l13 ankle ligament injuries
TRANSCRIPT
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