INSTITUTE- UIAHS

DEPARTMENT- PHYSIOTHERAPY
MASTER OF PHYSIOTHERAPY (MPT)
Advanced Sports injury Management Strategies-II
20MPB-752
Dr. Kamran Ali
Assistant Professor

DISCOVER . LEARN . EMPOWER

BIOCHEMISTRY- CARBOHYDRATE
ANKLE JOINT

Functional Anatomy
The ankle contains three
joints
1. talocrural (ankle) joint
2. inferior tibiofibular joint
3. Subtalar joint.
• The talocrural or ankle joint is a hinge joint formed between the
inferior surface of the tibia and the superior surface of the talus.
• The medial and lateral malleoli provide additional articulations and
stability to the ankle joint.
• The movements at the ankle joint are plantar flexion and
dorsiflexion ( least stable in plantar flexion)
• The inferior tibiofibular joint is the articulation of the distal parts of
the fibula and tibia. The inferior tibiofibular joint is supported by the
inferior tibiofibular ligament or syndesmosis.
• The subtalar joint between the talus and calcaneus, is divided into an
anterior and posterior articulation separated by the sinus tarsi.
• The main roles of the subtalar joint are to provide shock absorption, to
permit the foot to adjust to uneven ground and to allow the foot to remain
flat on the ground
• Inversion and eversion occur at the subtalar joint.
ligaments of the ankle join
lateral ligament consists of three parts:
• Anterior talofibular ligament (ATFL), which passes as a flat and rather thin
band from the tip of the fibula anteriorly to the lateral talar neck
• the calcaneo fibular ligament (CFL), which is a cord-like structure directed
inferiorly
• Posteriorly, and the short posterior talofibular ligament (PTFL), which runs
posteriorly from the fibula to the talus.
• The medial or deltoid ligament of the ankle is a strong, fan-shaped ligament
extending from the medial malleolus anteriorly to the navicular and talus,
inferiorly to the calcaneus and posteriorly to the talus (infrequently injured)
Acute Ankle Injuries
• Inversion injuries are far more common than eversion injuries due to the relative
instability of the lateral joint and weakness of the lateral ligaments compared
with the medial ligament. Eversion injuries are seen only occasionally.
• mechanism of injury is an important clue to diagnosis after ankle sprain. An
inversion injury suggests lateral ligament damage, an eversion injury suggest
• The onset of pain is very important. A history of being able to weight-bear
immediately after an injury. medial ligament damage with a subsequent increase
in pain and swelling as the patient continues to play sport or walk about suggests
a sprain rather than a fracture. The location of pain and concomitant swelling
and bruising generally gives an indication as to the ligaments injured. The most
common site is over the anterolateral aspect of the ankle.
Examination
• Observation (a) standing (b) supine
• Active movements (a) plantarflexion/dorsiflexion
• (b) inversion/eversion
• Passive movements (a) plantarflexion/dorsiflexion (b) inversion/eversion.
• Resisted movements (a) eversion
• Functional tests (a) lunge test (b) hopping
• Palpation (a) distal fibula
• (b) lateral malleolus
• (c) lateral ligaments
• (d) talus
• (e) peroneal tendon(s)
• (f) base of fifth metatarsal
• (g) anterior joint line
• (h) dome of talus (i) medial ligament (j) sustentaculum tali (k) sinus tarsi (l) anteroinferior
tibiofibular ligament..

