Ankle Region Flashcards

Functional Anatomy of the Ankle

• Overview: Functional anatomy of the ankle and common disorders.

Objectives

• Describe the functional anatomy of the ankle.
• Describe common clinical conditions, including acute and chronic injuries.

Talocrural Joint

• Definition: Articulation between the talus, medial malleolus (distal tibia), and lateral malleolus (distal fibula).
• Type: Weight-bearing synovial joint.
• Design: Designed for stability.
• Movement: Uniaxial modified hinge joint allowing flexion (plantarflexion) and extension (dorsiflexion).
• Combined movements of inversion/eversion are possible with the subtalar joint.

Inferior Tibiofibular Joint

• Definition: Articulation between the distal tibia and distal fibula.
• Type: Syndesmosis.
• Design: Designed for stability.
• Movement: Slight "give" during dorsiflexion.
• Clinical relevance: High ankle sprains.

Subtalar Joint (Talocalcaneal Joint)

• Definition: Articulation between the talus and calcaneus.
• Type: Plane synovial joint.
• Movement:
  • Pronation accompanied by calcaneal eversion (calcaneovalgus).
  • Supination accompanied by calcaneal inversion (calcaneovarus).

Ankle Movement and Muscles

• Dorsiflexion:
  • Muscles: Tibialis anterior, Extensor hallucis longus, Extensor digitorum longus.
• Plantar flexion:
  • Muscles: Gastrocnemius, Soleus, Plantaris.
• Inversion:
  • Muscles: Tibialis posterior, Flexor digitorum longus, Flexor hallucis longus, Tibialis anterior, Extensor hallucis longus, Extensor digitorum longus.
• Eversion:
  • Muscles: Peroneus longus, Peroneus brevis, Peroneus tertius.

Ligaments

• Lateral Aspect:
  • Anterior talofibular ligament (ATFL).
  • Calcaneofibular ligament (CFL).
  • Posterior talofibular ligament (PTFL).
  • Anterior tibiofibular ligament.
  • Posterior tibiofibular ligament.
  • Bifurcate ligament.
  • Long plantar ligament.
• Medial Aspect:
  • Deltoid ligament.
  • Talonavicular ligament.
  • Plantar calcaneonavicular ligament.
  • Plantar calcaneocuboid ligament.
  • Long plantar ligament.
• Inferior Tibiofibular:
  • Anterior inferior tibiofibular ligament.
  • Posterior inferior tibiofibular ligament.
  • Transverse tibiofibular ligament.
  • Interosseous membrane.

Muscles and Tendons

Refer to slide 12 for a comprehensive list.

Nerves

• Tibial nerve:
  • Medial plantar nerve.
  • Lateral plantar nerve.
• Sural nerve.
• Deep peroneal nerve.
• Intermediate dorsal cutaneous nerve.
• **Medial dorsal cutaneous nerve.

Causes of Ankle Pain - Acute

Many causes are categorized as "Horses" (common), "Zebras" (less common), and "Unicorns" (rare).

• Lateral ligament sprain:
  • ATFL, CFL, PTFL.
• Medial collateral ligament (Deltoid Ligament) sprain.
• Syndesmosis injury.
• Fractures:
  • Lateral/medial/posterior malleolus (Pott’s fracture – bimalleolar).
  • Tibial plafond.
  • Base of the 5th metatarsal (MT).
  • Anterior process of the calcaneus.
  • Lateral process of the talus.
  • Posterior process of the talus.
• Osteochondral lesion of the talus.
• Dislocated ankle.
• Tendon rupture/dislocation:
  • Tibialis posterior tendon.
  • Peroneal tendon (longitudinal rupture).
• Maisonneuve fracture.
• Complex regional pain syndrome type 1 (post injury).
• Os trigonum.
• Greenstick fracture (children).
• Tarsal coalition (may come to light as a result of an ankle sprain).

Lateral Ankle Sprain – Prevalence

• Most common ankle injury.
• Prevalence in basketball players:
  • 70% had a history of ankle sprain.
  • 80% of those had multiple sprains.
• Common in jumping and running/cutting sports.

