Mini Case

A basketball player was getting in position for a rebound when he stepped on another players foot and rolled his ankle. X-rays did not Xreveal a fracture, but the player left the game on crutches.
http://images.google.com/imgres?imgurl=http://www.kvue .com/sharedcontent

CORE OMM Curriculum for Students, Interns, & Residents

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Approaching the Problem

Differential? (break, sprain, etc.) Tissue changes? (swelling, warmth, ecchymosis) Pain can patient bear weight? ROM decreased? Neuro deficits? Treatment? Dont just look at the ankle think how it affects the rest of the patients body also
CORE OMM Curriculum for Students, Interns, & Residents
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Anatomy-Lateral Ligaments

OUCOM CORE OMM curriculum session 7

CORE OMM Curriculum for Students, Interns, & Residents

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Anatomy-Medial Ligaments

CORE OMM Curriculum for Students, Interns, & Residents

OUCOM CORE OMM curriculum session 7

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Anatomy of Foot/Ankle Talus is wider anteriorly

Medial malleolus only comes down over 1/3 of the talus and is more anterior Lateral malleolus covers entire talus
CORE OMM Curriculum for Students, Interns, & Residents
Des Moines University OMM II handouts, August 12, 2002 May 15, 2003 OUCOM Session 7 Lower Extremity lecture
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Anatomy
26 bones of the foot Plus 2 sesamoid bones under great toe for weight bearing and balance 33 joints Medial longitudinal arch Calcaneous, talus, navicular, first 3 cuneforms, first 3 metatarsals Strengthened by calcaneonavicular (Spring) ligament Lateral longitudinal arch Calcaneous, cuboid, 4th and 5th metatarsals Weight bearing Transverse arches Weight bearing and springing off with foot
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Biomechanics

In dorsiflexion foot everts, toeing out Most stable position closed packed position

In plantarflexion foot inverts, toeing in Ligaments less taut Joint more vulnerable to injury
CORE OMM Curriculum for Students, Interns, & Residents

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Biomechanics Talo-crural joint

Where distal tibia/fibula meet the talus Flexion/extension

Subtalar joint
Where calcaneous meets talus Inversion/eversion

Transverse tarsal joints

Talonavicular and calcaneocuboid joints Adduction/abduction
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Biomechanics Pronation
Abduction Eversion Dorsiflexion

Supination
Adduction Inversion Plantarflexion

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Cause of Ankle Sprain

85% are due to inversion

Deltoid ligament is stronger than the lateral ligaments Anterior tibiotalar, tibiocalcaneal, tibionavicular, and posterior tibiotalar ligaments Lateral malleolus is longer than medial malleolus Axis of talo-crural joint In plantar flexion, ankle naturally inverts In dorsiflexion, ankle is very stable
CORE OMM Curriculum for Students, Interns, & Residents
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Pathoanatomy and Mechanisms of Injury

The most common mechanism of injury is a combination of plantar flexion and inversion. The lateral stabilizing ligaments, which include the anterior talofibular, calcaneofibular and posterior talofibular ligaments. The anterior talofibular ligament is the most easily injured. The posterior talofibular ligament is the strongest of the lateral complex and is rarely injured in an inversion sprain.

CORE OMM Curriculum for Students, Interns, & Residents

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Mechanism of injury high ankle sprain

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Cause

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OUCOM CORE OMM curriculum session 7

Grading

Grade I: Grade II:

anterior talofibular ligament (ATF)

ATF plus calcaneofibular ligament (CF) ATF plus CF plus posterior talofibular ligament

Grade III:

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Ligaments used in Grading

CORE OMM Curriculum for Students, Interns, & Residents

Des Moines University OMM II handouts, August 12, 2002 May 15, 2003 OUCOM Session 7 Lower Extremity lecture
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Diagnosis

History of trauma Swelling/discoloration Pain/tenderness Eversion restriction Anterior drawer test for ankle X-ray
CORE OMM Curriculum for Students, Interns, & Residents

www.uwec.edu/kin/majors/AT/aidil/imag es/Ankle.JPG

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DX: The anterior drawer test and the inversion stress test

The inversion stress test can be used to assess the integrity of the calcaneofibular ligament.

The anterior drawer test can be used to assess the integrity of the anterior talofibular ligament.