• Special tests
• (a) anterior drawer
• (b) lateral talar tilt (increased inversion) proprioception
Lateral ligament injuries
• Lateral ligament injuries occur in activities requiring rapid changes in direction, especially
on uneven surfaces (e.g. grass fields). seen when a player, having jumped, lands on
another competitor’s feet.
• most common injuries seen in basketball, volleyball, netball and football . The usual
mechanism of lateral ligament injury is inversion and plantarflexion, and this injury
usually damages the ATFL before the CFL. because the ATFL is taut in plantarflexion and
the CFL is relatively loose
• Complete tear of the ATFL, CFL and PTFL results in a dislocation of the ankle joint and is
frequently associated with a fracture. Such an injury is rather infrequent, however.
Isolated ligament ruptures of the CFL and especially the PTFL are rare
• Depending on the severity of the injury, the athlete may continue to play or may rest
immediately. Swelling usually appears rapidly, although occasionally it may be delayed
some hours.
Grades of injuries
• In a grade I tear there is no abnormal ligament laxity. It is important to compare both sides
(assuming the other side has not been injured) as there is a large inter-individual variation in
normal ankle laxity.
• Grade II injuries reveal some degree of laxity but have a firm end point.
• Grade III injuries show gross laxity without a discernible end point. All three grades are
associated with pain and tenderness, although grade III tears may be least painful after the initial
episode has settled.
• Grading of these injuries guides prognosis and helps determine the rate of rehabilitation.
Treatment and rehabilitation of lateral
ligament injuries
Initial management
• Lateral ligament injuries require RICE treatment. This is essential
treatment limits the hemorrhage and subsequent edema .
• The injured athlete must avoid factors that will promote blood flow and
swelling, such as hot showers, heat rubs, alcohol or excessive weight
bearing. Gradually increased weight-bearing will help to reduce the
swelling and increase the ankle motion.
• Restoration of full range of motion If necessary, the patient may be non-
weight-bearing on crutches for the first 24 hours but partial weight-
bearing in normal heel–toe gait. This can be achieved while using
crutches or by protecting the damaged joint with strapping or bracing
and, ultimately, full weight-bearing .
• Lunge stretches and accessory and physiological mobilization of the
ankle subtalar and mid tarsal joints should begin early in rehabilitation.
As soon as pain allows, the practitioner should prescribe active range of
motion exercises (e.g. stationary cycling).
Muscle conditioning
• Active strengthening exercises, including plantarflexion, dorsiflexion,
inversion and eversion , should begin as soon as pain allows. They
should be progressed by increasing resistance (a common method is
to use rubber tubing). Strengthening eversion with the ankle fully
plantarflexed is particularly important in the prevention of future
lateral ligament injuries. Weight-bearing exercises (e.g. shuttle ,
wobble board exercises)
Proprioception
• It is invariably impaired after ankle ligament injury. It should begin
proprioceptive retraining early in rehabilitation . An example of a
common progression is balancing on one leg, then using the rocker
board or mini trampoline, and ultimately performing functional
activities while balancing.
• Functional exercises
• jumping, hopping, twisting, figure-of-eight running can be
prescribed when the athlete is pain-free, has full range of motion
and adequate muscle strength and proprioception. Specific
Return to sports

• Return to sport is permitted when functional exercises can be performed

without pain during or after activity.
• While performing rehabilitation activities and upon return to sport, added
ankle protection should be provided with either taping or bracing.
• Any athlete who has had a significant lateral ligament injury should use
protective taping or bracing while playing sport for a minimum of six to 12
months post-injury.
• There are a number of methods to protect against inversion injuries. The
three main methods of tape application are stirrups , heel lock and the
figure of six . Usually at least two of these methods are used
simultaneously.
Treatment of grade III injuries

• In clinical practice, it is widely agreed that all grade III ankle injuries
warrant a trial of initial conservative management over at least a six-
week period. despite appropriate rehabilitation and protection, the
patient complains of recurrent episodes of instability or persistent
pain, then surgical reconstruction of the lateral ligament is indicated.
• Following surgery, it is extremely important to undertake a
comprehensive rehabilitation program to restore full joint range of
motion, strength and proprioception
Less common causes

