tibiofibular and ankle joint complex

MOB TCD

Tibifibular and Ankle Joint Complex

Professor Emeritus Moira O’Brien

FRCPI, FFSEM, FFSEM (UK), FTCD

Trinity College

Dublin

Superior and Inferior Tibio-Fibular Joints

• Superior is synovial plane joint• Inferior is a syndesmosis• Interosseous tibiofibular

ligament• Anterior and posterior tibiofibular

ligament

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Ankle Joint

• The ankle joint is one of the most common joints to be injured

• The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured

Bröstrom, 1966

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Tennis MOB TCD

• Dorsiflexion and plantar flexion take place at the ankle joint

• In plantar flexion there is some side-to-side movement

Last, 1963

Ankle Joint MOB TCD

• Uniaxial, modified synovial hinge joint

• Close pack• Dorsiflexion• Least pack• PlantarflexionWilliams & Warwick, 1980

Ankle Joint MOB TCD

Proximal Articular Surface

• Distal surface of the tibia • Medial malleolus has comma

shaped facet• Lateral malleolus triangular

facetWilliams & Warwick, 1980

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Proximal Articulation

• Inferior transverse tibiofibular ligament • Deepens it posteriorly• Passes from the lower margin of the

tibia • To the malleolar fossa of the fibulaWilliams & Warwick, 1980

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• Proximally the articulation depends on the integrity of the inferior tibiofibular joint

• Syndesmosis

Proximal Articular Surface MOB TCD

Distal Articular Surface

• The superior surface of the body of the talus is wider anteriorly

• Convex from before backwards • Concave from side to side • Medial comma shaped facet• Lateral triangular facetFrazer, 1965

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Capsule

• Is attached just beyond the articular margin

• Except anterior-inferiorly• Attached to the neck of the talusWilliams & Warwick, 1980

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• The capsule is thin and weak in front and behind

• It is strengthened on either side by the collateral ligaments

Williams & Warwick, 1980

Ankle Joint MOB TCD

Medial (Deltoid) Ligament

• A strong triangular ligament• Superiorly attached • The medial malleolus of the

tibiaWilliams & Warwick, 1980

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• The tuberosity of the navicular

• The edge of the spring ligament

• The sustentaculum tali • The body of the talusLast, 1963

Medial Ligament MOB TCD

Medial or Deltoid Ligament (Superficial)

• Cross two joints• Anterior tibionavicular pass

to the tuberosity of the navicular

• The free edge of the spring ligament

• The middle fibres• The tibiocalcaneal are attached to

the sustentaculum taliWilliams & Warwick, 1980

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Medial or Deltoid Ligament (Deep)

• The anterior tibiotalar to the nonarticular part of the medial surface of the talus

• The posterior tibiotalar to the medial side of the talus

• The medial tubercle of the talus


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Lateral Ligaments of Ankle

• The anterior talofibular ligament (ATFL)

• The calcaneofibular ligament (CFL)

• The posterior talofibular ligament (PTF)

• They radiate like the spokes of a wheel

Liu & Jason, 1994

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Anterior Talofibular Ligament (ATFL)

• Is part of the capsule • An upper and lower bands• It is cylindrical• 6-10 mm long • 2 mm thickLiu & Jason, 1994

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ATFL

• The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion

• More perpendicular to the talus when the foot is equinus

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• It is the weakest ligament• Strain increases with

increasing plantar flexion and inversion

• The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion

Liu & Jason, 1994

ATFL MOB TCD

Calcaneofibular Ligament (CFL)

• A long rounded 20-25 mm long, 6-8 mm in diameter

• It contains the most elastic tissue

• It is attached in front of the apex of the fibular malleolus

• To a tubercle on the lateral aspect of the calcaneus


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CFL

• It is separated from the capsule by fibro-fatty tissue

• Part of the medial wall of the peroneal tendon sheath

• Crosses both the ankle and subtalar joints

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• The CFL is perpendicular to the long axis of the talus

