can extend beyond short term pain and discomfort into many areas of life [22].

Key Evidence

  • [L4] Osteochondral lesions of the talus are usually late sequelae of ankle trauma; correct early diagnosis is important due to the functional significance of the talus and its limited capacity for repair. (10.5435/00124635-201010000-00005)
  • [L5] Anatomic characteristics should be kept in mind when ankle surgery is performed, thereby reducing the risk of injury to the medial neurovascular bundle. (10.1016/j.arthro.2007.08.030)
  • [L1] Application of the OAR is highly sensitive and can correctly predict the likelihood of ankle fractures when present, however, lower specificity rates increase the likelihood of false positives. (10.1186/s12891-022-05831-7)
  • [L4] Multiple, various-stage bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults. (10.1177/0363546506295701)
  • [L4] Isolated lateral ligament ankle injury is not as common as is believed. (10.1177/2325967113517078)
  • [L3] Anterior ankle arthroscopy allowed for the successful performance of the microfracture procedure in most cases, unless there was a combined pathology necessitating surgical intervention on the posterior ankle. (10.1177/23259671251324176)
  • [L3] The non-surgical treatment of stable ankle fractures does not lead to an increase in reoperations caused by non-union. (10.1186/s12891-024-07924-x)
  • [L4] Although obviously rare, in light of the insidious onset of ankle pain in dancers and gymnasts, this diagnosis should be entertained. (10.1177/0363546513485938)
  • [L3] Associated injuries may delay return and symptoms may continue despite return to the same level of competition. (10.1007/s00167-015-3815-1)
  • [L2] Therefore, when treating ankle instability, arthroscopic repair of each and every ligament that appears injured provides the best potential outcomes and is the recommended treatment. (10.1002/ksa.12164)
  • [L3] MRI findings of varying injury grades did not significantly correlate with the final functional outcomes in this non-athletic population. (10.1186/s12891-024-08119-0)
  • [L3] The SEFAS is designed for a range of foot disorders including ankle fractures and has the best measurement properties in this population. (10.1186/s12891-018-2051-5)
  • [L2] Avulsion fracture of the lateral ankle ligaments in cases of severe inversion injury is more common than previously believed. (10.1177/0363546507299531)
  • [L1] Clinical examination was insufficient to detect syndesmotic injuries in acute ankle sprains. (10.1007/s00167-015-3604-x)
  • [L2] Open and arthroscopic ATFL repairs equally achieved statistically significant improvement in functional outcome and effectively addressed functional and mechanical ankle instability. (10.1177/23259671261417357)
  • [L4] The nature of life impact following ankle fractures can extend beyond short term pain and discomfort into many areas of life. (10.1186/1471-2474-13-224)
  • [Case_report] Our case details the importance of considering pathology of the Kager's fat pad when investigating posterior ankle pain. (10.1186/s12891-025-09336-x)
  • [L4] Prognostic factors for full recovery after initial ankle sprain are not consistent; however, factors such as young age, low activity level, low grade injury, good functional status, good neuromuscular function, and no associated injury are linked to better recovery. (10.1302/2058-5241.5.200019)
  • [L3] Acute ankle sprains in children frequently result in a high incidence of chondral avulsion fractures, but radiography may be inadequate for accurately diagnosing these fractures. (10.1186/s13018-025-05480-1)
