Week 6 Lecture

Mechanisms of injury 85% involve supination injury mechanisms 15% consist of pronation/eversion mechanisms

ATFL- anterior talofibular ligament PTFL -posterior talofibular ligament CFL- Calcaneofibular ligament

(medial aspect of foot) Posterior tibiotalar lig (PTTL) Tibiocalcaneal lig (TCL) Anterior tibiotalar lig (ATTL) Tibionavicular lig (TNL)

AITFL- Anterior inferior tibiofibular ligament PITFL- Posterior inferior tibiofibular ligament

Grade 1 Partial ATFL +- CFL well localised mild edema < 5 decrease in ROM Less common medial joint bone bruising FWB with only mild pain No ligamentous laxity, softer EF Average time RTS 10-12 days Grade 2 Complete ATFL +- partial CFL Localised moderate edema >5 decrease in ROM More common/marked medial joint bone bruising FWB with sig pain Mild-Mod ligamentous laxity, altered endfeel 2-3/52 Return to sport GRADE 3 Complete ATFL &amp; CFL +- PTFL Odema > 2 cm Decreased ROM > 10degrees Severe medial joint signs (bone bruising) Intolerant of FWB Marked ligamentous laxity, Empty end feel 6/52 RTS Normal stress radiograph GRADE 4 Complete ATFL &amp; CFL +- PTFL Odema > 2 cm Decreased ROM > 10 degrees Severe medial joint signs (bone bruising) Intolerant of FWB Marked ligamentous laxity, Empty end feel 10/52 RTS Stress radiography >3mm difference Found that clinical symptoms were not well correlated with the grade of injury. Amount of swelling and ability to weight bear were the factors most correlated with the severity of bone bruising.

GRADE 1 mild-min fibre disruption mild-min swelling (well localised) Tolerant of WB on flat ground Loading to DF is provocative Min- mild mechanical laxity(abnormal) GRADE 2 Mod fibre disruption Mod swelling(well localised) Less tolerant of WB on flat ground Marked provocation w loaded dorsiflexion Moderate Mechanical laxity with pathological end feel GRADE 3 Severe fibre disruption Severe swelling, diffuse but remains in high ankle region Unable to WB due to pain and/or apprehesion Marked laxity with clear pathological end feel

Avulsion fracture of the base of 5th MT Osteochondral injuries Malleolar fractures Dislocation/subluxation

An ankle XR series is required if: TOP midline distal 6cm of fibula OR of lateral malleolus TOP midline distal 6cm of tibia OR of medial malleolus Unable to WB at ]me of the injury and unable to walk 4 steps in the clinic or ED A foot XR series is required if… TOP base of 5th metatarsal and/or TOP at the navicular and/or Unable to WB at time of the injury and unable to walk 4 steps in the clinic or ED

-Size lig support deltoid thicker & broader than lat lig -Loose packed position of talocrual joint landing in PF TC joint is in loose pack position & more dependent on NM support -Speed on NM response Rapidity of ankle sprain injury exceeds ability of protective muscle reactions -size of medial malleolus MM blocks inversion fo calcaneus & talus less than LM blocks eversion • Relative capacity for excursion 2: 1 ratio of inversionn to eversion

-Supination (platarflexion) (Inversion) (Adduction) Lateral ankle complex strains 85% Structures affected ATFL CFL PTFL

-Pronation aka external rotation of foot (Dorsiflexion) (Eversion) (Abduction) • Hyperdorsiflexion(talus forces malleoli apart) Injury to Distal Tibifibular joint/syndesmosis -AITFL(Anterior inferior tibiofibular ligament) -PITFL(Posterior inferior tibiofibular ligament -Transverse ligament -Interosseous ligament

On AP views look for: -Tibiofibular Clear space(TFCS) Horozontal distance from lat boarder post tibial malleolus to medial boarder of fibular (>5 mm abnormal) -Tibiofibular overlap Horozontal distance between medial borader of fibula to lateral boarder of ant tibial promenence (<10 mm abnormal) On MORTICE veiws look for: -Medial clear space Distance b/n lateral aspect of medial malleolus & medial border of talus at level of talar dome. (>4mm abnormal)

• Symptoms – Focal pain above the ankle joint( radiates superiorly) – No significant swelling/bruising - Poor WB tolerance esp if combined with rotational stress or Loading in DF – Level of pain disability may be disproportionate to the initial perceived severity of the injury Diagnosis • Stress tests for injury to the syndesmosis – The Squeeze test( Sx reproduction induced by a gapping force applied to the mid tibia and fibula) – External rotation test Kleigers test – “Cotton” test Lateral shear of talus on a fixed leg Determines damage to Deltoid lig AITFL PITFL Interosseous membrane

The muscles which cause inversion of the foot are: Tibialis anterior Tibialis posterior The muscles which cause eversion of the foot are: Fibularis longus FIbularis brevis

Supination: Inversion Plantarflexion Adduction Pronation: Eversion Dorsiflexion Abduction

Talocrual joint: Plantar/dorsiflexion Subtalar joint(Talocalcaneal) joint: Inversion/eversion Transverse tarsal joint:Inversion eversion

HIND FOOT: talus & calcaneus (STJ) MIDFOOT: Cuboid, navicular, 3 cuniforms (Transverse tarsal joint) Inversion/eversion + plantarflexion/dorsiflexion FOREFOOT: metatarsals, phalanges

History of ankle trauma (chronic reccurent pattern) Recurrent giving way +/- recurrent ankle sprains (recurrent ankle effusion) Feelings of instability/howllowness/weakness

Complications of ankle lig sprains (non acute) Chronic ankle instability (CAI) Subluxing peroneal/fibularis tendons Talar dome fracture Post-traumatic synovitis Ankle impingement Recurring theme here is recovery taking longer than the expected biological healing time-frames for an otherwise uncomplicated ankle sprain *Perceived instability is the most consistant predictor of disability

Impaired balance/proprioception as measured by relevant FOM (hopping tests) SEBT( star excursion balance test) Jump-landing Side-side hop test Figure of 8 hop test High reliability for patients with CAI has also been demonstrated when performed as a cluster of single limb hop tests SEBT: -Reliability 0.67 to 0.87 No single test is sufficiently accurate for diagnosis but a combination of symptoms and tests can confirm ankle syndesmosis involvement • Sensitve – An inability to hop – Syndesmosis ligament (AITFL) TOP – Positive DF external rotation stress test • Specific – Pain out of proportion to injury and – Positve “Squeeze” test

Intrinsic: Extrinsic: Medial Tibial Stress Syndrome – Intrinsic • Excessive/uncontrolled pronation • Muscle tightness (PF’s) – Compensatory overpronation • Running technique – Extrinsic • High and/or unaccustomed training loads • Hard training surfaces • Poor footwear (inadequate support)

No ankle effusion Full pain free ankle/STJ ROM Pain free broad jumps Pain free hopping on the spot Normal walking gait Normal pain free straight line jogging/running gait

5% of cases Pronation (Dorsiflexion) (Eversion) (Abduction)

Reliability & validity LOW in acute phase Manual stress tests only acceptable: • Within 1st hour or • 4-7 days after injury