1. Injuries Syndesmosis Injuries Manny Moore ATS

2. Injuries Syndesmosis Injuries 11-18% of all ankle sprains Longer recovery v.s. Lateral sprains Men v.s. Women?

3. Bone Anatomy Tibia Articular Surface Fibula Articular Surface Talus Dome Articular Surface Provides Stability & Proper Ankle Function

4. Snydesmosis Ligaments AIFL- Chaput’s Tubercle Most Vulnerable PIFL- Wagstaffe’s Tubercle Strongest ITFL- Thickening of PIFL IM- Fibrous tissue Transmit force IL- Thickening of IM

5. 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?

6. Clinical Examination History ER with DF Contact None Contact Acute v.s. Chronic Observation Edema Eccymosis Antalgic gait Possible Deformity?

7. Clinical Examination Palpation Tenderness Length Special Test Nussbaum et al. Squeeze Test Dorsiflexion Test Kleigers Test Cross-leg Test

8. Imaging Techniques X-RAY Radiographs AP, Lateral, Mortise Views AP View Fractures Tibiofibular clear space widening of 6 mm Tibiofibular overlap > 42% Fibula Width Medial clear space widening > 4mm Lateral View Non weight bearing ER Fractures

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

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

11. Imaging Techniques X-RAY Lateral View

12. Imaging Techniques X-RAY AP View Heterotopic Ossification

13. 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

14. Imaging Techniques MRI Axial Views

15. West PointInstability Scale West Point Instability Scale 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 StretchPartial TearComplete Tear Ligament Involvement +AIFL +IL Possible AD +AIFL/PIFL +IL +AD Grade I Grade II Grade III

16. TreatmentCriteria Treatment Criteria ConservativeNon Conservative Grade I Non-Fractures Stable Grade II Grade III Unstable Grade II Fractures Chronic Injury Based on Patients Goals Length of Symptoms Severity of Injury

17. ConservativeProtocols Conservative Protocols Results vary patient to patient Grade I Injuries: 2-4 Weeks RTP Grade II Injuries: 6-8 Weeks RTP Without Without Instability or Fractures

18. ConservativeProtocols Conservative Protocols Phase I (0-5 Days) or (5-14Days)Phase I (0-5 Days) or (5-14Days) ImmobilizeImmobilize Reduce PainReduce Pain Reduce InflammationReduce Inflammation CryotherapyCryotherapy E-StimE-Stim Increase ROMIncrease ROM Manual 30* PF StretchManual 30* PF Stretch Ankle PumpsAnkle Pumps Toe CurlsToe Curls Towel StretchTowel Stretch

19. ConservativeProtocols Conservative Protocols Phase II (6-10 Days) or (2-4 weeks)Phase II (6-10 Days) or (2-4 weeks) Immobilize Grade IIImmobilize Grade II Reduce PainReduce Pain Reduce InflammationReduce Inflammation ProprioceptionProprioception Increase FlexibilityIncrease Flexibility Increase ROMIncrease ROM Increase StrengthIncrease Strength CV EnduranceCV Endurance

20. ConservativeProtocols Conservative Protocols Phase III (18-25 Days) or (4-8 Weeks)Phase III (18-25 Days) or (4-8 Weeks) Protect InjuryProtect Injury Reduce PainReduce Pain Increase Pain free ActivityIncrease Pain free Activity Sports SpecificSports Specific ProprioceptionProprioception Increase StrengthIncrease Strength Increase FlexibilityIncrease Flexibility CV EnduranceCV Endurance

21. ConservativeProtocols Conservative Protocols Phase III (18-25 Days) or (4-8 Weeks)Phase III (18-25 Days) or (4-8 Weeks) Sports SpecificSports Specific Drill#1 Drill#2

22. ConservativeProtocols Conservative Protocols Return To Play Criteria Full Strength Full ROM Functional Test Physician Clearance Protect Injury

23. Operative Treatment 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

24. Operative Treatment Operative Treatment Arthroscopy BeforeAfter

25. Post-Operative Protocols Post-Operative Protocols Arthroscopy Results vary patient to patient Grade III Injuries: 4-8 Months RTP Non Weight Bearing 6-8 Weeks Screw Removal @ 3 Months Follow-up Imaging every 2 weeks

26. Post-Operative Protocols Post-Operative Protocols Phase I (1-3 Weeks)Phase I (1-3 Weeks) Phase I- Conservative RehabilitationPhase I- Conservative Rehabilitation Immobilize & Non Weight BearingImmobilize & Non Weight Bearing Protect WoundProtect Wound Reduce PainReduce Pain Reduce InflammationReduce Inflammation ProprioceptionProprioception Increase ROMIncrease ROM Maintain FlexibilityMaintain Flexibility CV EnduranceCV Endurance

27. Post-Operative Protocols Post-Operative Protocols Phase II (3-8 Weeks)Phase II (3-8 Weeks) Phase I- Conservative RehabilitationPhase I- Conservative Rehabilitation Immobilize & Partial Weight BearingImmobilize & Partial Weight Bearing Protect WoundProtect Wound Reduce PainReduce Pain Reduce InflammationReduce Inflammation Increase ROMIncrease ROM Increase StrengthIncrease Strength ProprioceptionProprioception Increase FlexibilityIncrease Flexibility CV EnduranceCV Endurance

28. Post-Operative Protocols Post-Operative Protocols Phase III (8-12 Weeks)Phase III (8-12 Weeks) Phase II- Conservative RehabilitationPhase II- Conservative Rehabilitation Full Weight Bearing & Cam-walkerFull Weight Bearing & Cam-walker Remove ScrewsRemove Screws Reduce PainReduce Pain Increase ROMIncrease ROM Increase StrengthIncrease Strength ProprioceptionProprioception Increase FlexibilityIncrease Flexibility Sports SpecificSports Specific CV EnduranceCV Endurance

29. Post-Operative Protocols Phase IV (4-8 Months)Phase IV (4-8 Months) Phase III Conservative RehabilitationPhase III Conservative Rehabilitation Protect InjuryProtect Injury Increase Pain Free ActivityIncrease Pain Free Activity Increase ROMIncrease ROM Increase StrengthIncrease Strength ProprioceptionProprioception Increase FlexibilityIncrease Flexibility Sports SpecificSports Specific CV EnduranceCV Endurance

30. Post-Operative Protocols Return To Play Criteria Full Strength Full ROM Functional Test Physician Clearance Protect Injury

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

32. Questions

33. ReferencesReferences 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; 29:31-35. David A. Porter. Evaluation and Treatment of Ankle Syndesmosis Injuries. [Editorial]. 2009; 58:575-581. Cyrus M. Press, Asheesh Gupta, Mark R. Hutchinson Management of Ankle Syndesmosis Injuries in the Athlete. American Academy of Sports Medicine.2009; 8:228-233. 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; 12:1-7. Albert Alonso, Lynette Khoury, Roger Adams. Clinical Tests for Ankle Syndesmosis Injury: Journal of Sports and Physical Therapy. 1998; 27:276- 284.