Evaluation of the Ankle Sports Physiology

Ankle Injuries- Hard Tissue Bones Acute Jones Fracture, Ballarina Fracture Fibula, Tibia Fracture Chronic Stress Fractures

Fractured Fibula Ankle Fracture – commonly caused by eversion. The fibula is often broken.

Stress Fracture What is a stress fracture? -An overuse injury. -A small crack or fracture in the bone What causes it? -When muscles become fatigued or overloaded and can not absorb the stress and shock and repeated impact. -Fatigued muscles transfer that stress to the nearby bone and the result is a small crack or fracture, in the bone.

Ballerina Fracture Where does it occur? -5th metatarsal. What is it? -An avulsion of the proximal tip of the 5th metatarsal where the peroneus brevis muscle tendon attaches. Cause -A severe inversion ankle sprain causes peroneus brevis tendon to pull away the base of the 5th metatarsal (Ballerina fracture)

Jones Fracture These X-Rays show a fracture of the proximal end of the 5th Metatarsal. This fracture is commonly called a "Jones Fracture". Where does it occur? -5th metatarsal. What is it? -A fracture to the 5th metatarsal caused by direct trauma to the styloid process. Cause -Repetitive inversion ankle sprains -Poor shoe and tape support

Severe Jones Fracture fix

Ankle Injuries- Soft Tissue Muscles Ligaments Acute Muscle Strain Sprained ankle Grade 1,2,3 Grade 1, 2, 3 Achilles tendon rupture Shin Splints Chronic Plantar Fasciitis Achilles Tendonitis Turf Toe

Inversion Ankle Sprain 85% of sprains are caused by ankle inversion. Inversion sprains cause damage to the lateral ligaments Calcaneofibular and anterior and posterior talofibular ligaments

Eversion Ankle Sprain 15% of sprains result from eversion mechanisms which are often the result of an outside force such as being fallen on from the outside. Damage to the deltoid ligament

Syndesmosis Sprain What is it? -The tibia and fibula spread on the talus, the ankle mortise is disrupted and the ankle can become very unstable. -Syndesmosis damage -Anterior and Posterior tibiofibular ligament Cause -injured with an eversion force.

Ruptured Achilles Tendon Third degree strain of the tendon Achilles Tendon Tear and Repair

Achilles Tendonitis What is the Achilles tendon? -It is the largest and most vulnerable tendon in the body. -It joins the gastrocnemius and the soleus muscles of the lower leg to heel of the foot. -Tendons are strong, but not very flexible so they can only so far before they get inflamed and tear or rupture. What is it? -Chronic injury caused from overuse. -Inflammation of the Achilles tendon. What causes it? -Ignoring early warning signs and pushing through pain. -tight or weak calf muscles. -Tightness increases the stress on the Achilles tendon, and a tendonitis can develop.

Plantar Fasciitis What does the plantar fascia do? -Provides support for the medial longitudinal arch of the foot. The plantar fascia is stretched and the arch flattens slightly to absorb the impact each time the heel impacts the ground. The fascia is not very flexible and such repetitive stretching from impact can result in small tears in the fascia. What is plantar fasciitis? -Chronic injury -Common in runners -Common cause of pain on the bottom of the heel and usually defined by pain during the first steps of the morning. -Pain also occurs at the start of activity and go away with use. -It returns after a long rest and then restarting activity. What causes it? -Repetitive flexion and extension of the toes -Sudden weight gain

Turf Toe What is turf toe? -A sprain or jammed toe -Typically the hallux Possible Responsible Factors -artificial turf - no give, can be like playing on hard asphalt -shoes - too much forefoot flexion (no turf toe plate) -combination of turf & shoes Mechanism of injury -hyperextension (most common) -hyperflexion -valgus injury - usually from sudden acceleration What causes it? -When the toe is bent upwards this causes damage to the ligaments which can become stretched.

Assessing Injuries HOPS History Observation Palpation Special Tests

Assessing the Lower Leg and Ankle History Past history Mechanism of injury When does it hurt? Type of, quality of, duration of pain? Sounds or feelings? How long were you disabled? Swelling? Previous treatments?

Observations Posture? Is there difficulty with walking? Deformities, asymmetries or swelling? Color and texture of skin, heat, redness? Patient in obvious pain? Is range of motion normal?

Palpation Special Tests Does anything feel out of place? Is it hot? Depends on the injury

Percussion and compression tests Used when fracture is suspected Percussion test is a blow to the tibia, fibula or heel to create vibratory force that resonates w/in fracture causing pain Compression test involves compression of tibia and fibula either above or below site of concern Thompson test Squeeze calf muscle, while foot is extended off table to test the integrity of the Achilles tendon Positive tests results in no movement in the foot

Compression Test Percussion Test Thompson Test

Ankle Stability Tests Anterior drawer test Talar tilt 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

Medial Subtalar Glide 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) Walk on heels (dorsiflexion) Walk on lateral borders of feet (inversion) Walk on medial borders of feet (eversion) Hops on injured ankle Passive, active and resistive movements should be manually applied to determine joint integrity and muscle function If any of these are painful they should be avoided

Prevention of Injury to the Ankle Stretching of the Achilles tendon Strengthening of the surrounding muscles Proprioceptive training: balance exercises and agility Wearing proper footwear and or tape when appropriate

Injury Prevention Strength training allows the supporting musculature to stabilize where ligaments may no longer be capable of holding the original tension between bones of the joint. This will also help prevent reinjury.

Chronic Ankle Injury “the vicious cycle” Why are some people prone to ankle re-injury over and over? Most commonly due to lack of rehabilitation, but more importantly lack of neuromuscular training. This means the person has not retrained the body to recognize where the ankle and foot are during motion. This sets up the body part to be re-injured due to improper feedback to the brain about body position.

Injury Prevention Neuromuscular Control is the ability to compensate for uneven surfaces or sudden change in surfaces. It is retrained by using balance and agility exercises such as a BAPS board or standing on one leg with eyes closed as well as using a single leg on a mini trampoline.

Neuromuscular Control Training Can be enhanced by training in controlled activities Uneven surfaces, BAPS boards, rocker boards, or Dynadiscs can also be utilized to challenge athlete

Injury prevention Tight Achilles tendons can predispose someone to injuring the ankle. Tendonitis, plantar fasciitis, and other disorders may occur due to a tight Achilles tendon.

Injury Prevention Footwear is something often overlooked but improper footwear can predispose someone with a foot condition such as pes planus (flat feet) to be more prone to having problems with their feet and ankles.

Preventative Taping and Orthosis Taping is often post injury treatment. Some will argue that taping will weaken the ankle. This has not been proven without a doubt but exercise and strengthening of the ankle is always advised. Othotics will help rectify conditions that are permanent and will not be fixed by any other means.

Tape vs. Brace Why choose one over another Taping may be more time consuming over brace Braces may or may not allow more support over tape Tape allows more functional movement and often feels more stable Tape will loosen with time Braces will often loosen with time It really is based on the quality of the brace vs. the ability of the person to tape. Both have advantages and disadvantages.