Ankle sprains (Ankle Pathologies)

Syndesmosis ankle sprain

"high" ankle sprain"

Eversion ankle sprains

(Represent 5-10% of all ankle sprains) Etiology: Bony protection and ligament strength decreases likelihood of injury. Eversion force results in damage to deltoid ligament and possibly fx of the fibula. Deltoid can also be impinged and contused with inversion sprains. Due to severity of injury, it may take longer to heal Foot that is pronated, hypermobile or has a depressed medial longitudinal arch is more predisposed to eversion sprains. Signs & Symptoms: Pain may be severe; unable to bear weight; and pain with abduction and adduction but not direct pressure on bottom of foot.

Os Trigonum

-An os trigonum is a small, round bone that sits just behind the ankle joint. -The os trigonum is present in about 5-15% of normal feet. -An os trigonum occurs when one area of bone does not fuse with the rest of the talus (ankle bone) during growth. -Typically, this small bone is of no significance -Most commonly seen in ballet dancers who assume pointe and demipointe positions. ---These positions maximally plantarflex the ankle (point the toes down), and can cause the os trigonum to become pinched in the space behind the ankle

Leg cramps or spasms

-Sudden, violent, involuntary contraction, either clonic (intermittent) or tonic (sustained) in nature. Etiology: Difficult to determine; fatigue, loss of fluids, electrolyte imbalance, inadequate reciprocal muscle coordination. Signs & Symptoms: cramping with pain and contraction of calf muscle.

5 P's

5 P's Pain Pallor (redness) Pulselessness (dorsal pedal artery) Paresthesia (deep peroneal nerve) Paralysis (deep peroneal nerve)

Achilles Tendon Rupture

Avascular zone of tendon just proximal to calcaneal insertion point Chronic degeneration due to inflammatory condition/irritation contribute to tissue weakness - risk for rupture Forceful, sudden contraction is most common mechanism of injury Corticosteroid injection risk factor Palpable and/or visible defect in tendon Altered gait pattern - unable to push off Developing swelling Ability to PF with secondary muscles, but significantly weaker than normal Positive Thompson test Most treated surgically

Medial ankle injuries

Avulsion fracture of medial malleolus Bimalleolar (Pott's) fracture Talus/ankle mortise chondral lesions

Peroneal Tendon Subluxation

Due to sudden, forceful DF/eversion or PF/inversion which ruptures retinaculum May visibly/palpably move from behind lateral malleolus - become DF instead of normal PF function and can also contribute to development of biomechanical complications Local inflammatory symptoms at site of injury May require surgical intervention

Medial Tibial Stress Syndrome (Shin Splints)

Etiology: -Pain in anterior portion of shin -Catch all for stress fractures, muscle strains, chronic anterior compartment syndrome -Accounts for 10-15% of all running injuries, 60% of leg pain in athletes -Caused by repetitive microtrauma -Weak muscles, improper footwear, training errors, varus foot, tight heel cord, hypermobile or pronated feet and even forefoot supination can contribute to MTSS -May also involve, stress fractures or exertional compartment syndrome

Acute Achilles Strain

Etiology: Common in sports and often occurs with sprains or excessive dorsiflexion. Signs & Symptoms: Pain may be mild to severe. Most severe injury is partial/complete avulsion or rupturing of the Achilles.

Posterior Tibialis Tendinitis

Etiology: Common overuse condition in runners with foot hypermobility or over pronation. Repetitive micro trauma. Signs & Symptoms: Pain and swelling in area of medial malleolus. Edema, point tenderness and increased pain during resistive inversion and plantar flexion.

Stress fracture of tibia and fibula

Etiology: Common overuse condition, particularly in those with structural and biomechanics insufficiencies. Runners tends to develop in lower third of lower leg (dancers middle third). Often occur in unconditioned, non-experienced individuals. Often training errors are involved. Component of female athlete triad. Signs & Symptoms: Pain more intense after exercise than before Point tenderness; difficult to discern bone and soft tissue pain Bone scan results (stress fracture vs. periostitis)

Muscle Contusions

Etiology: Contusion of leg, particularly in the region of the gastrocnemius. Signs & Symptoms: Bruise may develop, pain, weakness and partial loss of limb function. Palpation will reveal hard, rigid, inflexible area due to internal hemorrhaging and muscle guarding.

