funtional anatomy of the ankle joint complex bmj

7/28/2019 Funtional Anatomy of the Ankle Joint Complex BMJ

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Functional Anatomy ofthe Ankle Joint Complex

Professor Emeritus Moira OBrien

FRCPI, FFSEM, FFSEM (UK), FTCD

Trinity College

Dublin


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The Ankle Joint

The ankle joint is one of the most common joints to

be injured.

The foot is usually in the plantar flexed and inverted

position when the ankle is most commonly injured.Brstrom, 1966

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Tennis

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Dorsiflexion and plantarflexion take place at the

ankle joint

In plantar flexion there

is some side-to-sidemovementLast, 1963

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The Ankle JointMOB TCD


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Inversion and Eversion

Initiated at the transversetarsal joint

A radiological term

Calcaneo-cuboid

Anterior portion of thetalocalcaneonavicular

Amputation at this joint,

no bones are cut

Last, 1963

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Main movement takeplace at the clinical

sub-talar joint i.e.:

Talocalcaneal

Inferior portion of thetalocalcaneonavicular

The pivot is the ligament

of the neck of the talus

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Inversion and Eversion

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A uniaxial, modifiedsynovial hinge joint

Proximally the articulation

depends on the integrity of

the inferior tibiofibular joint Close pack

DorsiflexionWilliams & Warwick, 1980

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In the anatomical positionthe axis of the ankle joint

is horizontal

But is set at 20-25

obliquely to the frontal

plane

Running posteriorly as it

passes laterallyPlastanga et al., 1990

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In dorsiflexion the foot movesupwards and medially

Downwards and laterally in

plantar flexionPlastanga et al., 1990

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Proximal Articular Surface

The distal surface of the tibia which is concave antero-

posteriorly and convex from

side to side

Medial malleolus (comma-shaped facet)

Lateral malleolus (triangular

facet is convex from above

downwards apex inferiorlyWilliams & Warwick, 1980

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Proximal Articulation

The inferior transverse tibiofibularligament

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

A syndesmosis

Lateral malleolus is larger,lies posteriorly

Extends more inferiorly

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Proximal Articular SurfaceMOB TCD


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Distal Articular Surface

The superior surface of the bodyof the 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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The talus has no musclesattached to it

Has a very extensive articular

surface

As a result fractures of the talusmay result in avascular necrosis

of either the body or the headOBrien et al., 2002

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Distal Articular Surface

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Posterior Aspect of Talus

Two tubercles Groove contains flexor

hallucis longus

Medial tubercle is smaller

Lateral is larger, posteriortalofibular ligament attached

7% separate ossification called os

trigonum

There is a triangular facet on theposterior surface which articulates with the inferior

transverse tibiofibular ligament

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Congenital Abnormalities

Congenital abnormalities includeos trigonum and tarsal coalition

Os trigonum in 7% of normal

population but in 32% of soccer

players

It is a problem in soccer players,

ballet dancers and javelin

Forced hyperplantar flexion

compresses the posterior portion

of the ankle and may fracture the

lateral tubercle or an os trigonum

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Articular Surfaces

Articular surfaces are

covered with hyaline or

articular cartilage

Synovial fold which may

contain fat

Fills the interval between

tibia, fibula and inferior

transverse tibiofibular

ligament

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Capsule

Is attached just beyond thearticular margin

Except anterior-inferiorly

Attached to the neck of the

talusWilliams & Warwick, 1980

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The capsule is thin and weakin front and behind

The anterior and posterior

ligaments are thickenings of

the joint capsule The anterior runs obliquely

from the tibia to the neck of

the talusWilliams & Warwick,1980

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The Posterior Ligament

The posterior ligament fibres passfrom: the tibia and fibula and

converge to be attached to the

medial tubercle of the talus

Transverse ligament fibres form the

lower part of the posterior part of the

capsule, blend with the inferior

transverse ligament

The posterior ligament is thicker

laterally

Capsule is strengthened on either

side by the collateral ligamentsWilliams & Warwick,1980

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The Medial (Deltoid) Ligament

A strong triangularligament

Superiorly attached

The medial malleolus of

the tibiaWilliams & Warwick, 1980

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Medial Ligament

Inferiorly, ant-post The tuberosity of the

navicular

Neck of talus

The free edge of thespring ligament

The sustentaculum tali

The body of the talusLast, 1963

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Medial or Deltoid Ligament

(Superficial)

Crosses two joints

Anterior tibionavicular

pass to the tuberosity of

the navicular

The free edge of thespring ligament

The middle fibres, the

tibiocalcaneal are

attached to thesustentaculum tali

Williams & Warwick, 1980

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Medial or Deltoid Ligament (Deep)