Lateral Ankle Sprain – Clinical Presentation

• Mechanism of Injury (MOI): Excessive supination/inversion (± plantarflexion).
  • ATFL is the first to rupture.
• Signs and Symptoms:
  • Pain.
  • Swelling/± Ecchymosis.
  • Instability.
  • Weight-bearing (WB) or non-weight-bearing (NWB)?
• Differential Diagnosis:
  • Syndesmosis sprain.
  • Fractures.

Lateral Ankle Sprain – Diagnosis

• Patient History – MOI
• Palpation
• Ottawa ankle rules  X-ray
• Special tests
  • Anterior drawer test, talar tilt test
• Outcome Measures
  • Lower Extremity Functional Scale (LEFS)
  • Foot and Ankle Disability Index
  • LLTQ

Lateral Ankle Sprain – Management

• Acute Phase (24 – 72 hours):
  • POLICE (Protection, Optimal Loading, Ice, Compression, Elevation)
  • Optimal Loading depends on the grade of injury
  • Ankle pumps 10 – 20/hour
  • Active and passive soft tissue techniques
  • Soft Tissue therapy to calf to help reduce swelling – caution on the grade of injury.
  • Crutches (gait retraining) - WBAT (Weight bearing as tolerated)
  • Ottawa Ankle Rules (Imaging)
  • Depending on severity (hydrotherapy)
  • Taping/bracing
• Reparative Phase (3 – 15 days):
  • Joint mobilizations
  • Passive stretch (gastroc/soleus)
  • Isometric exercise (as soon as the patient can tolerate)
  • Strengthening (peroneii, TA, extensors, triceps surae)
  • Proprioception (standing and sitting)
  • Shoe assessment
  • Taping/bracing
• Remodeling Phase (15 – 28 days, 3 weeks 60% strength, 3 months 100% strength):
  • Begin running/jumping forward and backwards
  • Incorporation of multidirectional agility drills
  • Progress to jumping sideways (over a line)
  • Progress to box drills
  • Incorporate multidirectional sports-specific proprioceptive exercises
  • Simulated sport-specific exercises

Lateral Ankle Sprain – Evidence

• Systematic Review of studies investigating conservative treatment for lateral ankle sprain.
• n = 20 studies (Limited high-quality studies)
• Effectively relieves pain and improves function
• No evidence for any one form of conservative approach… (e.g., ice, manual therapy, exercise, compression, topical ointment, bracing, etc)

Osteochondral Fractures of the Talar Dome

• Damage to the articular surface of the talus
• Incidence around 6.5% after ankle sprain
• Predominately during compression injuries (linked with high ankle sprains)
• Commonly superomedially
• Commonly missed
• Signs and Symptoms
  • Presents later with persistent ankle pain, catching, clicking, locking
  • Reduced ROM
  • MRI or CT required

Classification System

• Grade I: Subchondral fracture
• Grade II: Chondral fracture
• Grade IIa: Subchondral cyst
• Grade III: Chondral fracture with separated but non-displaced fragment(s)
• Grade IV: Chondral fracture with separated displaced fragment(s)

Treatment

• Grade I and II, treat conservatively
  • Activity modification
  • Cycling – non-painful
  • Limited WB within pain = promote loading on cartilage
  • Clicking, catching, locking after 3 months = arthroscope
• Grade III and IV surgical intervention
  • Post surg rehab

Malleoli Fractures

• Lateral malleolar fracture – most common
• MOI – typically lateral ankle sprain with significant WB forces (e.g. fall, uneven ground, jumping sports)
• Signs and Symptoms
  • Pain++ (constant ache pain – intense-sharp w movt)
  • swelling/±Ecchymosis
  • Instability
  • Loss of ROM
  • NWB?
  • Pain on palpation (OAR)
• Differential diagnosis
  • # of tibial plafond
  • Lateral ligament sprain
  • Syndesmosis injury
  • Maisonneuve fracture
• Diagnosis
  • OAR  Imaging – (X-ray)
• Treatment
  • Surgical (displaced or complicated)
  • Conservative (non-displaced)
    • Immobilisation in moonboot/aircast 6-8 weeks progress to FWB with crutches.
    • Physiotherapy starting at 7 days (↓ pain, ↓ swelling, ↑ ROM, ↑ Strength)
• Evidence
  • Surgical vs conservative – SR – 3 studies
    • No significant differences at 7 years
    • Found better outcomes in surgical group for pain at 7 years
    • No significant differences at 3.5 years
  • Importantly – treatment failure occurred in 19/129 (15%) of conservative group vs. 2/116 (<1%) in surgical group.