Shin Contusion

Etiology: Direct blow to lower leg (impacting periosteum anteriorly). Signs & Symptoms: Intense pain, rapidly forming hematoma w/ jelly like consistency.

Acute Leg Fractures

Etiology: Fibula has highest incidence of fracture, occurring primarily in the middle third. Tibial fractures occur predominantly in the lower third. Result of direct blow or indirect trauma. Signs & Symptoms: Pain, swelling, soft tissue insult Leg will appear hard and swollen (Volkman's contracture).

Achilles Tendonitis continued...

Etiology: Inflammatory condition involving tendon. Tendon is overloaded due to extensive stress. Presents with gradual onset and worsens with continued use. Decreased flexibility exacerbates condition. Signs & Symptoms: Generalized pain and stiffness, localized proximal to calcaneal insertion. May limit strength. Crepitus with active plantar flexion and passive dorsiflexion. Chronic inflammation may lead to thickening.

Syndesmotic sprain

Etiology: Injury to the distal tibiofemoral joint (anterior/posterior tibiofibular ligament). Torn w/ increased external rotation or dorsiflexion. Injured in conjunction w/ medial and lateral ligaments. Signs & Symptoms: Severe pain, loss of function; passive external rotation and dorsiflexion cause pain. Pain is usually anterolaterally located.

Grade 2 inversion ankle sprain

Etiology: Moderate inversion force causing great deal of disability with many days of lost time. Signs & Symptoms: Feel or hear pop or snap; moderate pain w/ difficulty bearing weight; tenderness and edema. Positive talar tilt and anterior drawer tests. Possible tearing of the anterior talofibular and calcaneofibular ligaments.

Osteochondritis Dissecans

Etiology: Occur in superior medial articular surface of the talar dome. One or several fragments of articular cartilage, w/ underlying subchondral bone partially or completely detached and moving within the jt. space. Mechanism may be single or repeated traumas. Signs & Symptoms: May be a complaint of pain and effusion with signs of atrophy. May also be catching, locking, or giving way.

Peroneal Tendon Subluxaton/ Dislocation

Etiology: Occurs in sports with dynamic forces being applied to the ankle. May also be caused by dramatic blow to posterior lateral malleolus, or moderate/severe inversion ankle. sprain resulting in tearing of perineal retinaculum. Signs & Symptoms: Complain of snapping in and out of groove with activity. Eversion against manual resistance replicates subluxation. Recurrent pain, snapping and instability. Present with ecchymosis, edema, tenderness, and crepitus over the tendon.

Achilles Tendon Rupture continued...

Etiology: Occurs w/ sudden stop and go; forceful plantar flexion w/ knee moving into full extension. Commonly seen in athletes > 30 years old. Generally has history of chronic inflammation. Signs & Symptoms: Sudden snap (kick in the leg) w/ immediate pain which rapidly subsides. Point tenderness, swelling, discoloration; decreased ROM. Obvious indentation and positive Thompson test. Occurs 2-6 cm proximal the calcaneal insertion.

Grade 1 inversion ankle sprain

Etiology: Occurs with inversion plantar flexion and adduction. Causes stretching of the anterior talofibular ligament. Signs & Symptoms: Mild pain and disability; weight bearing is minimally impaired; point tenderness over ligaments and no laxity.

Compartment Syndrome

Etiology: Rare acute traumatic syndrome due to direct blow or excessive exercise. Signs & Symptoms: Excessive swelling compresses muscles, blood supply and nerves. --Increase in fluid accumulation could lead to permanent disability. -Chronic cases appear as gradual build-up that dissipates following activity; generally bilateral and becomes predictable; can remain elevated producing ischemia and pain or ache w/ rare neurological involvement; increased pressure involvement. -Weakness with foot and toe extension and occasionally numbness in dorsal region of foot.

Grade 3 inversion ankle sprain

Etiology: Relatively uncommon but is extremely disabling. Caused by significant force (inversion) resulting in spontaneous subluxation and reduction. Causes damage to the anterior/posterior talofibular and calcaneofibular ligaments as well as the capsule. Signs & Symptoms: Severe pain, swelling, hemarthrosis, discoloration. Unable to bear weight. Positive talar tilt and anterior drawer.