The anterior tibio-talar to

the nonarticular part of the

medial surface of the talus

The posterior tibiotalar to

the medial side of the talus

The medial tubercle of the

talus

Tibialis posterior and

flexor digitorum longus

cross ligamentWilliams & Warwick, 1980

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Lateral Ligaments of Ankle

The anterior talofibularligament

(ATFL)

The calcaneofibular

(CFL) The posterior talofibular

(PTF)

They radiate like the spokes

of a wheelLiu & Jason, 1994

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The ATFL

Is part of the capsule An upper and lower bands

It is cylindrical, 6-10 mm

long and 2 mm thick

The anterior inferiorborder of the 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

equinusLiu & Jason, 1994

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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

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The ATFL

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The anterior draw teststhe ATFL

Test should be done

with the ankle in 10o-20o

plantar flexion

Low loads

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Test for the ATFL

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A long rounded 20-25 mm

long, 6-8 mm in diameter

It contains the most

elastic tissue

It is attached in front ofthe apex of the fibular

malleolus

Passes downwards and

backwards

To a tubercle on the lateral aspect of the calcaneusWilliams & Warwick, 1980

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The CFL

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It is separated from thecapsule by fibro-fatty tissue

Part of the medial wall of the

peroneal tendon sheath

Crossesboth the ankle andsubtalar joints

The CFL has the highest

linear elastic modulus of the

three ligamentsSiegler et al., 1988

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The CFL

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When the ankle is in the neutral or

dorsiflexion, the CFL is

perpendicular to the long axis of the

talus

Dorsiflexion and inversion result in

an increased strain

Talar tilt tests the CFL

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The CFL

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The Lateral Ligament

The angle between theATFL and CFL varies

between 100o and 135o

Increasing the potential

instability of the lateral

ligament

The ATFL is the main talar

stabiliser and the CFL acts

as a secondary restraintHamilton, 1994; Peters, 1991

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ATFL and CFL

A difference of 10o

between the two ankles issignificant.

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 ofthe AFTL and CFL occur in 20%

The CFL is a major stabiliser of the subtalar jointLiu & Jason, 1994

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The Posterior Talar Fibular (PTL)

The PTL is the strongest part of

the lateral ligament

It runs almost horizontally from

malleolar fossa to lateral

tubercle of talus

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During plantar flexion theposterior talofibular and the

posterior tibio fibular ligament are

edge to edge

They separate during dorsiflexion

The greatest strain on the

ligament is when the foot is

plantar flexed and everted

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The PTL

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In 7% of normal populationthe lateral tubercle has a

separate ossification and is

called an os trigonum

It occurs in 32% of soccer

players

Tarsal coalition is another

congenital abnormality

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The Ankle Joint

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Synovial Membrane

Lines the capsule and thenon articular areas

It is reflected on to the neck

Extends upwards between

the tibia and fibula to theinterosseous ligament of the

inferior tibiofibular joint

Covers the fatty pads that

lie in relation to the anterior

and posterior parts of the

capsulePlastanga et al.,1980

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Ankle Stability

The ankle is most stable indorsiflexion, with increasing

plantar flexion there is more

anterior talar translation

(drawer) and talar inversion

(tilt)

The ATFL is the main talar

stabiliser and the CFL acts

as a secondary restraint

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The tibiocalcaneal and the tibionavicular control

abduction of the talus

The calcaneofibular controls adduction

The anterior tibiotalar and the anterior talofibular

ligament control plantar flexion

Posterior tibiotalar and the posterior talar fibular

ligament resist dorsiflexion

Both the anterior tibiotalar and the tibionavicular

control external rotation and with the anterior

talofibular internal rotation of the talus

The anterior talofibular is the primary stabilizer of

the ankle joint

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Ankle Stability

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Blood Supply of the Ankle

Malleolar branches of the

anterior tibial

Perforating peroneal and

posterior tibial arteries

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Nerve Supply of the Ankle

Nerve supply is via articular

branches of the deep

peroneal

Tibial nerve from L4 - S2

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Anterior Aspect

Dorsi-flexors Tibialis anterior

Extensor hallucis longus

Anterior tibial becomes the

Dorsalis pedis artery Deep peroneal nerve

Extensor digitorum longus

Peroneus tertius

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The medial branch of the

superficial peroneal nerve is

superficial to the retinaculum

The long saphenous vein and

the saphenous nerve lie

anterior to the medialmalleolus

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Anterior Aspect

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Postero-Medial Aspect of the Ankle