Medial (deltoid) ligament injuries

• As the deltoid ligament is stronger than the lateral ligament, and eversion is a less common
mechanism of ankle sprain, medial ankle ligament injuries are less common than lateral ligament
injuries. Medial ligament injuries may occur together with fractures (e.g. medial malleolus, talar
dome, articular surfaces).
Pott’s fracture
• fracture affecting one or more of the malleoli (lateral, medial, posterior) is known as a Pott’s fracture.
• It can be difficult to distinguish a fracture from a moderate-to-severe ligament sprain as of similar
mechanisms of injury and cause severe pain and inability to weight-bear.
• Careful and gentle palpation can localize the greatest site of tenderness to either the malleoli
(fracture) or just distal to the ligament attachment (sprain).
• The management of Pott’s fractures requires restoration of the normal anatomy , internal fixation is
almost always required.
• Lateral malleolar fractures associated with medial instability, hairline medial
malleolar fractures or larger undisplaced posterior malleolar fractures are
potentially unstable but may be treated conservatively with six weeks of
immobilization (below-knee cast with extension to include the meta
Maisonneuve fracture
• The injury involves complete rupture of the medial ligament, the AITFL and
interosseous membrane, as well as a proximal fibular fracture. Urgent
referral to an orthopedic surgeon is necessary.
Osteochondral lesions of the talar dome
• It is not uncommon for osteochondral fractures of the talar dome to occur
in association with ankle sprains, as there is a compressive component to
the inversion injury, such as when landing from a jumping.
• Usually, the lesion is not detected initially. Patient often gives a history of
progressing well following a sprain but then developing symptoms of
increasing pain and swelling, stiffness and perhaps catching or locking as
activity is increased. Reduced range of motion is often a prominent
symptom.
• Examination with the patient’s foot plantarfl exed at 45° to rotate the talus
out of the ankle mortise may reveal tenderness of the dome of the talus.
Avulsion fracture of the base of the fifth metatarsal

• Inversion injury may result in an avulsion fracture of the base of the fifth
metatarsal either in isolation or, in association with a lateral ligament sprain.
• This fracture results from avulsion of the peroneus brevis tendon from its
attachment to the base of the fifth metatarsal.
• Fracture of the proximal diaphysis of the fifth metatarsal that does not
involve any joint surfaces. This fracture is known as the Jones’ fracture and
may oft en require internal fixation .
• Jones’ fracture is a result of repetitive overuse (i.e. a stress fracture) of the
proximal diaphysis of the fifth metatarsal. Fracture of the base of the fifth
metatarsal may be treated conservatively with immobilization for pain relief
followed after one to two weeks by protected mobilization and rehabilitation
Other fractures

Fracture of lateral talar process

• The lateral talar process is a prominence of the lateral talar body with an
articular surface dorsolaterally for the fibula and inferomedially for the
anterior portion of the posterior calcaneal facet
• Examination over the lateral aspect of the ankle and tenderness over the
lateral process, immediately anterior and inferior to the tip of the lateral
malleolus.
• The fracture is best seen on the mortise view X-ray of the ankle.
• Undisplaced fractures may be treated in a short leg cast. displaced fractures
require either primary excision or reduction and internal fixation.
Fracture of anterior calcaneal process

