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Subtle Ligament Injuries
of the Midfoot and Ankle
Robert B. Anderson, MD
Founder, Foot & Ankle Service
OrthoCarolina
Consultant, Carolina Panthers
Charlotte, North Carolina
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Disclosures
Consulting/Royalties:
DJO, Arthrex, Wright Medical, Zimmer Biomet
Consulting/Research:
Amniox
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You may not have seen it but it has
seen you…
Dr. Bill Hamilton
The eye sees what the
mind knows…
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Sport Ligament Injuries
• Ligament injuries may be subtly unstable
• Frank diastasis not always present
Why important?
Unstable joint segments may progress to deformity/DJD
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Subtle LISFRANC Injuries
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Sport Lisfranc Injuries
Not all are classic or readily apparent
• 23 y/o NFL WR with right foot injury on punt return
• Minimal clinical findings
• Normal xrays/stress
• MRI = edema
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Diagnosed with Midfoot “Sprain”
• Failed to improve with casting/boot x 3 months
• Decision made to proceed with open exploration
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More than a Midfoot “Sprain”
• Managed with “home run” screw– Symptoms resolved
– RTP after 5 months
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Lisfranc Not Always Apparent
Sport variety may be
subtle – consider…
• Painful WB
• Unable to heel rise
• Swelling and point
tenderness
– Often medial column (n-c)
– Plantar ecchymosis
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Radiographic Exam
• Beware of the
proximal variant!
– Increasing
incidence in
American football
• Hammit/Anderson
– AOFAS ‘04
– TFAS ’05/’10
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Proximal Variant = Medial
Column Lisfranc
• Occurring in all field
sports
• Effect of artificial
surfaces?
– Cleat
interaction???
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Proximal Variant/Medial
Column Lisfranc
• Results in an
unstable first ray →
can’t push-off
• Also leads to joint
deterioration if left
untreated
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Assessing Subtle Injuries
Stress testing?
• Very difficult to get
relaxed in office
– I rarely do…
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Assessing Subtle Injuries
MRI = may alert to
subtle pattern
• Example: proximal
variant with edema
in navicular
• Remember = a
static test
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Sometimes you just have to explore
• Fix all unstable segments– Screws
– Bridge plates
• Can use on TMT joints; avoids cartilage damage
• Hardware breakage not of concern
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Subtle SYNDESMOTIC and
DELTOID Injuries
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Syndesmotic +/- Deltoid Injuries =
the High Ankle Sprain
• Persistently common
– 10% of ankle sprains?
• Consistently high incidence in the NFL
– Avg > 130/season
• Multiple factors
– Cleat/turf interaction
• Ligament injuries occur as a result of torque/rotation
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High Ankle Sprain - Mechanism
• Classic = foot fixed to
surface and valgus thrust
applied to leg
– External Rotation a
constant
– Often eversion component
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NFL/UVa Research
• Injury modeling of the high ankle sprain
– Superficial deltoid frequently involved
– AITFL > PITFL
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NFL/UVa Research
• Variable presentation
• A number of different ligaments may be effected and to varying degree of disruption
• Frank diastasis not always present
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Evaluation of the HAS – Assessing
Stability
– Start with ankle radiographs
• Standing – single limb may accentuate
areas of diastasis and instability
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Stress Radiographs?
– Beumer et al (2003):
not reliable for
diagnosis of
syndesmotic instability
– I have difficulty getting
players to relax!!!!
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Stress Flouroscopy?
Helpful when positive…
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Role of CT and MRI?
• Help to define extent of ligament injuries, OCLs, and diastasis– MRI/CT very sensitive for
detecting ligament injuries/diastasis but not prognostic (Oek, 2003)
– MRI/CT are static studies - not predictive for instability
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Why do we care about Ankle
Diastasis/Instability?
• 1mm of lateral displacement of the talus results in 42% reduction in tibiotalar contact (Ramsey and Hamilton, 1976)
• Chissel and Jones, JBJS, 1995 – threshold of 1.5mm diastasis with worsening results with increasing malreduction/diastasis
• Weening and Bondari, JOT, 2005 – “the only significant predictor of functional outcome was reduction of the syndesmosis”
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Treatment of Stable Injuries
Individualized• Boot/Cast
• WBTT
• Ice/NSAIDS/compression
• PRP/cortisone injections
• Strengthening/proprioception/plyometrics
• RTP when symptoms allow
– 2-8 weeks?????
