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Slide 2 - 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
Slide 3 - The Ankle Joint The ankle joint is one of the most common joints to be injured. The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured. Bröstrom, 1966 MOB TCD
Slide 4 - Tennis 4 MOB TCD
Slide 5 - Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 5 The Ankle Joint MOB TCD
Slide 6 - Inversion and Eversion Initiated at the transverse tarsal joint A radiological term Calcaneo-cuboid Anterior portion of the talocalcaneonavicular Amputation at this joint, no bones are cut Last, 1963 6 MOB TCD
Slide 7 - Main movement take place at the clinical sub-talar joint i.e.: Talocalcaneal Inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus 7 Inversion and Eversion MOB TCD
Slide 8 - A uniaxial, modified synovial hinge joint Proximally the articulation depends on the integrity of the inferior tibiofibular joint Close pack Dorsiflexion Williams & Warwick, 1980 8 The Ankle Joint MOB TCD
Slide 9 - In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25º obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 9 The Ankle Joint MOB TCD
Slide 10 - In dorsiflexion the foot moves upwards and medially Downwards and laterally in plantar flexion Plastanga et al., 1990 10 The Ankle Joint MOB TCD
Slide 11 - Proximal Articular Surface The distal surface of the tibia which is concave antero- posteriorly and convex from side to side Medial malleolus (comma- shaped facet) Lateral malleolus (triangular facet is convex from above downwards apex inferiorly Williams & Warwick, 1980 11 MOB TCD
Slide 12 - Proximal Articulation The inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 12 MOB TCD
Slide 13 - Proximally the articulation depends on the integrity of the inferior tibiofibular joint A syndesmosis Lateral malleolus is larger, lies posteriorly Extends more inferiorly 13 Proximal Articular Surface MOB TCD
Slide 14 - Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma-shaped facet Lateral triangular facet Frazer, 1965 14 MOB TCD
Slide 15 - The talus has no muscles attached to it Has a very extensive articular surface As a result fractures of the talus may result in avascular necrosis of either the body or the head O’Brien et al., 2002 15 Distal Articular Surface MOB TCD
Slide 16 - Posterior Aspect of Talus Two tubercles Groove contains flexor hallucis longus Medial tubercle is smaller Lateral is larger, posterior talofibular ligament attached 7% separate ossification called os trigonum There is a triangular facet on the posterior surface which articulates with the inferior transverse tibiofibular ligament 16 MOB TCD
Slide 17 - Congenital Abnormalities Congenital abnormalities include os trigonum and tarsal coalition Os trigonum in 7% of normal population but in 32% of soccer players It is a problem in soccer players, ballet dancers and javelin Forced hyperplantar flexion compresses the posterior portion of the ankle and may fracture the lateral tubercle or an os trigonum 17 MOB TCD
Slide 18 - Articular Surfaces Articular surfaces are covered with hyaline or articular cartilage Synovial fold which may contain fat Fills the interval between tibia, fibula and inferior transverse tibiofibular ligament 18 MOB TCD
Slide 19 - Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 19 MOB TCD
Slide 20 - The capsule is thin and weak in front and behind The anterior and posterior ligaments are thickenings of the joint capsule The anterior runs obliquely from the tibia to the neck of the talus Williams & Warwick,1980 20 The Ankle Joint MOB TCD
Slide 21 - The Posterior Ligament The posterior ligament fibres pass from: the tibia and fibula and converge to be attached to the medial tubercle of the talus Transverse ligament fibres form the lower part of the posterior part of the capsule, blend with the inferior transverse ligament The posterior ligament is thicker laterally Capsule is strengthened on either side by the collateral ligaments Williams & Warwick,1980 21 MOB TCD
Slide 22 - The Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 22 MOB TCD
