Syndesmosis Injuries

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Syndesmosis Injuries
Manny Moore ATS
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Syndesmosis Injuries
11-18 of all ankle sprains Longer recovery v.s.
Lateral sprains Men v.s. Women?
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Bone Anatomy

• Tibia
• Articular Surface
• Fibula
• Articular Surface
• Talus
• Dome

Provides Stability Proper Ankle Function
Articular Surface
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Snydesmosis Ligaments

• AIFL- Chaputs Tubercle
• Most Vulnerable
• PIFL- Wagstaffes Tubercle
• Strongest

• ITFL- Thickening of PIFL
• IM- Fibrous tissue
• Transmit force
• IL- Thickening of IM

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Biomechanics

• Mechanism of Injury
• Eversion
• Dorsiflexion
• Pronation
• Closed Pack Position
• Forces the talus against the fibula
• Widening of mortise

• 1mm lateral shift increases joint
  surface pressure by 42

Associated injuries?
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Clinical Examination

• History
• ER with DF
• Contact
• None Contact
• Acute v.s. Chronic

• Observation
• Edema
• Eccymosis
• Antalgic gait
• Possible Deformity?

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Clinical Examination

• Palpation
• Tenderness Length

Nussbaum et al.

• Special Test

Squeeze Test Dorsiflexion Test Kleigers
Test Cross-leg Test
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Imaging Techniques
X-RAY

• Radiographs
• AP, Lateral, Mortise Views
• AP View
• Fractures
• Tibiofibular clear space
  widening of 6 mm
• Tibiofibular overlap gt 42
  Fibula Width
• Medial clear space widening gt 4mm
• Lateral View
• Non weight bearing ER
• Fractures

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Imaging Techniques
X-RAY
Tibiofibula overlap
Tibiofibula clearance space
Medial clear space
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Imaging Techniques
X-RAY
Tibiofibula overlap
Tibiofibula clearance space
Medial clear space
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Imaging Techniques
X-RAY

• Lateral View

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Imaging Techniques
X-RAY

• AP View

Heterotopic Ossification
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Imaging Techniques
MRI CT

• MRI (Magnetic Resonance Imaging)
• Frontal, Axial, Saggital Views
• High sensitivity and specificity
• More reliable detecting disruptions
• CT (Computed Tomography)
• More effective detecting minor disruptions
• Less Cost v.s. MRI

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Imaging Techniques
MRI

• Axial Views

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West Point Instability Scale
Grade I
Grade II
Grade III
Edema Ecchymosis Localized Mild Localized Moderate Diffuse Severe
Weight Bearing Ability Full or Partial Without Significant Pain Difficult Without Crutches Impossible Significant Pain
Ligament Damage Ligament Stretch Partial Tear Complete Tear
Ligament Involvement AIFL AIFL IL Possible AD AIFL/PIFL IL AD
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Treatment Criteria
Based on Patients Goals Length of
Symptoms Severity of Injury

• Conservative

• Non Conservative

Grade I Non-Fractures Stable Grade II
Grade III Unstable Grade II Fractures Chronic
Injury
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Conservative Protocols

• Results vary patient to patient
• Grade I Injuries 2-4 Weeks RTP
• Grade II Injuries 6-8 Weeks RTP
• Without Instability or Fractures

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Conservative Protocols

• Phase I (0-5 Days) or (5-14Days)
• Immobilize
• Reduce Pain
• Reduce Inflammation
• Cryotherapy
• E-Stim
• Increase ROM
• Manual 30 PF Stretch
• Ankle Pumps
• Toe Curls
• Towel Stretch

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Conservative Protocols

• Phase II (6-10 Days) or (2-4 weeks)

• Immobilize Grade II
• Reduce Pain
• Reduce Inflammation
• Proprioception
• Increase Flexibility
• Increase ROM
• Increase Strength
• CV Endurance

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Conservative Protocols

• Phase III (18-25 Days) or (4-8 Weeks)