Ottawa Ankle Rules

Refer to slide 27 for details on sensitivity and specificity.

Tibial Plafond/Pilon Fractures

• Tibial plafond – articular surface of the tibia.
• Vertical compression force – eg. Fall
• Can occur from ankle sprain
  *Classification system exists (see slide 30 for details).
• Diagnosis
  • Complaint of constant pain – esp during WB
  • Ottawa Ankle Rules
  • Limited ROM – esp dorsiflexion
  • Imaging required – plane radiography can be normal  CT, Bone Scan, MRI required
• Treatment
  • Conservative treatment where appropriate
    • NWB/PWB - Moon boot protection 6-8 weeks
    • Progressive Strengthening
    • Neuromuscular control
    • Manual therapy – improve ROM
    • Stretching – improve ROM
    • Proprioception – balance etc.
    • Sport specific - RTS
  • Surgical treatment if displaced (debridement)
    • Post op rehab
    • Pain can persist for up to 12 months

Fracture of the 5th Metatarsal

• Base of the 5th MT – avulsion # of peroneus brevis
• Jones fracture (Zone 2)
• MOI – plantarflexion/inversion injury or medially directed force on a planted foot
• Potential prodromal symptoms of lateral foot pain in 45% of soccer players that went onto have a Jones fracture
• Three Types
  • Type 1: narrow fracture line/no intramedullary sclerosis
  • Type 2: delayed union/widening fracture/intramedullary sclerosis
  • Type 3: non-union/complete obliteration of medullar canal by sclerotic bone
• Signs and symptoms
  • Pain on 5th MT
  • TOP along the 5th MT
  • Swelling and bruising
• Treatment
  • Conservative
    • Be aware of non-union due to poor blood supply
    • NWB 6 – 8 weeks
    • Gradual rehabilitation
  • Surgical
    • Screw fixation – faster RTS (early as 2-4 weeks) and fewer occurrences than conservative Rx.

Dislocated Ankle

• Sever lateral ankle sprain
• Immediate referral for relocation – under analgesia (MUA)

Syndesmosis Injury

• AKA – High ankle sprain
• MOI – internal rotation of the tibia on a fixed dorsiflexed foot resulting in external rotation of the talus.
• Structures affected
  • Interosseous membrane
  • AITFL
  • PITFL
  • Transverse ligament
• Differential diagnosis
  • Lateral ankle sprain
  • Deltoid ligament sprain
  • Fracture (lateral/posterior malleoli)
• Diagnosis
  • MOI – Clinical reasoning
  • Pain located at the DTFJ (higher than lateral ankle sprain)
  • Special tests
    • Squeeze test, Kleiger’s test, Cotton test
• Treatment
  • Period of WBAT with crutches
  • Phase 1 – Managing Pain/Swelling
    • ↓ pain, ↓ swelling, ↑ ROM (foot pumps, ankle circles), Isometric exercises, don’t forget hip and knee
  • Phase 2 – Improving ROM
    • Improve ROM (stretching gastroc/soleus), seated tilt board ROM/motor control, isolated strength training (Theraband movements) – low resistance cycling
  • Phase 3 – Strengthening
    • Building full strength – incorporating proprioception (foam/uneven surfaces), cardio – cycling – Lunges, squats, step ups (functional activities) building resistance
  • Phase 4. RTS
    • Sport specific training – single leg balance, SEBT, weighted squats, multi-tasking functional exercises that are sport specific (e.g. catching and landing, reactive contact)

Maisonneuve Fracture

• Complex injury involving proximal fracture of the fibular (spiral #), rupture of the MCL, and rupture of the AITFL. (urgent referral to orthopaedic surgeon is required)

Causes of Ankle Pain - Chronic

These conditions are categorized as "Horses" (common), "Zebras" (less common), and "Unicorns" (rare).

