Overview
Definition:
Return-to-sport (RTS) criteria for pediatric ankle sprains are a set of guidelines and objective measures used to determine when a young athlete can safely resume physical activity and sports participation following an ankle injury
These criteria aim to minimize the risk of re-injury, chronic ankle instability, and long-term functional deficits
They go beyond simple symptom resolution, incorporating functional and biomechanical assessments to ensure readiness.
Epidemiology:
Ankle sprains are among the most common musculoskeletal injuries in pediatric athletes, with incidence rates varying by sport and age group
Lateral ankle sprains, involving the anterior talofibular ligament (ATFL), are the most frequent
Recurrence rates can be significant, highlighting the importance of appropriate rehabilitation and RTS protocols.
Clinical Significance:
Inadequate rehabilitation and premature return to sport in pediatric athletes can lead to recurrent sprains, chronic ankle instability, osteochondral lesions, persistent pain, and altered biomechanics, potentially impacting long-term athletic careers and quality of life
Adhering to evidence-based RTS criteria is crucial for optimizing outcomes and preventing long-term sequelae.
Age Considerations
Pediatric Differences:
Children have open physes, requiring careful consideration of potential physeal injuries alongside ligamentous sprains
Their growth plates may be more susceptible to avulsion fractures
Psychosocial factors, such as peer pressure and desire to return, are also significant in pediatric populations.
Developmental Stages:
RTS decisions must account for the child's developmental stage, including their cognitive understanding of instructions, emotional maturity in reporting symptoms, and motor control development
The ability to perform complex movements safely varies with age.
Parental Involvement:
Engaging parents or guardians is essential for understanding the child's compliance with rehabilitation, monitoring at home, and making informed decisions regarding RTS, especially in younger children who may not fully articulate their readiness.
Clinical Presentation
Symptoms:
Sudden onset of pain, often with a popping sensation at the time of injury
Swelling and bruising around the ankle, particularly on the lateral side
Difficulty bearing weight or walking
Limited range of motion
Feeling of instability or giving way
Recurrent episodes of ankle giving way or pain during activity.
Signs:
Tenderness to palpation over the affected ligaments (ATFL, CFL, PTFL)
Edema and ecchymosis
Antalgic gait
Limited passive range of motion, especially inversion and dorsiflexion
Positive anterior drawer test (suggesting ATFL injury)
Positive talar tilt test (suggesting CFL injury)
Potential for palpable deformity in severe cases or avulsion fractures.
Diagnostic Criteria:
While no single set of diagnostic criteria exists solely for pediatric ankle sprains, the Ottawa Ankle Rules are often adapted to guide the need for imaging in suspected fractures, distinguishing them from isolated sprains
Definitive diagnosis of sprain severity relies on clinical assessment of ligamentous integrity and functional capacity.
Diagnostic Approach
History Taking:
Mechanism of injury (inversion, eversion, forced dorsiflexion)
Location and intensity of pain
Presence of swelling and bruising
Ability to bear weight immediately after injury and at presentation
Previous ankle injuries or instability
Involvement in specific sports and their demands
Red flags: inability to bear weight for 4 steps, localized bony tenderness over malleoli or navicular bone (Ottawa Ankle Rules).
Physical Examination:
Palpation for bony and ligamentous tenderness
Assess for edema and ecchymosis
Evaluate range of motion (active and passive)
Perform special tests: anterior drawer, talar tilt, syndesmosis squeeze test
Assess gait and ability to perform single-leg hop
Examine contralateral ankle for comparison
Evaluate for signs of fracture or physeal injury.
Investigations:
Plain radiographs (anteroposterior, lateral, oblique views of the ankle) are indicated if the Ottawa Ankle Rules are positive or if there is suspicion of fracture or physeal injury
Ultrasound can be useful for assessing ligamentous integrity and effusion, especially in younger children
MRI is typically reserved for cases with persistent symptoms, suspected osteochondral lesions, or when surgical intervention is being considered.
Differential Diagnosis:
Physeal fractures (Salter-Harris types I-V)
Osteochondral fractures
Syndesmotic injury (high ankle sprain)
Peroneal tendon injuries
Tibialis posterior tendon dysfunction
Stress fractures
Referred pain
Avulsion fractures of the malleoli or talus.
Management
Initial Management:
PRICE (Protection, Rest, Ice, Compression, Elevation) is the cornerstone of initial management
Protection may involve bracing, taping, or crutches to offload the injured ankle
Relative rest from aggravating activities is crucial.
