2006 NATA Annual Meeting

Atlanta, GA

The “Ankle” Joint

„ Widely viewed as a single joint

Evaluation and Management „ Actually a series of joints that

are highly integrated
of Subtalar Joint Dysfunction … Inferior Tibio-Fibular Syndemosis
Gary Wilkerson, EdD, ATC … Talocrural Joint
… Subtalar Joint
… Transverse Tarsal Joint
… Tarsometatarsal Joints
… Metatarsophalangeal Joints

Definition of Ankle Motions Definition of Ankle Motions

1) In relation to orthogonal cardinal planes
… Axis of motion assumed ⊥ to plane of motion „ Sagittal Plane
„ Where do planes/axes intersect? … Plantar Flexion – Dorsiflexion

… One segment assumed to be stationary

„ Are planes/axes fixed in relation to position of stationary „ Frontal Plane
segment? Horizontal and vertical? … Abduction – Adduction?
… Inversion – Eversion
… Supination – Pronation

„ Transverse Plane
… Internal Rotation – External Rotation
… Adduction – Adduction?
„ Foot moving on fixed leg?
„ Leg moving on fixed foot?

3 4

1
Definition of Ankle Motions
2) Motion of moving (usually distal) segment in relation to
stationary adjacent (usually proximal) segment
… Foot motion in relation to fixed leg?
„ Open-Chain (Foot Inv-Evr OR Sup-Pro?)
… Leg motion in relation to fixed foot?
„ Closed-Chain (Leg Inv-Evr OR Abd-Add?)
Definition of Ankle Motions
„ Simultaneous motion of both segments?
… Motion defined in relation to adjacent segment?
… Motion defined in relation to vertical or horizontal
reference lines?
„ Leg Angle + Foot Angle = Pronation Angle

MEDIAL LATERAL

5 6

Functional Axis of Subtalar Joint Definition of Ankle Motions

3) In relation to direction of movement around a
functional axis
„ Functions like “mitred hinge” ƒ Definition not dependent on position of adjacent
… Rotationof segments in opposite directions segment or vertical/horizontal reference planes
… Simultaneous motion in all 3 cardinal planes

7 8

2
Definition of Ankle Motions
„ Inversion – Eversion
1) Commonly use to describe “open-chain”
motion of foot in relation to leg.
2) Almost exclusively used to describe acute
ankle injury mechanism.
Definition of Ankle Motions
„ Supination – Pronation
1) Commonly used to define foot alignment
under weightbearing “closed-chain” condition.
2) Commonly used to describe foot position
during different phases of gait cycle.

9 10

Definition of Ankle Motions Talocrural Joint

„ Triplanar Displacement
„ “Upper Ankle Joint”
… Combined Sagittal + Transverse + Frontal
motions associated with subtalar joint function
„ Podiatry Definition
… Supination = PF + Adduction + Inversion
… Pronation = DF + Abduction + Eversion

„ Orthopedic Definition
… Inversion = PF + Adduction + Supination
… Eversion = DF + Abduction + Pronation

11 12

3
Inferior Tibio-Fibular Syndesmosis Talus
„ Key structure between leg & foot
„ Function similar to of ball bearing
… No muscle attachments
… Almost completely covered with articular cartilage

13 14

Talocrural Articular Surfaces Functional Axis of Talocrural Joint

15 16

4
Functional Axis of Talocrural Joint Ankle Ligaments - ATFL

17 18

Subtalar Joint Subtalar Joint:

„ “Lower Ankle Joint” – Talo-Calcaneal Joint Calcaneus + Talus
… Part of Talo-Calcaneo-Navicular (TCN) Joint

19 20

5
 Functional Axis of Subtalar Joint Subtalar Tri-planar Motion
„ Frontal Plane Component
… Supination or Inversion

21 22

Functional Axis of Subtalar Joint Integrated TC + ST Function

„ Functions like “mitred hinge”
… Rotation of segments in opposite directions Composite
TC/ST Axis
… Frontal Plane + Transverse Plane

23 24

6
Transverse Tarsal Joint Transverse Tarsal Joint
„ Transitional link
… Rearfoot– Forefoot 1) Oblique axis (OTT)
… S-shaped joint line … Motion in same direction as that of ST joint
2) Longitudinal axis (LTT)
… Motion in direction opposite to that of ST joint

