ANKLE INJURIES

ANATOMY
1) Distal end of tibia : ankle mortise Distal end of fibula 2) Talus trochlea of talus dome 3) Ligaments a) lateral ligament complex b) medial ( deltoid ligament ) c) syndesmosis

ANKLE SPRAINS
- The most common acute sport injuries, 25% in every running or jumping sport - Mechanism of injury: inversion and plantar flexion of the foot when landing off balance or clipping another players foot

ANKLE SPRAINS
Sequence of injury: anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, musculotendinous units supporting the ankle joint

ANKLE SPRAINS
Incidence increased in : - individuals with varus malalignment of lower limbs - calf muscle tightness - previous incompletely rehabilitated ankle sprains

ANKLE SPRAINS
- Diagnosis: x-rays, stress x-rays ( inversion stress, anterior drawer test), ? MRI scan - acute phase ( first 72 hours ): RICE, then varies according to the severity of injury

GRADE 1 ( Mild ) SPRAINS

- The anterior talofibular ligament affected - stress: minimal change on inversion, normal anterior drawer - treatment by encouraging early active movement: a) stationary cycling b) walking with protective taping or semi-rigid brace ( Aircast splint )

GRADE 1 ( Mild ) SPRAINS

c) NSAIDS (anti-inflammatory medication) d) physiotherapy: electrotherapy, strengthening exercises, propreoception (1 legged stand ) e) functional progression to running, jumping, hopping, swerving and cutting, recovery into 6 weeks

GRADE 2 (Moderate) SPRAINS

- Complete tear of anterior talofibular ligament with some damage of the calcaneofibular ligament - laxity when inversion, anterior drawer present - treatment: a) 1 week crutches, joint taped or in aircast splint b) follow grade 1 rehabilitation

GRADE 3 ( Severe ) SPRAINS

- Uncommon severe injuries, associated with fractures - treatment: 10 days NWB in aircast brace or POP, then PWB with the brace up to 6 weeks. Aggressive rehabilitation follows - surgical reconstruction must be considered

PERONEAL TENDON INJURIES

- Strong everters and weak plantar flexors of the foot - mechanism of injury: a) associated with lateral ligament injuries b) forced dorsiflexion with slight inversion and reflex contraction of the tendons ( sprinting, uneven ground, ballet)

PERONEAL TENDON INJURIES

- O/E: Behind lat.malleolus discomfort or swelling. Subluxation on resisting dorsiflexion with eversion - treatment: a) acute phase well-moulded short NWB cast with pad over lat.malleolus b) chronic phase surgical correction, POP 4 weeks c) rupture of peroneal tendons surgical correction

PERONEAL TENDON INJURIES

TENDINITIS: - occurs in dancers, basketball, volleyball - combined cause of the lat.malleolus pulley action and foot malalignment

PERONEAL TENDON INJURIES

TENDINITIS: - TREATMENT a) rest from sport, temporary use of heel wedge b) physiotherapy, extreme cases: local injection into the sheath c) gradual coaching programme, avoid rapid direction changes or sprinting 6 weeks d) failure of conservative treatment: tenolysis of peroneal tendons

TALAR DOME FRACTURES

- Suspicion if ankle sprains failed to recover - can present later: damage of subchondral bone (bone bruising), later separation and displacement of an osteochondral fragment

TALAR DOME FRACTURES

- Symptoms: locking, instability, weakness, discomfort - Diagnosis: x-rays in 6 weeks, bone scan, MRI scan - Treatment: removal of loose body and defect curettage

ANTERIOR IMPINGEMENT SYNDROME

- Mechanism: repetitive traction or injury over anterior capsule exostoses produced on the anterior margin of distal tibia and talus - footballers ankle, basketball,ballet - pain on dorsiflexion, reduced dorsiflexion later on - x-rays: lateral view exostoses, loose bodies - treatment: NSAIDS, local inj. Surgical excision

POSTERIOR IMPINGMENT SYNDROME

- Congenital: talar spur (trigonal process) or a separate un-united ossification centre of talus (OS trigonum ) - ballet, fast cricket bowling, jumping, swimming - NSAIDS, surgical excision ( difficult cases )

FOOT INJURIES

 MORTONS NEURALGIA ( NEUROMA ) - Mechanism: fibrous enlargement of a plantar interdigital nerve with entrapment between metatarsal heads (usually 3rd and 4th ) - repetitive trauma, dropped metatarsal heads, tight shoes, hard surfaces. Stress fractures also considered in the differential diagnosis

ENTRAPMENT NEUROPATHIES IN THE FOOT

 - Pain in the web, loss of sensation - metatarsal neck pads, other orthotic correction, local injection, surgery