• Dorsiflexion and inversion result in an increased strain

• Talar tilt tests the CFL

CFL MOB TCD

Lateral Ligament

• The angle between the ATFL and CFL varies between 100o and 135o

• Increasing the potential instability of the lateral ligament

Hamilton, 1994; Peters, 1991

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Ankle Stability

• The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint

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ATFL and CFL

• A difference of 10o between the two ankles is significant

• A talar tilt of more than 10o is a lateral ligament injury in 99% of cases

• The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20%

• The CFL is a major stabiliser of the subtalar joint

Liu & Jason, 1994

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Posterior Talofibular (PTL)

• The PTL is the strongest part of the lateral ligament

• It runs almost horizontally from malleolar fossa to lateral tubercle of talus

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PTL

• During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge

• They separate during dorsiflexion

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Ankle Joint

• The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles

• In 7% the lateral tubercle has a separate ossification and is called an os trigonum

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Synovial Membrane

• Lines the capsule and the non articular area• Covers the neck of talus• The fatty pads inside the capsule• It extends upwards to the interosseous

ligament of the inferior tibiofibular jointPlastanga et al., 1980

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Blood Supply of Ankle

• Malleolar branches of the anterior tibial

• Perforating peroneal and posterior tibial arteries

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Nerve Supply of Ankle

• Nerve supply is via articular branches of the deep peroneal

• Tibial nerve from L4 - S2

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Anterior Aspect

• Dorsiflexors• Tibialis anterior• Flexor hallucis longus• Anterior tibial > dorsalis pedis artery• Deep peroneal nerve • Extensor digitorum longus• Peroneus tertius

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Postero-Medial Aspect of Ankle

• Tibialis posterior• Flexor digitorum longus• Posterior tibial vessels• Posterior tibial nerve and

branches• Flexor hallucis longus

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Posterior Aspect

• Posterolateral portal• Lateral to achilles tendon, sural

nerve, short saphenous vein at risk

• Posteromedial not used; flexor retinaculum structures at risk

Jaivin & Ferkel, 1994

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Lateral Aspect of Ankle

• The inferior extensor retinaculum

• Extensor digitorum brevis• Peroneus longus and brevis• Peroneal retinaculum• Ligament of the neck of talus• Bifurcate ligament

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• Plantar flexor and evertor– Peroneus longus– Peroneus brevis

• Dorsiflexor and evertor– Peroneus tertius

Lateral Aspect of Ankle MOB TCD

Nerves Related to Ankle Joint MOB TCD

• In the anatomical position the axis of the ankle joint is horizontal

• But is set at 20-25o obliquely to the frontal plane

• Running posteriorly as it passes laterallyPlastanga et al., 1990

Ankle Joint MOB TCD

• The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt)

Ankle Joint MOB TCD

Ankle Examination

• Anterior drawer• Suction sign• Inversion stress• Squeeze test• External rotation • Test

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• Achilles tendon• Peroneal tendons• Posterior tibial tendon• Anterior process of calcaneus• Talar dome• Sinus tarsi• Bifurcate ligament

Ankle Examination MOB TCD

Tests for Ankle Ligament Injury MOB TCD

Ottawa Ankle Rules

• Anteroposterior• Oblique• Lateral views• Bone tenderness• Medial or lateral• Malleolus• Unable to weight bear• Four steps post injury

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Tibialis Posterior / Superficial Peroneal Nerve

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• ATFL• CFL• Distal tibiofibular• Syndesmosis• Deltoid ligament• Lateral malleolus• Medial malleolus• Base 5th metatarsal

Ankle Examination MOB TCD

• Inversion or supination• Raising the medial

border• Sole faces medially

Inversion and Eversion

• Eversion or pronation• Raising the lateral

border• Sole faces laterally

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• Initiated at the transverse tarsal joint