Navicular

Cuboid

25 26

Transverse Tarsal Joint Mid-Foot Ligaments

„ Bifurcated Ligament
„ Rearfoot-Forefoot
twist

Subtalar
Joint

Transverse
Tarsal Joint

27 28

7
 Tarsometatarsal Joints
Mid-Foot Ligaments
„ Collective function similar to that of
Transverse Tarsal Joint

Axis of
Axis of
1st Ray 5th Ray

Axis of
1st Ray

Axis of Subtalar
29 5th Ray Axis 30

Metatarsophalangeal Joints Integrated Function of Foot/Ankle Joints

„ Integrated function of the 5 MTP joints „ Weight-bearing heel elevation produces
represented by composite functional axis hindfoot inversion
… Transverse
„ greater extension of medial joints
… Oblique
„ greater extension of lateral joints

31 32

8
 Integrated Function of Foot/Ankle Joints Heel Elevation – Hindfoot Inversion
„ Composite hindfoot axis
… ST+TC
… parallel to MTP axis
„ transverse
„ Oblique

33 34

Muscle Actions: Eversion/Inversion Ankle/Foot Biomechanics

„ Forefoot, Rearfoot, & Leg mechanically linked

Lateral to ST Axis:
EVERTORS

Medial to ST Axis:
INVERTORS

35 36

9
 Conventional View of Pronation
Pronation-Related Conditions
„ Focus on rearfoot
„ Plantar Faciitis
„ Medial Tibial Stress Syndrome … Orientation of calcaneus in relation to leg
„ valgus position
„ Posterior Tibialis Tendinitis
„ Achilles Tendinitis … Status of longitudinal arch
„ Metatarsal Stress Fracture „ navicular height

„ Patello-Femoral Syndrome
… Position of talus relative to calcaneus
„ ACL Rupture „ “subtalar neutral”

37 38

Frontal Plane Component of

Pronation: Integrated Joint Motions Subtalar Tri-planar Motion
1) Calcaneal Eversion (Valgus)

2) Internal Rotation + Lateral Deviation Of Leg

3) Plantar Flexion + Internal Rotation Of Talar Head

4) Compensatory Forefoot Supination (Varus)

… Rearfoot Pronation (Subtalar Joint)
… Forefoot Supination (Transverse Tarsal Joint)

39

10
Pronation assessment tends to
be focused on position of foot in Pes Planus:
relation to horizontal support Plantar Flexion + Internal Rotation
surface.
of Head of Talus on Calcaneus
Pronation:

Foot Angle
vs.
Leg Angle

Leg segment does not remain

stationary in a vertical orientation Associated with “Navicular Drop”
during functional activities!!!
42

Gait Cycle Abnormal Pronation

Heelstrike → Mid-Stance → Toe-Off
„ Max pronation occurring beyond 25% of
„ Heelstrike to Mid-Stance
stance phase (walking)
… Supination to Pronation
„ joint mobility
… Diminished propulsive capability
„ shock absorption

… Prolonged & excessive loads on tissues

„ Mid-Stance to Toe-Off … Impropertiming of pronation may be more
… Pronation to Supination problematic than magnitude of pronation
„ joint surfaces locked
„ foot becomes rigid lever … May be due to deficiency in invertor
strength/endurance (posterior tibialis)
„ force transfer from Achilles tendon to toes

43 44

11
 Posterior Tibialis Tendon
SUPINATION
„ Primary insertion on navicular tuberosity
„ Dynamic stabilizer of medial longitudinal arch
PRONATION
… Subjected to great mechanical stress
„ Eccentric action: Heel strike to mid-stance
MAX
… Deceleration of pronation
„ Concentric action: Mid-stance to push-off
… Supination of foot (increased rigidity)

„ Pathology
… Tenosynovitis
… Longitudinal tears
… Complete rupture
46

Posterior Tibialis Role in Posterior Tibialis Test

Diminished capability to elevate heel, combined
Transfer of Force from
with lack of hindfoot supination
Rearfoot to Forefoot

47
NORMAL 48

12
 Excessive Pronation
1) Tibia + talus internally rotated
2) Navicular + forefoot externally rotated
… Forefoot abduction in relation to rearfoot
Forefoot-Hindfoot Twist
„ Forefoot relation to horizontal support surface: Neutral
„ Forefoot relation to hindfoot: Supinated (varus position)

