Topic:
Ankle Injuries
Content:
•Functional Anatomy;
•Acute Ankle Injuries;
•Ankle Examination;
•Lateral Ligament Injuries (Ankle Sprain);
•Medial Ligament Injuries;
•Pott's Fracture;
•Persistent Ankle pain;
•Some X-ray of Ankle Injuries;
ACUTE ANKLE INJURIES
Functional anatomy:
The ankle contains three joints:
1. Talocrural (ankle) joint;
2. Inferior tibiofibular joint;
3. Subtalar joint;
medial malleolus
•The talocrural or ankle joint is a
hinge joint formed between the
talus
inferior surface of the tibia and the
superior surface of the talus.
•The inferior tibiofibular joint is the
articulation of the distal parts of the
fibula and tibia.
The subtalar joint, between the talus and
Calcaneus, is divided into an anterior and
posterior articulation separated by the sinus tarsi.
Ligaments of the Ankle:
antero inferior tibiofibular
ligament
anterior talofibular ligament
Lateral
malleolus
calcaneofibular ligament
long plantar ligament
Posterior
Talofibular
Ligament
ligameni
Lateral View
talus
medial
malleolus
Talonavicular ligament
deltoid
ligament
navicular
Long plantar ligament
Calcaneonavicular ligament
Medial view
Acute Ankle Injuries:
•Ligament sprain (Lateral ligaments ) (Most Common);
•Ligament sprain
Medial ligament
AITFL
•Peroneal dislocation
•Fractures
Laterai/medial/posterior Malleolus (Pott's)
Talar dome
Tibial plafond
Base of the fifth metatarsal
Anterior process of the calcaneus
Lateral process of the talus
Posterior process of the talus
•Dislocated ankle
•Tendon rupture
Examination:
Examination of the ankle requires assessment of the degree of
instability present and the grading of the ligamentous injury.
Examination should detect functional disability such as loss of
range of motion, reduced strength and reduced proprioception, etc
1. Observation
(a) standing
(b) supine
2. Active movements
(a) plantarflexion/dorsrflexion
(b) inversion/aversion
3. Passive movements
(a) plantarfiexion/dorsiflexion
(b) inversion/eversion
4. Resisted movements
5. Functional tests
(a) lunge test (b) hopping
6. Palpation
(a) distal fibula (b) lateral
malleolus (c) lateral ligaments
(d) talus (e) peroneal tendon
(t) base of fifth metatarsal
(g) anterior joint line (h) dome
of talus (i) medial ligament
(j) sinus tarsi
Special tests
(a) Anterior drawer
(b) Lateral talar tilt
(c) Proprioception
Lateral Ligament Injuries:
Ligamentous injuries around the ankle joint are among the most
common sporting injuries, especially in jumping sports (e.g.
basketball, volleyball).
Lateral ligament injuries occur in activities involving rapid changes
in direction, especially on uneven surfaces. They are also seen
when contact with another competitor's feet causes imbalance in
jumping or landing.
FIGURE 1. Grading of sprains. (A) The grade I sprain is characterized by
stretching of the anterior talofibular and calcaneofibular ligaments. (B) In the
grade II sprain, the anterior talofibular ligament tears partially, and the
calcaneofibular igament stretches. (C) The grade III sprain is characterized by
rupture of the anterior talofibular and calcaneofibular ligaments, with partial
tearing of the posterior talofibular and tibiofibular ligaments.
Treatment:
Initial Management:
The initial management of lateral ligament injuries requires the
RICE regimen. This is probably (the single-most important factor
in treatment, particularly with grade I and grade II injuries). As well
as hot showers, heat rubs.
Reduction of Pain and swelling:
Pain and swelling can be reduced with the use of
electrotherapeutic modalities (e.g. TENS, interferential stimulation,
magnetic field therapy). Analgesics may be required. Gentle soft
tissue therapy and mobilization after the first 48 hours also may
help to reduce pain.
Restoring of Full Range of Motion:
The patient may be non-weight-bearing on crutches for the first 24
hours but should then commence partial weight-bearing in normal
heel-toe gait. It will be necessary from this stage to protect the
damaged joint with strapping or bracing. As soon as pain allows,
active range of motion exercises can be commenced.
