ANKLE INJURIES

ANATOMY
1) DIstaI end oI tIbIa
: ankIe mortIse
DIstaI end oI IIbuIa
2) TaIus - trochIea oI taIus dome
3) LIgaments - a) IateraI IIgament
compIex b) medIaI ( deItoId
IIgament )
c) syndesmosIs
ANKLE SPRAINS
The most common acute sport
InjurIes, 25Z In every runnIng or
jumpIng sport
MechanIsm oI Injury: InversIon and
pIantar IIexIon oI the Ioot when
IandIng oII baIance or cIIppIng
another pIayer`s Ioot
ANKLE SPRAINS
Sequence oI Injury: anterIor
taIoIIbuIar IIgament, caIcaneoIIbuIar
IIgament, posterIor taIoIIbuIar
IIgament, muscuIotendInous unIts
supportIng the ankIe joInt
ANKLE SPRAINS
ncIdence Increased In :
IndIvIduaIs wIth varus
maIaIIgnment oI Iower IImbs
caII muscIe tIghtness
prevIous IncompIeteIy rehabIIItated
ankIe spraIns
ANKLE SPRAINS
DIagnosIs: xrays, stress xrays
( InversIon stress, anterIor drawer
test), Z MR scan
acute phase ( IIrst 72 hours ):
RCE, then varIes accordIng to the
severIty oI Injury
RADE 1 ( Mild ) SPRAINS
The anterIor taIoIIbuIar IIgament
aIIected
stress: mInImaI change on InversIon,
normaI anterIor drawer
treatment by encouragIng earIy actIve
movement:
a) statIonary cycIIng
b) waIkIng wIth protectIve tapIng or semI
rIgId brace ( AIrcast spIInt )
RADE 1 ( Mild ) SPRAINS
c) NSADS (antIInIIammatory medIcatIon)
d) physIotherapy: eIectrotherapy,
strengthenIng exercIses, propreoceptIon
(1 Iegged stand )
e) IunctIonaI progressIon to runnIng,
jumpIng, hoppIng, swervIng and cuttIng,
recovery Into 6 weeks
RADE 2 (Moderate) SPRAINS
CompIete tear oI anterIor taIoIIbuIar
IIgament wIth some damage oI the
caIcaneoIIbuIar IIgament
IaxIty when InversIon, anterIor drawer
present
treatment: a) 1 week crutches, joInt
taped or In aIrcast spIInt
b) IoIIow grade 1 rehabIIItatIon
RADE 3 ( Severe ) SPRAINS
Uncommon severe InjurIes,
assocIated wIth Iractures
treatment: 10 days NW8 In aIrcast
brace or POP, then PW8 wIth the
brace up to 6 weeks. AggressIve
rehabIIItatIon IoIIows
surgIcaI reconstructIon must be
consIdered
PERONEAL TENDON
INJURIES
Strong everters and weak pIantar
IIexors oI the Ioot
mechanIsm oI Injury:
a) assocIated wIth IateraI IIgament
InjurIes
b) Iorced dorsIIIexIon wIth sIIght
InversIon and reIIex contractIon oI the
tendons ( sprIntIng, uneven ground,
baIIet)
PERONEAL TENDON
INJURIES
OJE: 8ehInd Iat.maIIeoIus dIscomIort or
sweIIIng. SubIuxatIon on resIstIng
dorsIIIexIon wIth eversIon
treatment: a) acute phase - weII
mouIded short NW8 cast wIth pad over
Iat.maIIeoIus b) chronIc phase - surgIcaI
correctIon, POP 4 weeks c) rupture oI
peroneaI tendons - surgIcaI correctIon
PERONEAL TENDON
INJURIES
TENDNTS:
occurs In dancers, basketbaII,
voIIeybaII
combIned cause oI the
Iat.maIIeoIus puIIey actIon and Ioot
maIaIIgnment
PERONEAL TENDON
INJURIES
TENDNTS:
TREATMENT - a) rest Irom sport,
temporary use oI heeI wedge
b) physIotherapy, extreme cases: IocaI
InjectIon Into the sheath
c) graduaI coachIng programme, avoId
