Page 1
1
Ankle Injuries
Dr Peter Brukner, OAMSports Physician
Associate Professor Centre for Sports Medicine Research & Education
The University of Melbourne
Adjunct ProfessorSchool of Human Movement Studies
The University of Queensland
Ankle Sprain
The most likely diagnosis is lateral ligament sprain
Range of Motion
Dorsiflexion Plantarflexion Inversion
Page 2
2
Lunge
Palpation
Palpation (Medial)
Page 3
3
Palpation
Anterior Drawer
Talar Tilt
Page 4
4
Proprioception
Ankle Sprain
The majority of these injuries respond well to a standard treatment regime
Ankle Sprains
R.I.C.ENWB/PWB/FWBelectrotherapeutic modalitiesstrengtheningproprioceptiontape/brace
Page 5
5
Mobilization
Strengthening
Proprioception
Page 6
6
Proprioception
Protection
Bracing / Taping
Page 7
7
The Difficult Ankle
A significant group do not progress
The Difficult Ankle
…. and complain of persistent pain, swelling and impaired function after 3-6 weeks
Principles of Diagnosis
1. Possible Causes2. History3. Examination4. Investigation
Page 8
8
Possible Causes
1. Common
2. Less common
3. Not to be missed
Possible Causes
Fracturechronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement
1. Common
Possible Causes
Fracture– talar dome– base of 5th metatarsal
chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement
1. Common
Page 9
9
Talar Dome Fractures
Talar Dome Fractures
CT Bone Scan
Talar Dome Fractures (MRI)
Page 10
10
Possible Causes
Fracture– talar dome– base of 5th metatarsal
chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement
1. Common
Base of 5th Metatarsal
Possible causes
Fracture– talar dome– base of 5th metatarsal
chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement
1. Common
Page 11
11
Possible Causes
Fracture– talar dome– base of 5th metatarsal
chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement
1. Common
Possible Causes
Fracture– talar dome– base of 5th metatarsal
chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement
1. Common
Page 12
12
Possible Causes
Fracture– talar dome– base of 5th metatarsal
chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement
1. Common
Page 13
13
Possible Causes
Fracture– talar dome– base of 5th metatarsal
chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement
1. Common
Page 14
14
Possible Causes
Fracture– lateral process talus– anterior process calcaneus– tibial plafond– os trigonum / posterior process talus
AITFL injuryanterolateral impingementneural causes
2. Less common
Possible Causes
Fracture– lateral process talus
2. Less common
Possible Causes
Fracture- anterior process calcaneus
2. Less common
Page 15
15
Possible Causes
Fracture– tibial plafond
2. Less common
Possible Causes
Fracture– os trigonum– posterior process talus
2. Less common
Possible Causes
Fracture– lateral process talus– anterior process calcaneus– tibial plafond– os trigonum/posterior process talus
AITFL injuryanterolateral impingementneural causes
2. Less Common
Page 16
16
Possible Causes
Fracture– lateral process talus– anterior process calcaneus– tibial plafond– os trigonum/posterior process talus
AITFL injuryanterolateral impingementneural causes
2. Less Common
Anterolateral Impingement
Page 17
17
Possible Causes
Fracture– lateral process talus– anterior process calcaneus– tibial plafond– os trigonum/posterior process talus
AITFL injuryanterolateral impingementneural causes
2. Less Common
Neural Tension
Possible Causes
dislocation peroneal tendonrupture tibialias posterior tendonreflex sympathetic dystrophy (RSD)OCD
3. Not to be missed
Page 18
18
Principles of Diagnosits
1.Possible causes
2.History
3.Examination
4.Investigation
Page 19
19
History
mechanism of injurypain, swelling, bruisinglevel of dysfunctionearly management? X-ray
Historysubsequent progresscurrent symptoms– pain– swelling– impingement– instability– function
history of previous injury
Principles of Diagnosits
1.Possible causes
2.History
3.Examination
4.Investigation
Page 20
20
Examination
inspectionrange of motionpalpationligament testingfunctional testing
Examinationstrength testingproprioceptionneural tensionimpingement tests–anterior–posterior
Principles of Diagnosits
1.Possible causes
2.History
3.Examination
4.Investigation
Page 21
21
Plain X-ray
1. fracture2. posterior impingement3. anterior impingement } Special
views
Triple Phase Bone Scan
important screening testingthree phases–angiogram (immediate)–blood pool (2 minutes)–bone phase (2-3 hours)
Page 22
22
Triple phase bone scan
⇑ ⇑ uptake⇑ uptake
no ⇑ uptake
⇑⇑ Uptake
- talar dome fracture- other fracture
Mild Uptake
- impingement syndrome- synovitis- RSD (late)
Page 23
23
No ⇑ ⇑ Uptakeimpingement syndromeAITFL injurysynovitissinus tarsi syndromedislocating peroneal tendonRSD (early)
CT scans
If bone scan shows ⇑⇑ uptake
CT performed to visualise fracture
MRI
alternative to CTmore sensitive in osteochondraldamagesoft tissue imaging
Page 24
24
The Difficult AnkleInvestigation
Conclusion
consider possible causesgood historythorough examinationinvestigate–bone scan/MRI is the key
Page 25
25
…..Yet another basketballer
Avoiding Ankle Injuries?