Ankle Lesions and

Management
 Overuse Syndromes of the Leg
• It is a local inflammatory response to stress.
• causes are either intrinsic (malalignment
syndromes, muscle imbalances) or extrinsic
(training error).
• A. SHIN SPLINTS
• Shin splints (idiopathic compartment syndrome)
is an etiological subset of exercise-induced pain:
• mechanical inflammation due to repetitive stress
of the broad proximal portion of any of the
musculotendinous units originating from the
lower part of the leg or tibia during weight
bearing.
• shin splints can be anterolateral or posteromedial.
• Anterolateral shin splints cause pain and
tenderness lateral to the tibia over the anterior
compartment and involve the pretibial muscles,
including anterior tibialis, extensor hallucis longus
, and extensor digitorum longus
• Cause is secondary to heel contact on hard
surfaces, or to wearing a shoe with a hard heel, or
to biomechanical abnormalities
• A muscle imbalance between a weak pre-tibial
muscle group and tight gastrocnemius soleus
muscles result in overactivation of these muscles
during heel-strike and swing phase.
• Posteromedial shin splints cause symptoms along the
posteromedial border of the middle to lower tibia over
the posterior compartment, which is appreciated more
during toe-of,
• In both there is typically weakness of the affected
muscles and pain reproduced by resisted active motion.
 b. MEDIAL TIBIAL STRESS
SYNDROME

• (MTSS) or tibial periostitis presents as exercise-

induced pain localized to the distal poteromedial
border of the tibia. It is usually more focal and more
painful than shin splint
• it is periosteal inflammation near the origin of the
posterior tibialis or the medial soleus.
• C. STRESS FRACTURE OF THE TIBIA

• account for 95 percent of all stress fractures in athletes

as a result from fatigue failure within' the bone,
• Associated features are repetitiveness of activity and
muscle forces acting across the bone.
• A stress fracture may not be visible on ordinary xray films for 2
to 8 weeks
• So bone scan is the gold standard in diagnosing stress fracture.
 TREATMENT OF OVERUSE
INJURIES
• Rest for the affected muscle-tendon-bone unit is the
mainstay of treatment in phase 1.
• Both shin splints and medial tibial stress syndrome can
progress to stress fracture, and stress fractures may
progress to complete cortical break.
• The duration of rest varies from 1 to 2 days for mild
shin splints to several months for severe stress
fractures.
• In phase I, ice, compression, and elevation are used
• to reduce swelling and inflammation.
Nonsteroidal anti-inflammatory drugs
(NSAIDs) used
• to evaluate for biomechanical factors such as
running on hard, uneven, or inclined surfaces,
improper footwear, and overzealous training.
• TENDINITIS

• Achilles tendinitis is the most common form in athletes.

• as it does not have a synovial sheath, Achilles tendinitis,
with or without peritendinitis is often associated with
repetitive or high-impact sports such as running,
basketball, or volleyball.
• Symptoms are usually gradual in onset over a 2- to 3-week
period.
• pain which initially occurs during activity and is relieved
by rest. In the next stage the pain continues for hours
and become worse during the night, which is highly
suggestive of bone pain.
• Swelling may occur particularly after activity.
• localized tenderness with or without swelling
• Common sites are the medial aspect of the tibia and 2
to 3 inches above the tip of the fibular malleolus above
the joint line.
• A positive percussion sign
• When overuse there is gradual onset of pain that may
be accentuated by excessive pronation or supination.

• Training errors, poor flexibility, and weakness of the

Achilles tendon are predisposing factors.

