tibiofibular and ankle joint complex bmj
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MOB TCD
Tibifibular and Ankle Joint Complex
Professor Emeritus Moira OBrien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
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Superior and Inferior
Tibio-Fibular Joints
Superior is synovial plane joint
Inferior is a syndesmosis
Interosseous tibiofibular
ligament
Anterior and posterior tibiofibular
ligament
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Ankle Joint
The ankle joint is one of the mostcommon joints to be injured
The foot is usually in the plantar
flexed and inverted position when
the ankle is most commonly injuredBrstrom, 1966
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TennisMOB TCD
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Dorsiflexion and plantarflexion take place at the
ankle joint
In plantar flexion there is
some side-to-sidemovementLast, 1963
Ankle JointMOB TCD
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Uniaxial, modified synovialhinge joint
Close pack
Dorsiflexion
Least pack PlantarflexionWilliams & Warwick, 1980
Ankle JointMOB TCD
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Proximal Articular Surface
Distal surface of the tibia Medial malleolus has comma
shaped facet
Lateral malleolus triangularfacet
Williams & Warwick, 1980
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Proximal Articulation
Inferior transverse tibiofibular ligament Deepens it posteriorly
Passes from the lower margin of the
tibia
To the malleolar fossa of the fibulaWilliams & Warwick, 1980
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Proximally the articulationdepends on the integrity of the
inferior tibiofibular joint
Syndesmosis
Proximal Articular SurfaceMOB TCD
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Distal Articular Surface
The superior surface of the body ofthe talus is wider anteriorly
Convex from before backwards
Concave from side to side
Medial comma shaped facet Lateral triangular facetFrazer, 1965
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Capsule
Is attached just beyond the articularmargin
Except anterior-inferiorly
Attached to the neck of the talusWilliams & Warwick, 1980
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The capsule is thin and weak in frontand behind
It is strengthened on either side by the
collateral ligamentsWilliams & Warwick, 1980
Ankle JointMOB TCD
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Medial (Deltoid) Ligament
A strong triangular ligament Superiorly attached
The medial malleolus of the
tibiaWilliams & Warwick, 1980
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The tuberosity of thenavicular
The edge of the spring
ligament
The sustentaculum tali The body of the talusLast, 1963
Medial LigamentMOB TCD
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Medial or Deltoid Ligament
(Superficial)
Cross two joints
Anterior tibionavicular pass
to the tuberosity of the
navicular
The free edge of the springligament
The middle fibres
The tibiocalcaneal are attached to
the sustentaculum taliWilliams & Warwick, 1980
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Medial or Deltoid Ligament
(Deep)
The anterior tibiotalar to thenonarticular part of the
medial surface of the talus
The posterior tibiotalar to the
medial side of the talus The medial tubercle of the
talusWilliams & Warwick, 1980
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Lateral Ligaments of Ankle
The anterior talofibularligament (ATFL)
The calcaneofibular
ligament (CFL)
The posterior talofibularligament (PTF)
They radiate like the spokes
of a wheelLiu & Jason, 1994
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Anterior Talofibular Ligament (ATFL)
Is part of the capsule An upper and lower bands
It is cylindrical
6-10 mm long
2 mm thickLiu & Jason, 1994
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ATFL
The anterior inferior border ofthe 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
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It is the weakest ligament Strain increases with
increasing plantar flexion
and inversion
The AFTL is a primarystabiliser against inversion
and internal rotation for all
angles of plantar flexionLiu & Jason, 1994
ATFLMOB TCD
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Calcaneofibular Ligament (CFL)
A long rounded 20-25 mmlong, 6-8 mm in diameter
It contains the most elastic
tissue
It is attached in front of theapex of the fibular malleolus
To a tubercle on the lateral
aspect of the calcaneusWilliams & Warwick, 1980
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CFL
It is separated from thecapsule by fibro-fatty tissue
Part of the medial wall of the
peroneal tendon sheath
Crossesboth the ankle andsubtalar joints
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The CFL is perpendicular tothe long axis of the talus
