Ankle ppt

CASE HISTORY PRESENTATION

HOUSSEM EDDINE MECHRINSMP STAFF

Ankle

• Anatomical Structures– Tibia– Fibular– Talus

Tibia

• This is the strongest largest bone of the lower leg. It bears weight and the bone creates the medial malleoli .

The Tibia is the medial bone and largest bone of the lower leg.

Tibia

Fibula

• This is a smaller lateral bone of the lower leg. It is not vital for weight bearing yet it comprises the lateral (outside) aspect of the malleoli and makes up the lateral aspect of the mortise.

Fibula--->

The fibula is longer and non weight bearing. It makes up the lateral aspect of the mortise. The lateral malleoli lies inferior (below) the medial malleoli

_______________________

Talus

• This bone transmits the forces from the calcaneus up into the tibia and also allows the articulations of Plantar Flexion, Dorsiflexion or pulling the foot upward and Inversion and Eversion

------ Talus

Talocrural Joint

• The formation of the mortise (a hole) by the medial malleoli (Tibia) and lateral malleoli (fibula) with the talus lying in between them makes up the talocrural joint. This is a hinge joint and allows most of the motion with plantarflexion and dorsiflexion.

________________

________________Talocrural Jt.

Subtalar Joint

• The articulation between the talus and the calcaneus is referred to as the subtalar joint.

calcaneus

Talus

---Subtalar Joint

Medial aspect of foot

Ankle Ligaments

• There are three lateral ligaments predominantly responsible for the support and maintenance of bone apposition (best possible fit). These ligaments prevent inversion of the foot.

• These ligaments are:– Anterior talofibular ligament– Calcaneofibular ligament– Posterior talofibular ligament

Talus

FibulaTibia

Ant. Talofibular Ligament

Ant.T

ibio

fibula

r

Lig.

Post. Tibiofibular Lig.

<- Fibula

<- Ant. Talofibular Lig

<- Talus

Peroneal Tendons

Calc

aneofi

bula

r Li

gam

ent

Calcaneus

Subtalar Joint Space

Cuboid

calcaneus

<-Fibular head

Posterior tibiofibular Ligament

Ach

illes T

endon

Talus

Posterio

r

talo

fibular lig

.

Peroneal tendons

The deltoid ligament

• This is located on the medial aspect of the foot. It is the largest ligament but is actually comprised of several sections all fused together. This ligament prevents (eversion) of the ankle. The deltoid ligament is triangular in shape and has superficial and deep layers. It is the most difficult ligament in the foot to sprain.

Tibia

X

X

X

Navicular ---

-- Talus

Tibia

lis P

oste

rior T

endon

Tibi

alis

Ant

.

Tend

on

Deltoid LigamentX

PLAYER INFORMATION

• NAME : NASSER LAST NAME: NAIMI

• LENGTH : 1.68 CM WEIGHT : 52.3 KG AGE : 14 YEARS

• POSTION :MID-FILED CATEGORY; AL-NASHINE TEAM

• DOMINANT LEG : RIGHT

• ALLERGIE : NO SURGERY: NO

• MRN: 01152693

HISTORY

in the friendly game (Ramadan league) , in the second half-time (65min) ,Nasser is was kicked by an opponent player in the lateral face of his ankle (right) He was stopped directly the game ,and referred to Aspetar (emergency department ) he made a radiograph of the front and side of the ankle. has provide that "there is no fracture and the next day made a consultation with Dr target

Assessing the Lower Leg and Ankle

• History– Past history: no past history of ankle sprain – Mechanism of injury : dorsi-flexion +inversion (kicked by

other player )– When does it hurt : directly after the kick – Type of, quality of, duration of pain : vas 10/10 , he feel

pulse , functional dysfunction , he can't walk , no weight bearing, bruising .

