The Ankle
High Ankle Sprain: Exam
+ Squeeze test + Kleiger's Test
Low Ankle Sprain: Exam
+ TTP over ligamentous structures +/- Talar Tilt +/- Anterior Drawer +/- External Rotation + Swelling/Ecchymosis
Achilles Tendonopathy/Rupture: Clinical History
- Posterior heel pain and swelling - A sudden "snap" or "pop" in the lower calf accompanied by severe pain - Feeling of being "Shot" or "Kicked" in the back of the leg - Difficult Ambulation/Limp
Ankle Tendons
- Posterior tibial tendon: medial side, common cause of pain in flat feet - Peroneus longus and brevis: lateral side, injured w/ Jones fracture
Hindfoot Valgus/Varus
- Valgus = flat foot - Varus = high arch
High Ankle Sprain: Imaging
- X-Ray • May have a concomitant fracture • Widening of mortise • Displacement of talus - MRI/CT • To evaluate soft tissue structures
Low Ankle Sprain: Imaging
- X-Ray: AP/Lateral/Mortise • Normal- MRI/CT, if concerns
Lateral Ankle Ligament Anatomy
1. Anterior Talofibular Ligament (ATFL)* • Most commonly involved ligament in low ankle sprains • Resists plantar flexion and inversion 2. Posterior Talofibular Ligament (PTFL) • 2nd most common ligament injury in lateral ankle sprains • Resists dorsiflexion and inversion 3. Calcaneal Fibular Ligament (CFL)** • Stabilize sub-talar joint • Limits inversion
Ice
20 min 3-4x a day Protect the skin
Tendon Rupture: Medical Management
Elderly/Inactive, Systemic Illness, Poor Skin Integrity • Crutches • Serial Casting • Heel lifts • NSAIDS • Analgesics • Physical Therapy
Pes Planus
Flat Foot
Distal TibioFibular Syndesmotic Ligaments
High Ankle Sprain • Anterior Inferior Tibiofibular Ligament (AITFL) • Posterior Inferior Tibiofibular Ligament (PITFL) • Interosseous Membrane
Achilles Tendonopathy/Rupture: Risk Factors
Intrinsic Factors: • Functional Factors: Malalignment, Poor gastrocnemius strength, Inflexibility, Limited ankle dorsiflexion, Cavus Foot • Systemic Diseases -CKD, RA, SLE, Gout, Thyroid & Parathyroid D/O, DM • + Family Hx (5x more likely) Extrinsic Factors: • Drugs: Steroids, Quinolones • Overuse - Excessive, repetitive strain - Tendon subject to 8-10x body weight during strenuous exercise - Change in exercise type, intensity, duration - Improper footwear, stretching, training surface
Achilles Tendonopathy/Rupture: Etiology
Mechanism: Usually Running, Jumping, Sudden Acceleration/Deceleration • Sudden, forced plantar flexion of the foot • Unexpected dorsiflexion of the foot • Violent dorsiflexion of a plantar-flexed foot • H/O Tendonopathy High Risk Activities • Basketball, running, diving, tennis, etc.,
Matles Test
Patient prone with knees flexed. Loss of tone in neutral position.
Thompson's Test
Patient prone, squeeze the calf slightly distal to the widest girth. No plantarflexion of the foot indicates rupture.
Achilles Tendonopathy: Surgical Management
Removal of adhesions and tendon nodules, tenotomy
Ankle Sprains
Tearing of the ligamentous structures of the ankle
Medial Ankle Ligament Anatomy
The Deltoid Ligament supports and stabilizes the medial side of the joint. - Superficial Ligaments 1. Tibiocalcaneal Ligament (TCL)* 2. Tibiospring Ligament (TSL) 3. Tibionavicular Ligament (TNL) - Deep Ligaments 1. Posterior Tibiotalar Ligament (PTTL)* 2. Anterior Tibiotalar Ligament (ATTL) Spring Ligament aka Plantar Calcaneonavicular Ligment • Stabilizes the arch
Pes Cavus
high arch
Ankle X-Ray: 3 Views
• AP • Mortise (Joint line) • Lateral * Ideally weight bearing
Low Ankle Sprain: Surgical Management
• Chronic Instability • Multi-ligament Injury • Ligament Reconstruction
Ankle Mortise Anatomy
• Disruption of ligamentous or bony structures can cause disruption to Mortise • Mortise shows you stability & integrity of ankle joint • Includes: medial mallelous, lateral mallelous, talar dome, tibial plafond • < 4 mm of clear space
3 Main Sets of Ankle Ligaments
• Distal tibiofibular syndesmosis • Lateral ligaments • Medial ligaments
Anterior Drawer
• Evaluate integrity of the anterior talofibular ligament • Neutral position at 0° or 90° to the leg. Stabilize the distal tibia with one hand. Grasp the heel & apply a firm, steady, anterior force to the heel. Perform bilaterally to compare anterior translation. + Pain or increased joint laxity in the injured ankle indicates disruption of the anterior talofibular ligament.
