ANKLE COMPLEX INJURIES IN

SPORTS
 This chapter will begin by giving a brief outline of the
anatomy and biomechanics of the sporting ankle.
 We will look at acute ankle sprains and chronic ankle
instability as well as some of the other pathologies that
are found in the region.
EPIDEMIOLOGY
 Ankle injuries are one of the most common injuries seen
by the sports medicine clinician, accounting for up to
30% of all sports injuries
 The lateral ligaments are primarily implicated in these
injuries with the anterior tibiofibular ligament (ATFL)
being particularly susceptible to damage
 Sprains to the lateral ligaments of the ankle are
responsible for more time lost from sports participation
than any other injury
FUNCTIONAL ANATOMY AND BIOMECHANICS OF
THE SPORTING ANKLE

 Functionally, the ankle complex is composed of three

joints
 1. the talo-crual joint (TCJ – between the talus and the
inferior aspect of the tibia)
 2. the inferior tibiofibular joint (ITFJ – between the
distal ends of the tibia and the fibula)
 3. the subtalar joint (STJ – between the talus and the
calcaneus).
STABILITY OF THE ANKLE COMPLEX

 The bony architecture of the ankle is partially

responsible for joint stability but only in certain
situations.
 The medial and lateral malleoli prove a certain degree of
side-to-side stability and in full weight bearing
 The ankle is least stable in plantarflexion (the loose
packed position) and so it comes as no surprise that this
is the position most widely implicated in acute ankle
injuries.
LIGAMENTS OF ANKLE COMPLEX
1. Anterior talo-fibular ligament(ATFL)
 Limits excessive plantarflexion and inversion as well as
ant movement of the foot
2. Calcaneo-fibular ligament(CFL)
 Helps to limit inversion particularly during weight bearing

3. Posterior talo-fibular ligament(PTFL)

 Taught in end range of dorsiflexion

4. Inferior tibiofibular ligament

Talar stabilization
5. Deltoid ligament
Provides medial stability against eversion forces
 Dynamic stability of the ankle complex is provided by
the peroneal muscle group, in particular the peroneus
brevis and longus
HISTORY OF ACUTE INJURY
MECHANISMS OF ANKLE INJURY
 Position of ankle at the time of injury is important
 Common mechanism of spraining the lateral ligaments is
when ankle is rolled into planterflexion and inversion
 Isolated injury of CFL in infrequent , if occurs is
associated with inversion in dorsiflexion or external
rotation in weight bearing position
 PTFL injury occurs in severely injured ankle along with
CFL and ATFL
 Sequence of ligament rupture under inversion stress
would be
ATFL…..inferior tibiofibular……CFL……PTFL
Ankle may dislocate or fracture in case of continuing
inversion stresses
ONSET OF PAIN
 The most important thing to exclude in an acute ankle
injury is the presence of a fracture. It is for this reason
that the Ottawa Ankle Rules were formed
 An ankle fracture will almost invariably not allow the
athlete to put any weight on it at all whereas a sprain
may allow weight bearing but may get worse as it is
continued
AREA OF PAIN
 Determining the area of pain can be particularly
helpful ,many of the ligaments are quite superficial and
can therefore be located with ease
 It is often useful to ask the athlete to “point with one
finger” where it is most painful.
 The most frequent area for pain is around the antero-
lateral ankle.
 The pain from syndesmosis and talar dome injuries tends
to be more centrally located, deeper and more diffuse
 Ankle fractures tend to be exquisitely painful on
palpation.
 The most common sites of ankle fractures are the distal
fibula and the 5th metatarsal. These sites should be
carefully examined
 Whilst the site, extent and intensity of pain, swelling and
bruising can be a useful early indicator of the location
and extent of damage, injury severity is more reliably
judged by the degree of disability
RADIOGRAPHIC INVESTIGATIONS AND THE
OTTAWA ANKLE RULES
 According to these rules, it is only necessary to seek an
X-ray of an injured ankle in those patients with:
 pain along the posterior edge of the distal 6cm of the
fibula (including the tip of the malleolus)
 Or an inability to walk more than four steps either
immediately or at a subsequent closer assessment within
10 days
 Or pain at the base of the 5th metatarsal
PHYSICAL EXAMINATION
STRESS TESTS
 Anterior drawer test
 Talar tilt test
ANTERIOR DRAW TEST
TALAR TILT TEST
PALPATION OF STRUCTURES

 Palpation of the ankle after an injury can be especially

useful when trying to localise an injury to a structure.
 A good habit to get into is to systematically palpate
structures in order and see if this elicits pain.
GRADING OF ANKLE LIGAMENT INJURY SEVERITY

