Conditions affecting the Ankle joint Flashcards
Excessive prominence of the posterosuperior aspect of the calcaneus (where achilles tendon is inserted)
Symptoms are due to rubbing against the calcaneal prominence of the heel counter of the shoe
- Chronic inflammation of the adventitious superficial pretendinous Achilles bursa
- Coexists with retrocalcaneal bursitis
Haglund deformity
Developmental and aggravated by shoe wear
has gout
etiology of hugland deformity
Pain on the posterior heel
Signs of skin irritation like skin erythema and focal swelling
If there is retrocalcaneal bursitis, sign & symptoms of this symptoms will be seen
Signs and symptoms of haglund’s deformity
Radiographs
There is an extra bone formation at the prominence of the heel
Dx of Haglund deformity
Ice, heel lift, open back shoe (wear wedged shoes)
NSAID
Steroid injection
Surgical – excision of bony prominence and retrocalcaneal bursitis
Treatment of Haglund deformity
Failure of the lateral tubercle of the posterior process to unit with the body of the talus during ossification (8-10 for girl, 11-13 for boys) producing impingement with extreme plantar flexion
Present in 10% of patients
Os Trigonum
Persistent separation of the secondary center of the lateral tubercle from the remainder of the posterior talus secondary to the microtrauma during development
Congenital cause of Os Trigonum
Secondary to an actual fracture that did not unite
Common in young athletes who actively plantar flexes the foot such as gymnasts, ice skaters, ballet dancers, soccer players
Acquired cause of Os Trigonum
Pain on the posterolateral of the ankle due to impingement of the posterior talus between posterior tibial and calcaneus
Hypertrophic capsulitis
Concurrent posteromedial due to flexor hallucis tendonitis
Signs and symptoms of Os Trigonum
Conservative – Rest, NSAID
Surgery if it doesn’t go away
Management of Os Trigonum
Disruption of the Achilles tendon
Due to degeneration and repeated microtrauma/microstress
Achilles Tendon Rupture
Antecedent non insertional Achilles tendinitis
Sedentary lifestyle
Use of steroids (oral or injection)
Systemic disease such as gout
Risk factors of Achilles Tendon Rupture
Non surgical with cast
pt foot in plantarflexion,
Surgical reconstruction for chronic rupture
treatment for achilles tendon rupture
Higher re-rupture rate
Incomplete return of function and performance (no extreme activities)
Surgical
Infection
Wound dehiscence (infection at the wound and it opens again)
complications of achilles tendon rupture
classification of achilles tendon rupture
acute, chronic
Delay of 2 months as chronic or neglected while other consider 3 months as chronic
Chronic achilles tendon rupture
Painful pop on the distal aspect of the heel cord
Weak ankle plantarflexion
+ Simon’s sign (palpable defect in the tendon)
Thomson’s test – squeezing the calf
Symptoms of achilles tendon rupture
squeezing the calf
Thomson’s test
palpable defect in the tendon
+ Simon’s sign
Lateral Ligaments complex of the ankle
The anterior talofibular ligament (ATFL)
The calcaneofibular ligament (CFL)
The posterior talofibular ligament (PTFL)
is a strong, flat, triangular band, attached, above, to the apex and anterior and posterior borders of the medial malleolus.
The deltoid ligament (or medial ligament of talocrural joint)
Components of ankle deltoid ligament
Anterior tibiotalar ligament
Tibiocalcaneal ligament
Posterior tibiotalar ligament
Tibionavicular ligament.
2 types of ankle sprain
high ankle sprain
low ankle sprain
syndesmosis injury
1-10% of all ankle sprains
nasa distal tibi-fibular jt
high ankle sprain
ATFL and CFL injury
>90% of all ankle sprains
low ankle sprain
most commonly involved ligament in low ankle sprains
mechanism is plantar flexion and inversion
physical exam shows + drawer’s test
ATFL (anterior talofibular ligament)
2nd most common ligament injury in lateral ankle sprains
mechanism is dorsiflexion and inversion
physical exam shows drawer laxity in dorsiflexion
subtalar instability can be difficult to differentiate from posterior ankle instability because the CFL contributes to both
CFL (calcaneo fibular ligament)
less commonly involved ligament
PTFL (posterior talofibular ligament)
clinical features of ankle sprain
pain w weight bearing
recurrent instability
catch or popping sensation may occur following recurrent sprains
focal tenderness and swelling over involved ligament
anterior drawer test
pain and tenderness and swelling on lateral aspect of foot
physical exam for ankle sprain
The examiner then places the patient’s foot into 10-15 degrees of plantar flexion and translates the rear foot anteriorly.
A positive test results if the talus translates forward. Positive test results are often graded on a “0 to 3 scale”, with 0 indicating no laxity & 3 indicating gross laxity
Drawer’s test
ATFL best tested in
plantarflexion
CFL best tested in
dorsiflexion
With the ankle in neutral, gentle inversion force is applied to the affected ankle and is compared to the opposite ankle (invert/evert)
Talar tilt test
+ talar tilt test indicates injury to
ATFL and CFL
no ligament disruption
minimal swelling
normal weight bearing
grade I ankle sprain
stretch without tear
moderate swelling
mild pain w weight bearing
grade II ankle sprain
complete tear of ligament
severe swelling
severe pain w weight bearing
grade III ankle sprain
Also known as a “high ankle sprain”
Syndesmosis ankle sprain
most commonly associated with external rotation injuries
mechanism of injury of syndesmosis ankle sprain
Foot is planted on the ground and then an excessive outwards twisting of foot occurs
pathoanatomy of syndesmosis ankle sprain
incidence 0.5% of all ankle sprains without fracture
13% of all ankle fractures
Syndesmosis ankle sprain
distal tibiofibular syndesmosis includes
anterior-inferior tibiofibular ligaments (AITFL)
posterior-inferior tibiofibular ligament (PITFL)
interosseous membrane
originates from anterolateral tubercle of tibia
inserts on anterior tubercle of fibula
anterior-inferior tibiofibular ligaments (AITFL)
riginates from posterior tubercle of tibia
inserts on posterior part of lateral malleolus
strongest component of syndesmosis
posterior-inferior tibiofibular ligament (PITFL)
maintains integrity between tibia and fibula
resists axial, rotational, and translational forces
function of distal tibiofibular ligaments
syndesmosis widens 1mm during gait
normal gait of syndesmosis ankle sprain
anterolateral ankle pain proximal to AITFL
may have medial sided ankle tenderness/swelling
difficulty bearing weight
Sx of Syndesmosis Ankle Sprain
palpation
syndesmosis tenderness is the single best predictor for return to play
+ squeeze test
Physical exam of Syndesmosis ankle sprain
Examiner grasps the patient’s leg midway up the calf and perform a compress and release motion
+ test if patient experiences pain in the syndesmosis
Squeeze test
non-weight-bearing CAM (control ankle motion) boot or cast for 2 to 3 weeks
indications
non operative treatment of syndesmosis ankle sprain
Syndesmosis screw fixation
fiberwire suture with two buttons tensioned around the syndesmosis
operative treatment of syndesmosis ankle sprain