rapId dIrectIon changes or sprIntIng - 6
weeks
d) IaIIure oI conservatIve treatment:
tenoIysIs oI peroneaI tendons
TALAR DOME FRACTURES
SuspIcIon II ankIe spraIns IaIIed to
recover
can present Iater: damage oI
subchondraI bone (bone bruIsIng),
Iater separatIon and dIspIacement
oI an osteochondraI Iragment
TALAR DOME FRACTURES
Symptoms: IockIng, InstabIIIty,
weakness, dIscomIort
DIagnosIs: xrays In 6 weeks, bone
scan, MR scan
Treatment: removaI oI Ioose body
and deIect curettage
ANTERIOR IMPINEMENT
SYNDROME
MechanIsm: repetItIve tractIon or Injury
over anterIor capsuIe - exostoses
produced on the anterIor margIn oI dIstaI
tIbIa and taIus
" IootbaIIer`s ankIe", basketbaII,baIIet
paIn on dorsIIIexIon, reduced
dorsIIIexIon Iater on
xrays: IateraI vIew - exostoses, Ioose
bodIes
treatment: NSADS, IocaI Inj. SurgIcaI
excIsIon
POSTERIOR IMPINMENT
SYNDROME
CongenItaI: taIar spur (trIgonaI
process) or a separate ununIted
ossIIIcatIon centre oI taIus (OS
trIgonum )
baIIet, Iast crIcket bowIIng,
jumpIng, swImmIng
NSADS, surgIcaI excIsIon ( dIIIIcuIt
cases )
FOOT INJURIES
ENTRAPMENT
NEUROPATHIES IN THE
FOOT
MORTON`S NEURALCA ( NEUROMA )
MechanIsm: IIbrous enIargement oI a
pIantar InterdIgItaI nerve wIth
entrapment between metatarsaI heads
(usuaIIy 3
rd
and 4
th
)
repetItIve trauma, " dropped" metatarsaI
heads, tIght shoes, hard surIaces. Stress
Iractures aIso consIdered In the
dIIIerentIaI dIagnosIs
ENTRAPMENT
NEUROPATHIES IN THE
FOOT
PaIn In the web, Ioss oI sensatIon
metatarsaI neck pads, other
orthotIc correctIon, IocaI InjectIon,
surgery
ENTRAPMENT
NEUROPATHIES IN THE
FOOT
Other neuropathIes:
dorsaI cutaneous branch oI the
deep peroneaI nerve on the dorsum
oI the Ioot
suraI nerve behInd the IateraI
maIIeoIus or over the styIoId
process oI the IIIth metatarsaI
SINUS TARSI SYNDROME
SInus tarsI: concavIty at the IateraI tarsaI
canaI oI the subtaIar joInt
dIscomIort In Iront oI Iat.maIIeoIus,
runnIng
dIIIerentIaI dIagnosIs Irom chronIc
Iat.IIgament spraIn
treatment: controI oI over pronatIon,
strengthenIng oI post.tIbIaIIs muscIe,
IocaI InjectIon
URSITIS AOUT THE HEEL
Over achIIIes tendon: posterIor caIcaneaI
bursa
8eIow achIIIes tendon: retrocaIcaneaI
bursa
runnIng wIth IIIIIttIng shoes
HagIund`s syndrome: (bony bossIng) on the
posterIor aspect oI caIcaneum
treatment: rest, Iow IrIctIon
tapIng,NSADS, physIo, IocaI Inj.,
Iootwear attentIon
HEEL FAT PAD SYNDROME
(RUISED HEEL )
DIsruptIon oI the IIbroIatty protectIve
tIssue over the sensItIve perIosteum oI
caIcaneum
veteran runners: age and repeated
trauma
treatment: decreased weIght bearIng
actIvIty, weIght Ioss, orthotIcs: use oI a
semI rIgId mouIded heeI cup, shoes wIth
a snug IIrm heeI counter
DON`T USE: IocaI Inj., IIat or convex pads
PLANTAR FASCIITIS
RunnIng on hard surIaces, tennIs,
netbaII, jumpIng
mechanIsm: MTP extensIon
produces a "wIndIass" stress over
pIantar IascIa IIItIng the IongItudInaI
arch oI the Ioot