ENTRAPMENT NEUROPATHIES IN THE FOOT

 Other neuropathies: - dorsal cutaneous branch of the deep peroneal nerve on the dorsum of the foot - sural nerve behind the lateral malleolus or over the styloid process of the fifth metatarsal

ENTRAPMENT NEUROPATHIES IN THE FOOT

SINUS TARSI SYNDROME

- Sinus tarsi: concavity at the lateral tarsal canal of the subtalar joint - discomfort in front of lat.malleolus, running - differential diagnosis from chronic lat.ligament sprain - treatment: control of over pronation, strengthening of post.tibialis muscle, local injection

BURSITIS ABOUT THE HEEL

- Over achilles tendon: posterior calcaneal bursa - Below achilles tendon: retrocalcaneal bursa - running with ill-fitting shoes Haglunds syndrome: (bony bossing) on the posterior aspect of calcaneum - treatment: rest, low friction taping,NSAIDS, physio, local inj., footwear attention

HEEL FAT PAD SYNDROME (BRUISED HEEL )

- Disruption of the fibrofatty protective tissue over the sensitive periosteum of calcaneum - veteran runners: age and repeated trauma - treatment: decreased weight bearing activity, weight loss, orthotics: use of a semi rigid moulded heel cup, shoes with a snug firm heel counter DONT USE: local inj., flat or convex pads

PLANTAR FASCIITIS
- Running on hard surfaces, tennis, netball, jumping - mechanism: MTP extension produces a windlass stress over plantar fascia lifting the longitudinal arch of the foot - Periosteal reaction may produce a heel spur ( x-rays )

PLANTAR FASCIITIS
- Pain under medial aspect of the heel, worse on tip toeing, early in the morning, stairs - treatment: NSAIDS, 4-8mm heel raise, physiotherapy, orthotics to modify over pronation

CALCANEONAVICULAR LIGAMENT SPRAIN ( Spring Ligament )

- Acute twisting injuries of the foot in football, jumping - pain and tenderness over medial arch of the foot - Ice, NSAIDS, electrotherapy, orthotics

CUBOID SYNDROME
- Cuboid bone: pulley for peroneus longus tendon, stabilizer of the transverse arch of the foot - lateral mid foot pain. Tenderness with pressure proximal of the 5th metatarsal - orthotics to support in flexion the cubometatarsal joint and control pronation. Physio for strength of the toes long flexors and anterior tibialis

REFLEX SYMPATHETIC DYSTROPHY OF THE FOOT

- Associated with minor strains, sprains, laceration or foot surgery - painful, swollen, hypersensitive to touch, hot or cold, moist foot. Stiff joints, atrophic muscles, anxious patient - x-rays: osteopenia and soft tissue swelling

REFLEX SYMPATHETIC DYSTROPHY OF THE FOOT

- Treatment: aggressive physiotherapy, tubigrip, sympathectomy by epidural injection - recovery from 8 weeks to 2 years

ANTERIOR METATARSALGIA
- Tenderness at plantar aspect of metatarsal heads - over pronated feet, excessive mobility of 1st metatarsal - callus formation under 2nd and 3rd metatarsal heads - treatment: callus care, weight loss, orthotics incorporating metatarsal bars, correct pronation. Physio ( tight triceps surae ) Attention to shoes

SESAMOIDITIS
- Sesamoid bones in the tendon of flexor hallucis brevis - dancers, ice skaters, gymnasts, basketball - crush fractures, avulsion, bipartite sesamoid, osteonecrosis - x-rays and bone scan imaging - shoes with elevated heels avoided, orthotics. Dancers, gymnasts: adhesive padding and rest, surgical excision

ACHILLES TENDON INJURIES

- Common tendon of gastrocnemius and soleus muscles - tendon twists laterally from 15cm above insertion becoming more pronounced at 2-5cm above insertion. Blood supply reduced at this level

ACHILLES TENDON INJURIES

- Aetiology factors: lack of rear foot support in shoes, terrain, excessive training loads, biomechanical factors of foot: over pronation, rear foot varus or valgus, pes cavus, tight calf muscles

ACHILLES TENDON INJURIES

- Assessment: ultrasound scan: ruptures, swelling, degenerative cysts, calcifications - treatment: correct biomechanics with orthotics. Acute phase: rest, ice, electrotherapy, heel raise, gentle stretching, NSAIDS, no inj. - surgery: ( ruptures, adhesive peritendinitis )

FRACTURES
- Ankle fractures: intarticular, if displaced ORIF -talus fracture: surgical treatment to avoid osteonecrosis - calcaneum fractures: most conservative, early ROM

FRACTURES
- Metatarsal fractures: reduce dislocations, most common fracture 5th metatarsal base ( Jones ) - toe fractures: most treated conservative, strapping with next toe for 3 weeks