• Dorsiflexion causes pain, and crepitus felt along the tendon

• Treatment follows similar lines as that of other
overuse injuries.
• Chronic paratendon lesions that do not respond to
appropriate physical therapy, require a surgical
tenolysis.
• Tendinosis or intratendinous lesions may require
surgical exploration. Necrotic tissue is cureted and
the tendon is repaired.
• A rupture of the Achilles tendon requires immediate
surgical repair.
 Ankle Sprain
• The most common lesion
• The anterior talofibular ligament is the most commonly
sprained ligament at the ankle and is probably the most
commonly sprained ligament in the body.
• The next most frequently sprained ligaments at the
ankle are the calcaneocuboid and the calcaneofibular
ligaments.
• Portions of the deltoid ligament may also be
sprained, but a forceful eversion stress will result in
an avulsion of the tibial malleolus rather than
damage to the ligament.
• History
• Onset of pain.
• the traumatic incident.
• Mechanism of injury for an anterior talofibular ligament is a
plantar flexion-inversion stress.
• Typical examples include an athlete who lands from a jump on
the lateral border of the plantarly flexed foot, a person wearing
high-heeled shoes or walking on uneven ground who catches a
toe on the lateral side of the foot, or a person stepping off a
curb or step who rolls over the lateral side of the plantarly flexed
foot. If the forefoot is forced into supination or adduction, the
calcaneocuboid ligament may be injured instead or as well.
• The calcaneofibular ligament restricts inversion with the foot in a
more neutral or dorsiflexed position. When torn, the deltoid
ligament is usually injured because the foot is forced into external
rotation and eversion with respect to the leg and a portion of the
tibial malleolus avulse
• The anterior tibiofibular ligament is torn with as the talus rotates
• B. Site of pain .
• Corresponds with the approximate location of the injury. pain may
be referred distally into the foot or proximally into the lower leg
• e. Nature of pain or disability.
• These patients describe intermittent giving way of the ankle,
followed by pain and effusion lasting for a few days.
• II. Physical Examination
• A. Observation.
• A patient hobble into the office walking with a characteristic
"foot flat," short-stance gait;
• both heel-strike and push-off are lacking.
• If the pain is more severe, the patient may walk in with the
aid of crutches or hop on one leg.
• B. Inspection. Localized swelling over the region
 • within several hours after the injury.
• there may be some associated articular effusion.
• Within a day or so following it may extravasate distally into
the foot.
• e. Selective tissue tension tests
• 1. Active movements.
• In the acute stage there is difficulty in ankle movements so
avoid undue discomfort or stress to the part.
• 2. Passive movements and joint-play movements
• If the ankle mortise joint capsule has been stressed with subsequent
articular effusion, the ankle movements will be limited in a capsular
pattern; plantar flexion will be slightly more restricted than
dorsiflexion.
• b. In the case of a mild or moderate ligamentous sprain,
pain will be reproduced with movements that stress the
involved ligament an associated muscle-spasm end feel.
• Painless hypermobility noted in the presence of chronic
ruptures.
• The common ligaments injured and the passive movements
• used to test their integrity are as follows:
i. Anterior talofibular ligament.
Combined plantar flexion-inversion-adduction of the
hindfoot and anterior glide of the talus on the tibia
ii. Calcaneocuboid ligament.
Combined supination-adduction of the forefoot
 iii. Calcaneofibular ligament.
Inversion of the hindfoot in a neutral position of plantar flexion-
dorsiflexion
iv. Deltoid ligament.
• Anterior fibers: combined plantar flexion-eversion abduction of the
hindfoot;
• Middle fibers: eversion of the hindfoot
• 3. Resisted movements.
• These should be strong and painless. Occasionally the
peroneal tendons are strained in conjunction with an
inversion ligamentous strain. In this case, isometric resistance
to eversion will be strong and painful. Weakness of plantar
flexion and eversion may be present..
Palpation
• 1. Tenderness at site of the lesion in acute injuries.
• 2. Joint effusion from synovitis
• 3. Skin temperature
III. Management
• A. Acute sprains-
• Ice, elevation, compression, mobility exercises, and
strengthening can be carried out easily at home by
most patients.
• A follow-up visit after 2 or 3 days
• 1.For stability:
• Ankle strapping
• Crutches should be used to relieve stress and pain during ambulation.
2. Reduction of the acute inflammation
• a. Ice
• b. Compression
• c. Elevation
• 3. Prevention of residual disability.
• a. Motion of the part in not stress planes
• b. Isometric exercises
B. Acute sprains-subsequent measures
• In the case of a simple sprain,
• Weight-bearing should be regained, and the crutches discarded,
by the fifth day.
• Range of motion strength, and joint play should be restored
to normal.
• Friction massage, promote healing
• As the swelling subsides strapping should be substituted for
elastic bandage to provide support and increase
proprioceptive feedback
• The athlete should begin by jogging, then running, in straight lines.
• Progress to figure-of-eight patterns that impose some lateral
stress strength, then to sharp cutting drills. Then to
competitive activity resumption
• Progression from challenging one-legged standing to one-legged
standing on a rocking stage to one-legged standing on a board
supported on half a sphere
• 2. Moderate sprains and complete ruptures.
• Surgical management:
• suturing of the ligament does result in a more stable joint, but
the functional status of those undergoing surgery is really no
better than those treated "conservatively.
• Conservative (nonsurgical) management:
• follow the same approach as management for Less serious
injuries;
• With more extensive damage need to be protected, by
crutches and strapping, as long as 2 weeks.
• early motion and strengthening at pain-free intensities
should be initiated
• return to normal and, especially, to vigorous activity
levels should be more gradual
• C. Chronic recurrent ankle sprains.
• There are three possible causes
• 1. Healing of the ligament with adherence to adjacent
tissues. pain and swelling will result from a fatigue
phenomenon. With forceful stress to the structure, the
adhesion will rupture, producing another sprain.
• painful, minor restriction on passive plantar flexion-
inversion of the hindfoot and on anterior glide of the talus.
• Treatment: deep, transverse friction massage to the ligament
and specific joint mobilization in the directions of
restriction.
• Normal mobility gradually restored .
• 2. Loss of protective reflex muscle stabilization.
• when the anterior talofibular ligament is stressed, the
peroneus tertius is called to reduce the load to the
ligament.
• Management is by instituting a program of balance
training, and good muscle strength
3. Gross mechanical instability of the joint.
• If both the anterior talofibular ligament and the
calcaneofibular ligament are ruptured, or extensive capsular
disruption with an anterior talofibular ligament rupture-
mechanical instability
• It does not allow functional weight-bearing activities without
giving way.
• obvious hypermobility on joint-play movement
• Treatment is:
• aggressive muscle strengthening and balance training
program until balance well during one-leg standing.If not
sufficient then surgical reconstruction done
• PLANTAR FASCIATIS
• inflammation of the plantar fascia and the perifascial structures.
• Chronic stress to the origin of fascia on the calcaneus cause
calcium to deposit, forming a spur (plantar calcaneal spurs).
• Both spur and fasciatis develop via similar mechanisms,
• plantar fasciitis can be caused by an acute injury (strain) from
excessive loading of the foot.
• chronic irritation from an excessive amount of pronation or
prolonged duration of pronation,
• A cavus or high-arched foot because of a tight plantar fascia
• Plantar fasciitis is a common cause of heel pain.
• It is associated with prolonged standing or walking.