• Fractures of the anterior calcaneal process may cause persistent pain

after ankle sprain.
• Palpation of the anterior calcaneal process, cause considerable pain in
those with a fracture of the anterior process.
• If the fracture is small, symptomatic treatment may sufficient. If
large, it requires four weeks of non-weight-bearing cast
immobilization or surgical excision of the fragment.
Tendon dislocation or rupture
Dislocation of peroneal tendons
• They are occasionally dislocated as a result of forceful passive dorsiflexion. This
may occur when a skier catches a tip and falls forward over the ski.
• Examination reveals tender peroneal tendons .
• Treatment of dislocation of peroneal tendons is surgical replacement of the
tendons in the peroneal groove and repair of the retinaculum.
Dislocation of the tibialis posterior tendon
• Dorsiflexion and inversion so that strong contraction of the tibialis posterior
muscle pulls the tendon out of its retinaculum using the malleolus as a fulcrum.
• Examination reveals swelling and bruising of the medial ankle above and about
the medial malleolus with tenderness along the path of the tibialis posterior
tendon.
• Immediate surgical treatment is indicated .
• Post-operatively the ankle is immobilized in a below-knee plaster cast with a total
of six weeks non weight-bearing on the affected ankle. After the cast is removed,
an ankle brace can be used to immobilize the ankle but active ankle motion is
permitted three times daily while taking care to avoid resisted inversion.
Sinus tarsi syndrome
• It may occur as an overuse injury secondary to excessive subtalar pronation
or as a sequel to an ankle sprain.
• Pain occurs at the lateral opening of the sinus tarsi The pain is oft en more
severe in the morning and improves as the patient warms up.
• Forced passive inversion and eversion may both be painful. The most
appropriate aid to diagnosis is to monitor the effect of injection of a local
anesthetic agent into the sinus tarsi
• Treatment consists of relative rest, NSAIDs, electrotherapeutic modalities,
subtalar joint mobilization and taping to correct excessive pronation if
present. If conservative management is unsuccessful, injection of
corticosteroid and local anesthetic agents may help resolve the inflammation.
Complex regional pain syndrome type
• Initially, it appears that the patient with a ‘sprained ankle’ is improving but then
symptoms begin to relapse.
• The patient complains of increased pain, swelling recurs and the skin may become
hot or, more frequently, very cold, localized sweating, discoloration and
hypersensitivity.
• It is most important that the peculiar nature of the condition be explained to the
patient as it may be a particularly painful condition, even at rest. It remains very
difficult to treat
• Physiotherapy may play a role15 and ultrasound and hydrotherapy may facilitate
range of movement exercises. Gabapentin, an anticonvulsant with a proven analgesic
effect in various neuropathic pain syndromes,
• If the pain does not settle, chemical or surgical blockade is indicated.
ANKLE PAIN
Sportspeople, particularly ballet dancers, footballers and high jumpers,
may complain of ankle pain that is not related to an acute ankle injury.
Types of ankle pain
• medial ankle pain
• lateral ankle pain
• anterior ankle pain.
MEDIAL ANKLE PAIN
• the most common cause of medial ankle pain is tibialis posterior tendinopathy.
Posterior impingement syndrome of the ankle
• Flexor hallucis longus tendinopathy may occur together with posterior
impingement syndrome.
• Tarsal tunnel syndrome, in which the posterior tibial nerve is compressed behind
the medial malleolus, may present as medial ankle pain with sensory symptoms
distally.
In patients with medial ankle pain history of overuse,
especially running or excessive walking (tibialis posterior
tendinopathy),
toe flexion in ballet dancers and high jumpers (fl exor
hallucis longus tendinopathy) or
Plantar flexion in dancers and footballers (posterior
impingement syndrome). Pain may radiate along the
line of the tibialis posterior tendon to its insertion on
the navicular tubercle or into the arch of the foot with
tarsal tunnel syndrome. Sensory symptoms such as pins
and needles or numbness present.
Examination
• Observation
• Active movements and passive movements
• Resisted movements
• Functional test
Hop
Jump
Palpations
Special tests
Tinel’s test
Sensory examination
Investigations
X-ray, radioisotopic bone scan, Ultrasonography or MRI
Tibialis posterior tendinopathy
Main dynamic stabilizer of hind foot against valgus forces, provide
stability to plantar arch
Causes: overuse injury
Clinical features: medial ankle pain, Swelling, tenderness, resisted
inversion
Investigation: MRI or ultrasound
Treatment: conservatite care with controlling pain where needed ice,
concentric and eccentric tendon loading exercise
Flexor hallucis longus tendinopathy