– Sounds or feelings: yes – Swelling : yes and painful

• Observations– Postural deviations : yes – Is there difficulty with walking: yes ,he can”t– Color and texture of skin, heat, redness;blue – Is range of motion normal: no,it”s painful

Compression Test Percussion Test

Homan’s Test Thompson Test

• Ankle Stability Tests– Anterior drawer test

• Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarily

• A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point

– Talar tilt test• Performed to determine extent of inversion or eversion

injuries• With foot at 90 degrees calcaneus is inverted and

excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments

• If the calcaneus is everted, the deltoid ligament is tested

Anterior Drawer Test Talar Tilt Test

– Kleiger’s test• Used primarily to determine extent of damage to the

deltoid ligament and may be used to evaluate distal ankle syndesmosis, anterior/posterior tibiofibular ligaments and the interosseus membrane

• With lower leg stabilized, foot is rotated laterally to stress the deltoid

– Medial Subtalar Glide Test• Performed to determine presence of excessive medial

translation of the calcaneus on the talus• Talus is stabilized in subtalar neutral, while other hand

glides the calcaneus, medially• A positive test presents with excessive movement,

indicating injury to the lateral ligaments

Kleiger’s Test Medial Subtalar Glide Test

• Functional Tests– While weight bearing the following should be

performed• Walk on toes (plantar flexion) : painful• Walk on heels (dorsiflexion) : painful• Walk on lateral borders of feet : painful• Walk on medial borders of feet :painful• Hops on injured ankle : he can”t• Passive, active and resistive movements : painful

Rapport of examination

There is little swelling around the medial and lateral malleolus .all movement are painful and he is able to dorsi-flex to neutral and plantar flex to about 45 degree All test are painful over the lateral and medial ankle It’s very tender over deltoid ligament ,anterior joint line distal tibio fibular joint as well as the lateral ligaments

Radiography

MRI

INVESTIGATIONS

• X-ray were reviewed and appear normal • MRI shows grade 3 ATFL tear ,high grade CFL tear and some

DELTOID ligament signal change • No bony injury and AITFL • SYNDESMOSIS is intact • There is a small osteochandral injury to the lateral talar

dome

DIAGNOSIS AND MANAGEMENT

• He appears to have sustained a high grade tear of the lateral ligaments with involvement of the deltoid ligament and possibly distal tibiofibular joint as well

• No bone injury and injury to the distal tibiofibular joint which showed the

• Review in two weeks above

Physical therapy and treatment

• The most important factors is swelling and pain • If these factors are reduced ,you can take a faster results • The difference between the players are the reduced of

swelling and the control of pain • That’s why the exercise who decreased the swelling is too

much important • In the most case , the pain and swelling are synchronized in

all phase

Swelling vs pain

Day Swelling (right / left)

Pain /vas

Day 1 39/36 10

Day 3 38.75/36 10

Day 6 38.22/36 9

Day 9 38.00/36 9

Day 12 37.80/36 8

Day 15 37.55/36 7

Day 18 37.25/36 6

Day 21 37.00/36 5

Day 25 36.45/36 3

Chart

The most important phase

• R.I.C.E.

Grade II

• Immobilization

Grade II

• Splinting/Bracing

Grade II

• Physical Therapy

Grade II

12 to 72 hrs.

1 to 2 weeks

1 to 4 weeks

3 to 12 weeks

Joint Flexibility

– Decreased joint flexibility results from:• muscle spasm, pain (Therapeutic exercise with cold)• connective tissue adhesions (Therapeutic exercise

with heat)

– When 80% of flexibility is restored rehabilitation emphasis moves to the development of muscular strength

Muscular Strength

– Must perform a progressive resistive exercise on a regular basis.

– Each side of the body should be worked independently.– Once strength in the injured side is 90% of the non-

injured side, emphasis moves to the development

Closed Chain Ankle Strength Exercises

Muscular Endurance

– Stationary bike– Running when tolerated (jog 400 meters first

day and increase by 400 meters each 1 or 2 days)

– When athlete can run 1 mile emphasis should move to next phase

• Muscular Speed– high intense stationary bike– Cybex

• Muscular Power– Isokinetic devices– high- speed resistive work

TAPING

heel and lace pads

Angle tape to avoid wrinkles medial to lateral direction First horseshoe Figure of eight

First step of lateral heel lock Second step of lateral heel lock Final step of lateral heel lock Completed tape job

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