Tibialis posterior

Flexor digitorum longus

Posterior tibial vessels

Posterior tibial nerve

Flexor hallucis longus

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The tibial nerve gives off the

medial calcaneal nerve then

divides into the medial and

lateral plantar nerves

The medial calcaneal vessels

and nerve pierce the flexorretinaculum to supply the skin of

the heel

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Postero-Medial Aspect of the Ankle

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Posterior Aspect

Achilles tendon separated bya bursa and pad of fat

Posterolateral portal is lateral

to achilles tendon, sural

nerve and short saphenousvein at risk

Postero-medial not used;

flexor retinaculum structures

at riskJaivin & Ferkel, 1994

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Lateral Aspect of the Ankle

The inferior extensor

retinaculum

Extensor digitorum brevis

Peroneus longus and

brevis

Peroneal retinaculum

Ligament of the neck of

talus

Bifurcate ligament Sural nerve

Short saphenous vein

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Plantar flexion andeversion

Peroneus longus

Peroneus brevis

Dorsi-flexion andeversion

Peroneus tertius

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Lateral Aspect of the Ankle

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Nerves Related to Ankle Joint

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Tibialis Posterior

Superficial Peroneal Nerve

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Movements of Ankle joint

Dorsiflexion is close

packed or stable position

Wider portion of body of

talus between malleoli

Range of 30o

Need 10 o dorsiflexion to

run

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Dorsiflexion

Dorsiflexion is produced by the tibialis

anterior

Extensor hallucis longus

Extensor digitorum longus

The peroneus tertius Deep peroneal nerve

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Movements of Ankle joint

Plantar flexion

Some side to side

movement

Narrow portion of body

between malleoli, 50-60 o

Least pack, unstable

position

Wide variation

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Plantar Flexion

During plantar flexion

The dorsal capsule

The anterior fibres of the

deltoid

The anterior talofibularligaments are under

maximum tension

Plantar flexion is caused

mainly by the action of

the achilles tendon

Assisted by the tibialis

posterior

Flexor digitorum longus

Flexor hallucis longus

Peroneus longus and

brevis

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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)

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The Ankle Joint

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Examination of Ankle

ATFL

CFL

Distal tibiofibular

Syndesmosis

Deltoid ligament Lateral malleolus

Medial malleolus

Base 5th metatarsal

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Achilles tendon Peroneal tendons

Posterior tibial tendon

Anterior process of calcaneus

Talar dome Sinus tarsi

Bifurcate ligament

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Examination of Ankle

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Ankle Examination

Anterior drawer

Talar tilt

Inversion stress

Squeeze test

External rotation test

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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

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A Few Statistics

Basketball 5.5 ankle injuries/1000 player hours

Netball 3.3 ankle injuries/1000 player hours

Volleyball 2.6 ankle injuries/1000 player hours

Soccer 2.0 ankle injuries/1000 player hoursHopper et al., 1999

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Basketball Statistics

53% of basketball injuriesare ankle injuries

30.4 ankle injuries/1000

games

10.0 ankle injuries/seasonfor a squad of twelveGarrick, 1977

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Risk Factors

Extrinsic

Training error

Type of sport

Playing time

Level of competition Equipment

Environmental

Intrinsic

Malalignment

Strength deficit

Reduced ROM

Joint instability Joint laxity

Foot type

Height/weight

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Previous ankle injury Ekstrand & Gillquist, 1983; Milgrom et al., 1991

Competition Ekstrand & Gillquist, 1983

Muscle Imbalance Baumhauer et al., 1995

Mass moment of inertia Milgrom et al., 1991

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Risk Factors

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Ankle Injuries

Lateral ligament sprain

Medial ligament sprain

Peroneal dislocation

Fractures

Dislocations

Tendon rupture

Tibialis posterior

Peroneal tendons

Ruptured syndesmosis

Superficial peronealnerve lesion

Reflex sympathetic

dystrophy

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A kl S i

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Ankle Sprains

Grade one

Stretch of ATFL; mild swelling; no instability

Grade two

Partial macroscopic tear; pain; swelling; mild-

moderate instability

Grade three

Complete tear; severe swelling; unable to weight

bear; limited function; and instability

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Proprioception Theory

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Proprioception Theory

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R d i I j

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Reducing Injury

Proprioceptive

Agility and Flexibility training Ekstrand & Gillquist, 1983

Taping

Loosens in 10 minutes Garrick, 1977

Nil effect in 30 minutes? Tropp et al., 1985;Rovere et al., 1988; Sitler et al., 1994

Bracing

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funtional anatomy of the ankle joint complex bmj

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