Gastrocnemius Strain

Etiology: Susceptible to strain near musculotendinous attachment. Caused by quick start or stop, jumping. Signs & Symptoms: Depending on grade, variable amount of swelling, pain, muscle disability. May feel like being "hit in leg with a stick." Edema, point tenderness and functional loss of strength.

Anterior Tibialis Tendinitis

Etiology: commonly occurs after extensive downhill running. Signs & Symptoms: Point tenderness over anterior tibialis tendon.

Ankle fractures/ dislocations

Etiology: number of mechanisms Signs & Symptoms: Swelling and pain may be extreme with possible deformity.

Medial ankle sprains

External rotation is most common mechanism (differentiate between syndesmosis injury) Typically present with localized point tenderness and swelling ROM/strength deficits per MOI and tissue involved Positive eversion stress test

Lateral Ankle injuries

Impingment of medial joint capsule/ligaments Peroneal tendon strain/rupture Medial malleolar "push-off" fracture Avulsion fracture of 5th metatarsal or lateral malleolus Talus/ankle mortise chondral lesions Superficial branch of peroneal nerve injuries

Anterior Compartment Syndrome

Increased pressure within anterior compartment - traumatic or exertional Traumatic - bleeding from direct blow to compartment muscles Exertional - can be acute or chronic due to volumetric changes in muscle tissue and/or poor vascular function/venous outflow secondary to arterial inflow Increased pressure in compartment compromises neurovascular supply to dorsal foot - ischemia to affected tissues Require immediate referral for treatment, may be limb threatening if not treated

Lateral ankle sprain

Least stable in "loose packed position" - PF with inversion. Progression of tissue damage with severity from ATF to CF to PTF. Most common and result in injury to the lateral ligaments. Occasionally the force is great enough for an avulsion fracture to occur w/ the lateral malleolus.

Medial ankle sprain

Less common due to decreased eversion ROM and bony architecture

Stress Fractures

Microtraumatic, accumulative events May affect tibia, fibula or talus Not visible via x-ray until approximately 3 weeks post-onset If advanced, may present with positive bump or squeeze tests Tuning fork test May have same symptoms of MTSS or compartment syndrome

Syndesmosis sprains

Much more debilitating and difficult recovery process versus med/lat injuries Pain with DF/ER due to wider anterior dome of talus spreading distal tib-fib joint Must rule out involvement of fibular fracture due to common mechanism --Proximal 1/3 of fibula fracture (Maisonneuve) from rotational stress that can cause syndesmosis injury

Lateral Ankle sprains

Prior history of injury is predisposing factor in inversion injury: -Decreased proprioception -Decreased muscle strength -Lack of muscular coordination Tight gastroc-soleus complex is risk factor Pain and swelling to lateral ankle Point tenderness to involved structure/s ROM limited due to pain (eversion and dorsiflexion) Strength deficits due to pain Positive ligamentous stress test/s Severity of sprains is graded (1-3) With inversion sprains the foot is forcefully inverted or occurs when the foot comes into contact w/ uneven surfaces

Medial Tibial Stress Syndrom (Shin Spints) continued...

Signs & Symptoms: Four grades of pain: Pain after activity Pain before and after activity and not affecting performance Pain before, during and after activity, affecting performance Pain so severe, performance is impossible

Os Trigonum injury

Steida's process - posterior projection off talus Can be developmental or traumatic (non-union or stress fracture to Steida's process) Impinges on surrounding soft tissues causing symptoms - typically gradual onset If acute fracture, acute symptoms Peri-Achilles swelling/point tenderness, pain with terminal PF Visible on plain film radiograph

Achilles Tendonitis

What is this? Vascular issues Paratenon (highly vascular structure surrounding tendon) irritated causing peritendonitis Risk factors: Biomechanics (running and walking), tight triceps surae/hamstrings, rearfoot valgus, hyperpronation Point tenderness May present with crepitus to palpation or ROM testing Tightness to triceps surae group with possible resultant foot/ankle biomechanical conditions/pathologies Weakness to PF