l13 ankle ligament injuries

Ligamentous and Tendon Injuries About the Ankle

J. Stephen Brecht, MDGrant Medical Center

Neil F. Watnik, MDLong Island Jewish Medical Center

Outline

Ankle and Foot Anatomy Lateral and Medial Ankle Sprains Syndesmotic Injuries Ankle Dislocations Achilles Tendon Ruptures Peroneal Tendon Dislocations Poster Tibial Tendon ruptures

Ankle Anatomy Distal fibula and distal

tibia form a bony mortise that allows talar dorsiflexion and plantarflexion

Talar body is wider anterior than posterior which leads to less stability with plantarflexion and internal rotation

Talar Anatomy

The talus has a shallow bicondylar appearance that has reciprocal articulations on the tibial plafond

Injuries that leave the ankle unstable can change the ankle articulation and contribute to premature articular cartilage damage

Medial Collateral Ligaments Superficial

– Superficial talotibial, naviculotibial, and calcaneotibial fibers

Deep– Deep anterior talotibial and

posterior talotibial fibers from posterior colliculus to talus

– Strongest portion of the Deltoid ligament

Lateral Collateral Ligaments Anterior Talofibular

Ligament– First injured in lateral sprain

with plantarflexed ankle Calcaneofibular Ligament

– Strongest lateral ligament– First injured in lateral sprain

with dorsiflexed ankle Posterior Talofibular

Ligament

Syndesmosis Anterior inferior

tibiofibular ligament Posterior inferior

tibiofibular ligament Transverse tibiofibular

ligament Interosseous

membrane

Anatomy Tendons

– Achilles Tendon– Posterior Tibial Tendon– FDL and FHL– Tibialis Anterior tendon

Vessels– Saphenous vein anteriorly– Posterior tibial artery

Nerves– Tibial nerve posteriorly

Anatomy

Tendons– Peroneus Brevis – Peroneus Longus

Nerves– Superficial peroneal

nerve– Sural nerve

Anatomy

Extensor retinaculum Tendons

– Tibialis Anterior– EHL– EDL

Dorsalis Pedis Artery Deep Peroneal Nerve

Ankle Sprains

Most common ligamentous injuryOne sprain per day per 10,000 people40% will have intermittent chronic

problems (Garrick, Am J Sports Med, 1977)

More common on the lateral aspect of the ankle

Ankle Sprains Most common mechanism

of ankle injury is inversion stress with plantarflexion– May lead to ankle fracture,

sprain, or syndesmotic injury

Abduction or adduction are other mechanisms

Ankle Sprain

Differential Diagnosis– Syndesmotic Injury– Peroneal tendon subluxation– Posterior tibial tendon tear– Achilles tendon tear– 5th metatarsal base fracture– Midfoot injuries– Lateral talar process fracture– Anterior process of calcaneus fracture

Ankle Sprain

History– Description of the injury– Position of the ankle during the injury– Able to continue to play or bear weight– Previous injury– Site of injury

Ankle SprainPhysical Exam

– Palpation over medial and lateral malleoli– Palpation over deltoid ligament– Palpation over ATFL, CFL, and PTFL– Neurovascular exam– Anterior drawer test for ATFL– Talar tilt to assess CFL– Squeeze test to look for syndesmotic injury

Ankle Radiographs

AP of the Ankle– AB < 5mm is normal– BC > 10 mm is normal

Ankle Radiographs

Mortise View– Ankle internally

rotated– AB clear space– BC– Talocrural angle (83

degrees)– Medial clear space <4

mm

Ankle Stress Radiographs Talar tilt view

– Ankle block allows better exam

– Shows complete ligamentous instability

– Talar tilt <2 mm

External rotation view– Useful in identifying

syndesmotic injury

Ankle Stress Radiographs Anterior drawer stress

view– No fracture seen– >3 mm anterior

translation compared to contralateral side or >10 mm translation

– Incongruency of ankle joint present

– Ligamentous instability present

Ankle Sprain Classification

Histologic Classification– Grade I – Ligamentous stretching without macroscopic

tearing– Grade II – Partial macroscopic tearing– Grade III – Complete ligamentous rupture

Ankle Sprain Classification Anatomic Classification

– Grade I – ATFL disruption– Grade II – ATFL and CFL disruption– Grade II – Complete ligamentous disruption