 Grading an injury to the lateral ankle ligaments remains

a controversial topic because, by-and-large, grading
scales are subjective and hard to validate.
 The three main scales used to grade severity are listed
1. Grading based on number of ligaments injured. (ie, a
1,2 or 3 ligament injury).
2. The downfall of this method is that it does not assess
to what extent each ligament is injured.
2. Traditional grading based on the extent of structural
damage.
A grade I injury exhibits microscopic unfurling of the
crimped pattern of the ligament without any macroscopic
damage.
A grade II injury has macroscopic stretching without
ligament rupture.
A grade III injury is a complete rupture. The downfall of
this method is that it is almost impossible to validate in the
clinical setting.
 Clinical judgement grading based on functional ability.
 In this method, a grade I injury is assessed as involving
no or minimal functional loss, no extra joint ROM, little
or no pain, swelling or bruising.
 A grade II injury is where the patient’s ankle ROM is
reduced although accessory movement testing reveals
extra joint movement but a firm end-feel, moderate pain
over the injured ligament, swelling and bruising.
 A grade III injury implies complete rupture where there
is no longer an end-feel on accessory movement testing,
overall joint motion is markedly reduced, there is
marked swelling and bruising and function has been lost.
 Syndesmosis are often graded in terms of amount of
damage sustained with a Grade I indicating AITFL
stretch, Grade II indicating AITFL partial tear and Grade
III indicating complete AITFL rupture
 The AITFL is tender on palpation, particularly when it is
stressed with the external rotation stress test
ANTERIOR IMPINGEMENT
 Anterior impingement occurs when either anterioraly
located hypertrophied soft tissue, boney exostosis on the
talus or tibia, or loose body limits tibio-talar
dorsiflexion.
 The athlete complains of persistent pain at the front of
the ankle, particularly when lunging
 It may be caused by repeated loading at the extremes of
dorsiflexion as seen in football or ballet.
MANAGEMENT
 Manual therapy to restore normal accessory talus motion
and anti-inflammatory medications/modalities are often
helpful and a period of rest from loaded dorsiflexion
activities is recommended.
 Tape can be applied to limit the extent of talo-crual
dorsiflexion.
SINUS TARSI SYNDROME

 The sinus tarsi is a small tunnel that is located near the

talar neck and the calcaneus at the antero-lateral aspect
of the ankle, slightly antero-inferior to the lateral
malleolus.
 The sinus tarsi is densely packed with synovial tissue
that is easily inflamed.
 In the majority of cases, the athlete will have a history of
at least one ankle sprain and present complaining of
diffuse pain slightly below and anterior to the ATFL
 They may describe pain when walking on uneven
ground, jumping or hopping to the side of the injury,
landing from a jump or running off-line.
TREATMENT
 Manual therapy of the subtalar joint can be very effective
and whilst frequently the athlete will receive great
benefit from a corticosteroid injection into the sinus, a
proprioceptive, strength and biomechanical rehabilitation
programme is imperative to correct the underlying
causes of the pathology
OSTEOCHONDRAL LESIONS OF THE TALAR DOME

 Osteochondral defects (OCD) of the talar dome are

commonly thought to be due to impact of the talar dome
as it shears across the tibial plafond as either a single
trauma or as a result of repetitive plantarflexion +
inversion ankle sprains.
 A large fracture of the chondral surface can be diagnosed
at the time of injury
 Athlete complains of recalcitrant, deep and diffuse
anterior ankle pain
 The are best diagnosed with an MRI scan
LATERAL ANKLE PAIN

 Peroneal tendinopathy
 Peroneal tendinopathy is usually an overuse injury and is
one of the most common causes of nontraumatic lateral
ankle pain.
 The athlete will usually present with an insidious onset
of lateral ankle pain, often located either posterior to the
lateral malleolus, at the base of the 5th metatarsal.
 Peroneus brevis was by far the most commonly
implicated tendon (88% of cases) with the rest being
made up of peroneus longus tears
TREATMENT

 Rest from aggravating activities

 Biomechanical correction with footwear analysis and
potentially orthotic insertion.
 Soft tissue therapy is useful to reduce muscle tone in the
peroneals and gastro-soleus complex
 Whilst strengthening of the peroneals is vital in both the
acute and degenerative condition
ISELIN’S DISEASE
 Traction apophysitis of the peroneustbrevis at its
attachment onto the base of thet5th metatarsal.
 It is found in adolescents, particularly those with a
prominent 5th metatarsal that participates in sports that
require sudden changes in direction such as football,
lacrosse and cross country running.
 Treatment for Iselin’s disease is always conservative and
may involve rest from provocative activities, anti-
inflammatory interventions and medications followed by
a progressive rehabilitation programme
POSTERIOR ANKLE PAIN

 The posterior aspect of the ankle is a common site of

pain in the athlete who participates in activities that
requires extremes of talo-crual plantarflexion such as ,
ballet, running and football.
 PAI is labelled as a “syndrome” because it is an umbrella
term that is used to describe pain anywhere in the
posterior region of the ankle joint.
 The athlete will commonly report pain upon
plantarflexion, particularly if it is forced.
 PAI can arise from overuse or traumatically.
 The structures in this area of the ankle that can be
compressed and thus cause pain are:
 os trigonum (an unfused part of the back of the talus,
present in 10–15% of the population).
 thickened posterior joint capsule or PTFL

 enlarged posterior talar process or distal tibial

osteophyte
 posterior joint synovitis

 flexor hallucis longus tendon

SYMPTOMS
 The athlete will usually describe a pain at the back of the
ankle
 The pain is usually aggravated by forced plantar flexion.
MEDIAL ANKLE PAIN