• Chronic ankle instability
• Calcaneal stress fracture
• Complex regional pain syndrome type 1 (post injury)
• Medial ankle
  • Os Trigonum
  • Talus stress fracture
  • Navicular stress fracture
  • Tibialis posterior tendinopathy
  • Tarsal tunnel syndrome
  • FHL tendinopathy
  • Medial malleolus stress fracture
  • Medial calcaneal nerve entrapment
• Lateral ankle
  • Peroneal tendinopathy
  • Impingement syndrome
  • Distal fibular stress fracture
  • Sinus tarsi syndrome
  • Peroneal tendon subluxations
  • Cuboid syndrome
• Posterior ankle
  • Achilles tendinopathy (mid portion or insertional)
  • Severe’s disease
  • Achilles tendon rupture
  • Posterior impingement
  • Subcutaneous bursae

Chronic Ankle Instability - Prevalence

• Estimated that 30% of people will develop CAI after initial sprain
• Mechanical (MAI) – laxity of a joint due to loss of mechanical restraint (ligamentous)
• Functional (FAI). – perception/realisation that the ankle gives way, is weaker, more painful

CAI – Clinical Presentation

• Recurrent ankle sprains
• Giving way
• Altered activity level
• Outcome Measures:
  • Cumberland Ankle Instability Tool
  • Ankle Instability Instrument
  • Identification of Functional Ankle Instability Questionnaire
  • Foot and Ankle Disability Index
  • Foot Posture Index (FPI)

CAI – Clinical Diagnosis

• Patient history (recurrent ankle sprain)
• Special tests (ligament laxity/rupture)
• Altered neuromuscular control
  • Impaired balance (SEBT, TTS)
  • Impaired proprioception
  • Impaired strength
  • Slower firing of peroneal muscles (?)
  • Single Leg Stance
  • Proprioception testing/balance
• SEBT, TTS
• Imaging (x-ray, MRI)

CAI – Management

• Physical Therapy
  • Strength
  • Neuromuscular control
    • EMG biofeedback
    • US – as feedback (diagnostic)
  • Proprioception/balance
  • Ankle supports/braces
  • Foot orthoses (poor evidence)

CAI – Evidence

• Systematic review w meta-analysis – No significant effect of ankle bracing/taping on proprioception compared to no bracing/taping for recurrent ankle sprains or FAI.
• There is also evidence that 6 weeks of isokinetic exercise is effective for functional outcomes
  • Increasing strength
  • Improving joint position sense
  • Improving functional test
    • Single leg hoping
    • Single and triple hop for distance
    • 6m and 6m crossed hop for time

Os Trigonum

• The os trigonum is an extra (accessory) bone that sometimes develops behind the ankle bone (talus). It is connected to the talus by a fibrous band.
• Occurs in about 5-10% of people – usually asymptomatic
• Combined with ankle injury or sporting activities with frequent plantarflexion (e.g. ballet/dance, gymnastics).
• Signs and Symptoms
  • Deep ache at the back of the ankle
  • TOP posterior ankle
  • Pain during plantarflexion (AROM and PROM)
• Differential diagnosis
  • Achilles tendon pain
  • Bursae
  • Fat pad impingement
  • High ankle sprain ?trauma
• Diagnosis
  • Subjective history.
  • Minimal pain with MMT in dorsiflexed position (differential diagnosis)
  • Pain with AROM & PROM during plantarflexion – non-contractile tissue (differential diagnosis)
  • TOP – localised
• Treatment
  • Activity modification
  • Advice and education
  • Immobilisation if necessary
  • Ice/heat for pain relief
  • NSAIDs
  • Injections (CSI, analgesic)
  • Surgery (remove bone) in serious cases

Achilles Tendinopathy - Prevalence

• Incidence of 1.9 / 1,000 registered patients (GP clinic)
• Associated with physical activity
• ⅓ of patients did not participate in sport