  • [L4] The posteromedial approach to the ankle is a safe technique that enables good visualisation and reduction of the individual fracture fragments with promising early outcomes. (10.1302/0301-620x.99b11.bjj-2017-0558.r1)
  • [L1] This trial suggested that a 7-day course of treatment with a ketoprofen patch is useful in benign ankle sprain, without revealing unexpected adverse events. (10.1177/0363546504268135)
  • [L3] It is concluded that repair or reconstruction of the deltoid ligament is only performed in patients reporting ankle instability and with peroperatively demonstrated medial instability and pathology to the ligament. (10.1002/ksa.12459)
  • [L1] The meta-analysis does not allow for a definitive recommendation of conservative treatment over surgical intervention for isolated Weber B ankle fractures. (10.1186/s13018-024-04835-4)
  • [L4] Games played and prior history of hip, hamstring, or quadriceps injuries were found to be risk factors for ankle injuries, while factors associated with physiologic burden such as minutes per game and usage rate were associated with increased time loss after injury. (10.1177/23259671231184459)
  • [L4] Current radiological parameters are insufficient to differentiate mild inherent anatomical asymmetry from malreduction of the syndesmosis. (10.1302/0301-620x.103b1.bjj-2020-0844.r1)
  • [L5] Functional treatment yields comparable results to operative treatment at a lower cost with a faster return to work or sports, and is preferable in most cases of ankle sprains. (10.1007/s001670050111)
  • [L4] The DAFC system offers a reliable and comprehensive framework for ankle fracture classification, with the added benefit of prognostic insights, particularly regarding dislocation and posterior malleolus involvement. (10.1186/s13018-025-05539-z)
  • [L4] Enhanced ankle MRI was found to be useful and important for predicting the nature of cystic osteochondral lesions. (10.1007/s00167-011-1411-6)
  • [L3] In contrast, MRI is indispensable for evaluating deeper complex structures, such as the SDM and fracture lesions, with both modalities exhibiting a complementary relationship. (10.1186/s12891-026-09662-8)
  • [L3] In Achilles tendon partial tears recalcitrant to conservative treatment, operative intervention is highly successful in most cases, irrespective of the level of the injury. (10.1186/s13018-020-01856-7)
  • [L4] The occurrence of bone bruises should be kept in mind following ankle sprains, as their incidence appears to be correlated to the degree of severity of the soft-tissue injury. (10.1007/s001670050036)
  • [L2] Ultrasonography may be used as an option of imaging modality for lateral ankle sprain in children. (10.1186/s12891-020-03287-1)
  • [L4] This technique allows for a bridging of the defect present in chronic ruptures of Achilles tendons, with a minimum of complications and a good final outcome. (10.1177/0363546509333009)
  • [L5] The four typical types of mechanoreceptors were all identified in the collateral ligaments of the human ankle, with Pacinian corpuscles being predominant in all complexes, indicating that the main function of ankle collateral ligaments is to sense joint speeds in motions. (10.1186/s13018-015-0215-7)
  • [L5] Treatment begins with nonsurgical measures, but symptomatic athletes may require surgical excision of the os trigonum. (10.5435/jaaos-22-09-545)
  • [L1] The roles of ultrasonography and magnetic resonance imaging during the healing process after Achilles tendon rupture are limited, due to a weak correlation with clinical findings. (10.1007/s001670100245)