Rehabilitation Principles:
Phase 1: Protection and pain/swelling reduction
Phase 2: Restoration of range of motion, proprioception, and neuromuscular control
Phase 3: Strengthening and sport-specific drills
Gradual progression based on pain, swelling, and functional milestones
Education on proper technique and load management.
Functional Rehabilitation Exercises:
Range of motion exercises: alphabet drawing with the foot, passive stretches
Proprioception exercises: single-leg stance, tandem stance, balance board exercises
Strengthening exercises: calf raises, resistance band exercises for inversion/eversion
Plyometric exercises: hopping, jumping (progressed cautiously)
Sport-specific drills: cutting, pivoting, agility exercises.
Supportive Care:
Pain management with NSAIDs or acetaminophen as needed
Psychological support to address fear of re-injury and foster confidence
Nutritional support for tissue healing
Education for the athlete and parents on the rehabilitation process and RTS criteria.
Return To Sport Criteria
Objective Measures:
Full, pain-free range of motion (ROM) compared to the contralateral ankle
Minimal or no pain with weight-bearing activities and sports-specific movements
Successful completion of functional progression tests, including single-leg hop for distance (≥85% of contralateral limb), triple hop for distance (≥85%), and shuttle run tests without pain or instability
Absence of significant edema or tenderness.
Functional Strength And Proprioception:
Demonstrated adequate strength in ankle dorsiflexion, plantarflexion, inversion, and eversion, typically assessed via manual muscle testing or isokinetic dynamometry if available
Ability to maintain balance on unstable surfaces for a specified duration
Successful completion of agility drills without any signs of instability.
Psychological Readiness:
The athlete expresses confidence in their ankle's ability to withstand the demands of their sport
Absence of fear of re-injury or apprehension during sport-specific movements
Clear communication from the athlete about their readiness and willingness to adhere to any sport-specific return protocols.
Graded Return Protocol:
A phased approach allowing gradual reintroduction to sport
Starting with non-contact drills, progressing to limited contact, and finally full participation
Continuous monitoring for any recurrence of pain, swelling, or instability
A return-to-play decision should be made collaboratively by the athlete, parents, and healthcare provider.
Complications
Early Complications:
Infection (rare, usually related to surgery)
Compartment syndrome (rare, typically with severe trauma)
Significant neurovascular compromise (rare).
Late Complications:
Chronic ankle instability
Recurrent ankle sprains
Osteochondral lesions of the talus
Post-traumatic arthritis
Chronic pain
Peroneal tendon pathology
Tarsal tunnel syndrome
Altered biomechanics leading to injuries in other joints (knee, hip).
Prevention Strategies:
Adherence to RTS criteria
Comprehensive rehabilitation program focusing on strength, ROM, and proprioception
Proper footwear and bracing when indicated
Education on safe sports techniques and avoiding risky maneuvers
Prompt and appropriate management of initial injury
Gradual increase in training load.
Prognosis
Factors Affecting Prognosis:
Severity of the initial sprain
Adherence to rehabilitation protocols
Age of the athlete
Presence of associated injuries (e.g., osteochondral lesions)
Previous history of ankle instability
Return to sport without meeting full RTS criteria.
Outcomes:
Most pediatric ankle sprains, when managed appropriately and with adherence to RTS criteria, have a good prognosis for full recovery and return to sport
However, a significant minority may develop chronic instability or pain if rehabilitation is incomplete or RTS is premature.
Follow Up:
Regular follow-up with a healthcare provider or physical therapist is recommended during rehabilitation
Post-RTS, continued monitoring for recurrence of symptoms is advised
Educating athletes and parents on long-term ankle health is important.
Key Points
Exam Focus:
Emphasis on objective RTS criteria (ROM, strength, hop tests) rather than just time elapsed
Understanding the Ottawa Ankle Rules for pediatric fractures
Awareness of physeal injury implications in children
Differentiating between sprains and other ankle injuries in the pediatric population.
Clinical Pearls:
Always compare injured ankle to the contralateral side for objective assessment
Emphasize proprioception and neuromuscular control as key to preventing recurrence
Educate athletes and parents about the risks of premature return
Consider psychological readiness alongside physical parameters.
Common Mistakes:
Relying solely on subjective reports of "feeling better"
Returning athletes to sport based on arbitrary timeframes without functional assessment
Neglecting proprioceptive and neuromuscular training
Underestimating the importance of psychological readiness
Inadequate assessment for associated injuries or physeal damage.