Forefoot -
Hindfoot Hindfoot
Neutral Pronation

Compensatory
Forefoot
Supination
Tendency for
Lateral Lift-Off

49 50

Fabrication of Thermoplastic Orthotics

52

13
Fabrication of Thermoplastic Orthotics Fabrication of Thermoplastic Orthotics

53 54

Fabrication of Thermoplastic Orthotics Chronic Ankle Dysfunction

„ 10% to 50% of all lateral ankle sprains
… Pain
… Swelling
… Giving-way
… Repetitive reinjury

Isakov et al, Int J Sport Biomech, 1986

Karlsson & Lansinger, Clin Orthop, 1992
Konradsen et al, Foot Ankle, 1991
Peters et al, Foot Ankle, 1991
Smith & Reischl, AJSM, 1986
55 56

14
 MRI Studies:
Chronic Ankle Dysfunction Ankle Pathology
„ Clinicians often underestimate
1) Undiagnosed subtalar pathology? severity of ankle ligament damage
… Frey: FAI, 1996
„ Initial diagnosis vs. MRI results

2) Inadequate compensation for rotary

instability? „ Subtalar ligaments are often
damaged by inversion injury
… Togichi et al: FAI, 1998
„ > 50% of lateral ankle sprain cases

57 58

Subtalar Pathology Subtalar Joint:

„ Lateral Talocalcaneal Ligament
Lateral Pain/Instability
„ Interosseus Talocalcaneal Ligament
„ Sinus Tarsi Syndrome
… Abnormality of one or more structures within
„ Cervical Ligament sinus tarsi or tarsal canal
… Feeling of hindfoot instability
… Responsive to injection of local anesthetic
… Etiology:
Sinus „ Trauma: 70% of cases
Tarsi „ Insidious inflammation: 30% of cases
… Ankylosing spondylitis
… Rheumatoid arthritis
… Gout
LTCL
… Ganglion cyst
… Foot deformity

59 60

15
 Sinus Tarsi Subtalar Pathology
„ Separates anterior & posterior articulations
of subtalar joint „ Lateral Talocalcaneal Ligament
„ Inferior Peroneal Retinaculum
„ Contents: Sinus
Tarsi „ Inferior Extensor Retinaculum - Lateral Root
… Fat, nerves, arteries
… Joint capsules (anterior & posterior)
… ITFL & CL
… Inferior Extensor Retinaculum “Roots”
„ Medial
„ Intermediate
„ Lateral

Inf. Per. Ret.

61 LTCL Inf. Ext. Ret. 62

Subtalar Joint Ligaments Lateral Ankle Sprain

ITCL
Pathomechanics
Cervical
Ant.Band Ligament
Post Band

Inf Ext Ret

Plantar ITCL
Ant.Band Calcaneo- Ant. Band
Post Band Navicular
Ant.Band Ligament Capsule of
Post Band Post ST Articulation

Post Band = Capsule of

Post ST Articulation

63 64

16
 Talocrural PF:
VGRF Medial to ST Axis
ST Axis Orientation

65 66

Typical Mechanism of LAS

67 68

17
Forefoot – Rearfoot Torque Transfer Subtalar Inversion +
External Leg Rotation

69 70

Frontal Plane Lateral Talar Tilt

Locked Joints = Rigid Lever „ Excessive talar tilt associated with ATFL damage

… Widely viewed as a component of the ATFL injury mechanism

… Support systems designed to restrict frontal plane motion

71 72

18
 Simplistic View of Ankle Sprain
Talar Tilt vs. Rotary Subluxation Mechanism of Injury
„ ATFL critical role: restraint of
transverse plane rotation

… Cass & Settles: FA, 1994

… Colville et al: AJSM,1990
… Hintermann: MSSE, 1999
… Johnson & Markolf: JBJS(A), 1983
… McCullough & Burge: JBJS(B), 1980
… Parlasca et al: Clin Orthop, 1979
… Rasmussen & Tovborg: Acta Orthop Scand, 1981
… Renstrom et al: FA, 1988
… Stormont et al: AJSM, 1985
73 74

Ankle Taping
Lateral Subtalar Sling
„ Stirrup strips & heel locks
„ High-strength semi-elastic tape
… Encasing hindfoot probably resists lateral distraction of … 1 or 2 strips oriented at 45º in sagittal
joint surfaces within the frontal plane plane & wrapped around leg