• Calcaneocuboid• Anterior portion of the

talocalcaneonavicularLast, 1963

Inversion and Eversion MOB TCD

• Main movement take place at the clinical subtalar joint i.e.– talocalcaneal – inferior portion of the

talocalcaneonavicular• The pivot is the ligament

of the neck of the talusLast, 1963


• Axis passes through the middle of the convex posterior facet on calcaneus

• Upwards forwards and medially

• Through middle of convex articular facet of head of talus

Last, 1963


Talocalcaneal

• Synovial plane joint• Articular surface• Concave facet inferior body

of talus• Convex posterior facet,

superior aspect of calcaneus

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Talocalcaneal Joint

• Capsule attached just beyond articular margin ligaments

• Interosseous• Ligament of neck of talus

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Tarsal Canal and Tarsal Sinus MOB TCD

Inversion or Supination

• Invertor and dorsiflexion• Tibialis anterior• Invertor and plantarflexion• Tibialis posterior

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Eversion and Pronation

• Evertor and dorsiflexion• Peroneus tertius• Evertor and plantarflexion• Peroneus brevis• Peroneus longus

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Talocalcaneonavicular Joint

• Synovial ball and socket• Ball head of talus• Socket• Posterior aspect of the

navicular, two anterior facets on superior surface of calcaneus

• Spring ligament and CNL

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• Synovial ball and socket joint

• Ball is anterior and inferior aspect of the head of the talus

Talocalcaneonavicular Joint MOB TCD

• Socket• Two anterior facets on the

superior surface of the calcaneus

• Posterior aspect of the navicular

• Spring ligament• LCN ligament


• Capsule attached just beyond the articular margin

• Interosseous ligament• Spring ligament• Superficial portion deltoid

ligament• LCL of bifurcate• Ligament neck of talus


• Synovial membrane lines the capsule and non-articular structures

• Nerve supply• Tibial nerve• Deep and superficial

peroneal nerves


Subtalar Interosseosus

• Capsule of both talocalcaneal

• Posterior portion of the talocalcanoeonavicular joint

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Ligaments of Subtalar Joint

• Inferior extensor retinaculum• Ligament of the neck of talus• Interosseous ligament• Bifurcate ligament

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Ligament of Neck of Talus

• Sinus tarsi• Lateral aspect of neck of talus• Pivot of inversion and

eversionLast, 1963

*

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Tarsal Canal and Tarsal Sinus

• Fat• Nerve endings• Branches of posterior tibial

and peroneal arteries • Capsules and ligaments of

talocalcaneal and talocalcaeonavicular joints

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Inferior Extensor Retinaculum

• Medial root inside the tarsal sinus

• Intermediate to talus with the interosseous ligament, inside sinus

• Lateral root to calcaneus outside sinus

Klein & Spreitzer, 1993

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Ligament Attachments MOB TCD

Bifurcate Ligament

• Lateral calcaneo- navicular ligament (CNL)

• Medial calcaneocuboid ligament (CCL)

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• Two individual ligaments• Separate attachments• Different fibre orientation• Different histology

Bifurcate Ligament MOB TCD

Talocalcaneonavicular Joint

• Invertors• In dorsiflexion• Tibialis anterior• In plantarflexion• Tibialis posterior

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• Evertor• In dorsiflexion• Peroneus tertius • In plantarflexion• Peroneus longus• Peroneus brevis


Calcaneo Navicular Ligament

• Folded and twisted appearance• Prominent medial and lateral

edges / folds• Three groups of fibres

– Medial– Lateral (deep)– Intra-articular

N

A

C

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Calcaneocuboid Ligament

• Intra-capsular CC joint• Smaller than CNL, always

present• Hourglass shaped fibres,

twisted medially

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Calcaneocuboid Joint

• Plane synovial• Ligaments• Capsular• Ligament of neck of talus• Long and short plantar

ligament• Bifurcate ligament

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• The long and short plantar ligaments support the calcaneocuboids portion of the transverse tarsal joint

Calcaneocuboid Joint MOB TCD

tibiofibular and ankle joint complex

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