Flexes the big toe and assist in

plantarflexion of the ankle. It is
common in ballet dancers.
Causes: secondry to overuse,
tendon tear
Clinical features: Pain on toe-off or
forefoot weight bearing, triggering
of the first toe.
Investigation: MRI or Ultrasound
Treatment: Ice, avoidance of
activities that stress flexor,
strengthening and stretching
exercises, manual mobilization,
tapping, or orthosis
Tarsal tunnel syndrome
• Entrapment of posterior tibial nerve in tarsal tunnel.
• Causes: In 50% cases idiopathic, result of trauma, or overuse with
excessive pronation.
• Clinical features: Burning, tingling or numb sensations radiating to
toes, pain aggravated by activity, present of swelling, tenderness,
ganglion or cyst may be palpable around the medial ankle.
• Investigation: Ultrasound or MRI, CT scan, X-ray
Differential diagnosis includes entrapment of the
medial and/or lateral plantar nerves, or both, plantar
fasciitis, intervertebral disk degeneration and other
causes of nerve inflammation or degeneration.
Treatment: Conservative treatment should be
attempted in those with either an idiopathic or
biomechanical cause.
NSAID and if required an injection of a corticosteroid If
excessive pronation is present, an orthosis should be
utilized.
Stress fracture of the medial malleolus
• Stress fracture of the medial malleolus is an unusual injury but should be
considered in the runner presenting with persistent medial ankle pain aggravated
by activity.
• Clinical features: Athletes classically present with medial ankle pain that
progressively increases with running and jumping activities.
• Investigation: MRI or X-ray
• Treatment: If no fracture or an undisplaced fracture is evident on X-ray, treatment
requires weight-bearing rest with an air-cast brace until local tenderness resolves, a
period of approximately six weeks. If, however, a displaced fracture or a fracture
that has progressed to non-union is present, surgery with internal fi xation is
required. Following fracture healing, the practitioner should assess biomechanics
and footwear.
Lateral ankle pain
• Lateral ankle pain is generally associated with a biomechanical
abnormality. The two most common causes are peroneal
tendinopathy and sinus tarsi syndrome.
• Examination: testing resisted eversion of the peroneal tendons and
careful palpation for tenderness and crepitus.
Lateral ankle pain

