Ankle Pathologies

Lateral Ankle Sprain: Primary etiological factors

Hx of previous ankle sprains, Chronic Ankle instability, sports and physical activity,

Lateral Ankle Sprain: Key pathophysiological findings

Stretching or tearing of lateral ligaments,

Lateral Ankle Sprain: Most common signs and symptoms

pain, swelling, difficulty weight-bearing).

Lateral Ankle Sprain: Key mechanisms of injury

Ankle inversion injury

Lateral Ankle Sprain: Key anatomical structures affected

ATFL, CFL, PTFL

Lateral Ankle Sprain: Medical screening considerations

Hx of previous ankle sprain and CAI, altered ROM, balance deficits, impaired strength, OARs

Lateral Ankle sprain: test cluster

OAR - Rule out fracture

Anterior Drawer - ATFL test

Talar Tilt - CFL and ATFL

Palpation and swelling - TOP ATFL, CFL

Lateral Ankle Sprain: Medical imaging recommended

MRI
Diagnostic US

Syndesmosis Sprain: Primary etiological factors

Forceful twisting or rotation movements, direct trauma, overextension

Syndesmosis Sprain: Key pathophysiological findings

Involves an injury to the syndesmotic ligaments

Syndesmosis Sprain: Most common signs and symptoms

pain above the ankle, often with tenderness and pain when the foot is rotated outwards

Syndesmosis Sprain: Key mechanisms of injury

External rotation of the foot on fixed tibia, excessive dorsiflexion

Syndesmosis Sprain: Key anatomical structures affected

AITFL, PITFL, interosseous ligament, TTFL

Syndesmosis Sprain: Medical screening considerations

Squeeze Test, External rotation stress test both being positive

Syndesmosis Sprain: Test cluster

Palpation of AITFL

Squeeze test - pain at syndesmosis

ER stress test - Pain, assesses AITFL

DF-ER test - AITFL under tension

Syndesmosis Sprain: Medical imaging recommended

X-rays - initial, Stress radiographs - assess widening/instability, MRI - viewing the ligaments

Growth Plate Fracture: Primary etiological factors

Growth plates prone to injury as they are softer and weaker, resulting from trauma

Growth Plate Fracture: Key pathophysiological findings

Break or damage to physis

Growth Plate Fracture: Most common signs and symptoms

Pain, swelling, inability to bear weight, TOP

Growth Plate Fracture: Key mechanisms of injury

Falls, sports injuries, car accidents

Growth Plate Fracture: Key anatomical structures affected

The growth plate (physis) of the bones in the ankle, primarily the distal tibia and fibula.

Growth Plate Fracture: Medical screening considerations

How injury occured, location/severity of pain, swelling, ability to bear weight

Growth plate fracture: Test cluster

MOI - axial load, near growth plate

Palpation - TOP growth plate

Weight-bearing - refusal to bear weight

Tuning fork test - vibration causes localised pain over fracture site

Growth Plate Fracture: Medical imaging recommended

X-rays: diagnose

Sever’s Apophysitis: Primary etiological factors

Pediatric overuse injury

Repetitive microtrauma or traction to calcaneal apophysis

Sever’s Apophysitis: Key pathophysiological findings

Involves inflammation of the calcaneal apophysis,

Sever’s Apophysitis: Most common signs and symptoms

Heel pain, aggravated by physical activity, relieved with rest, TOP

Sever’s Apophysitis: Key mechanisms of injury

Repetitive traction or pulling on calcaneal apophysis

During growth spurt (can increase)

Sever’s Apophysitis: Key anatomical structures affected

The calcaneal apophysis (growth plate of the heel bone)

Sever’s Apophysitis: Medical screening considerations

Hx of symptoms, TOP over calcaneal apophysis, squeeze test at heel

Sever’s Apophysitis: Test cluster

Age - 8-13 years

Pain on palpation - posterior heel achilles insertion

Squeeze test calcaneus - heel pain

SL Heel raise - pain/inability to perform

Sever’s Apophysitis: Medical imaging recommended

Not required, but X-ray to rule out other pathology

Atraumatic Fatigue and Insufficiency Fractures: Primary etiological factors

Overuse, repetitive loading, adolescent athlete

Atraumatic Fatigue and Insufficiency Fractures: Key pathophysiological findings

Mismatch between bone repair and bone resorption, rate of breakdown exceeds rate of formation, leads to microscopic damage

Atraumatic Fatigue and Insufficiency Fractures: Most common signs and symptoms

Localized pain, worse with physical activity, relieved with rest, TOP over fracture site