Clinical Grading Grade I

– Stress tests normal Grade II

– Increased pain swelling– May have positive stress tests

Grade III– Severe pain swelling

– Positive stress tests

Lateral Ankle Sprains

Commonly missed diagnoses– Peroneal tendon injuries– Achilles injuries– FX’s

Lateral process of talus Anterior process of calcaneus Fifth metatarsal Lisfranc injuries

– Osteochondritis dessicans

Lateral Ankle SprainsLateral Process FX of the Talus

Lateral Ankle Sprains

X-rays are based on careful physical examMRI rarely indicated in the acute settingConsider stressing syndesmosis and lisfranc

joints if injury is suspected

Ankle Sprain Treatment RICE with ankle brace initially and protected weight

bearing for Grade I and II ROM exercises Peroneal strengthening and proprioceptive training Bracing or taping for 4-6 weeks depending on activity Return to sports when able to cut without pain Severe sprain may require up to 6 months of protective

bracing

Ankle Sprain Treatment

Grade III sprain may require a walking boot or a cast for 4 – 6 weeks

Extended period of protective bracing may be warranted

Return to play criteria remain the sameNeed to be aware of possibility for

syndesmosis injury (high ankle sprain)

Lateral Ankle Sprains

Management surgical– Acute surgical repair not supported by literature– symptomatic chronic instability may require

surgical intervention Anatomic Brostrom repair favored over nonanatomic

rerouting procedures

Medial Ankle Sprain 5% ankle sprains Forced eversion Injury to deltoid

ligament May be associated with

syndesmotic injury and/or Weber C fibula FX

Medial Ankle Sprain

Tenderness/swelling over deltoidExternal rotation test elicits pain in the deltoid

and possibly in syndesmosis

Medial Ankle Sprain

AP/LAT/OBLIQUE ankle x-rays to assess mortise and syndesmosis– Medial joint space widening– Syndesmotic widening– Presence fibula FX

Consider external rotation stress x-rays if syndesmotic disruption is suspected

Medial Ankle Sprain

Management– Stable (no talar subluxation)

Similar to lateral sprains– RICE, early wgt bearing, early ROM, functional brace,

functional rehab

– Unstable (talar subluxation) No talar subluxation is acceptable Anatomic reduction and surgical stabilization of

syndesmosis

Chronic Ankle Instability

Continued instability or recurrent injury despite rehabilitation and proprioceptive training

Protective Bracing vs. Surgical treatments – Modified Brostrom procedure– Chrisman-Snook procedure

Modified Brostrom

Repair of the ATFL Repair of the CFL Reefing of the lateral

extensor retinaculum May be modified to

advance the ligaments through drill holes or use of suture anchors

Nonanatomic Reconstructions

These procedures use the peroneal tendons to reconstruct the lateral ligamentous complex

Higher complication rates than Brostrom More restricted ankle and subtalar motion (Colville, JAAOS, 1998)

Syndesmosis Injury 10% of ankle sprains Rupture of the interosseous

ligaments between the tibia and fibula with or without fibular fracture

Medial malleolar fracture or deltoid ligament rupture

Persistent instability and gap in the joint after bimalleolar fixation

Syndesmosis Exam

Squeeze Test– Squeeze the

syndesmosis above the anklepain

Abduction-External Rotation Stress Test– Further instability with

external rotation (may be shown with x-ray)

Syndesmotic (High) Ankle Sprains AP/LAT/OBLIQUE ankle x-rays

– Syndesmotic widening– Medial joint space widening– Presence of fibula FX

External rotation stress x-rays– Severe pain associated with

normal x-rays Must get tib/fib xrays to rule out

high fibula fracture

Syndesmosis Injury

Classification– Type I – straight lateral talar subluxation– Type II – plastic deformation of the fibula with

Type I– Type III – posterior rotatory displacement of

the fibula and talus– Type IV – diastasis of the tibia and fibula with

superior displacement of the talus

Syndesmosis Injury

Treatment– Non-displaced without fracture

May consider casting for 6 weeks (high ankle sprain)

