injuries syndesmosis injuries manny moore ats. injuries syndesmosis injuries 11-18% of all ankle...

Syndesmosis InjuriesInjuriesManny Moore ATS

Syndesmosis InjuriesInjuriesSyndesmosis InjuriesInjuries

11-18% of all ankle sprains

Longer recovery v.s. Lateral sprains

Men v.s. Women?

BoneBone Anatomy AnatomyBoneBone Anatomy Anatomy

• TibiaArticular Surface

• FibulaArticular Surface

• Talus Dome

Articular Surface

Provides Stability & Proper Ankle Function

SnydesmosisSnydesmosis Ligaments LigamentsSnydesmosisSnydesmosis Ligaments Ligaments

• AIFL- Chaput’s Tubercle Most Vulnerable

• PIFL- Wagstaffe’s Tubercle Strongest

• ITFL- Thickening of PIFL

• IM- Fibrous tissue Transmit force

• IL- Thickening of IM

BioBiomechanicsmechanicsBioBiomechanicsmechanics

• Mechanism of Injury Eversion

Dorsiflexion Pronation

• Closed Pack Position Forces the talus against the fibula

Widening of mortise

1mm lateral shift increases joint surface pressure by 42%

Associated injuries?

ClinicalClinical Examination ExaminationClinicalClinical Examination Examination

• History ER with DF Contact None Contact

Acute v.s. Chronic

• Observation Edema Eccymosis Antalgic gait Possible Deformity?

ClinicalClinical Examination ExaminationClinicalClinical Examination Examination

•Palpation Tenderness Length

•Special Test

Nussbaum et al.

Squeeze TestDorsiflexion Test Kleigers Test Cross-leg Test

Imaging Imaging TechniquesTechniquesImaging Imaging TechniquesTechniques

X-RAY• Radiographs

AP, Lateral, Mortise Views

• AP View Fractures Tibiofibular clear space widening of 6 mm Tibiofibular overlap > 42% Fibula Width

Medial clear space widening > 4mm• Lateral View

Non weight bearing ER Fractures


X-RAY

Tibiofibula clearance space

Tibiofibula overlap

Medial clear space


X-RAY

• Lateral View


X-RAY

•AP View

Heterotopic Ossification


MRI & CT

• MRI (Magnetic Resonance Imaging)

Frontal, Axial, Saggital Views

High sensitivity and specificity More reliable detecting disruptions

• CT (Computed Tomography) More effective detecting minor disruptions

Less Cost v.s. MRI


MRI

• Axial Views

West PointWest Point Instability ScaleInstability Scale West PointWest Point Instability ScaleInstability Scale

Edema &

Ecchymosis

Localized

Mild

Localized

Moderate

Diffuse

Severe

Weight Bearing Ability

Full or Partial Without Significant Pain

Difficult Without Crutches

Impossible Significant Pain

Ligament Damage

Ligament Stretch Partial Tear Complete Tear

Ligament Involvement

+AIFL +AIFL

+IL

Possible AD

+AIFL/PIFL

+IL

+AD

Grade IGrade I Grade IIGrade II Grade IIIGrade III

TreatmentTreatment CriteriaCriteriaTreatmentTreatment CriteriaCriteria

• Conservative • Non Conservative

Grade INon-FracturesStable Grade II

Grade IIIUnstable Grade IIFracturesChronic Injury

Based on Patients GoalsLength of SymptomsSeverity of Injury

ConservativeConservative ProtocolsProtocols ConservativeConservative ProtocolsProtocols

Results vary patient to patient

• Grade I Injuries: 2-4 Weeks RTP

• Grade II Injuries: 6-8 Weeks RTP WithoutWithout Instability or Fractures


•Phase I (0-5 Days) or (5-14Days)Phase I (0-5 Days) or (5-14Days)

•ImmobilizeImmobilize•Reduce PainReduce Pain•Reduce InflammationReduce Inflammation•Cryotherapy Cryotherapy •E-StimE-Stim•Increase ROMIncrease ROM•Manual 30* PF StretchManual 30* PF Stretch•Ankle PumpsAnkle Pumps•Toe CurlsToe Curls•Towel StretchTowel Stretch


•Phase II (6-10 Days) or (2-4 weeks)Phase II (6-10 Days) or (2-4 weeks)

•Immobilize Grade IIImmobilize Grade II•Reduce PainReduce Pain•Reduce InflammationReduce Inflammation•ProprioceptionProprioception•Increase FlexibilityIncrease Flexibility•Increase ROMIncrease ROM•Increase StrengthIncrease Strength•CV EnduranceCV Endurance


•Phase III (18-25 Days) or (4-8 Weeks)Phase III (18-25 Days) or (4-8 Weeks)