See Also

References

[1] Osteochondral Lesions of the Talus. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201010000-00005

[2] Chapter 43 Ankle Fractures. 2021.

[3] The Posteromedial Neurovascular Bundle of the Ankle: An Anatomic Study Using Plastinated Cross Sections. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.08.030

[4] Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05831-7

[5] Chapter 103 Fractures of the Ankle and Tibial Plafond. 2019.

[6] Bone Stress Injuries of the Ankle and Foot. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506295701

[7] Chapter 53 Ankle Injuries. 2020.

[8] Chapter 23 Ankle and Foot Injuries and Other Disorders. 2019.

[9] The Anatomic Pattern of Injuries in Acute Inversion Ankle Sprains. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113517078

[10] Approach to Osteochondral Lesions of the Posteromedial Talar Dome: A Review of Arthroscopic Videos. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251324176

[11] Non-surgical treatment of lateral malleolar fractures is safe: long-term follow-up of a comprehensive treatment algorithm. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07924-x

[12] Stress Fracture of the Distal Tibial Physis in an Adolescent Recreational Dancer. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513485938

[13] Return to sport following acute lateral ligament repair of the ankle in professional athletes. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3815-1

[14] Etiology_of_Ankle_Osteoarthritis_00003086-200907000-00022. 2009.

[15] Arthroscopic treatment of ankle multiligamentous injuries provides similar clinical outcomes to the treatment of isolated lateral ligament injury at the 2‐year follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12164

[16] Correlation between MRI findings and functional outcomes in patients with calf muscle strain injuries: a retrospective study on 78 patients. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08119-0

[17] Evaluation of three patient reported outcome measures following operative fixation of closed ankle fractures. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2051-5

[18] Avulsion Fracture of the Lateral Ankle Ligament Complex in Severe Inversion Injury. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507299531

[19] Isolated syndesmotic injuries in acute ankle sprains: diagnostic significance of clinical examination and MRI. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3604-x

[20] No Difference Between Open and Arthroscopic ATFL Repair, Both Yielding Clinically Significant Improvement in Chronic Ankle Instability: A Randomized Controlled Trial. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261417357

[21] Chapter 44 Distal Tibial Pilon Fractures. 2021.

[22] Life impact of ankle fractures: Qualitative analysis of patient and clinician experiences. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-224

[23] Chapter 114 Arthritides of the Foot and Ankle. 2019.

[24] Traumatic fracture of Kager’s fat pad: a case report. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09336-x

[25] Prognostic factors in ankle sprains: a review. EFORT Open Reviews. 2020. DOI: 10.1302/2058-5241.5.200019

[26] Radiography may not be accurate in assessing acute ankle sprains in children. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05480-1

[27] An evolution in the management of fractures of the ankle. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b11.bjj-2017-0558.r1

[29] Topical Ketoprofen Patch (100 mg) for the Treatment of Ankle Sprain: A Randomized, Double-Blind, Placebo-Controlled Study. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546504268135

[30] Good rate of satisfaction but suboptimal clinical outcome at long‐term follow‐up in a large series of patients who had operative stabilization of the deltoid ligament of the ankle. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12459

[31] Comparison of operatively and nonoperatively treated isolated Weber B ankle fractures: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04835-4

[32] Characterization of Ankle Injuries and Associated Risk Factors in the National Basketball Association: Minutes Per Game and Usage Rate Associated With Time Loss. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/23259671231184459

[35] Assessment of malreduction standards for the syndesmosis in bilateral CT scans of uninjured ankles. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b1.bjj-2020-0844.r1

[36] Treatment of ankle sprains. Knee Surgery, Sports Traumatology, Arthroscopy. 1999. DOI: 10.1007/s001670050111

[37] A novel alphanumeric classification system for ankle fractures: clinical applications and evaluation. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05539-z

[39] Role of arthroscopic microfracture for cystic type osteochondral lesions of the talus with radiographic enhanced MRI support. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1411-6

[40] Diagnostic performance of ultrasound and magnetic resonance imaging in ankle injuries: a retrospective cohort study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09662-8

[41] Minimum 3.5-year outcomes of operative treatment for Achilles tendon partial tears in the midportion and retrocalcaneal area. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01856-7

[42] Bone bruises detected by magnetic resonance imaging following lateral ankle sprains. Knee Surgery, Sports Traumatology, Arthroscopy. 1997. DOI: 10.1007/s001670050036

[43] Diagnosis of avulsion fractures of the distal fibula after lateral ankle sprain in children: a diagnostic accuracy study comparing ultrasonography with radiography. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03287-1

[44] Repair of Chronic Rupture of the Achilles Tendon using 2 Intratendinous Flaps from the Proximal Gastrocnemius-Soleus Complex. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509333009

[45] Morphological study of mechanoreceptors in collateral ligaments of the ankle joint. Journal of Orthopaedic Surgery and Research. 2015. DOI: 10.1186/s13018-015-0215-7

[46] Os Trigonum Syndrome. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-09-545

[47] The ultrasonographic appearance of the ruptured Achilles tendon during healing: a longitudinal evaluation of surgical and nonsurgical treatment, with comparisons to MRI appearance. Knee Surgery, Sports Traumatology, Arthroscopy. 2001. DOI: 10.1007/s001670100245

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Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.