CORE OMM Curriculum for Students, Interns, & Residents

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Diagnosis

The entire length of the tibia and fibula should be palpated to detect fracture of the proximal fibula (Maisonneuve fracture), which may be associated with syndesmosis injury. Tenderness along the base of the fifth metatarsal may indicate an avulsion of the peroneal brevis tendon. Effusion along the talocrural joint line should raise suspicion of an osteochondral talar dome lesion.

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Special Tests

A "squeeze test," performed by compressing the fibula and tibia at the midcalf, positive if pain is elicited distally. An "external rotation test" to identify a syndesmosis sprain. With the patient's knee resting over the edge of the table. The physician stabilizes the leg proximal to the ankle joint while grasping the plantar aspect of the foot and rotating the foot externally relative to the tibia. Pain the test is positive

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Ottawa Ankle Rules

Radiographs should be obtained to rule out fracture when a patient presents (within 10 days of injury) with bone tenderness in the posterior half of the lower 6 cm (2.5 in) of the fibula or tibia or an inability to bear weight immediately after the injury. Bone tenderness over the navicular bone or base of the fifth metatarsal is an indication for radiographs.

Anteroposterior, lateral and mortise radiographs should be obtained after the initial physical examination. The mortise projection is an anteroposterior view obtained with the leg internally rotated 15 to 20 degrees.

CORE OMM Curriculum for Students, Interns, & Residents

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Functional Rehabilitation
Prolonged immobilization of ankle sprains is a common treatment error. Functional stress stimulates the incorporation of stronger replacement collagen. The four components of rehabilitation are: 1. 2. 3. 4. Range-of-motion rehabilitation Progressive muscle-strengthening exercises Proprioceptive training Activity-specific training

CORE OMM Curriculum for Students, Interns, & Residents

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Range of Motion
Achilles tendon stretch, nonweight-bearing. Use a towel to pull foot toward face. Pain-free stretch for 15 to 30 seconds; perform five repetitions; repeat three to five times a day. Maintain extremity in a nongravity position with compression. Achilles tendon stretch, weight-bearing. Stand with heel on floor and bend at knees. Pain-free stretch for 15 to 30 seconds; perform five repetitions; repeat three to five times a day. Alphabet exercises, Move ankle in multiple planes of motion by drawing letters of alphabet (lower case and upper case). Repeat four to five times a day.Exercises can be performed in conjunction with cold therapy.
CORE OMM Curriculum for Students, Interns, & Residents

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Muscle Strengthening
Isometric exercises, Resistance can be provided by immovable object (wall or floor) or contralateral foot. For each exercise, hold 5 seconds; do 10 repetitions; repeat three times a day. Strengthening exercises should only be done in positions that do not cause pain. Plantar flexion, Push foot downward (away from head). Dorsiflexion, Pull foot upward (toward head). Inversion, Push foot inward (toward midline of body). Eversion, Push foot outward (away from midline of body). For each exercise, hold 1 second for concentric component and perform eccentric component over 4 seconds; do three sets of 10 repetitions; repeat two times a day.

CORE OMM Curriculum for Students, Interns, & Residents

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Muscle-Strengthening Exercises

FIGURE 9. Use of elastic tubing in strengthening exercises for eversion. FIGURE 8. Achilles tendon stretching using a towel.

CORE OMM Curriculum for Students, Interns, & Residents

AAFP website article; Management of Ankle Sprains January 1, 2001

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Muscle Strengthening

Toe curls and marble pickups, Place foot on a towel; then curl toes, moving the towel toward body. Use toes to pick up marbles or other small object. Two sets of 10 repetitions; repeat two times a day.Toe curls can be done throughout the day, at work or at home. Toe raises, heel walks and toe walks, Lift body by rising up on toes. Walk forward and backward on toes and heels.Three sets of 10 repetitions; repeat two times a day; progress walking as tolerated. Strengthening can occur from using the body as resistance in weight- bearing position.
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Muscle-Strengthening Exercises

FIGURE 10. Single-leg toe raises done on a step.

FIGURE 11. Single-leg wobble board exercise to increase proprioception.

CORE OMM Curriculum for Students, Interns, & Residents

AAFP website article; Management of Ankle Sprains January 1, 2001

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Range of Motion

Range of motion must be regained before functional rehabilitation is initiated. Regardless of weight-bearing capacity, Achilles tendon stretching should be instituted within 48 to 72 hours after the ankle injury because of the tendency of tissues to contract following trauma. Once range of motion is attained, and swelling and pain are controlled, the patient is ready to progress to the strengthening phase of rehabilitation.

