ANKLE INJURIES

ANATOMY

• 1) Distal end of tibia• : ankle mortise• Distal end of fibula • 2) Talus – trochlea of talus dome• 3) Ligaments – a) lateral ligament complex b) medial ( deltoid ligament )• c) syndesmosis

ANKLE SPRAINS

• - The most common acute sport injuries, 25% in every running or jumping sport

• - Mechanism of injury: inversion and plantar flexion of the foot when landing off balance or clipping another player’s foot

ANKLE SPRAINS

• Sequence of injury: anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, musculotendinous units supporting the ankle joint

ANKLE SPRAINS

• Incidence increased in :• - individuals with varus

malalignment of lower limbs• - calf muscle tightness• - previous incompletely

rehabilitated ankle sprains

ANKLE SPRAINS

• - Diagnosis: x-rays, stress x-rays • ( inversion stress, anterior drawer

test), ? MRI scan• - acute phase ( first 72 hours ):• RICE, then varies according to the

severity of injury

GRADE 1 ( Mild ) SPRAINS

• - The anterior talofibular ligament affected

• - stress: minimal change on inversion, normal anterior drawer

• - treatment by encouraging early active movement:

• a) stationary cycling• b) walking with protective taping or

semi-rigid brace ( Aircast splint )

GRADE 1 ( Mild ) SPRAINS

• c) NSAIDS (anti-inflammatory medication)

• d) physiotherapy: electrotherapy, strengthening exercises, propreoception (1 legged stand )

• e) functional progression to running, jumping, hopping, swerving and cutting, recovery into 6 weeks

GRADE 2 (Moderate) SPRAINS

• - Complete tear of anterior talofibular ligament with some damage of the calcaneofibular ligament

• - laxity when inversion, anterior drawer present

• - treatment: a) 1 week crutches, joint taped or in aircast splint

• b) follow grade 1 rehabilitation

GRADE 3 ( Severe ) SPRAINS

• - Uncommon severe injuries, associated with fractures

• - treatment: 10 days NWB in aircast brace or POP, then PWB with the brace up to 6 weeks. Aggressive rehabilitation follows

• - surgical reconstruction must be considered

PERONEAL TENDON INJURIES

• - Strong everters and weak plantar flexors of the foot

• - mechanism of injury:• a) associated with lateral ligament

injuries• b) forced dorsiflexion with slight

inversion and reflex contraction of the tendons ( sprinting, uneven ground, ballet)

PERONEAL TENDON INJURIES

• - O/E: Behind lat.malleolus discomfort or swelling. Subluxation on resisting dorsiflexion with eversion

• - treatment: a) acute phase – well-moulded short NWB cast with pad over lat.malleolus b) chronic phase – surgical correction, POP 4 weeks c) rupture of peroneal tendons – surgical correction

PERONEAL TENDON INJURIES

• TENDINITIS:• - occurs in dancers, basketball,

volleyball• - combined cause of the

lat.malleolus pulley action and foot malalignment

PERONEAL TENDON INJURIES

• TENDINITIS:• - TREATMENT – a) rest from sport,

temporary use of heel wedge• b) physiotherapy, extreme cases: local

injection into the sheath• c) gradual coaching programme, avoid

rapid direction changes or sprinting – 6 weeks

• d) failure of conservative treatment: tenolysis of peroneal tendons

TALAR DOME FRACTURES

• - Suspicion if ankle sprains failed to recover

• - can present later: damage of subchondral bone (bone bruising), later separation and displacement of an osteochondral fragment

TALAR DOME FRACTURES

• - Symptoms: locking, instability, weakness, discomfort

• - Diagnosis: x-rays in 6 weeks, bone scan, MRI scan

• - Treatment: removal of loose body and defect curettage

ANTERIOR IMPINGEMENT SYNDROME

• - Mechanism: repetitive traction or injury over anterior capsule – exostoses produced on the anterior margin of distal tibia and talus

• - “ footballer’s ankle”, basketball,ballet• - pain on dorsiflexion, reduced dorsiflexion

later on• - x-rays: lateral view – exostoses, loose

bodies• - treatment: NSAIDS, local inj. Surgical

excision

POSTERIOR IMPINGMENT SYNDROME

• - Congenital: talar spur (trigonal process) or a separate un-united ossification centre of talus (OS trigonum )

• - ballet, fast cricket bowling, jumping, swimming

• - NSAIDS, surgical excision ( difficult cases )

FOOT INJURIES

ENTRAPMENT NEUROPATHIES IN THE

FOOT• MORTON’S NEURALGIA ( NEUROMA )• - Mechanism: fibrous enlargement of a

plantar interdigital nerve with entrapment between metatarsal heads (usually 3rd and 4th )

• - repetitive trauma, “ dropped” metatarsal heads, tight shoes, hard surfaces. Stress fractures also considered in the differential diagnosis