Atraumatic Fatigue and Insufficiency Fractures: Key mechanisms of injury

Chronic repetitive stress or overuse

Atraumatic Fatigue and Insufficiency Fractures: Key anatomical structures affected

Any bone, e.g. 5th metatarsal

Atraumatic Fatigue and Insufficiency Fractures: Medical screening considerations

Onset of pain, location, agg/alleviating factors

Atraumatic Fatigue and Insufficiency Fractures: Test clusters

TOP - fracture site

Hop/fulcrum test - Loading bone stress

Tuning Fork - stress vibration - deep local bone pain

SL loading - pain/inability to perform

Atraumatic Fatigue and Insufficiency Fractures: Medical imaging recommended

X-rays initial, MRI Gold standard for bone stress injuries

Lisfranc Injury/Fracture: Primary etiological factors

MVA, Industrial accidents, falls from height
Axial load on plantarflexed foot, or twisting on a fixed foot

Lisfranc Injury/Fracture: Key pathophysiological findings

Osseous or ligamentous injury, damage to bones or ligaments in midfoot region

Lisfranc Injury/Fracture: Most common signs and symptoms

Midfoot pain and swelling, inability to bear weight. ecchymosis on plantar aspect of foot, apparent deformity

Lisfranc Injury/Fracture: Key mechanisms of injury

Direct trauma (crash injuries)

Indirect trauma (Axial load on plantarflexed foot, or twisting on a fixed foot)

Lisfranc Injury/Fracture: Key anatomical structures affected

Lisfranc joint (between cuneiforms, cuboid and bases of metatarsals

lisfranc region Ligaments

Lisfranc Injury/Fracture: Medical screening considerations

Hx of current condiiton, TOP, swelling, plantar ecchymosis, piano key test, single-limb heel rise test

Lisfranc injury/fracture: Test cluster

Midfoot palpation - focal pain over 2nd TMT

Piano key test/Midfoot squeez - Pain or increase laxity

Plantar midfoot ecchymosis - highly suggestive of injury

SL heel raise - inability

Lisfranc Injury/Fracture: Medical imaging recommended

AP and oblique X-rays, Weight bearing X-ray

Chronic Ankle Instability: Primary etiological factors

Hx of previous lateral ankle sprain, recurrent ankle sprains

Chronic Ankle Instability: Key pathophysiological findings

Mechanical (laxity or excessive motion) and functional (giving way feeling) instability

Chronic Ankle Instability: Most common signs and symptoms

Recurrent ankle sprains, subjective instability

Chronic Ankle Instability: Key mechanisms of injury

Repeated ankle sprains, not rehabbed properly

Chronic Ankle Instability: Key anatomical structures affected

ATFL, CFL, PTFL

Chronic Ankle Instability: Medical screening considerations

Previous ankle sprains, instability, recurrent ankle sprains

Chronic Ankle Instability: Test cluster

Anterior drawer/talar tilt

Balance/proprioception test

Reproduce symptoms during functional activity (hopping)

History of >1 significant ankle sprain and episodes of giving way

Chronic Ankle Instability: Medical imaging recommended

X-rays rule out abnormalities, Stress radiographs ankle laxity, MRI ligament injury

Ankle pain due to OA, inflammatory disorders resulting in degenerative change: Primary etiological factors

Post-traumatic ankle osteoarthritis (OA), inflammatory arthropathies

Ankle pain due to OA, inflammatory disorders resulting in degenerative change: Key pathophysiological findings

Progressive degeneration and OA of articular cartilage, narrowed joint space, osteophyte, changes in subchondral bone, inflammation

Ankle pain due to OA, inflammatory disorders resulting in degenerative change: Most common signs and symptoms

Ankle pain worse with activity, morning joint stiffness, swelling, tenderness reduced ROM, crepitus

Ankle pain due to OA, inflammatory disorders resulting in degenerative change: Key mechanisms of injury

Degeneration, abnormal joint mechanics, cartilage damage, chronic inflammations, repetitive microtrauma or chronic overloading

Ankle pain due to OA, inflammatory disorders resulting in degenerative change: Key anatomical structures affected

The articular cartilage, subchondral bone, synovium membrane

Ankle pain due to OA, inflammatory disorders resulting in degenerative change: Medical screening considerations

ROM, swelling, pain, location, Hx of inflammatory disease

Ankle pain due to OA, inflammatory disorders resulting in degenerative change: Medical imaging recommended

Weight-bearing X-rays are the primary imaging modality, MRI for cartilage

Plantar Fasciitis: Primary etiological factors

Overuse injury, obesity, prolonged standing, tight calves, (runners and athletes)