Dorsiflexion and inversion
result in an increased strain
Talar tilt tests the CFL
CFLMOB TCD
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Lateral Ligament
The angle between theATFL and CFL varies
between 100o and 135o
Increasing the potential
instability of the lateral
ligamentHamilton, 1994; Peters, 1991
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Ankle Stability
The ATFL is the main talarstabiliser and the CFL acts
as a secondary restraint
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ATFL and CFL
A difference of 10o
betweenthe 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 jointLiu & Jason, 1994
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Posterior Talofibular (PTL)
The PTL is the strongest part of thelateral ligament
It runs almost horizontally from
malleolar fossa to lateral tubercle of
talus
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PTL
During plantar flexion the posteriortalofibular and the posterior tibio
fibular ligament are edge to edge
They separate during dorsiflexion
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Ankle Joint
The flexor hallucis longus liesin a grove between the smaller
medial and larger lateral
tubercles
In 7% the lateral tubercle has a
separate ossification and is
called an os trigonum
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Synovial Membrane
Lines the capsule and the non articular area Covers the neck of talus
The fatty pads inside the capsule
It extends upwards to the interosseous
ligament of the inferior tibiofibular jointPlastanga et al., 1980
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Blood Supply of Ankle
Malleolar branches of the anteriortibial
Perforating peroneal and posterior
tibial arteries
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Nerve Supply of Ankle
Nerve supply is via articularbranches of the deep peroneal
Tibial nerve from L4 - S2
O C
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Anterior Aspect
Dorsiflexors Tibialis anterior
Flexor hallucis longus
Anterior tibial > dorsalis pedis artery
Deep peroneal nerve Extensor digitorum longus
Peroneus tertius
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Postero-Medial Aspect of Ankle
Tibialis posterior Flexor digitorum longus
Posterior tibial vessels
Posterior tibial nerve and
branches Flexor hallucis longus
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Posterior Aspect
Posterolateral portal Lateral to achilles tendon, sural
nerve, short saphenous vein at
risk
Posteromedial not used; flexorretinaculum structures at riskJaivin & Ferkel, 1994
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Lateral Aspect of Ankle
The inferior extensorretinaculum
Extensor digitorum brevis
Peroneus longus and brevis
Peroneal retinaculum Ligament of the neck of talus
Bifurcate ligament
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Plantar flexor and evertor
Peroneus longus
Peroneus brevis
Dorsiflexor and evertor
Peroneus tertius
Lateral Aspect of Ankle
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Nerves Related to Ankle Joint
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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 laterallyPlastanga et al., 1990
Ankle Joint
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The ankle is most stable in
dorsiflexion, with increasing
plantar flexion there is more
anterior talar translation
(drawer) and talar inversion
(tilt)
Ankle Joint
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Ankle Examination
Anterior drawer
Suction sign
Inversion stress
Squeeze test
External rotation Test
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Achilles tendon
Peroneal tendons
Posterior tibial tendon
Anterior process of calcaneus
Talar dome
Sinus tarsi
Bifurcate ligament
Ankle Examination
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Tests for Ankle Ligament Injury
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Ottawa Ankle Rules
Anteroposterior
Oblique
Lateral views
Bone tenderness
Medial or lateral Malleolus
Unable to weight bear
Four steps post injury
Tibi li P t i / S fi i lMOB TCD
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Tibialis Posterior / Superficial
Peroneal Nerve
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ATFL
CFL
Distal tibiofibular
Syndesmosis
Deltoid ligament Lateral malleolus
Medial malleolus
Base 5th metatarsal
Ankle Examination
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Inversion or supination
Raising the medial
border
Sole faces medially
Inversion and Eversion
Eversion or pronation
Raising the lateral
border
Sole faces laterally
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Initiated at the transverse
tarsal joint
Calcaneocuboid
Anterior portion of the
talocalcaneonavicularLast, 1963
Inversion and Eversion
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Main movement take
place at the clinical
subtalar joint i.e.