CORE OMM Curriculum for Students, Interns, & Residents

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Rehabilitation/Strengthening

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Training for Return to Activity

When walking a specified distance is no longer limited by pain, the patient may progress to a regimen of 50 percent walking and 50 percent jogging. When this can be done without pain, jogging eventually progresses to forward, backward and pattern running. Circles and figure-eights are commonly employed for pattern running. Although these routines are time-consuming, they represent the final phase and are essential for the recovery of ankle stability.

CORE OMM Curriculum for Students, Interns, & Residents

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Treatment X-ray
Reset the talus in the mortise of ankle Milk the peroneal muscles Correct ipsilateral posterior fibular head Correct ipsilateral posterior 3rd rib RICE (rest, ice, compression, elevation) Rehabilitate peroneal and tibialis anterior muscles

CORE OMM Curriculum for Students, Interns, & Residents

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Reset the Talus in the Mortise

Apply traction with dorsiflexion and eversion Quick tug to reset the talus in the mortise

CORE OMM Curriculum for Students, Interns, & Residents

Des Moines University OMM II handouts, August 12, 2002 May 15, 2003 OUCOM Session 7 Lower Extremity lecture
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Milk the Peroneal Muscles

Start distally and work your way proximally

CORE OMM Curriculum for Students, Interns, & Residents

Des Moines University OMM II handouts, August 12, 2002 May 15, 2003 OUCOM Session 7 Lower Extremity lecture
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Correct ipsilateral posterior fibular head - Passive Motion

Patient supine, knee flexed Sit on foot Stabilize knee with hand Pull fibular head anterolaterally and then push posteromedially repeatedly

Des Moines University OMM II handouts, August 12, 2002 May 15, 2003 OUCOM Session 7 Lower Extremity lecture

CORE OMM Curriculum for Students, Interns, & Residents

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Correct ipsilateral posterior fibular head Muscle Energy

Remember PIP AID

For a Posterior fibular head, Invert and Plantarflex For an Anterior fibular head, Invert and Dorsiflex

CORE OMM Curriculum for Students, Interns, & Residents

Des Moines University OMM II handouts, August 12, 2002 May 15, 2003 OUCOM Session 7 Lower Extremity lecture
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Correct ipsilateral posterior fibular head - HVLA

Patient supine, knee flexed Physicians hand in popliteal fossa, 1st MCP joint behind fibular head Flex knee, externally rotate leg at knee Thrust patients ankle toward buttocks

CORE OMM Curriculum for Students, Interns, & Residents

Des Moines University OMM II handouts, August 12, 2002 May 15, 2003 OUCOM Session 7 Lower Extremity lecture
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Correct Ipsilateral Posterior 3rd Rib

Full Nelson Physicians hands behind patients head, patients hands on top of physicians Rotate head toward posterior rib Sidebend toward rib Rotate away from rib Thrust at end of exhalation Strain/Counterstrain Patient seated Physician foot on table same side as rib Patients arm on physicians leg Flex patients head Patient leans back, other arm off table behind Sidebend and rotate patient away Still Patient seated, physician behind patient Extend, abduct arm until release, exaggerate Add compressive force through humerus toward rib head
Des Moines University OMM II handouts, August 12, 2002 May 15, 2003 OUCOM Session 7 Lower Extremity lecture
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CORE OMM Curriculum for Students, Interns, & Residents

Treatment - Still Technique

1. Put ankle in position of ease 2. Add activating force of gentle compression or distraction 3. Move slowly toward barrier 4. Return to neutral OK for acute sprains
CORE OMM Curriculum for Students, Interns, & Residents
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Lab Exercises
Anterior drawer test for ankle Reset the talus in the mortise Milk the peroneal muscles Posterior fibular head correction Muscle energy Passive motion HVLA Still technique
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What would A.T. Still do?

CORE OMM Curriculum for Students, Interns, & Residents

American Osteopathic Association copyright 2003-2006

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References
Des Moines University OMM II handouts, August 12, 2002 May 15, 2003 OUCOM Session 7 Lower Extremity lecture

http://www.uwec.edu/kin/majors/AT/aidil/images/Ankle.JPG

Management of Ankle Sprains

MICHAEL W. WOLFE, M.D.,

Lewis-Gale Clinic, Salem, Virginia TIM L. UHL, PH.D., A.T.-C., P.T., and CARL G. MATTACOLA, PH.D, A.T.-C. University of Kentucky College of Allied Health Professions, Lexington, Kentucky LELAND C. MCCLUSKEY, M.D., Hughston Clinic, Columbus, Georgia

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