ankle injuries.ppt
DESCRIPTION
ANKLE INJURIES.pptTRANSCRIPT
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 player’s 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
• - “ footballer’s 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 )
ENTRAPMENT NEUROPATHIES IN THE
FOOT• MORTON’S 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
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 shoesHaglund’s 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
• DON’T 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