Slide 23 - Medial Ligament Inferiorly, ant-post The tuberosity of the navicular Neck of talus The free edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 23 MOB TCD
Slide 24 - Medial or Deltoid Ligament (Superficial) Crosses two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres, the tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 24 MOB TCD
Slide 25 - Medial or Deltoid Ligament (Deep) The anterior tibio-talar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Tibialis posterior and flexor digitorum longus cross ligament Williams & Warwick, 1980 25 MOB TCD
Slide 26 - Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular (CFL) The posterior talofibular (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 26 MOB TCD
Slide 27 - The ATFL Is part of the capsule An upper and lower bands It is cylindrical, 6-10 mm long and 2 mm thick The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus Liu & Jason, 1994 27 MOB TCD
Slide 28 - It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 28 The ATFL MOB TCD
Slide 29 - The anterior draw tests the ATFL Test should be done with the ankle in 10o-20o plantar flexion Low loads 29 Test for the ATFL MOB TCD
Slide 30 - A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus Passes downwards and backwards To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 30 The CFL MOB TCD
Slide 31 - It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints The CFL has the highest linear elastic modulus of the three ligaments Siegler et al., 1988 31 The CFL MOB TCD
Slide 32 - When the ankle is in the neutral or dorsiflexion, the CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL 32 The CFL MOB TCD
Slide 33 - The Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint Hamilton, 1994; Peters, 1991 33 MOB TCD
Slide 34 - ATFL and CFL A difference of 10o between the two ankles is significant. A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 34 MOB TCD
Slide 35 - The Posterior Talar Fibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus 35 MOB TCD
Slide 36 - During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion The greatest strain on the ligament is when the foot is plantar flexed and everted 36 The PTL MOB TCD
Slide 37 - In 7% of normal population the lateral tubercle has a separate ossification and is called an os trigonum It occurs in 32% of soccer players Tarsal coalition is another congenital abnormality 37 The Ankle Joint MOB TCD
Slide 38 - Synovial Membrane Lines the capsule and the non articular areas It is reflected on to the neck Extends upwards between the tibia and fibula to the interosseous ligament of the inferior tibiofibular joint Covers the fatty pads that lie in relation to the anterior and posterior parts of the capsule Plastanga et al.,1980 38 MOB TCD
Slide 39 - Ankle Stability The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint 39 MOB TCD
Slide 40 - The tibiocalcaneal and the tibionavicular control abduction of the talus The calcaneofibular controls adduction The anterior tibiotalar and the anterior talofibular ligament control plantar flexion Posterior tibiotalar and the posterior talar fibular ligament resist dorsiflexion Both the anterior tibiotalar and the tibionavicular control external rotation and with the anterior talofibular internal rotation of the talus The anterior talofibular is the primary stabilizer of the ankle joint 40 Ankle Stability MOB TCD
Slide 41 - Blood Supply of the Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries 41 MOB TCD
Slide 42 - Nerve Supply of the Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 42 MOB TCD
Slide 43 - Anterior Aspect Dorsi-flexors Tibialis anterior Extensor hallucis longus Anterior tibial becomes the Dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius 43 MOB TCD
Slide 44 - The medial branch of the superficial peroneal nerve is superficial to the retinaculum The long saphenous vein and the saphenous nerve lie anterior to the medial malleolus 44 Anterior Aspect MOB TCD
Slide 45 - Postero-Medial Aspect of the Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve Flexor hallucis longus 45 MOB TCD