Squeeze/Compression Test
• Evaluate integrity of the distal tibiofibular joint. Assess for fractures of the tibia and fibula, and/or syndesmotic injuries. • Patient sitting supine with their foot on the table. Grasp the mid-calf and squeeze the tibia and fibula together. Gradually move distally towards the ankle while continuing to apply the same amount of pressure + pain in the lower leg may be indicate a fracture or syndesmotic sprain
External Rotation/Kleiger's Test
• Evaluate syndesmotic injuries. • Seat patient with their knee bent on the table. Stabilize the distal tibia & externally rotate the foot. External rotation of the talus applies pressure to the lateral malleolus, causing a widening of the tibiofibular joint. Feel for the talus displacing from the medial malleolus + Increased external rotation of the foot when compared bilaterally, or pain in the anterolateral ankle joint
Return to Play Guidelines
• Grade I/II: 1-2 Weeks • Grade III: 3-6 Weeks • High ankle - 6+ weeks with Immobilization - Out for the season with Screw Fixation
Ankle Sprains: Clinical Exam
• H/O Injury/Fall • Medial or Lateral Pain • Swelling/Bruising • "Weak"/Instability - A feeling of "giving way" at the ankle
Ankle Sprains: Risk Factors
• Hindfoot varus • Jumping and cutting sports • Improper footwear • Deconditioning • Previous Instability/Recurrent • Sprains • Weakness
High Ankle Sprain: Surgical Management
• Indication: A syndesmotic sprain with diastasis &/or ankle instability • Mechanism - ORIF With Syndesmotic Screw - Removal of screw at 9 weeks • Outcomes - Improved stability - Improved functionality & motion
High Ankle Sprain: Non-Operative Management
• Indication: A syndesmotic sprain without diastasis or ankle instability • Mechanism - NWB CAM boot or cast for 2-3 weeks - No weight-bearing until pain free - Physical therapy program using a brace that limits external rotation • Outcomes - Prolonged and highly variable recovery period - Recovery may extend to twice that of standard ankle sprain
Achilles Tendonopathy/Rupture: Clinical Exam
• Inspect/Compare lower extremity • Palpate gastrocsoleus complex + tenderness, nodules, swelling, warmth, atrophy, defects - Usually occurs 2-6 cm above calcaneal insertion • Special Tests for Rupture + Heel Rise Test + Thompson + Matles • Check ROM/Strength • Imaging: X-ray, US, MRI - Mostly clinical exam
Ankle: physical exam
• Inspection/Palpation • Gait • Standing Alignment - Hindfoot Valgus/Varus • Shoe Wear Pattern • Soft tissue, bony structures • Inversion & eversion • Range of Motion - AROM, PROM, Resisted • Stability Testing - Anterior Drawer - Talar Tilt - External Rotation • Special Tests - Squeeze Test - Standing Heel-Rise - Thompsons • NV
Talur Tilt Test
• Integrity of the lateral ankle ligaments, particularly the calcaneofibular ligament. • Neutral position. Stabilize the distal tibia with one hand & apply inversion force to the foot. + any pain in the ankle or increased joint laxity
Ankle Sprains: Epidemiology
• Laterally > Medially • Ankle sprains are the most common reason for missed athletic participation! • Low Ankle Sprain (90%) • Syndesmotic/High Ankle Sprains (1- 10%)
Tendon Rupture: Surgical Management
• Open Reconstruction with Reapproximated Ends • NSAIDS • Analgesics • Benefit: Quicker return, Lower Re-Rupture Rate • Risks: Infection, Wound Healing Difficulty, Sural Nerve Injury, DVT
The Ottowa Rules
• Point tenderness at posterior edge (of distal 6 cm) or tip lateral malleolus. (Zone A) • Point tenderness at posterior edge (of distal 6 cm) or tip medial malleolus. (Zone B) • Inability to weight bear (four steps) immediately after the injury and in emergency department • Get X-ray for Zone C & D
Achilles Tendonopathy: Medical Management
• RICE • Orthotics (Heel lifts) • NSAIDS • Nitric Oxide: NTG Patch (1/4 of 5mg patch x 12-24 weeks) • Activity Modification (Swimming) • Physical Therapy • PRP Injections • Shock wave therapy/Phonophoresis/Iontophoresis
Low Ankle Sprain: Non-Operative Management
• RICE (48-72hours) • NSAIDS • If painful WB, short immobilization in a walking boot • Physical Therapy • Brief bracing until strengthened in PT
High Ankle Sprain
• Syndesmosis - Complex ligamentous structure that maintains the integrity between tibia and fibula, resists axial, rotational, and translational forces.
Achilles Tendonopathy/Rupture: Special Testing
• Thompson's Test • Matles Test
Standing Heel-Rise Test
• To help differentiate evaluate integrity of posterior tibial tendon- Patient fully weightbearing, rise up onto toes and foot should invert slightly (hindfoot valgus corrects + Absence of foot inversion = PTT rupture or insufficiency
Achilles Tendonopathy/Rupture: Diagnostic Imaging
• Xray: - Ruling out other issues • Ultrasonography: - Rule out DVT/Baker cyst - Can use to identify a ruptured Achilles tendon or the signs of tendinosis • MRI - Definitive diagnosis of a disrupted tendon - Differentiate paratenonitis, tendinosis, & bursitis