… spans all joints between forefoot & leg

„ 4th & 5th Tarsometatarsal Joints

„ Transverse Tarsal Joint
„ Subtalar Joint
„ Talocrural Joint

75 76

19
Lateral Subtalar Sling Lateral Subtalar Sling
„ ER of leg generates tension within
„ Tension generated within longitudinal fibers of tape longitudinal fibers of tape
… Vertical component resists frontal plane motion of foot … restrains INV of lateral border of foot
… A-P component resists anterior translation of talus (anterior drawer) … restrains IR of talus in relation to leg ER

77 78

Subtalar Joint Ligaments

Intermediate Cervical Lateral Subtalar Sling
Root - Ligament
Inf. Ext. Ret. Ext.Dig.
Ant. Articular Surface Brevis „ Wilkerson: AJSM, 1991
Medial Root -
Inf. Ext. Ret
… Standard: Gibney/Heel-Locks
Lateral Root - … Modified: Gibney/Heel-Locks + Lateral Subtalar Sling
Inf. Ext. Ret.
„ 2 - 3 hours of football practice
Peroneal
Tendons

Interosseus Posterior
Talo-Calcaneal Articular
Ligament Surface

Capsule of
Posterior
Subtalar
Articulation
Superior
View
ST Axis
80

20
 Wilkerson: AJSM, 1991
Ankle Capsule: Normal vs. Distended
… Post-ex INV restraint increased 94%
„ Untaped INV: 40º
„ Tape residual restriction: 8.5º vs 16.5º

8.5º 16.5º

Sagittal: 9.56 Nm (7 ft lbs)

Frontal: 6.67 Nm (5 ft lbs)

81 82

ATFL-Capsule Compaction Antero-Lateral Impingement

„ Edema proteins absorbed by synovium
„ Chronic inflammatory response
… Synovial hypertrophy
… Development of extensive adhesions
… Fibrous scarring of synovium
… Hyalinization of lesion
… Chondromalacia of talus

83 84

21
Ankle Impingement Syndrome Medial Subtalar Sling
„ Support of medial longitudinal arch
„ Restraint of subtalar eversion
… Decreased Antero-Lateral Impingement
… Decreased load on Posterior Tibialis
… Protection of Deltoid Ligament
… Protection of Tibio-Fibular Syndesmosis

85 86

Subtalar Sling: Mechanical Effect Antero-Posterior Displacement (mm)

Wilkerson G, Kovaleski J, Meyer M, Stawitz C
„ 6 degree of freedom arthrometer „ 125 N (28 lb) anterior-posterior force
… 23 physically active subjects „ Significant Trial X Method interaction (p <.001)
„ 12 males & 11 females
18
„ No history of ankle dysfunction
… Standard taping vs. modified taping
„ Modified: medial + lateral ST sling 16

14

Estimated Marginal Means

12

METHOD
10
1

8 2
1 2 3
Untaped Taped Untaped
Pre-Ex
TRIAL Post-Ex Post-Ex
87 88

22
 Measurement of
Advantages of Taping Inversion Velocity &
„ Improved Joint Position Sense Leg External Rotation

„ Peroneal Facilitation

„ Inversion Deceleration
3X greater restraint
of Max ER
„ Restriction of Max Subtalar Motion
2X greater reduction
„ Control of Anterior Drawer of Avg Inv Velocity

2X greater reduction
„ Restraint of Anterolateral Rotary Instability? of Peak Inv Velocity

89 90

Mechanical
Advantages of Bracing Effect?

„ Ease of Application

„ Improved Joint Position Sense

„ Inversion Deceleration

„ Restriction of Max Inversion

„ Restriction of Leg Rotation??? 45°

91

23
 Ankle Brace Designs Measurement of Leg External Rotation

„ Articulated Stirrup

„ Lace-Up Ankle Gauntlet

(with or without straps)

„ Combination

No Brace: 11.7 ±3.9

93 94

Measurement of Leg Rotation Summary

Gary-Wilkerson@utc.edu

Downloadable PDF file of slides:

10.7 ±4.2 11.5 ±4.6
www.utc.edu/gatp → “Program News”

9.9 ±3.1 11.4 ±3.8 8.5 ±3.1

No Brace: 11.7 ±3.9

95 96

24