Plantar Fasciitis: Key pathophysiological findings

Degenerative process rather than inflammation, microtears and structural changes

Plantar Fasciitis: Most common signs and symptoms

Heel Pain (worse in the morning/after rest)

Pain at bottom of heel (worse with prolonged standing)

Plantar Fasciitis: Key mechanisms of injury

Repetitive microtrauma and excessive tension

Plantar Fasciitis: Key anatomical structures affected

The plantar fascia

Plantar Fasciitis: Medical screening considerations

Foot posture, calf tightness, activity levels

Plantar Fasciitis: Test cluster

Pain on palpation - medial calcaneal tubercle

Windlass test

First-step pain in morning

Dec dorsiflexion

No neural symptoms

Combined with subjective assessment

Plantar Fasciitis: Medical imaging recommended

X-rays rule out other patho, US to visualise thickening, MRI as well

Achilles Tendinopathy: Primary etiological factors

Overuse injury (runners), sudden increases in training volume or intensity, footwear, biomechnical abnormalities

Achilles Tendinopathy: Key pathophysiological findings

Degenerative process of achilles tendon, midportion or insertion

continuum from reactive to degenerative

Achilles Tendinopathy: Most common signs and symptoms

Pain and stiffness in the Achilles tendon, with first steps in morning, worsens with activity, TOP along tendon

Achilles Tendinopathy: Key mechanisms of injury

Repetitive tensile loading and mechanical stress, training errors,

Achilles Tendinopathy: Key anatomical structures affected

The Achilles tendon, which connects the calf muscles (gastrocnemius and soleus) to the calcaneus (heel bone).

Achilles Tendinopathy: Medical screening considerations

Pain on palpation of Achilles tendon

Changes in training/footwear

Achilles Tendinopathy: Medical imaging recommended

Ultrasound tendon thickening, MRI more details

Achilles tedninopathy: Test cluster

Localised pain on palpation - 2-6cm above insertion

SL Heel raise - pain

Gradual onset

Morning stiffness

Retrocalcaneal Bursitis: Primary etiological factors

Overuse - repetitive friction/compression at back of heel

Tight footwear (halgund’s deformity)

Retrocalcaneal Bursitis: Key pathophysiological findings

Involves inflammation of the retrocalcaneal bursa

Retrocalcaneal Bursitis: Most common signs and symptoms

Pain at the back of the heel, w/ activity/pressure, TOP of achilles tendon insertion, swelling at back of heel, Pain increases with Dorsiflexion

Retrocalcaneal Bursitis: Key mechanisms of injury

Repetitive friction or direct compression on the retrocalcaneal bursa, tight footwear/halgund’s deformity

Retrocalcaneal Bursitis: Key anatomical structures affected

The retrocalcaneal bursa, distal achilles tendon, posterior calcaneus

Retrocalcaneal Bursitis: Medical screening considerations

Footwear and activity levels,

Retrocalcaneal Bursitis: Test cluster

Focal TOP anterior to achilles insertion

Squeeze test at heel - pain

End range dorsiflexion - pain

Swelling/Haglund deformity

Retrocalcaneal Bursitis: Medical imaging recommended

X-rays can identify a Haglund's deformity, US swelling

Post-foot and ankle fracture trauma stiffness & pain Etiology:

Ankle stiffness related to prior ankle injury,

Post-foot and ankle fracture trauma stiffness & pain pathophysiology:

Degeneration of articular cartialge, joint space narrowing, osteophytes

Post-foot and ankle fracture trauma stiffness & pain Common SSx

Pain, stiffness after rest, decreased ROM, Swelling

Post-foot and ankle fracture trauma stiffness & pain MOI

after ankle injury

Post-foot and ankle fracture trauma stiffness & pain Anatomical structures involved

bones and articular surfaces of ankle joint, articular cartilage, subchondral bone

Post-foot and ankle fracture trauma stiffness & pain Medical screening questions

Hx

Post-foot and ankle fracture trauma stiffness & pain Medical imaging recommended

X-rays, weightbearing, CT for detailed bony assessment

Bone Stress Injury: Primary etiological factors

Overuse and repetitive loading, common in high impact activities, increases in training, inadequate recovery, excessive foot pronation

Bone Stress Injury: Key pathophysiological findings

Bone responses to excessive load

Traction on bone

Stress accumulation and microscopic damage

Bone Stress Injury: Most common signs and symptoms

Pain along the borders of the bone

Worsens with activity

TOP along bone border

Bone Stress Injury: Key mechanisms of injury

Repetitive mechanical stress and loading

Bone Stress Injury: Key anatomical structures affected

Any particular bone, and its surrounding muscles

Bone Stress Injury: Medical screening considerations

Biomechanical Factors

TOP along borders of affected bone