Slide 46 - The tibial nerve gives off the medial calcaneal nerve then divides into the medial and lateral plantar nerves The medial calcaneal vessels and nerve pierce the flexor retinaculum to supply the skin of the heel 46 Postero-Medial Aspect of the Ankle MOB TCD
Slide 47 - Posterior Aspect Achilles tendon separated by a bursa and pad of fat Posterolateral portal is lateral to achilles tendon, sural nerve and short saphenous vein at risk Postero-medial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 47 MOB TCD
Slide 48 - Lateral Aspect of the Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament Sural nerve Short saphenous vein 48 MOB TCD
Slide 49 - Plantar flexion and eversion Peroneus longus Peroneus brevis Dorsi-flexion and eversion Peroneus tertius 49 Lateral Aspect of the Ankle MOB TCD
Slide 50 - Nerves Related to Ankle Joint 50 MOB TCD
Slide 51 - Tibialis Posterior Superficial Peroneal Nerve 51 MOB TCD
Slide 52 - Movements of Ankle joint Dorsiflexion is close packed or stable position Wider portion of body of talus between malleoli Range of 30 o Need 10 o dorsiflexion to run 52 MOB TCD
Slide 53 - Dorsiflexion Dorsiflexion is produced by the tibialis anterior Extensor hallucis longus Extensor digitorum longus The peroneus tertius Deep peroneal nerve 53 MOB TCD
Slide 54 - Movements of Ankle joint Plantar flexion Some side to side movement Narrow portion of body between malleoli, 50-60 o Least pack, unstable position Wide variation 54 MOB TCD
Slide 55 - Plantar Flexion During plantar flexion The dorsal capsule The anterior fibres of the deltoid The anterior talofibular ligaments are under maximum tension Plantar flexion is caused mainly by the action of the achilles tendon Assisted by the tibialis posterior Flexor digitorum longus Flexor hallucis longus Peroneus longus and brevis 55 MOB TCD
Slide 56 - The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) 56 The Ankle Joint MOB TCD
Slide 57 - Examination of Ankle ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal 57 MOB TCD
Slide 58 - Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament 58 Examination of Ankle MOB TCD
Slide 59 - Ankle Examination Anterior drawer Talar tilt Inversion stress Squeeze test External rotation test 59 MOB TCD
Slide 60 - Tests for Ankle Ligament Injury 60 MOB TCD
Slide 61 - Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral malleolus Unable to weight bear Four steps post injury 61 MOB TCD
Slide 62 - A Few Statistics Basketball 5.5 ankle injuries/1000 player hours Netball 3.3 ankle injuries/1000 player hours Volleyball 2.6 ankle injuries/1000 player hours Soccer 2.0 ankle injuries/1000 player hours Hopper et al., 1999 62 MOB TCD
Slide 63 - Basketball Statistics 53% of basketball injuries are ankle injuries 30.4 ankle injuries/1000 games 10.0 ankle injuries/season for a squad of twelve Garrick, 1977 63 MOB TCD
Slide 64 - Risk Factors Extrinsic Training error Type of sport Playing time Level of competition Equipment Environmental Intrinsic Malalignment Strength deficit Reduced ROM Joint instability Joint laxity Foot type Height/weight 64 MOB TCD
Slide 65 - Previous ankle injury Ekstrand & Gillquist, 1983; Milgrom et al., 1991 Competition Ekstrand & Gillquist, 1983 Muscle Imbalance Baumhauer et al., 1995 Mass moment of inertia Milgrom et al., 1991 65 Risk Factors MOB TCD
Slide 66 - Ankle Injuries Lateral ligament sprain Medial ligament sprain Peroneal dislocation Fractures Dislocations Tendon rupture Tibialis posterior Peroneal tendons Ruptured syndesmosis Superficial peroneal nerve lesion Reflex sympathetic dystrophy 66 MOB TCD
Slide 67 - Ankle Sprains Grade oneStretch of ATFL; mild swelling; no instability Grade twoPartial macroscopic tear; pain; swelling; mild-moderate instability Grade three Complete tear; severe swelling; unable to weight bear; limited function; and instability 67 MOB TCD
Slide 68 - Proprioception Theory 68 MOB TCD
Slide 69 - Reducing Injury Proprioceptive Agility and Flexibility training Ekstrand & Gillquist, 1983 Taping Loosens in 10 minutes Garrick, 1977 Nil effect in 30 minutes? Tropp et al., 1985; Rovere et al., 1988; Sitler et al., 1994 Bracing 69 MOB TCD
Slide 70 - “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.” 70