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Decision Making Easy when
Diastasis or Proven Instability
Need to fix to reduce risk of DJD
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Treatment of Unstable
Syndesmotic Injuries
Surgery if…
1. Any diastasis
2. Instability with stress
• Stress plain films
• Weightbearing ankle xrays
• Flouroscopic exam
Reduction/fixation to reduce
risk for DJD
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What about the injury that
appears stable but player not
improving…
• Persistent discomfort and swelling with activity
• Pain/weakness with heel rise
• Difficulty with cutting maneuvers
• General performance issues
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Think Subtle Syndesmotic and/or
Deltoid Instability
• Clinical/functional exam
important
– Inability to perform heel rise
or repeated hop
– Peroneal/posterior tibial
tendonitis
– Chronic inflammation
– Serial MRI changes
• Worsening of bone edema
• OCLs
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Test for Subtle Syndesmotic
Instability
• Wolf BR, Amendola A: Curr
Opin Orthop 2002
– Described a test for dynamic
instability = “syndesmotic
taping”
• Player asked to perform single
limb heel rise with and without
tape wrapped around distal tib-fib
• If binding assists then consider
instability and need for surgical
fixation from Wolf et al
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Subtle Syndesmotic/Deltoid
Instability
• Concern = may lead to chondral injury and eventual DJD
– How do we identify those athletes with subtle syndesmotic injuries and in need of surgical stabilization
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EUA with Ankle Arthroscopy
• Best diagnostic tool
• Very helpful in cases of
negative xray, positive
MRI and protracted
recovery with vague pain
– Lue et al. = arthroscopic
evaluation superior to
fluoroscopic stress testing
• Arthroscopy 2005
Syndesmotic
Instability
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Syndesmotic/Deltoid Instability
• Arthroscopic evaluation is superior to any
imaging studies in subtle injuries
– Done with EUA – different exam with patient
relaxed
Deltoid Instability = Anterior Drawer with
External Rotation
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Case Example
• 23 y/o WO with
recurrent high ankle
sprains
• Normal xrays, stress
imaging, flouro exam
• MRI: chondral defects
• Scope
– Chondral changes lateral
talar dome
– Loose body
– Unstable syndesmosis
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Case Example
• 26 y/o RB
– Unable to return for
last 6 games of ‘12
season due to left ankle
pain after “minor” high
ankle sprain
– Normal xrays/stress;
MRI with edema in
syndesmosis/lateral
talar OCL
OCL lateral talus
with syndesmotic
instability
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Case Example
• 25 y/o RB with recurrent high
ankle sprains
• Difficulty with “cutting”
• Normal xrays, stress imaging,
flouro exam
• MRI: chronic ligament
changes medial and lateral,
progressive OCL lateral talus
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Case Example
• Intraop exam
– EUA – medial
instability pattern
– Arthroscopic:
synovitis, medial
laxity confirmed
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Case Example
• Intraop exam
– Arthroscopic:
syndesmotic
instability
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Case Example
• Intraop exam
– Arthroscopic:
chronic bipolar
OCL lateral
“Corkscrew phenomena”
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Case Example
• Intraop repair
– Chondral debridement
– Superficial deltoid
• Medial Brostrom
– Syndesmotic stabilization
• Suture-button fixation
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Deltoid Fixation Options
• Superficial deltoid
reconstruction
– Advancement to anterior
medial malleolus with
suture anchor(s)
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Postop Treatment
• Postop
– Individualize• Size
• Time
• Severity
– Cast, NWB x 4-6 weeks, then
WB in boot 4-6 weeks
– Progressive strengthening
– RTP at 4-6 months
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Syndesmotic Fixation Options
• Addition of fibular
plate may allow for
earlier and safer
return to play
– Reduce fibular
fracture risk
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Syndesmotic Injuries
Complications and poor
outcomes can and will
occur
• Understand the spectrum of
the injury and importance of
obtaining and maintaining
anatomic reduction
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Syndesmotic Complications
• Pain
– Inflammation, degeneration
in the syndesmosis
• Bone scan/CT helps to
diagnose
• Consider injection under
flouro or CT
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Syndesmotic Complications
• Pain
– Inflammation, degeneration
in the syndesmosis
• Bone scan/CT helps to
diagnose
• Consider injection under
flouro or CT
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Syndesmotic Complications
• Pain from iatrogenic
syndesmotic
injury/degeneration
– Avoid placing devices within the “functional” syndesmotic joint
• Failed hardware an issue
• Place at least 1.5cm above
joint line to avoid “true”
syndesmotic joint
– Kukreti et al: Injury ’05
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The Syndesmosis is a Joint!
• Sickle shaped synovial
lined functional joint
with cartilage on both
sides
• Pistons, rotates, widens
• It has a purpose!
• Preserve when possible
Articulating
Joint
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Syndesmotic Complications
• Pain
– Ossification of the
syndesmosis
• Usually incomplete
types
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Incomplete Synostosis
• Chronic
inflammation/pain
• Mechanical symptoms
with activity
• Treatment
– Injection
– Immobilization
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Case Example
• Incomplete synostosis with
pain/popping sensation
– Injection attempted (fluoro
assistance)
– Debridement vs. fusion
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Case Example
Treatment
• Incomplete synostosis
– Debridement
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Persistent/Recurrent Diastasis
• Decision making
– Condition of tibio-talar joint
– Condition of syndesmotic
joint
– Degree/direction of diastasis
and instability
– Early vs. Late?
• 6 months is arbitrary threshold
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Late Diastasis (or Syndesmotic DJD)
• Best to achieve tib-fib
fusion
– ICBG; Plate and screw
fixation
– Synostoses don’t hurt but
may limit some motion –
especially external
rotation
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Late Diastasis (or Syndesmotic DJD)
• Case example
– 32 y/o female triathlete
– External rotation injury
two years prior
– Treated in a boot for 3
months
– Disabling pain in
anterolateral ankle
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Late Diastasis (or Syndesmotic DJD)
• Case example
– Temporary relief with
injection to
syndesmotic joint
• Flouroscopic guidance
and confirmation
– CT optional
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Late Diastasis (or Syndesmotic DJD)
• Case example
– Syndesmotic fusion
• ICBG
• Plate/screw fixation
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Ligament Injuries of the F/A
Summary
• Have a high index of suspicion →
diastasis/gross instability not
always present on initial evaluation
– Clinical signs (heel rise) and lack of
recovery can be as helpful as imaging
– Beware of worsening bone edema
– EUA with incision/scope if not
improving
– Fix if unstable to reduce risk of
chondral injury and DJD
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Thank You