The Ankle

1
The Ankle

• Amanda Myers
• Jenny Schlick
• Lindsey Amling
• Nicole Silver

2
The Ankle Joint Bones

• Tibia (1)
• Distal end of the tibia forms the roof of the
  socket
• Medial malleolus forms the medial side of the
  socket
• Fibula (2)
• Lateral malleolus forms the lateral side of the
  socket
• Talus (3)
• Wider on anterior side than posterior side
• For all bones the articular surfaces are covered
  with hyaline cartilage

3
The Ankle Joint

• Synovial hinge joint
• Two main joint movements
• Dorsiflexion extension
• Plantarflexion flexion

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Joints of the Foot

• Intertarsal Joints
• Numerous synovial joints between individual
  tarsal bones
• Inversion and eversion
• Supinate and pronate
• Subtalar Joint
• Allows for gliding and rotation
• Lateral, medial, posterior and interosseous
  talocalcaneal ligaments stabilize this joint

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Transverse Tarsal Joint

• Talocalcaneonavicular
• Complex synovial joint
• Head of the talus articulates with the calcaneus
  and the plantar calcanavicular ligament below and
  the navicular in front
• Allows for gliding and rotation
• Reinforced by 3 ligaments
• Interosseous talocalcaneal
• Talonavicular
• Plantar calcaneonavicular

• Calcaneocubiod joint
• Synovial joint
• Between the anterior surface of the calcaneus and
  the cubiod
• Involved with inversion and eversion
• Contributes to pronation and supination of the
  forefoot
• Reinforces by 3 ligaments
• Bifurcate
• Long planter
• Plantar calcaneocubiod

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Ligaments

• Medial (Deltoid) Ligaments
• Tibionavicular
• Connects the navicular bone to the sustentaculum
  tali of the calcaneus bone
• Tibiocalcaneal
• More central
• Attaches to the sustentaculum tali
• Posterior tibiotalar
• Attaches to the medial side and medial tubercle
  of the talus
• Anterior tibiotalar
• Deep to the tibionavicular and tibiocalcaneal
• Attaches to the medial surface of the talus

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More Ligaments

• Lateral Ligaments
• Anterior talofibular
• Short ligament
• Attaches the anterior portion of the lateral
  malleolus to the talus
• Posterior talofibular
• Runs horizontally and backwards
• Attaches the malleolar fossa on the medial side
  of the lateral malleolus to the posterior process
  of the talus
• Calcaneofibular
• Attaches the malleolar fossa to the lateral
  surface of the calcaneus

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Lateral Ligaments
1. Anterior talofibular 2. Posterior talofibular
3. Calcaneofibular
Medial Ligaments
1. Tibionavicular 2. Tibiocalcaneal 3. Posterior
tibiotalar 4. Anterior tibiotalar
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Flexor Retinaculum

• Strap-like layer of connective tissue
• Runs from the medial malleolus, medial and
  posterior surfaces of the talus, medial surface
  of the calcaneus and inferior surface of the
  sustentaculum tali
• Attaches above the medial malleolus and below to
  the inferiomedial margin of the calcaneus
• Components (passing underneath from anterior to
  posterior)
• Tendon of tibialis anterior
• Tendon of flexor digitorum longus
• Posterior tibial artery
• Tibial nerve
• Tendon of flexor hallucis longus

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Extensor Retinacula

• Superior
• Thickening of deep fascia
• Superior to ankle joint
• Attached to anterior borders of the tibia and
  fibula

• Inferior
• Y shaped
• Attached to the lateral side of the upper surface
  of the calcaneus
• Passes medially over the foot to the medial
  malleolus and the plantar aponeurosis

• Components (medial to lateral)
• Tendon of tibialis anterior
• Anterior tibial artery
• Tendon of extensor hallucis longus
• Tendon of extensor digitorum longus
• Tendon of fibularis tertius

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Fibular Retinacula

• Superior
• Extends from the lateral malleolus to the
  calcaneus

• Inferior
• Attaches the lateral surface of the calcaneus to
  blend with the inferior extensor retinaculum

• Components (anterior to posterior)
• Tendon of the fibularis brevis
• Tendon of the fibularis longus

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Achilles Tendon

• Thickest and strongest tendon in the body
• Formed from
• Gastrocnemuis muscle
• Soleus muscle
• Attaches to the calcaneus bone
• Contraction of the calf muscles causes the
  achilles tendon to help push the foot downward
• Enables standing on the toes, walking, running,
  and jumping
• May withstand up to 3-12 times a persons body
  weight (such as in a sprint or push off)