• Pain is worse by activity, and tends to be relieved by rest.

• localized tenderness at the plantar fascial attachment of the
calcaneus, in the medial arch area and in the abductor hallucis
muscle.
• Range of motion of the great toe is limited in dorsiflexion, and
ankle dorsiflexion is less then 90°,Small granuloma is palpated on
the medial fascial origin.
• Patient keep the foot in a rather supinated or inverted posture
from foot-strike through to toe-off to minimize pain.
• Those with tarsal tunnel syndrome have a positive Tinel sign
• Those who do not respond to treatment may be of
seropositive and seronegative collagen vascular disorders (e.g. ,
rheumatoid arthritis, spondylitis, and Reiter's syndrome)
• the treatment is directed at both a short-term goal (to control
inflammation at the insertion of the fascia into the calcaneus
in conjunction with relieving undue stress in the plantar fascia
itself) and a long-term goal (correction of mechanical factors)
• Ice-massage, rest, and anti-inflammatory.
• Ultrasound and phonophoresis with 10 percent
hydrocortisone used
• non-weight-bearing until symptoms subside.
• Excessive pronation should be limited by strapping
• an in shoe orthotic device or over-the-counter arch support
is recommended.
• night splints has effective results.
• heel pads made specifically for heel pain.
• stretching the plantar fascia, friction massage joint
mobilizations for hind foot, subtalar joint, and inferior
navicular