Download Patellar Tendinopathy

Ankle Syndesmosis
Normal Anatomy
• Distal tibiofibular syndesmosis made up of several
ligaments
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Anterior tibiofibular ligament
Posterior tibiofibular ligament
Transverse tibiofibular ligament
Interosseous tibiofibular ligament
• Strongest connection between tibia and fibular is
by the interosseous tibiofibular ligament
• During dorsiflexion the fibula moves laterally and
posteriorly
• During plantarflexion the fibula moves medially
and anteriorly
• From plantarflexion to dorsiflexion the distance
between the medial and lateral malleolus
increases
• The syndesmotic ligaments restrict lateral
movement of the fibula
Pathology
• External rotation of the foot causes
disruption of the anterior syndesmotic
ligaments
• Disruption to the syndesmotic
ligaments can increase fibula lateral
movement and therefore lead to
instability
• Large external rotation force and
increased fibula movement can lead
to complete tibiofibular diastasis
(separation)
• Diastasis usually occurs in
combination with medial and
sometimes lateral malleolus fractures
Mechanism of Injury
• Traumatic
• Forced external rotation of the
foot
• Rapidly pivoting internally with the
foot planted in an externally rotated
position
• Valgus force to a planted foot in a
tackle
• Direct blow to the lateral aspect of
the heel
• Forced Dorsiflexion
Classification
• Grade 1
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Injury to anterior deltoid ligament
Injury to distal interosseous ligament
Nil tear of proximal syndesmosis or deep deltoid ligament
Stable
• Grade 2
• Disruption of anterior and deep deltoid ligaments
• Tear in syndesmosis
• Unstable Ankle with normal alignment on radiographs
• Grade 3
• Complete disruption of deltoid, anterior and syndesmotic ligaments
• Proximal fibula fracture (Maisonneuve fracture)
• Unstable clinical and on radiographs
Associated Pathology
• Deltoid ligament sprains
• Weber Type B Fracture
• Lateral malleolus fracture level
with the talar dome
• Weber Type C Fracture
• Lateral malleolus fracture above
the ankle joint
• Maisonneuve fractures
• Spiral fracture of the proximal
third of the fibula
• Osteochondral Lesions
Subjective Examination
• Pain above ankle joint line
• Traumatic history of forced external rotation
• Pain with pivoting internally with a planted foot
• Pain with “pushing off” during gait or running
• History of sports requiring a boot that fixes the ankle such as skiing or
hockey
Objective Examination
• Swelling anterior medial ankle
joint
• Painful Dorsiflexion
• Painful External rotation of the
foot
• Tenderness over distal anterior
tibiofibular ligament
• Tenderness along the
interosseous membrane
Special Test
• Passive dorsiflexion
• Squeeze test
• External Rotation
Stress Test
• Crossed Leg Test
• Cotton Stress Test
• Fibular Translation
Further Investigation
• X-ray (rule out fracture)
• Ultrasound
• MRI
Management
• Prolonged recovery time
• Surgery not always considered if a fracture is present
• Weber Type C Fracture is unstable and usually operated on
• Weber Type B Fracture maybe stable or unstable
• Conservative management considered where injury is stable
• If symptoms persist longer than 6 months surgery is considered
Conservative
• Reduce pain and inflammation
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Immobilisation
NSAID’s
Ice
Massage
• Restore Normal Range of Movement
• Ankle
• Massage
• Joint mobilisation
• Joint manipulation
• Restore Normal Muscle Activation
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Evertors
Invertors
Plantarflexors
Dorsiflexors
Intrinsic Foot Muscles
• Restore Dynamic Stability
• Proprioceptive Training
• Sport Specific Training
Plan B
• Dependent on instability and fracture sites
• Arthroscopic debridement
• Screw fixation
• Arthrodesis (joint fusion)
References
• Bloemers, F. W. and F. C. Bakker (2006). "Acute Ankle Syndesmosis Injury In Athletes." European
Journal of Trauma 32(4): 350-356.
• Magan, A., P. Golano, N. Maffulli and V. Khanduja (2014). "Evaluation and management of injuries
of the tibiofibular syndesmosis." Br Med Bull 111(1): 101-115.
• McCollum, G. A., M. P. van den Bekerom, G. M. Kerkhoffs, J. D. Calder and C. N. van Dijk (2013).
"Syndesmosis and deltoid ligament injuries in the athlete." Knee Surg Sports Traumatol Arthrosc
21(6): 1328-1337.
• Miller, T. L. and T. Skalak (2014). "Evaluation and treatment recommendations for acute injuries to
the ankle syndesmosis without associated fracture." Sports Med 44(2): 179-188.
• Porter, D. A., R. R. Jaggers, A. F. Barnes and A. M. Rund (2014). "Optimal management of ankle
syndesmosis injuries." Open Access J Sports Med 5: 173-182.
• Sman, A. D., C. E. Hiller and K. M. Refshauge (2013). "Diagnostic accuracy of clinical tests for
diagnosis of ankle syndesmosis injury: a systematic review." Br J Sports Med 47(10): 620-628.
• Van Heest, T. J. and P. M. Lafferty (2014). "Injuries to the Ankle Syndesmosis." The Journal of Bone
& Joint Surgery 96(7): 603-613.
• Williams, G. N. and E. J. Allen (2010). "Rehabilitation of Syndesmotic (High) Ankle Sprains." Sports
Health: A Multidisciplinary Approach 2(6): 460-470.