ENTRAPMENT NEUROPATHIES IN THE

FOOT• - Pain in the web, loss of sensation• - metatarsal neck pads, other

orthotic correction, local injection, surgery

ENTRAPMENT NEUROPATHIES IN THE

FOOT• Other neuropathies:• - dorsal cutaneous branch of the

deep peroneal nerve on the dorsum of the foot

• - sural nerve behind the lateral malleolus or over the styloid process of the fifth metatarsal

SINUS TARSI SYNDROME

• - Sinus tarsi: concavity at the lateral tarsal canal of the subtalar joint

- discomfort in front of lat.malleolus, running

- differential diagnosis from chronic lat.ligament sprain

• - treatment: control of over pronation, strengthening of post.tibialis muscle, local injection

BURSITIS ABOUT THE HEEL

- Over achilles tendon: posterior calcaneal bursa

- Below achilles tendon: retrocalcaneal bursa

- running with ill-fitting shoesHaglund’s syndrome: (bony bossing) on

the posterior aspect of calcaneum- treatment: rest, low friction

taping,NSAIDS, physio, local inj., footwear attention

HEEL FAT PAD SYNDROME (BRUISED HEEL )

• - Disruption of the fibrofatty protective tissue over the sensitive periosteum of calcaneum

• - veteran runners: age and repeated trauma

• - treatment: decreased weight bearing activity, weight loss, orthotics: use of a semi rigid moulded heel cup, shoes with a snug firm heel counter

• DON’T USE: local inj., flat or convex pads

PLANTAR FASCIITIS

• - Running on hard surfaces, tennis, netball, jumping

• - mechanism: MTP extension produces a “windlass” stress over plantar fascia lifting the longitudinal arch of the foot

• - Periosteal reaction may produce a heel spur ( x-rays )

PLANTAR FASCIITIS

• - Pain under medial aspect of the heel, worse on tip toeing, early in the morning, stairs

• - treatment: NSAIDS, 4-8mm heel raise, physiotherapy, orthotics to modify over pronation

CALCANEONAVICULAR LIGAMENT SPRAIN

( Spring Ligament )

• - Acute twisting injuries of the foot in football, jumping

• - pain and tenderness over medial arch of the foot

• - Ice, NSAIDS, electrotherapy, orthotics

CUBOID SYNDROME

• - Cuboid bone: pulley for peroneus longus tendon, stabilizer of the transverse arch of the foot

• - lateral mid foot pain. Tenderness with pressure proximal of the 5th metatarsal

• - orthotics to support in flexion the cubometatarsal joint and control pronation. Physio for strength of the toes long flexors and anterior tibialis

REFLEX SYMPATHETIC DYSTROPHY OF THE FOOT• - Associated with minor strains,

sprains, laceration or foot surgery• - painful, swollen, hypersensitive to

touch, hot or cold, moist foot. Stiff joints, atrophic muscles, anxious patient

• - x-rays: osteopenia and soft tissue swelling

REFLEX SYMPATHETIC DYSTROPHY OF THE FOOT• - Treatment: aggressive

physiotherapy, tubigrip, sympathectomy by epidural injection

• - recovery from 8 weeks to 2 years

ANTERIOR METATARSALGIA

• - Tenderness at plantar aspect of metatarsal heads

• - over pronated feet, excessive mobility of 1st metatarsal

• - callus formation under 2nd and 3rd metatarsal heads

• - treatment: callus care, weight loss, orthotics incorporating metatarsal bars, correct pronation. Physio ( tight triceps surae ) Attention to shoes

SESAMOIDITIS

• - Sesamoid bones in the tendon of flexor hallucis brevis

• - dancers, ice skaters, gymnasts, basketball

• - crush fractures, avulsion, bipartite sesamoid, osteonecrosis

• - x-rays and bone scan imaging• - shoes with elevated heels avoided,

orthotics. Dancers, gymnasts: adhesive padding and rest, surgical excision

ACHILLES TENDON INJURIES

• - Common tendon of gastrocnemius and soleus muscles

• - tendon twists laterally from 15cm above insertion becoming more pronounced at 2-5cm above insertion. Blood supply reduced at this level

ACHILLES TENDON INJURIES

• - Aetiology factors: lack of rear foot support in shoes, terrain, excessive training loads, biomechanical factors of foot: over pronation, rear foot varus or valgus, pes cavus, tight calf muscles

ACHILLES TENDON INJURIES

• - Assessment: ultrasound scan: ruptures, swelling, degenerative cysts, calcifications

• - treatment: correct biomechanics with orthotics. Acute phase: rest, ice, electrotherapy, heel raise, gentle stretching, NSAIDS, no inj.

• - surgery: ( ruptures, adhesive peritendinitis )

FRACTURES

• - Ankle fractures: intarticular, if displaced ORIF

• -talus fracture: surgical treatment to avoid osteonecrosis

• - calcaneum fractures: most conservative, early ROM

FRACTURES

• - Metatarsal fractures: reduce dislocations, most common fracture 5th metatarsal base ( Jones )

• - toe fractures: most treated conservative, strapping with next toe for 3 weeks