1. Evaluation of the Ankle
Sports Physiology

2. Ankle Injuries- Hard Tissue
Bones
Acute
Jones Fracture, Ballarina Fracture
Fibula, Tibia Fracture
Chronic
Stress Fractures

3. Fractured Fibula
Ankle Fracture – commonly caused by eversion. The fibula is often broken.

4. Stress Fracture What is a stress fracture? -An overuse injury.
-A small crack or fracture in the bone
What causes it?
-When muscles become fatigued or overloaded and can not absorb the stress and shock and repeated impact.
-Fatigued muscles transfer that stress to the nearby bone and the result is a small crack or fracture, in the bone.

5. Ballerina Fracture Where does it occur? -5th metatarsal. What is it?
-An avulsion of the proximal tip of the 5th metatarsal where the peroneus brevis muscle tendon attaches.
Cause
-A severe inversion ankle sprain causes peroneus brevis tendon to pull away the base of the 5th metatarsal (Ballerina fracture)

6. Jones Fracture
These X-Rays show a fracture of the proximal end of the 5th Metatarsal. This fracture is commonly called a "Jones Fracture".
Where does it occur?
-5th metatarsal.
What is it?
-A fracture to the 5th metatarsal caused by direct trauma to the styloid process.
Cause
-Repetitive inversion ankle sprains
-Poor shoe and tape support

7. Severe Jones Fracture fix

8. Ankle Injuries- Soft Tissue
Muscles
Ligaments
Acute
Muscle Strain
Sprained ankle
Grade 1,2,3
Grade 1, 2, 3
Achilles tendon rupture
Shin Splints
Chronic
Plantar Fasciitis
Achilles Tendonitis
Turf Toe

9. Inversion Ankle Sprain
85% of sprains are caused by ankle inversion.
Inversion sprains cause damage to the lateral ligaments
Calcaneofibular and anterior and posterior talofibular ligaments

10. Eversion Ankle Sprain
15% of sprains result from eversion mechanisms which are often the result of an outside force such as being fallen on from the outside.
Damage to the deltoid ligament

11. Syndesmosis Sprain What is it?
-The tibia and fibula spread on the talus, the ankle mortise is disrupted and the ankle can become very unstable.
-Syndesmosis damage
-Anterior and Posterior tibiofibular ligament
Cause
-injured with an eversion force.

12. Ruptured Achilles Tendon
Third degree strain of the tendon
Achilles Tendon Tear and Repair

13. Achilles Tendonitis What is the Achilles tendon?
-It is the largest and most vulnerable tendon in the body.
-It joins the gastrocnemius and the soleus muscles of the lower leg to heel of the foot.
-Tendons are strong, but not very flexible so they can only so far before they get inflamed and tear or rupture.
What is it?
-Chronic injury caused from overuse.
-Inflammation of the Achilles tendon.
What causes it?
-Ignoring early warning signs and pushing through pain.
-tight or weak calf muscles.
-Tightness increases the stress on the Achilles tendon, and a tendonitis can develop.

14. Plantar Fasciitis What does the plantar fascia do?
-Provides support for the medial longitudinal arch of the foot. The plantar fascia is stretched and the arch flattens slightly to absorb the impact each time the heel impacts the ground. The fascia is not very flexible and such repetitive stretching from impact can result in small tears in the fascia.
What is plantar fasciitis?
-Chronic injury
-Common in runners
-Common cause of pain on the bottom of the heel and usually defined by pain during the first steps of the morning.
-Pain also occurs at the start of activity and go away with use.
-It returns after a long rest and then restarting activity.
What causes it?
-Repetitive flexion and extension of the toes
-Sudden weight gain

15. Turf Toe What is turf toe? -A sprain or jammed toe
-Typically the hallux
Possible Responsible Factors
-artificial turf - no give, can be like playing on hard asphalt
-shoes - too much forefoot flexion (no turf toe plate)
-combination of turf & shoes
Mechanism of injury
-hyperextension (most common)
-hyperflexion
-valgus injury - usually from sudden acceleration
What causes it?
-When the toe is bent upwards this causes damage to the ligaments which can become stretched.