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Achilles Tendon Injury

• Causes
• overuse, misalignment, improper footwear,
  medication side effects, and/or accidents
• Prevention
• being in good physical shape, warming-up, and
  stretching
• Achilles tendinosis
• Results in soreness/stiffness
• Common in runners
• Achilles tendon rupture
• Partial or complete tear
• Common in middle age athletes
• Treatment
• rest, muscle strengthening, and physical therapy
• Surgery for complete ruptures

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COMMON INJURIES OF THEANKLE
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Risk Factors and Causes

• If a ligament tears and pulls a piece of bone
  with it, an avulsion fracture occurs.
• Usually the cause is accidental (slipping or
  stepping into a hole).
• People who are overweight or wear high heeled
  shoes increase their risk for an ankle injury.

• The ankle supports the entire weight of the body.
  
• Each year approximately 2 million patients are
  treated for ankle sprains, strains, and
  fractures.
• Ankle injuries usually involve an unexpected loss
  of balance that results in a sharp twisting of
  the ankle.
• Lack of conditioning, warming up and stretching

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Ankle Sprains Strains
                                                
                           
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What is an ankle strain?

• Injuries that affect muscles or tendons
• They occur in response to a quick tear, twist, or
  pull of the muscle
• Results from overstretching or over contraction
• Pain, weakness, and muscle spasms are common
  symptoms

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What is an ankle sprain?

• An injury that results from a twisting action,
  which stretches or tears the ligaments of the
  ankle joint
• Results from trauma such as a fall or outside
  force that displaces the surrounding joint from
  its normal alignment
• Bruising, swelling, instability, and painful
  movement are common symptoms
• Injuries to the ligaments are usually divided
  into 3 categories first second and third
  degree sprains

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First Degree Sprain

• The least severe
• Result of some minor stretching of the ligaments
• Has mild pain, some swelling and joint stiffness
• Usually very little loss of joint stability

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Second Degree Spain

• Result of both stretching and tearing of the
  ligaments
• Increased swelling and pain
• A moderate loss of stability

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Third Degree Sprain

• Most severe
• A complete tear or rupture of one or more of the
  ligaments that make up the ankle joint
• Massive swelling combined with severe pain
• Almost complete loss of stability

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What are some things you can do to prevent an
ankle sprain?

• Warm up properly
• Plyometric training
• Balancing exercises
• Stretch and strengthen
• Footwear
• Strapping (taping)

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R.I.C.E.

• The most effective, initial treatment is the
  R.I.C.E. regimen
• (R) rest
• (I) ice
• (C) compression
• (E) elevation
• This has been shown to significantly reduce
  recovery time

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Fractures of the Ankle

• The ankle joint and related structures can be
  regarded as a fibro-osseous ring oriented in the
  coronal plane.
• The upper part of the ring is formed by the joint
  between the distal heads of the fibula and tibia
  and by the ankle joint itself.
• The sides of the ring are formed by the ligaments
  that connect the medial malleolus and lateral
  malleolus to the adjacent carpal bones.
• The bottom of the ring is not part of the ankle
  joint, but consists of the subtalar joint and
  associated ligaments.
• Visualizing the ankle joint and surrounding
  structures as a fibro-osseous ring allows the
  physician to predict the type of damage likely to
  result from a particular type of injury.
• The ring may be disrupted not only by damage to
  the bones, producing fractures, but also damage
  to the ligaments.

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Fractures of the Talus

• The talus ossifies from a single primary
  ossification center, which initially appears in
  the neck.
• The posterior aspect of the talus appears to
  ossify last, normally after puberty.
• In up to 50 of people there is a small accessory
  ossicle posterior to the lateral tubercle of the
  posterior process.
• Articular cartilage covers approximately 60 of
  the talar surface and there are no direct tendon
  or muscle attachments to the bone.
• One of the problems with this type of fracture is
  that the blood supply to the bone is vulnerable
  to damage.

• The main blood supply to the bone enters the
  talus through the tarsal canal from a branch of
  the posterior tibial artery.
• The vessel supplies most of the neck and the body
  of the talus.
• Branches of the dorsalis pedis artery enter the
  superior aspect of the talar neck and supply the
  dorsal portion of the head and neck, and branches
  from the fibular artery supply a small portion of
  the lateral talus.
• Fractures of the neck of the talus often
  interrupt the blood supply to the talus, making
  the body and posterior aspect of the talus
  susceptible to osteonecrosis, which may lead to
  premature osteoarthritis and require surgery.

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Questions??