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ANKLE INJURIES

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... physiotherapy, extreme cases: local injection into the sheath c) gradual coaching programme, avoid rapid direction changes or sprinting 6 weeks d) ... – PowerPoint PPT presentation

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Title: ANKLE INJURIES


1
ANKLE INJURIES
2
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

3
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 players foot

4
ANKLE SPRAINS
  • Sequence of injury anterior talofibular
    ligament, calcaneofibular ligament, posterior
    talofibular ligament, musculotendinous units
    supporting the ankle joint

5
ANKLE SPRAINS
  • Incidence increased in
  • - individuals with varus malalignment of lower
    limbs
  • - calf muscle tightness
  • - previous incompletely rehabilitated ankle
    sprains

6
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

7
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 )

8
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

9
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

10
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

11
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)

12
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

13
PERONEAL TENDON INJURIES
  • TENDINITIS
  • - occurs in dancers, basketball, volleyball
  • - combined cause of the lat.malleolus pulley
    action and foot malalignment

14
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

15
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

16
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

17
ANTERIOR IMPINGEMENT SYNDROME
  • - Mechanism repetitive traction or injury over
    anterior capsule exostoses produced on the
    anterior margin of distal tibia and talus
  • - footballers ankle, basketball,ballet
  • - pain on dorsiflexion, reduced dorsiflexion
    later on
  • - x-rays lateral view exostoses, loose bodies
  • - treatment NSAIDS, local inj. Surgical excision

18
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 )

19
FOOT INJURIES
20
ENTRAPMENT NEUROPATHIES IN THE FOOT
  • MORTONS 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

21
ENTRAPMENT NEUROPATHIES IN THE FOOT
  • - Pain in the web, loss of sensation
  • - metatarsal neck pads, other orthotic
    correction, local injection, surgery

22
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

23
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

24
BURSITIS ABOUT THE HEEL
  • - Over achilles tendon posterior calcaneal bursa
  • - Below achilles tendon retrocalcaneal bursa
  • - running with ill-fitting shoes
  • Haglunds syndrome (bony bossing) on the
    posterior aspect of calcaneum
  • - treatment rest, low friction taping,NSAIDS,
    physio, local inj., footwear attention

25
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
  • DONT USE local inj., flat or convex pads

26
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 )

27
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

28
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

29
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

30
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

31
REFLEX SYMPATHETIC DYSTROPHY OF THE FOOT
  • - Treatment aggressive physiotherapy, tubigrip,
    sympathectomy by epidural injection
  • - recovery from 8 weeks to 2 years

32
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

33
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

34
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

35
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

36
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 )

37
FRACTURES
  • - Ankle fractures intarticular, if displaced
    ORIF
  • -talus fracture surgical treatment to avoid
    osteonecrosis
  • - calcaneum fractures most conservative, early
    ROM

38
FRACTURES
  • - Metatarsal fractures reduce dislocations, most
    common fracture 5th metatarsal base ( Jones )
  • - toe fractures most treated conservative,
    strapping with next toe for 3 weeks

39
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