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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