Download ANKLE INJURIES

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 semirigid 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 – wellmoulded 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 shoes
Haglund’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