PerIosteaI reactIon may produce a
heeI spur ( xrays )
PLANTAR FASCIITIS
PaIn under medIaI aspect oI the
heeI, worse on tIp toeIng, earIy In
the mornIng, staIrs
treatment: NSADS, 48mm heeI
raIse, physIotherapy, orthotIcs to
modIIy over pronatIon
CALCANEONAVICULAR
LIAMENT SPRAIN
( Spring Ligament )
Acute twIstIng InjurIes oI the Ioot
In IootbaII, jumpIng
paIn and tenderness over medIaI
arch oI the Ioot
ce, NSADS, eIectrotherapy,
orthotIcs
CUOID SYNDROME
CuboId bone: puIIey Ior peroneus
Iongus tendon, stabIIIzer oI the
transverse arch oI the Ioot
IateraI mId Ioot paIn. Tenderness wIth
pressure proxImaI oI the 5
th
metatarsaI
orthotIcs to support In IIexIon the
cubometatarsaI joInt and controI
pronatIon. PhysIo Ior strength oI the toes
Iong IIexors and anterIor tIbIaIIs
REFLEX SYMPATHETIC
DYSTROPHY OF THE FOOT
AssocIated wIth mInor straIns,
spraIns, IaceratIon or Ioot surgery
paInIuI, swoIIen, hypersensItIve to
touch, hot or coId, moIst Ioot. StIII
joInts, atrophIc muscIes, anxIous
patIent
xrays: osteopenIa and soIt tIssue
sweIIIng
REFLEX SYMPATHETIC
DYSTROPHY OF THE FOOT
Treatment: aggressIve
physIotherapy, tubIgrIp,
sympathectomy by epIduraI
InjectIon
recovery Irom 8 weeks to 2 years
ANTERIOR
METATARSALIA
Tenderness at pIantar aspect oI
metatarsaI heads
over pronated Ieet, excessIve mobIIIty
oI 1
st
metatarsaI
caIIus IormatIon under 2
nd
and 3
rd
metatarsaI heads
treatment: caIIus care, weIght Ioss,
orthotIcs IncorporatIng metatarsaI bars,
correct pronatIon. PhysIo ( tIght trIceps
surae ) AttentIon to shoes
SESAMOIDITIS
SesamoId bones In the tendon oI IIexor
haIIucIs brevIs
dancers, Ice skaters, gymnasts,
basketbaII
crush Iractures, avuIsIon, bIpartIte
sesamoId, osteonecrosIs
xrays and bone scan ImagIng
shoes wIth eIevated heeIs avoIded,
orthotIcs. Dancers, gymnasts: adhesIve
paddIng and rest, surgIcaI excIsIon
ACHILLES TENDON
INJURIES
Common tendon oI gastrocnemIus
and soIeus muscIes
tendon twIsts IateraIIy Irom 15cm
above InsertIon becomIng more
pronounced at 25cm above
InsertIon. 8Iood suppIy reduced at
thIs IeveI
ACHILLES TENDON
INJURIES
AetIoIogy Iactors: Iack oI rear Ioot
support In shoes, terraIn, excessIve
traInIng Ioads, bIomechanIcaI
Iactors oI Ioot: over pronatIon, rear
Ioot varus or vaIgus, pes cavus,
tIght caII muscIes
ACHILLES TENDON
INJURIES
Assessment: uItrasound scan: ruptures,
sweIIIng, degeneratIve cysts,
caIcIIIcatIons
treatment: correct bIomechanIcs wIth
orthotIcs. Acute phase: rest, Ice,
eIectrotherapy, heeI raIse, gentIe
stretchIng, NSADS, no Inj.
surgery: ( ruptures, adhesIve
perItendInItIs )
FRACTURES
AnkIe Iractures: IntartIcuIar, II
dIspIaced ORF
taIus Iracture: surgIcaI treatment to
avoId osteonecrosIs
caIcaneum Iractures: most
conservatIve, earIy ROM
FRACTURES
MetatarsaI Iractures: reduce
dIsIocatIons, most common Iracture
5
th
metatarsaI base ( ]ones )
toe Iractures: most treated
conservatIve, strappIng wIth next
toe Ior 3 weeks