Muscle Conditioning:
Strengthening exercises should be commenced as soon as pain
allows. Active exercises should be performed initially with
gradually increasing resistance Exercises should include
plantarflexion and dorsiflexion, inversion and eversion. Eversion
strength is particularly important in the prevention of future lateral
ligament injuries. Weight-bearing exercises should be
commenced as soon as possible.
Restoration of Proprioception:
Proprioceptive retraining exercises can be commenced early in
the rehabilitation program and should be gradually progressed
from balancing on one leg to the use of the rocker board and
ultimately to functional activities while balancing.
Functional Exercise:
Functional exercises (e.g. jumping, hopping, twisting, figure-ofeight running) should be commenced when the athlete is painfree, has full range of motion and adequate muscle strength and
proprioception.
Rocker board
Functional activity while
Balancing
Return to Sports:
Return to sport is permitted when functional exercises can be
performed without pain during or after activity. While performing
rehabilitation activities and upon return to sport, added ankle
protection is required. This can be provided either with taping or
bracing.
Treatment of grade III injuries:
Treatment of grade III ankle injuries requires initial conservative
management over a six-week period. If the patient continues to
make good progress and is able to perform sporting activities with
the aid of taping or bracing and without persistent problems during
or following activity, surgery may not be required. If, however,
despite appropriate rehabilitation and protection, the patient
complains of recurrent episodes of instability or persistent pain,
then surgical reconstruction of the lateral ligament.
Following surgery, it is extremely important to undertake a
comprehensive rehabilitation program to restore full joint range of
motion, strength and proprioception.
Medial ligament injuries:
Medial ligament injuries do not occur as frequently as lateral
ligament injuries because the deltoid ligament requires
considerable force to be damaged. Occasionally they may be
seen in conjunction with a lateral ligament injury. Medial ligament
injuries may occur with fracture of the medial malleolus or damage
to articular surfaces.
Treatment:
Medial ligament sprains should be treated in the same manner as
lateral ligament sprains, although return to activity may be
prolonged.
Pott's fracture:
A fracture affecting one or more of the malleoli (lateral, medial,
posterior) is known as a Pott's fracture. It can be difficult to
distinguish clinically between a fracture and a moderate to severe
ligament sprain. Both conditions may result from inversion injuries,
with severe pain and swelling.
Persistent ankle pain:
In most cases of ligament sprain, the patient progresses
satisfactorily through the rehabilitation process. However, there is
a significant group of patients who do not progress well and
complain of persistent pain.
It may be due to the following conditions:
• inadequate rehabilitation
• osteochondral fracture of the dome of the talus
• dislocation of the peroneal tendons
• chronic synovitis of the ankle joint
• chronic ligamentous instability
• sinus tarsi syndrome
• anterior impingement syndrome
• posterior impingement syndrome
• anterolaleral impingement
• rupture of the tibialis posterior tendon
• reflex sympathetic dystrophy (RSD)
Other fractures:
• avulsion fracture of the base of the fifth metatarsal
• fracture of the lateral process of the talus
• fracture of the anterior process of the calcaneus
• fracture of the posterior process of the talus
An ankle ligament injury that is inadequately rehabilitated may
present with persistent pain and loss of function. This usually
occurs with increased activity levels. The common problems
associated with inadequate rehabilitation are a loss of range of
motion in the ankle joint (especially dorsiflexion), weakness
of the peroneal muscles and impaired proprioception.
Management involves restoration of full dorsiflexion by active and
passive mobilization of the ankle joint, a program of strengthening
exercises for the peroneal muscles and proprioccptive exercises.
Distal Fibula fracture with associated
medial deltoid ligament
disruption. This injury is frequently the
result of the foot being planted with a
valgus load applied to the leg.
Talar Dome Fracture
Ankle dislocation with no fractures. This takes a high degree of trauma
and force. In this case this was generated as the result of a high flip off of
a trampoline and impact with the ground. The ankle was in a plantar
flexion and inverted position upon impact. This was an open dislocation.
This is a ballerina type
fracture of the 5th
metatarsal.
These X-Rays show a fracture of the proximal end of the 5th Metatarsal.
This fracture is commonly called a "Jones Fracture".
Achilles Tendon Tear and Repair