Other Tendinopathy

• Lateral:
  • Fibularis brevis
• Medial:
  • Tibialis anterior
  • Tibialis posterior
  • Flexor hallucis longus

Tendinopathy – Clinical Presentation/Diagnosis

• Typically 2° Overuse &/or change in activity level/type
• Signs and Symptoms
  • Pain
  • Activity related pain
  • Tendon thickening
  • Pain on palpation
  • Reduced strength (Pain)
  • Stiffness of the tendon
• Imaging – Ultrasound
• Outcome Measure: VISA-A

Achilles Tendon Management

• Activity modification
• Advice and education
• Transverse frictions – STT local muscles
• Therapeutic Exercise
  • Stage 1 Isometrics - ? Not beneficial in all tendinopathy
  • Stage 2 Isotonics
  • Stage 3 Energy storage
  • Stage 4 Energy storage and release

AT- Management/Evidence

• Systematic Review on different protocols
• Historically - Alfredson Exercise Protocol (Eccentric exercises)
  • 3 sets x 15 reps twice daily, both w knee bent and straight

Achilles Tendinopathy

• Heavy slow resistance training vs. eccentric training
• N = 58 - 12 weeks of treatment
• Both groups improved from 0 – 12 weeks
• HSR had better patient satisfaction at follow-up
• Take home message: HSR better than ECC for AT in terms of patient satisfaction but both groups improved

Tendon Rehabilitation

• Evidence suggests that soleus plays a key role in Achilles tendinopathy. Don’t forget rehab of soleus!
• Energy storage and release exercises (sport specific)
  • Storage and release exercises
  • Load needs to be controlled to build up tendon capacity (volume, intensity, duration)
• RTS – Training then competition

Sinus Tarsi Syndrome

• Small osseous canal
• Impingement of the tissues between
  • Houses synovium, fat, blood vessels, connective tissue
• Independent injury – overuse/excessive pronation, repeated forceful eversion
• ~70% of patients had a previous lateral ankle sprain
• Inflammatory conditions – Gout – OA – Rhematoid Arthritis
• Signs and Symptoms
  • Poorly localised pain anterior to lateral malleolus
  • Pain during forceful activities – running, jumping etc
  • Ankle and foot stiffness
  • Full pain-free ROM but subtalar joint might be stiff
  • PROM – eversion/inversion = pain
  • Instability in the hindfoot
• MRI often not helpful
• Diagnostic test – Injection of local anaesthetic during fluoroscopy
• Treatment
  • Rest
  • Short term NSAIDs
  • Mobilisation of the subtalar joint
  • Corticosteroid injection
  • Corrective footwear and biomechanics
  • Proprioception and progressive strength training

Posterior Impingement

• Impingement of the tissues between tibia and calcaneous (in extreme plantarflexion)
• Impinged tissues: synovium, capsuloligamentous, os trigonum
  *Ballet dancers, gymnasts, cricket bowlers, football players
• FHL tenosynovitis commonly co-exists
• “Fishing” the foot increased risk in ballet dancers
• Diagnosis
  • Pain during active and PASSIVE plantarflexion (AROM especially loaded – SLS on toes)
  • Acute presentation: ? # of posterior talus
  • Imaging of os trigonum presence
  • Technique assessment
• Treatment
  • Technique modification
  • Strength and endurance of hip ER, calf muscles, foot intrinsics
  • Manual therapy: Subtalar joint, talocrural joint, midfoot
  • NSAID or paracetamol
  • Cross-training: pilates progress to en pointe
  • CSI
  • Surgery

Sever’s Disease

• Calcaneal apophysitis
  *Adolescents
• Activity related heel pain
• Local TOP and swelling at calcaneal insertion of the AT
• Limited dorsiflexion
• Reduced length of gastroc/soleus
• Biomechanical examination (kinetic chain)
• Treatment
  • Activity modification (decrease pain-full activites)
  • Advice and Education (typically settle within 6-12 months)
  • Heel raise inserted in shoes
  • Stretching calf (gastroc/soleus)
  • Correct biomechanical abnormalities
  • Orthoses?
  • Strengthening plantarflexors when pain-free
  • NO CSI/Surgery (contraindicated)