 Deltoid ligament sprain

 The most commonly reported mechanism of injury to the
deltoid ligament is when the athlete has their foot
planted on the ground in a pronated position and then
falls outward, placing a large abduction force on the
ligament
 Given the amount of force required to injure the deltoid
ligament, there is a high probability of injury to
associated structures.
FLEXOR HALLUCIS LONGUS PATHOLOGY

 FHL tenosynovitis is an important cause of

posteromedial ankle pain.
 It is particularly common in ballet dancers and kicking
athletes due to the extraordinary range of motion that the
tendon must travel from a fully dorsiflexed position to a
fully plantar flexed one.
 The athlete will often complain of posterior ankle pain
on landing from a jump or when striking a kick/ball
impact.
 A steroid injection may be useful in the short term to
reduce any inflammatory component but the athlete will
also need assessment
TARSAL TUNNEL SYNDROME

 Tarsal tunnel syndrome is a painful condition involving

entrapment of the posterior tibial nerve in the tarsal tunnel
and is characterized by a burning pain in the toes, plantar
aspect of the foot or around the tarsal tunnel itself which is
worsened by load-bearing (Kinoshita et al. 2006).
Occasionally
 There may be a positive Tinel’s sign but may also require
nerve conduction studies and/or MRI.
 Conservative treatment involves rest, orthotic or tape
intervention to reduce excessive STJ pronation and
sometimes, steroid injection.
 Should it fail to resolve, surgical decompression may be
indicated.
STRESS FRACTURES IN THE ANKLE COMPLEX

 Stress fractures involving the ankle complex are not

common but it is important that they are not missed in an
assessment.
 Treatment of a stress fracture in the ankle will most
often require non-weight bearing or sometimes surgical
internal fixation.
ACUTE TREATMENT AND REHABILITATION OF
THE
LATERAL ANKLE SPRAIN

 Comprehensive rehabilitation aims to control pain and

swelling, restore full joint ROM and kinematics,
proprioceptive function, muscle strength and functional
performance.
ACUTE MANAGEMENT

 PRICE
 Full weight bearing should be encouraged as soon as
possible so long as the gait pattern is not antalgic.
 This may necessitate an initial period of partial weight
bearing with crutches or walking in a pool (to reduce
loading).
 Manual therapy to restore normal talo-crual kinematics
and motion at the subtalar and midtarsal joints can be
beneficial.
PROPRIOCEPTIVE RETRAINING

 Ankle injuries can disrupt the body’s neuromuscular

feedforward and feedback mechanisms, which may be
displayed as reduced proprioception.
 Proprioception contributes to postural control and joint

 There is strong evidence that people with chronically

unstable ankles demonstrate proprioceptive deficits
whether it be in errors in detecting ankle positions to
ground contact failure to accurately replicate passively
positioned joint angles
 Recent study showed that proprioceptive training was
more effective than orthotics or strength training in
reducing the rates of ankle sprains in male soccer players
 Initially this may involve single leg standing and can be
made more challenging by performing this with eyes
closed and on less stable surfaces such as a trampoline
 The SEBT is a dynamic lower limb reaching test that has
been shown to be sensitive in detecting subjects with
chronic ankle instability
MUSCLE STRENGTHENING

 All directions of motion should be considered when

prescribing exercises for muscle strengthening and
conditioning around the ankle. This may involve the use
of elastic tubing or weighted cables.
 The ankle should be stressed both concentrically and
eccentrically.
 This will involve working into progressively more
plantarflexion and inversion
FUNCTIONAL RETRAINING

 Once the athlete can demonstrate that they have a return

of full ankle ROM and have appropriate levels of muscle
strength, fatigue resistance and proprioception (as
determined by the SEBT), they can progress to more
functional, sports-specific tasks.
 Tapping can be applied
CHRONIC ANKLE INSTABILITY

 The rate of recurrence of an ankle sprain has been

reported to be as high as 80%
 Chronic ankle instability (CAI) is the term used to
describe the occurrence of repeated bouts of instability
leading to numerous ankle sprains
 CAI gives rise to repeated complaints of pain, swelling,
giving way, and degenerative joint disease.
MECHANICAL ANKLE INSTABILITY

 (MAI) refers to repeated episodes of ‘giving way’ due to

structural abnormalities within the ankle complex. This
can be due to:
 pathological ligamentous laxity

 athrokinematic abnormalities (such as restricted

 posterior talar glide in the mortise that limits the

 ankle’s ability to reach a fully dorsiflexed (i.e. close-

packed) position)
 synovial inflammation and degenerative joint

 changes (such as degenerative osteochondral lesions).

FUNCTIONAL ANKLE INSTABILITY (FAI)
 Functional Ankle Instability (FAI) is said to occur when
there are repeated episodes of ‘giving-way’ without a
specific mechanical cause
 FAI is a complex matrix of contributing factors that may
include
 impaired proprioception (joint position sense,
kinaesthesia and joint resistance sense)
 muscle weakness and arthrogenic muscle inhibition

 altered postural equilibrium sense (Riemann 2002)

 reduction in preparatory muscle activity to stabilise the

ankle prior to ground contact