talocalcaneal
inferior portion of the
talocalcaneonavicular
The pivot is the ligament
of the neck of the talusLast, 1963
Inversion and Eversion
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Axis passes through the
middle of the convex
posterior facet on
calcaneus
Upwards forwards and
medially
Through middle of convex
articular facet of head of
talusLast, 1963
Inversion and Eversion
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Talocalcaneal
Synovial plane joint Articular surface
Concave facet inferior body
of talus
Convex posterior facet,superior aspect of calcaneus
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Talocalcaneal Joint
Capsule attached just beyond
articular margin ligaments
Interosseous
Ligament of neck of talus
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Tarsal Canal and Tarsal Sinus
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Inversion or Supination
Invertor and dorsiflexion
Tibialis anterior
Invertor and plantarflexion
Tibialis posterior
E i d P iMOB TCD
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Eversion and Pronation
Evertor and dorsiflexion
Peroneus tertius
Evertor and plantarflexion
Peroneus brevis
Peroneus longus
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Talocalcaneonavicular Joint
Synovial ball and socket
Ball head of talus
Socket
Posterior aspect of the
navicular, two anterior facetson superior surface of
calcaneus
Spring ligament and CNL
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Synovial ball and socket
joint
Ball is anterior and inferior
aspect of the head of the
talus
Talocalcaneonavicular Joint
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Socket
Two anterior facets on thesuperior surface of thecalcaneus
Posterior aspect of the
navicular Spring ligament
LCN ligament
Talocalcaneonavicular Joint
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Capsule attached just beyond
the articular margin
Interosseous ligament
Spring ligament
Superficial portion deltoidligament
LCL of bifurcate
Ligament neck of talus
Talocalcaneonavicular Joint
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Synovial membrane lines the
capsule and non-articular
structures
Nerve supply
Tibial nerve
Deep and superficial
peroneal nerves
Talocalcaneonavicular Joint
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Subtalar Interosseosus
Capsule of both
talocalcaneal
Posterior portion of the
talocalcanoeonavicular
joint
Li t f S bt l J i tMOB TCD
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Ligaments of Subtalar Joint
Inferior extensor retinaculum Ligament of the neck of talus
Interosseous ligament
Bifurcate ligament
Li t f N k f T lMOB TCD
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Ligament of Neck of Talus
Sinus tarsi Lateral aspect of neck of talus
Pivot of inversion and
eversionLast, 1963
*
T l C l d T l SiMOB TCD
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Tarsal Canal and Tarsal Sinus
Fat
Nerve endings
Branches of posterior tibial
and peroneal arteries
Capsules and ligaments oftalocalcaneal and
talocalcaeonavicular joints
Inferior E tensor Retinac l mMOB TCD
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Inferior Extensor Retinaculum
Medial root inside the tarsalsinus
Intermediate to talus with the
interosseous ligament, inside
sinus
Lateral root to calcaneus
outside sinusKlein & Spreitzer, 1993
Ligament AttachmentsMOB TCD
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Ligament Attachments
Bifurcate LigamentMOB TCD
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Bifurcate Ligament
Lateral calcaneo-
navicular ligament (CNL)
Medial calcaneocuboid
ligament (CCL)
Bifurcate LigamentMOB TCD
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Two individual ligaments
Separate attachments
Different fibre orientation
Different histology
Bifurcate Ligament
Talocalcaneonavicular JointMOB TCD
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Talocalcaneonavicular Joint
Invertors
In dorsiflexion
Tibialis anterior
In plantarflexion
Tibialis posterior
Talocalcaneonavicular JointMOB TCD
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Evertor
In dorsiflexion
Peroneus tertius
In plantarflexion
Peroneus longus Peroneus brevis
Talocalcaneonavicular Joint
Calcaneo Navicular LigamentMOB TCD
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Calcaneo Navicular Ligament
Folded and twisted appearance Prominent medial and lateral
edges / folds
Three groups of fibres
Medial Lateral (deep)
Intra-articular
N
A
C
Calcaneocuboid LigamentMOB TCD
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Calcaneocuboid Ligament
Intra-capsular CC joint
Smaller than CNL, always
present
Hourglass shaped fibres,
twisted medially
Calcaneocuboid JointMOB TCD
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Calcaneocuboid Joint
Plane synovial
Ligaments
Capsular
Ligament of neck of talus
Long and short plantarligament
Bifurcate ligament
Calcaneocuboid JointMOB TCD
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The long and short plantar ligaments
support the calcaneocuboids portion of
the transverse tarsal joint
Calcaneocuboid Joint
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