16. Assessing Injuries
HOPS
History
Observation
Palpation
Special Tests

17. Assessing the Lower Leg and Ankle
History
Past history
Mechanism of injury
When does it hurt?
Type of, quality of, duration of pain?
Sounds or feelings?
How long were you disabled?
Swelling?
Previous treatments?

18. Observations Posture? Is there difficulty with walking?
Deformities, asymmetries or swelling?
Color and texture of skin, heat, redness?
Patient in obvious pain?
Is range of motion normal?

19. Palpation Special Tests Does anything feel out of place? Is it hot?
Depends on the injury

20. Percussion and compression tests
Used when fracture is suspected
Percussion test is a blow to the tibia, fibula or heel to create vibratory force that resonates w/in fracture causing pain
Compression test involves compression of tibia and fibula either above or below site of concern
Thompson test
Squeeze calf muscle, while foot is extended off table to test the integrity of the Achilles tendon
Positive tests results in no movement in the foot

21. Compression Test
Percussion Test
Thompson Test

22. Ankle Stability Tests Anterior drawer test Talar tilt test
Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarily
A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point
Talar tilt test
Performed to determine extent of inversion or eversion injuries
With foot at 90 degrees calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments
If the calcaneus is everted, the deltoid ligament is tested

23. Anterior Drawer Test
Talar Tilt Test

24. Medial Subtalar Glide Test
Kleiger’s test
Used primarily to determine extent of damage to the deltoid ligament and may be used to evaluate distal ankle syndesmosis, anterior/posterior tibiofibular ligaments and the interosseus membrane
With lower leg stabilized, foot is rotated laterally to stress the deltoid
Medial Subtalar Glide Test
Performed to determine presence of excessive medial translation of the calcaneus on the talus
Talus is stabilized in subtalar neutral, while other hand glides the calcaneus, medially
A positive test presents with excessive movement, indicating injury to the lateral ligaments

25. Kleiger’s Test
Medial Subtalar Glide Test

26. Functional Tests
While weight bearing the following should be performed
Walk on toes (plantar flexion)
Walk on heels (dorsiflexion)
Walk on lateral borders of feet (inversion)
Walk on medial borders of feet (eversion)
Hops on injured ankle
Passive, active and resistive movements should be manually applied to determine joint integrity and muscle function
If any of these are painful they should be avoided

27. Prevention of Injury to the Ankle
Stretching of the Achilles tendon
Strengthening of the surrounding muscles
Proprioceptive training: balance exercises and agility
Wearing proper footwear and or tape when appropriate

28. Injury Prevention
Strength training allows the supporting musculature to stabilize where ligaments may no longer be capable of holding the original tension between bones of the joint. This will also help prevent reinjury.

29. Chronic Ankle Injury “the vicious cycle”
Why are some people prone to ankle re-injury over and over?
Most commonly due to lack of rehabilitation, but more importantly lack of neuromuscular training.
This means the person has not retrained the body to recognize where the ankle and foot are during motion.
This sets up the body part to be re-injured due to improper feedback to the brain about body position.

30. Injury Prevention
Neuromuscular Control is the ability to compensate for uneven surfaces or sudden change in surfaces. It is retrained by using balance and agility exercises such as a BAPS board or standing on one leg with eyes closed as well as using a single leg on a mini trampoline.

31. Neuromuscular Control Training
Can be enhanced by training in controlled activities
Uneven surfaces, BAPS boards, rocker boards, or Dynadiscs can also be utilized to challenge athlete

32. Injury prevention
Tight Achilles tendons can predispose someone to injuring the ankle. Tendonitis, plantar fasciitis, and other disorders may occur due to a tight Achilles tendon.

33. Injury Prevention
Footwear is something often overlooked but improper footwear can predispose someone with a foot condition such as pes planus (flat feet) to be more prone to having problems with their feet and ankles.

34. Preventative Taping and Orthosis
Taping is often post injury treatment. Some will argue that taping will weaken the ankle. This has not been proven without a doubt but exercise and strengthening of the ankle is always advised.
Othotics will help rectify conditions that are permanent and will not be fixed by any other means.

35. Tape vs. Brace Why choose one over another
Taping may be more time consuming over brace
Braces may or may not allow more support over tape
Tape allows more functional movement and often feels more stable
Tape will loosen with time
Braces will often loosen with time
It really is based on the quality of the brace vs. the ability of the person to tape. Both have advantages and disadvantages.