• Protect Injury
• Reduce Pain
• Increase Pain free Activity
• Sports Specific
• Proprioception
• Increase Strength
• Increase Flexibility
• CV Endurance

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Conservative Protocols

• Phase III (18-25 Days) or (4-8 Weeks)

• Sports Specific

Drill2
Drill1
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Conservative Protocols
Return To Play Criteria

• Full Strength
• Full ROM
• Functional Test
• Physician Clearance
• Protect Injury

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Operative Treatment
Arthroscopy

• Goal is to restore structures, and mobility
• Open Reduction Internal Fixations
• Autographs
• Modified Brostrum Technique
• 4.5 mm Cortical Screws
• Complications
• Screw Breakage
• Screw Type
• Infection
• Calcification Joint Stiffness

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Operative Treatment
Arthroscopy
Before
After
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Post-Operative Protocols
Arthroscopy

• Results vary patient to patient
• Grade III Injuries 4-8 Months RTP
• Non Weight Bearing 6-8 Weeks
• Screw Removal _at_ 3 Months
• Follow-up Imaging every 2 weeks

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Post-Operative Protocols

• Phase I (1-3 Weeks)
• Phase I- Conservative Rehabilitation
• Immobilize Non Weight Bearing
• Protect Wound
• Reduce Pain
• Reduce Inflammation
• Proprioception
• Increase ROM
• Maintain Flexibility
• CV Endurance

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Post-Operative Protocols

• Phase II (3-8 Weeks)
• Phase I- Conservative Rehabilitation
• Immobilize Partial Weight Bearing
• Protect Wound
• Reduce Pain
• Reduce Inflammation
• Increase ROM
• Increase Strength
• Proprioception
• Increase Flexibility
• CV Endurance

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Post-Operative Protocols

• Phase III (8-12 Weeks)
• Phase II- Conservative Rehabilitation
• Full Weight Bearing Cam-walker
• Remove Screws
• Reduce Pain
• Increase ROM
• Increase Strength
• Proprioception
• Increase Flexibility
• Sports Specific
• CV Endurance

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Post-Operative Protocols

• Phase IV (4-8 Months)
• Phase III Conservative Rehabilitation
• Protect Injury
• Increase Pain Free Activity
• Increase ROM
• Increase Strength
• Proprioception
• Increase Flexibility
• Sports Specific
• CV Endurance

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Post-Operative Protocols
Return To Play Criteria

• Full Strength
• Full ROM
• Functional Test
• Physician Clearance
• Protect Injury

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Conclusion

• Early Recognition
• Determine Extent of Injury
• Rule out Associated Injuries
• Conservative Treatment (2-8 Weeks)
• Surgical Intervention (4-8 Months)
• Complications

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Questions
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References

• Eric Nussbaum, Timothy M. Hosea, Shawn Sieler,
  Brian Incremona, Donald Kessler. Prospective
  Evaluation of Syndesmotic Ankle Sprains Without
  Diastasis. American Journal of Sports Medicine.
  2001 2931-35.
• David A. Porter. Evaluation and Treatment of
  Ankle Syndesmosis Injuries. Editorial. 2009
  58575-581.
• Cyrus M. Press, Asheesh Gupta, Mark R. Hutchinson
  Management of Ankle Syndesmosis Injuries in the
  Athlete. American Academy of Sports
  Medicine.2009 8228-233.
• Marc L Wagener, Annechien Beumer, Bart A
  Swierstra. Chronic instability of the anterior
  tibiofibular syndesmosis of the ankle.
  Arthroscopic Findings and Results of Anatomical
  Reconstruction. Bio Med Central Musculoskeletal
  disorders 2011 121-7.
• Albert Alonso, Lynette Khoury, Roger Adams.
  Clinical Tests for Ankle Syndesmosis Injury
  Journal of Sports and Physical Therapy. 1998
  27276-284.