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 player’s 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 - “ footballer’s 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 MORTON’S NEURALGIA ( NEUROMA ) - Mechanism: fibrous enlargement of a plantar interdigital nerve with entrapment between metatarsal heads (usually 3 rd and 4 th ) - 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 Haglund’s 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 DON’T 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 5 th 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 1 st metatarsal - callus formation under 2 nd and 3 rd 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 5 th metatarsal base ( Jones ) - toe fractures: most treated conservative, strapping with next toe for 3 weeks