Surgical treatment with syndesmotic screws– Displaced

Surgical treatment with syndesmotic screws

Syndesmosis Injury Reduce the syndesmosis

with a large clamp under fluoro

Place 1.5 cm proximal to the plafond

Place with 30 degrees anterior angulation

Do not use lag screw technique

Syndesmosis ControversiesNumber of Screws

– One vs. two, 3.5 mm screw vs. 4.5 mm screw Number of Cortices

– Three vs. four corticesAnkle position during placement

– Classically dorsiflexion was advocated– Tornetta showed no difference with

plantarflexion

Syndesmosis Post-Op

Place in a cast or removable boot NWBMay consider screw removal after 3 monthsWeight bearing will break screws, but does

not cause clinical problemsPremature weight bearing may break screws

and lead to syndesmosis widening

Ankle Dislocations Isolated ankle dislocation

is rare Mechanism is forced

inversion that results in a posteromedial dislocation

Anterolateral ligaments damaged

Commonly open 30 - 90% Rule out neurovascular

injury

Tibiotalar Dislocations OTA classification

– Anterior– posterior

Tibiotalar Dislocations

Management closed injury– Check neurovascular status– Prompt closed reduction– Cast for 6 weeks in plantigrade position– Results generally good– Results not improved with acute ligament repair– Late instability rare

Tibiotalar Dislocations Management open

injuries– Check neurovascular

status– IV ABX and reduction in

ER– Emergent I&D– Ligament repair if they

can be identified easily

Tibiotalar Dislocations Management open injuries

– Consider stabilization with ex-fix to facilitate care of soft tissues

– Prognosis worse than closed injuries

– Stabilize syndesmosis if disrupted

– Immediate wound closure if possible

Ankle Dislocations

Post operative care– Open reduction may require ex fix or cast to

hold the repair in place– Long term instability is rare– May have development of arthosis over time

Achilles Tendon Ruptures

Anatomy– 10-12 cm long– 0.5-1.0 cm diameter– Avascular zone 2-6 cm proximal to insertion– Fibers rotate 90 degrees at insertion

Achilles Tendon RuptureHistory

– Acute pain in the back of the ankle with contraction

– Average age 35– Steroids, fluorquinolones, and chronic overuse

may predispose to rupturePathology

– Rupture occurs 2 – 6 cm above the Achilles insertion in a watershed area

Achilles Tendon Rupture

Physical Exam– Tenderness over

achilles tendon– Palpable defect– Positive Thompson’s

test

Achilles Tendon Injury

X-ray– Lateral ankle X-ray to

exclude avulsion from the calcaneus

MRI– May be useful to

diagnose partial rupture only

Achilles Tendon Ruptures

Nonoperative treatment– Weaker tendon– Higher risk rerupture (10-15%)– Slower return to sport– No surgical morbidity– Lower cost

Achilles Tendon Rupture

Non-Operative– Splint in plantarflexion for 2 wk– Short leg cast or boot with progressive dorsiflexion and

weight bearing starting at 4 – 6 weeks after injury– Heel lift used in boot and footwear– Resistance exercises started at 8 weeks– Return to sports in 4 – 6 months– May take 12 months to regain maximal plantarflexion

power

Achilles Tendon Ruptures

Surgical repair– Superior tendon strength– Lower risk rerupture (1-3%)– Quicker return to sport– surgical morbidity

Infection Dehiscence Superficial nerve injury

– Increased cost

Achilles Tendon Rupture

Surgical treatment– Preferred for athletes– Medial incision avoids

the sural nerve– Percutaneous vs. Open

treatments described– Isolate the paratenon as

a separate layer

Achilles Tendon Ruptures

Surgical repair– Younger active patients

Nonoperative treatment– Older sedentary patients– Patients with increased risk of soft tissue

complications IDDM Smokers Vascular disease

Percutaneous Achilles Repair

Achilles Tendon Avulsion

Treatment includes ORIF of avulsion or reinsertion on the calcaneus with suture anchors

Chronic Achilles Rupture

Chronic rupture may be reconstructed with FHL, FDL, or slip from gastrocnemius

Achilles Tendon RupturesReconstruction of neglected rupture with peroneus longus and plantaris weave

Peroneal Tendon Dislocation

Peroneal tendons course behind the distal fibula

The peroneus brevis may have degenerative changes if the injury is not identified in a timely fashion

Peroneal Tendon Dislocation

The peroneal retinaculum may be avulsed from the fibula or calcaneus or lifted up enough to allow tendon dislocation

