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1 Cover slide

2 Functional Anatomy of the Ankle Joint Complex
MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin

3 MOB TCD 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

4 MOB TCD Tennis

5 MOB TCD The Ankle Joint Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963

6 Inversion and Eversion
MOB TCD 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

7 Inversion and Eversion
MOB TCD Inversion and Eversion 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

8 The Ankle Joint A uniaxial, modified synovial hinge joint
MOB TCD The Ankle Joint A uniaxial, modified synovial hinge joint Proximally the articulation depends on the integrity of the inferior tibiofibular joint Close pack Dorsiflexion Williams & Warwick, 1980

9 MOB TCD The Ankle Joint 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

10 The Ankle Joint In dorsiflexion the foot moves upwards and medially
MOB TCD The Ankle Joint In dorsiflexion the foot moves upwards and medially Downwards and laterally in plantar flexion Plastanga et al., 1990

11 Proximal Articular Surface
MOB TCD 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

12 Proximal Articulation
MOB TCD 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

13 Proximal Articular Surface
MOB TCD Proximal Articular Surface Proximally the articulation depends on the integrity of the inferior tibiofibular joint A syndesmosis Lateral malleolus is larger, lies posteriorly Extends more inferiorly

14 Distal Articular Surface
MOB TCD 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

15 Distal Articular Surface
MOB TCD Distal Articular Surface 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

16 Posterior Aspect of Talus
MOB TCD 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

17 Congenital Abnormalities
MOB TCD 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

18 MOB TCD 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

19 Capsule Is attached just beyond the articular margin
MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980

20 The Ankle Joint The capsule is thin and weak in front and behind
MOB TCD The Ankle Joint 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

21 The Posterior Ligament
MOB TCD 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

22 The Medial (Deltoid) Ligament
MOB TCD The Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980

23 Medial Ligament Inferiorly, ant-post The tuberosity of the navicular
MOB TCD 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

24 Medial or Deltoid Ligament (Superficial)
MOB TCD 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

25 Medial or Deltoid Ligament (Deep)
MOB TCD 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

26 Lateral Ligaments of Ankle
MOB TCD 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

27 The ATFL Is part of the capsule An upper and lower bands
MOB TCD 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

28 The ATFL It is the weakest ligament
MOB TCD The ATFL 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

29 Test for the ATFL The anterior draw tests the ATFL
MOB TCD Test for the ATFL The anterior draw tests the ATFL Test should be done with the ankle in 10o-20o plantar flexion Low loads

30 The CFL A long rounded 20-25 mm long, 6-8 mm in diameter
MOB TCD The CFL A long rounded 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

31 The CFL It is separated from the capsule by fibro-fatty tissue
MOB TCD The CFL 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

32 MOB TCD The CFL 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

33 MOB TCD 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

34 MOB TCD 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

35 The Posterior Talar Fibular (PTL)
MOB TCD 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

36 MOB TCD The PTL 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

37 MOB TCD The Ankle Joint 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

38 Synovial Membrane Lines the capsule and the non articular areas
MOB TCD 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

39 MOB TCD 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

40 MOB TCD Ankle Stability 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

41 Blood Supply of the Ankle
MOB TCD Blood Supply of the Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries

42 Nerve Supply of the Ankle
MOB TCD Nerve Supply of the Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2

43 Anterior Aspect Dorsi-flexors Tibialis anterior
MOB TCD Anterior Aspect Dorsi-flexors Tibialis anterior Extensor hallucis longus Anterior tibial becomes the Dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius

44 MOB TCD Anterior Aspect 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

45 Postero-Medial Aspect of the Ankle
MOB TCD Postero-Medial Aspect of the Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve Flexor hallucis longus

46 Postero-Medial Aspect of the Ankle
MOB TCD Postero-Medial Aspect of the Ankle 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

47 Posterior Aspect Achilles tendon separated by a bursa and pad of fat
MOB TCD 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

48 Lateral Aspect of the Ankle
MOB TCD 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

49 Lateral Aspect of the Ankle
MOB TCD Lateral Aspect of the Ankle Plantar flexion and eversion Peroneus longus Peroneus brevis Dorsi-flexion and eversion Peroneus tertius

50 Nerves Related to Ankle Joint
MOB TCD Nerves Related to Ankle Joint

51 Tibialis Posterior Superficial Peroneal Nerve
MOB TCD Tibialis Posterior Superficial Peroneal Nerve

52 Movements of Ankle joint
MOB TCD 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

53 Dorsiflexion Dorsiflexion is produced by the tibialis anterior
MOB TCD Dorsiflexion Dorsiflexion is produced by the tibialis anterior Extensor hallucis longus Extensor digitorum longus The peroneus tertius Deep peroneal nerve

54 Movements of Ankle joint
MOB TCD Movements of Ankle joint Plantar flexion Some side to side movement Narrow portion of body between malleoli, o Least pack, unstable position Wide variation

55 Plantar Flexion During plantar flexion
MOB TCD 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

56 MOB TCD The Ankle Joint The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt)

57 Examination of Ankle ATFL CFL Distal tibiofibular Syndesmosis
MOB TCD Examination of Ankle ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal

58 Examination of Ankle Achilles tendon Peroneal tendons
MOB TCD Examination of Ankle Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament

59 Ankle Examination Anterior drawer Talar tilt Inversion stress
MOB TCD Ankle Examination Anterior drawer Talar tilt Inversion stress Squeeze test External rotation test

60 Tests for Ankle Ligament Injury
MOB TCD Tests for Ankle Ligament Injury

61 Ottawa Ankle Rules Anteroposterior Oblique Lateral views
MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral malleolus Unable to weight bear Four steps post injury

62 A Few Statistics Basketball 5.5 ankle injuries/1000 player hours
MOB TCD 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

63 Basketball Statistics
MOB TCD 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

64 Risk Factors Extrinsic Training error Type of sport Playing time
MOB TCD 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

65 MOB TCD Risk Factors 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

66 Ankle Injuries Lateral ligament sprain Tendon rupture
MOB TCD 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

67 Ankle Sprains Grade one Stretch of ATFL; mild swelling; no instability
MOB TCD Ankle Sprains Grade one Stretch of ATFL; mild swelling; no instability Grade two Partial macroscopic tear; pain; swelling; mild-moderate instability Grade three Complete tear; severe swelling; unable to weight bear; limited function; and instability

68 Proprioception Theory
MOB TCD Proprioception Theory

69 Reducing Injury Proprioceptive
MOB TCD 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

70 “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved
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