ANKLE ANATOMY & FUNCTION

   Joint is formed by the tibia and fibula and the talus.
   Joint allows for the dorsiflexion (up) and plantarflexion (down).
   Tibia forms the medial malleolus (inner bony prominence).
   The lateral malleolus (outer bony prominence) and is formed by the fibula.
   Stability of the joint comes from several factors:

         The unique structural arrangement of the bones forming the joint
         The surrounding ligaments.

   Instability may develop from fractures to thee bones surrounding the joint.
   The joint may also become unstable when the surrounding ligaments are
Lateral View

       Complex of three ligaments.
       Ligaments provide stability by attaching the lateral malleolus to the talus
        and calcaneus.
       They are the:

              anterior talo-fibular ligament (goes from the talus to the fibula)
              calcaneo-fibular ligament (goes from the calcaneus to the fibula)
              posterior talo-fibular ligament (goes from the talus to the fibula).

Medial Side

   Deltoid ligament complex which goes from the medial malleolus of the tibia to
    the talus.

    The lateral ligaments are the most commonly injured
    Ligaments are typically damaged in a direction that goes from the front to
       the back.
     Most severe injury being in the anterior and the least severe being in the

Inversion Ankle Sprains

    Most common type of ankle sprain occurs when the foot is inverted / twisted

     About 90% of ankle sprains are inversion injuries. Pain is always on the
     outside of the ankle, and there is usually no pain on the inside of the ankle

Eversion Ankle Sprains

    Foot is twisted outwards.
    The deltoid ligament are stretched and pain on the inner side of the ankle is

Grade I Sprain

   Most common and requires the least amount of treatment and recovery.
   The ligaments over-stretched, and damaged microscopically, but not actually
   The ligament damage has occurred without any significant instability
   2 – 3 weeks recovery
Grade II Sprain

 Indicates that the ligament has been more significantly damaged, often
  partially torn.
 No significant instability.
 3 – 6 weeks recovery

Grade III Sprain

      Most severe and ligament has been torn.

      Ligament has been significantly damaged, and that instability has resulted.

      4 – 12 months.

      Diagnosis of the injury is determined by examination of the location of the
       bruising (ecchymosis), swelling, and tenderness.
       Need to perform stress testing of the ligaments to determine whether the
       ligament has been torn.
      Stress testing of the ligaments is done by pushing on the ankle and
       attempting to determine if there is any abnormal motion at the joint which
       would indicate that a ligament has been torn.
      X-rays are often performed to check for the possibility of a chipped bone or
      When performing a stress test of the ligaments, a posteriorly directed force
       is applied to the front of the tibia (shin bone). If the ankle ligaments are
       completely torn, the tibia will visibly shift backwards at the ankle joint. When
       the force is removed, the tibia will snap back into its proper position at the
       ankle joint. When this abnormal motion occurs, the anterior talo-fibular
       ligament (ATFL) has been torn.

    Lateral (Side) View of            (Side) View of Left Ankle with
    Normal Left Ankle                 Grade III tear of ATFL


      Depends on the severity of the sprain.
      RICER
      Bracing
      Surgery
Residual Ankle Instability

   Ligaments heal weaker or looser then prior to the injury.
   This results in an ankle that is more likely to be unstable and twist more
   When this happens exercise often allows the adjacent muscles to
    strengthen and stabilize that joint.
   Sometimes, it is necessary to wear a brace.
    Surgically reconstruct maybe required with chronic instability.
   However, when it does become necessary to reconstruct the torn ligaments,
    the reconstruction may be done in several ways.
Anterior Ankle Impingement

   bony growth at the front of the ankle where the joint capsule attaches.
   It can follow an injury where the ankle has been over stretched or over
   The bony deposits cause inflammation in the joint capsule and tendons.


     Pain and tenderness when pressing in with the fingers over the front of the
      ankle joint.
     Pain when you bend your foot up or down.
     A bony lump at the front of the ankle.


     If the bony growth is large surgery may be required to remove it.
     Massage techniques.
     Steroid injection
     Strengthening exercises.
Peroneal Dislocation

                                        The peroneal tendon runs behind the lateral
                                        If the tissue that holds the tendons in place
                                         is torn by an ankle sprain the tendons can
                                         slip forward over the malleolus.
                                        Repeated dislocations can result in
                                        The injury is common with unstable ankles.
                                        Often a contributing factor to this is tension
                                         in the muscle belly of Peroneal tendon.


      Pain when soles of the feet are pronated
      Pain or tenderness behind the lateral malleolus
      Swelling and bruising.

    RICER
    Gentle stretching when the inflammation has gone.
    Massage
    Cast for 3 to 4 weeks if the injury is fairly recent.
   Operation to repair tissue that holds tendon.
Stress fracture of the talus

     More susceptible to developing a stress fracture when the ankle is
      repeatedly over pronated and plantar flexed (or rolling on / flattening at the
      same time as pointing the foot downwards).


     Gradual onset pain on the outside of the ankle.
     Pain is worse during running.
     Tenderness and possible swelling over the sinus tarsi (a small canal
      where nerves pass.)
     Bone scans and CT scans to confirm.