Peroneal Tendon Dislocation

Forceful contraction of peroneals during sudden dorsiflexion and inversion

Usually cutting sportFrequently misdiagnosed as ankle sprain

Peroneal Tendon Dislocation

Tenderness/swelling retromalleolar areaActive eversion may demonstrate subluxing

tendonsX-rays may reveal a small avulsion FX off the

posterior lateral malleolusMRI may reveal subluxed tendons

Peroneal Tendon Dislocation

X-ray– May show avulsion of retinaculum from fibula

Conservative treatment– Casting in slight plantarflexion and inversion

for 6 weeks non weight bearing– Allows the retinaculum to heal if the tendons

can be reduced closed– Successful if the injury is identified early

Peroneal Tendon Dislocation

Surgery– ORIF retinacular piece

if possible – Repair retinaculum if

possible– Soft tissue

reconstruction with sling for retinaculum

Peroneal Tendon Dislocation

Bone block surgeries such as Kelly’s or DuVries modification

Debridement of peroneus brevis may be necessary if degenerative changes are present and tenodesis

Peroneal Tendon Dislocation Surgery

– Deepening of the groove has become more popular

Post Operative Care– NWB for 6 weeks – Passive motion after 2

weeks– Strengthening after 6

weeks

Posterior Tibial Tendon Rupture

Anatomy– Arises from posterior aspect intermuscular septum– Inserts on tarsal bones– Avascular zone posterior to medial malleolus– High frictional load posterior to medial malleolus

Posterior Tibial Tendon Rupture

Function– Inverter of hindfoot– Locks transverse tarsal joint– Maintains height longitudinal arch– Maintains neutral position of hindfoot at 7-10

degrees

Posterior Tibial Tendon

History– More commonly an attritional rupture over time than an

acute rupture– Patient may complain of flat foot and midfoot pain– Sports with quick changes of direction may put

increased force on tendon Xray

– Foot xray may show medial talar displacement

Posterior Tibial TendonPhysical Exam

– Hindfoot valgus and forefoot abduction that give the “too many toes sign”

– Pain in the midfoot and weakness in inversion from an everted position

– Late stages may demonstrate sinus tarsi pain from impingement

– Single heel rise - Lack of supination of the foot and inversion of the heel while rising on toes

– Flexible vs. rigid deformity

Posterior Tibial Tendon

Lateral subtalar dislocation

Posterior Tibial Tendon

Conservative Treatment– UCBL orthosis for chronic problem or in the

relatively inactive population– Rest and NSAIDS– Consider casting in recalcitrant cases– Shoe modification– Orthotics with medial wedges

Posterior Tibialis Reconstruction

Surgery for the flexible deformity– Reconstruction of the

posterior tibial tendon with FDL or FHL

– Medial calcaneal wedge osteotomy or lateral column lengthening through the calcaneus

– Fig 14, page 1705 from “Acquired adult flatfoot deformity” in Orthopaeidcs, 2002

Posterior Tibial Tendon RuptureChronic rupture

– Develop gradually– Women over 40– Tenderness/swelling over tendon– Forefoot abduction– Hindfoot valgus– Loss of height of arch– “too many toes” sign– Absent single heel raise

Posterior Tibial Tendon Rupture

Imaging– Weightbearing radiographs

Degree deformity Presence arthritis Assessment longitudinal arch

– MRI Method of choice in imaging posterior tibial tendon

Posterior Tibial Tendon Rupture

Chronic rupture– Stage I

Pain, weakness, no deformity– Stage II

Flexible flatfoot deformity– Stage III

Rigid flatfoot deformity Radiographic subluxation/arthritis

Posterior Tibial Tendon Rupture

Chronic rupture– Stage I

Pain, weakness, no deformity– Stage II

Flexible flatfoot deformity– Stage III

Rigid flatfoot deformity Radiographic subluxation/arthritis

Posterior Tibial Tendon Rupture

Management – Chronic rupture

Stage III– Nonop AFO– Surgical arthrodesis (type depends on deformity and site of

arthritis)• Subtalar• Double • Triple

Posterior Tibial Tendon RuptureManagement

– Chronic rupture Stage I

– Nonop (NSAID, arch support, AFO)– Tenosynovectomy if SXs persist

Stage II– nonop (medial wedge, arch support, or AFO)– Surgical TX controversial– Reconstruction utilizing FDL or split anterior tibial tendon– Deformity frequently recurs– Calcaneal osteotomies hold promise

Return to Lower Extremity

Index