Lateral ankle pain is generally

associated with a biomechanical
abnormality. The two most
common causes are peroneal
tendinopathy and sinus tarsi
syndrome.
Examination: testing resisted
eversion of the peroneal
tendons and careful palpation
for tenderness and crepitus.
Peroneal tendinopathy
• The most common overuse injury causing lateral ankle pain is
peroneal tendinopathy.
• Causes: an acute ankle inversion injury or secondary to an overuse
injury.
• Common causes of an overuse injury include: 1. excessive eversion of
the foot, such as occurs when running on slopes, excessive pronation
of the foot, secondary to tight ankle plantarfl exors (most commonly
soleus) resulting in excessive load on the lateral muscles, excessive
action of the peroneals (e.g. dancing, basketball, volleyball).
• There are three main sites of peroneal tendinopathy:
• 1. posterior to the lateral malleolus
• 2. at the peroneal trochlea
• 3. at the plantar surface of the cuboid.
• Clinical features: lateral ankle or heel pain, swelling,
tenderness, calf muscles tightness and painful passive motions.
• Investigation: MRI
• Treatment: initially involves settling the pain with rest from
aggravating activities, analgesic medication if needed and soft
tissue therapy.
• Stretching with mobilization of the subtalar and
midtarsal joints. Footwear should be assessed and
use of lateral heel wedges or orthoses may be
required to correct biomechanical abnormalities.
• Strengthening exercises should include resisted
eversion (e.g. rubber tubing, rotagym), especially
in plantarfl exion as this position maximally
engages the peroneal muscles. In severe cases,
surgery may be required, which may involve a
synovectomy, tendon debridement repair.
Sinus tarsi syndrome
• Although injury to the sinus tarsi may result from chronic overuse secondary to
poor biomechanics (especially excessive pronation), approximately 70% of all
patients with sinus tarsi syndrome have had a single or repeated inversion injury
to the ankle. It may also occur aft er repeated forced eversion to the ankle, such
as high jump take off .
• Other causes of sinus tarsi syndrome may include chronic inflammation in
conditions such as gout, infl ammatory arthropathies and osteoarthritis.
• Clinical features: Pain, tenderness, difficulty in walking on uneven ground,
• Investigation: X-ray MRI
• Treatment
Conservative management includes relative rest, ice, NSAID and electrotherapeutic modalities.
Mobilization of the subtalar joint. Rehabilitation involves proprioception and strength training and
biomechanical correction.
Anterolateral impingment
• Repeated minor ankle sprains or a major sprain involving the anterolateral aspect
of the ankle may cause of anterolateral ankle impingement another postulated
cause is chondromalacia of the lateral wall of the talus with an associated
synovial reaction.
• Clinical features: pain at anterior aspects of lateral malleolus, tenderness,
proprioception may be poor.
Stress fracture of the talus
• These stress fractures may develop secondary to excessive subtalar pronation and plantarflexion,
resulting in impingement of the lateral process of the calcaneus on the posterolateral corner of
the talus.16 In pole vaulters, this injury is attributed to ‘planting’ the pole too late.
• Clinical features: gradual onset, made worse by running and weight bearing. Clinical examination
reveals marked tenderness and occasionally swelling in the region of the sinus tarsi.
• Investigation: Isotopic bone scan CT scan
• Treatmet
• Treatment requires six weeks’ cast immobilization and then a supervised
graduated rehabilitation. In elite athletes, when a rapid recovery is required, or in
the case of failure of conservative management, surgical removal of the lateral
process has been shown to produce good results. As is required before activity is
resumed.
• this injury is invariably associated with excessive pronation, biomechanical
correction with orthoses
 Anterior ankle pain

• Pain over the anterior aspect of the ankle joint without a history of
acute injury is usually due to either tibialis anterior tendinopathy or
anterior impingement of the ankle.
Anterior impingement of the ankle

• Anterior impingement of the ankle joint (anterior tibiotalar impingement) is a

condition in which additional soft or bony tissue is trapped between the tibia and
talus during dorsifl exion and may be the cause of chronic ankle pain or may
result in pain and disability persisting aft er an ankle sprain. Although this
syndrome has been called ‘footballer’s ankle’, it is also seen commonly in ballet
dancers.
• Causes: Anterior impingement occurs secondary to the development of exostoses
on the anterior rim of the tibia and on the upper anterior surface of the neck of
talus. direct osseous impingement during extremes of dorsifl exion, as occurs
with kicking in football and the plié (lunge) in ballet.
• Clinical features: anterior ankle pain, which initially starts
as a vague discomfort pain ultimately becoming sharper
and more localized to the anterior aspect of the ankle
and foot pain that is worse with activity, particularly with
running, descending plié (lunge) in classical ballet,
kicking in football or other activities involving
dorsiflexion. tenderness along the anterior margin of the
talocrural joint and, if the exostoses are large, they may
be palpable. Dorsiflexion of the ankle is restricted and
painful. The anterior impingement test where the
patient lunges forward maximally with the heel
remaining on the floor, reproduce the pain.
• Investigation: Lateral X-ray in flexion and extension,
perform in lunges position.
• Treatment: In milder cases, conservative treatment
consists of a heel lift , rest, modification of activities to
limit dorsiflexion, NSAID and physiotherapy, including
accessory anteroposterior glides of the talocrural joint
at the end of range of dorsiflexion. Taping or orthoses
may help control the pain if they restrict ankle
dorsiflexion or improve joint instability, which has been
shown to contribute to the development of anterior
impingement. More prominent exostoses may require
surgical removal arthroscopically or as an open
procedure.
Reference

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