•Protect InjuryProtect Injury•Reduce PainReduce Pain•Increase Pain free ActivityIncrease Pain free Activity•Sports Specific Sports Specific •ProprioceptionProprioception•Increase StrengthIncrease Strength•Increase FlexibilityIncrease Flexibility•CV EnduranceCV Endurance


•Phase III (18-25 Days) or (4-8 Weeks)Phase III (18-25 Days) or (4-8 Weeks)

•Sports Specific Sports Specific

Drill#1 Drill#2


Return To Play Criteria

•Full Strength•Full ROM•Functional Test•Physician Clearance•Protect Injury

Operative Operative TreatmentTreatment Operative Operative TreatmentTreatment

Arthroscopy

• Goal is to restore structures, and mobility

Open Reduction & Internal FixationsAutographsModified Brostrum Technique4.5 mm Cortical Screws

• Complications

Screw BreakageScrew TypeInfectionCalcification & Joint Stiffness

Operative Operative TreatmentTreatment Operative Operative TreatmentTreatment

Arthroscopy

Before After

Post-Operative Post-Operative ProtocolsProtocols Post-Operative Post-Operative ProtocolsProtocols

Arthroscopy

Results vary patient to patient

• Grade III Injuries: 4-8 Months RTP

• Non Weight Bearing 6-8 Weeks

• Screw Removal @ 3 Months

• Follow-up Imaging every 2 weeks


•Phase I (1-3 Weeks)Phase I (1-3 Weeks)

•Phase I- Conservative RehabilitationPhase I- Conservative Rehabilitation•Immobilize & Non Weight BearingImmobilize & Non Weight Bearing•Protect WoundProtect Wound•Reduce PainReduce Pain•Reduce InflammationReduce Inflammation•ProprioceptionProprioception•Increase ROMIncrease ROM•Maintain FlexibilityMaintain Flexibility•CV EnduranceCV Endurance


•Phase II (3-8 Weeks)Phase II (3-8 Weeks)

•Phase I- Conservative RehabilitationPhase I- Conservative Rehabilitation•Immobilize & Partial Weight BearingImmobilize & Partial Weight Bearing•Protect WoundProtect Wound•Reduce PainReduce Pain•Reduce InflammationReduce Inflammation•Increase ROMIncrease ROM•Increase StrengthIncrease Strength•ProprioceptionProprioception•Increase FlexibilityIncrease Flexibility•CV EnduranceCV Endurance


•Phase III (8-12 Weeks)Phase III (8-12 Weeks)

•Phase II- Conservative RehabilitationPhase II- Conservative Rehabilitation•Full Weight Bearing & Cam-walkerFull Weight Bearing & Cam-walker•Remove ScrewsRemove Screws•Reduce PainReduce Pain•Increase ROMIncrease ROM•Increase StrengthIncrease Strength•ProprioceptionProprioception•Increase FlexibilityIncrease Flexibility•Sports SpecificSports Specific•CV EnduranceCV Endurance


•Phase IV (4-8 Months)Phase IV (4-8 Months)

•Phase III Conservative RehabilitationPhase III Conservative Rehabilitation•Protect InjuryProtect Injury•Increase Pain Free ActivityIncrease Pain Free Activity•Increase ROMIncrease ROM•Increase StrengthIncrease Strength•ProprioceptionProprioception•Increase FlexibilityIncrease Flexibility•Sports SpecificSports Specific•CV EnduranceCV Endurance


Return To Play Criteria

•Full Strength•Full ROM•Functional Test•Physician Clearance•Protect Injury

ConclusionConclusion

• Early Recognition

• Determine Extent of Injury

• Rule out Associated Injuries

• Conservative Treatment (2-8 Weeks)

• Surgical Intervention (4-8 Months)

• Complications

Questions

ReferencesReferencesReferencesReferences

• Eric Nussbaum, Timothy M. Hosea, Shawn Sieler, Brian Incremona, Donald Kessler. Prospective Evaluation of Syndesmotic Ankle Sprains Without Diastasis. American Journal of Sports Medicine. 2001; 29:31-35.

• David A. Porter. Evaluation and Treatment of Ankle Syndesmosis Injuries. [Editorial]. 2009; 58:575-581.

• Cyrus M. Press, Asheesh Gupta, Mark R. Hutchinson Management of Ankle Syndesmosis Injuries in the Athlete. American Academy of Sports Medicine.2009; 8:228-233.

• Marc L Wagener, Annechien Beumer, Bart A Swierstra. Chronic instability of the anterior tibiofibular syndesmosis of the ankle. Arthroscopic Findings and Results of Anatomical Reconstruction. Bio Med Central Musculoskeletal disorders 2011; 12:1-7.

• Albert Alonso, Lynette Khoury, Roger Adams. Clinical Tests for Ankle Syndesmosis Injury: Journal of Sports and Physical Therapy. 1998; 27:276-284.

injuries syndesmosis injuries manny moore ats. injuries syndesmosis injuries 11-18% of all ankle...

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