     Treatment usually involves six weeks rest in a plaster cast.
     Surgery to remove the lateral process of the talus bone is sometimes done
      which can speed up the healing and rehabilitation process.
     A full and gradual rehabilitation program to increase strength.
     Biomechanical correction of any over pronation with orthotic inserts.
Stress Fracture in the Foot

     Often due to prolonged repeated loads on the legs. Long distance runners
      are susceptible to this type of injury.
     Mainly in the calcaneus, navicular and metatarsal bones).
     A stress fracture of the 2nd or 3rd metatarsal bone is sometimes called a
      'march fracture' because soldiers running in boots often get it!


     Pain in the affected bone during exercise.
     Tenderness and swelling at a point on the bone.


     Xray often will not show anything until it starts to heal.
     Rest 6 – 8 weeks.
     Stretching
Tibialis Posterior Syndrome

     The tibialis posterior muscle comes from behind tibia and runs into a
      tendon that passes behind the medial malleolus
      Inflammation can occur around the medial malleolus and further down
      under the foot where the tendon attaches.
      If you over pronate you are more likely to suffer from this injury.


     Pain over the attachment of the tendon to the navicular bone in the foot.
     Pain when the tendon slides in the sheath during exercise.
     Swelling around the medial malleolus.


     Rest 2 - 3 weeks.
     ICE first 3 days then heat and support.
     NSAIDS
     Plaster for 3 weeks in severe cases
     Operation for ruptures
Achilles tendon rupture

      More common injury in older men who are recreational athletes.
       It sometimes occurs following a history of inflammation or degeneration of
       the tendon but nearly always results from a sudden event such as pushing
       off hard on the toes or suddenly bending the foot upwards.


      Sudden sharp pain
      Audible noise ‘Crack”
      Unable to walk and stand
      There may be a gap felt in the tendon.
      There will be a lot of swelling.

    Refer
    Operation
    Cast
    6 – 12 months
    Higher chance of reinjury with surgery
Achilles tendon rupture (Partial)

     A partial achilles tendon rupture can occur in athletes from all sports but
      particularly running, jumping, throwing and racket sports.
     The tendon tears but not completely.
     Scar tissue will form which is likely to lead to inflammation of the tendon.


     A sudden sharp pain in the Achilles tendon.
     Sometimes while warming down pain is felt.
     Stiffness in achilles tendon first thing in the morning.
     A small swelling in the tendon.

    RICER
    Taping
    Strengthening
    Operation
Ankle Fractures

      Injury may be to the medial malleolus or to the fibula (the lateral
       malleolus), or both.
      Many different type of ankle fractures.


      Pain to touch
      Swelling
      Bruising
      Inability to walk on the leg
      Deformity around the ankle


      Reference
      XRAY
      Cast
      Surgery
      Rehab

Fracture Examples

   Supination adduction

      The foot is supinated (inverted), and an adducting force is exerted on the
       talus, resulting in 2 sequential injuries.
       First, tension on the lateral ligaments (the calcaneofibular
       ligament, primarily) leads to a transverse fracture of the lateral malleolus
       below or up to the level of the tibiofibular joint, or a ligament tear occurs.
      Second, the talus adducts, impacts the medial malleolus, and causes an
       oblique medial malleolar fracture

Supination external rotation

      This is the most common mechanism for a "twisted ankle" injury.
      The foot is supinated, and an external rotation force acts on the talus,
       resulting in up to 4 sequential injuries

      First, the anteroinferior tibiofibular ligament tears.

      Second, a short oblique fracture of the fibula occurs

      Third, fracture of the posterior malleolus is observed.

      Fourth, transverse fracture of the medial malleolus or tear of the deltoid
       ligament occurs.
Pronation abduction

      The foot is in a pronated position (everted), and an abducting force is
       exerted on the talus, resulting in up to 3 sequential injuries:

      First, the deep portion of the deltoid ligament becomes tense and a
       transverse fracture of the medial malleolus occurs.

      Second, the talus abducts and stresses the ligaments of the tibiofibula
       syndesmosis, resulting in a tear of the anteroinferior tibiofibula ligament.

      Third, further abduction of the talus results in oblique fracture of the distal

Pronation external rotation

      The foot is in a pronated position (everted), and an external rotation force
       acts through the talus, resulting in up to 4 sequential injuries

      The first 2 injuries are the same as in the pronation abduction (PA)
       mechanism (medial malleolar fracture and syndesmosis injury)

      For the third injury, the external rotation force results in a different fibula
       fracture. It is a short spiral or oblique fracture well above the level of the
       syndesmosis (usually 6-8 cm above the syndesmosis but may be as high
       as the mid-shaft level).

      The fourth injury is a fracture of the posterior malleolus.

Maisonneuve fracture

      The exact mechanism leading to a Maisonneuve fracture is not clear.
       First, a tear of the anteroinferior tibiofibula ligament and the interosseous
       membrane occurs.

      Second, fracture of the posterior malleolus or a posterior ligament tear is

      Third, anteromedial capsular injury is present.

      Fourth, fracture of the proximal fibula occurs (usually at the neck).

      Fifth, fracture of the medial malleolus or a deltoid ligament tear is

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