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Ankle Injuries

Dr Peter Brukner, OAMSports Physician

Associate Professor Centre for Sports Medicine Research & Education

The University of Melbourne

Adjunct ProfessorSchool of Human Movement Studies

The University of Queensland

Ankle Sprain

The most likely diagnosis is lateral ligament sprain

Range of Motion

Dorsiflexion Plantarflexion Inversion

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Lunge

Palpation

Palpation (Medial)

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Palpation

Anterior Drawer

Talar Tilt

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Proprioception

Ankle Sprain

The majority of these injuries respond well to a standard treatment regime

Ankle Sprains

R.I.C.ENWB/PWB/FWBelectrotherapeutic modalitiesstrengtheningproprioceptiontape/brace

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Mobilization

Strengthening

Proprioception

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Proprioception

Protection

Bracing / Taping

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The Difficult Ankle

A significant group do not progress

The Difficult Ankle

…. and complain of persistent pain, swelling and impaired function after 3-6 weeks

Principles of Diagnosis

1. Possible Causes2. History3. Examination4. Investigation

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Possible Causes

1. Common

2. Less common

3. Not to be missed

Possible Causes

Fracturechronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement

1. Common

Possible Causes

Fracture– talar dome– base of 5th metatarsal

chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement

1. Common

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Talar Dome Fractures

Talar Dome Fractures

CT Bone Scan

Talar Dome Fractures (MRI)

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Possible Causes

Fracture– talar dome– base of 5th metatarsal

chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement

1. Common

Base of 5th Metatarsal

Possible causes

Fracture– talar dome– base of 5th metatarsal

chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement

1. Common

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Possible Causes

Fracture– talar dome– base of 5th metatarsal

chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement

1. Common

Possible Causes

Fracture– talar dome– base of 5th metatarsal

chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement

1. Common

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Possible Causes

Fracture– talar dome– base of 5th metatarsal

chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement

1. Common

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Possible Causes

Fracture– talar dome– base of 5th metatarsal

chronic instabilitysynovitis ankle jointsinus tarsi syndromeposterior impingementanterior impingement

1. Common

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Possible Causes

Fracture– lateral process talus– anterior process calcaneus– tibial plafond– os trigonum / posterior process talus

AITFL injuryanterolateral impingementneural causes

2. Less common

Possible Causes

Fracture– lateral process talus

2. Less common

Possible Causes

Fracture- anterior process calcaneus

2. Less common

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Possible Causes

Fracture– tibial plafond

2. Less common

Possible Causes

Fracture– os trigonum– posterior process talus

2. Less common

Possible Causes

Fracture– lateral process talus– anterior process calcaneus– tibial plafond– os trigonum/posterior process talus

AITFL injuryanterolateral impingementneural causes

2. Less Common

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Possible Causes

Fracture– lateral process talus– anterior process calcaneus– tibial plafond– os trigonum/posterior process talus

AITFL injuryanterolateral impingementneural causes

2. Less Common

Anterolateral Impingement

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Possible Causes

Fracture– lateral process talus– anterior process calcaneus– tibial plafond– os trigonum/posterior process talus

AITFL injuryanterolateral impingementneural causes

2. Less Common

Neural Tension

Possible Causes

dislocation peroneal tendonrupture tibialias posterior tendonreflex sympathetic dystrophy (RSD)OCD

3. Not to be missed

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Principles of Diagnosits

1.Possible causes

2.History

3.Examination

4.Investigation

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History

mechanism of injurypain, swelling, bruisinglevel of dysfunctionearly management? X-ray

Historysubsequent progresscurrent symptoms– pain– swelling– impingement– instability– function

history of previous injury

Principles of Diagnosits

1.Possible causes

2.History

3.Examination

4.Investigation

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Examination

inspectionrange of motionpalpationligament testingfunctional testing

Examinationstrength testingproprioceptionneural tensionimpingement tests–anterior–posterior

Principles of Diagnosits

1.Possible causes

2.History

3.Examination

4.Investigation

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Plain X-ray

1. fracture2. posterior impingement3. anterior impingement } Special

views

Triple Phase Bone Scan

important screening testingthree phases–angiogram (immediate)–blood pool (2 minutes)–bone phase (2-3 hours)

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Triple phase bone scan

⇑ ⇑ uptake⇑ uptake

no ⇑ uptake

⇑⇑ Uptake

- talar dome fracture- other fracture

Mild Uptake

- impingement syndrome- synovitis- RSD (late)

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No ⇑ ⇑ Uptakeimpingement syndromeAITFL injurysynovitissinus tarsi syndromedislocating peroneal tendonRSD (early)

CT scans

If bone scan shows ⇑⇑ uptake

CT performed to visualise fracture

MRI

alternative to CTmore sensitive in osteochondraldamagesoft tissue imaging

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The Difficult AnkleInvestigation

Conclusion

consider possible causesgood historythorough examinationinvestigate–bone scan/MRI is the key

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…..Yet another basketballer

Avoiding Ankle Injuries?