Case review presentation

MEDIAL ANKLE SPRAIN

MOHAMED AOUINI NSMP PHYSIOTHERAPIST

Case Load plan• Anatomy • History• Assessment• Management • Take Home Message

Ankle

Anatomical structure

Tibia Fibula Talus

Tibia

This is the strongest largest bone of the lower and it is bears weight the bones creates the medial malleoli

Fibula

This is lateral bone of the lower leg is not vital for weight bearing it comprises the lateral outside aspect of the lateral malleoli and makes up the lateral aspect of the mortise .

Talus

This bone transmits the force from the calcaneus up into the tibia and also allows the articulation of palantar flexion, dorsiflexion or pulling the foot upward and inversion and eversion

Joints of the Ankle/Foot

• Talocrural Joint in the ankle found between the tibia ,fibula, and talus. • Subtalar Joint-joint in the ankle found between the talus and calcaneus.

•Transverse tarsal joint It is formed of 2 joints:talo-navicular joint calcaneo-cuboid joint

Ankle ligaments and roles There are three lateral ligaments Responsible for the support

and maintenance of bone appositionThese ligaments are:_ anterior talofibular ligament: prevents anterior subluxation

of talus when ankle is in plantar flexion_ calcaneofibular ligament: primarily to stabilize sub-talar

joint and limit inversion, it is lax in normal standing position due to relative valgus orientation of calcaneus.

_ posterior talofibular ligament: prevents posterior and rotatory subluxation of the talus.

The deltoid ligaments _ This is locates on medial aspect of the foot it is the largest

ligament triangular in shape _ prevents eversion of the ankle_ deep and superficial part : Superfical part:Anterior tibio-navicularMiddle tibio-calcanean Psoterior tibio-talarDeep part: it is also called as tibio-talar ligament attached on

the anterior part of the medial surface of talus

Superficial deltoid: resist talar abduction and primarily resists eversion of hind

foot. Tibionavicular portion prevents inward displacement of head of talus, while tibiocalcaneal portion prevents valgus displacement.

Deep deltoid ligament : _ prevents lateral displacement and external rotation of the

talus. _ latter effect is pronounced in plantar flexion, when deep

deltoid tends to pull talus into internal rotation.

KINEMATICS OF ANKLE & FOOT 1 .Primary plane motions defined a. Sagittal plane motion is dorsiflexion (15°) and

plantarfiexion (55°). b. Frontal plane motion is inversion (35°) and eversion (20°) c. Transverse plane motion is abduction and adduction . 2. Triplanar motions occurring about oblique axes defined: a. Pronation (20°) is a combination of dorsiflexion, eversion,

and abduction. b. Supination (35°) is a combination of plantarfiexion,

inversion, and adduction.

Player information

NAME: Hassan Last name: Elsaafady

Length: 1.83 cm Weight: 76kg Age: 16 years

Position: player maker Category: Naachine

Allergy: no previous injury: left big toe injury 2013

surgery: no MRN: 01366624

History

• During game on 9/03/2014 in the second half he injured his right ankle when he changed directions and sustained

An eversion injury, he complete full game without any first treatment, the day after his coach called me about the injury of his player, we went to aspetar he made an X_RAY and there is no fracture.

Assessing the Lower Leg and Ankle• History _ past history: no past history of ankle sprain_ Mechanism of injury: eversion of the foot_ NRS was 8/10 on the time of the injury_ currently pain on walking 7/10 on the medial side _ Aggravating factor: walk _ Easy factor: Rest _ sound or feeling: no_ swelling was immediate _ No Red flags and there is no other health issue

• Inspection

_ player walk with pain in the medial side _ no deformity _ there is swelling in the medial side

• Palpation

_ tenderness on the deltoid ligaments _ no pain on the :malleoli, navicular bone ,fibula

head .

• R.O.M

_ Normal range of motion

• Special tests_ Thompson's test: -ve _ compression test : -ve_ reverse talar tilt : +ve_ Kleiger’s test: -ve_ anterior drawer (ATFL): -ve_ Talar tilt (CFL) : -ve

Functional tests

_ Single leg balance: painfull _ walk Heel raise (bi-lat/uni-lat): paifull _ Step up/down: painfull _ Jump/hop: unable_ Jog/run/lat movement: unable_ walk on toe : painfull_ walk on lateral borders : painfull_ walk on medial borders: painfull

Recent investigation

_ X-Ray : there is no bony articular or soft tissue abnormality

_ Ultrasound: The ATFL and CFL are normalThere is no syndesmotic injuryThere is thickening of the anterior superficial of

the deltoid ligament ( Grade 1 )There is no tenosynovitis

DIAGNOSIS

_ There is thickening of the anterior superficial of the deltoid ligament ( Grade 1 )

_ no bone injury

• PROBLEM LIST• Swelling • Pain 8 over 10 • Treatment Plan and Goals • Eliminate swelling• Eliminate pain • Increase muscle strength • Increase neuro muscular control

Physical therapy and treatment

_ The most important factors in this case swelling and pain .

_ If these factors are reduced ,you can take a faster results .

_ That’s why the exercise who decreased the swelling is too much important.

_ In the most case , the pain and swelling are synchronized in all phase

Swelling vs pain Day pain /NRS Swelling( right/ left)Day 1 8 59.50/57Day3 7 59.23 /57Day 5 7 59.50/57Day 8 7 59.50 /57Day 11 6 59.20 /57Day 15 5 58.70 / 57Day 18 4 58.25/57Day 21 3 58/57Day 24 2 57.60/57Day 28 2 57.20/ 57Day 31 1 57/57Day 33 1 57/57Day 35 0 57/57Day 38 0 57 / 57

Day 1 Day3 Day 5 Day 8 Day 11 Day 15 Day 18 Day 21 Day 24 Day 28 Day 31 Day 33 Day 35 Day 38 0

1

2

3

4

5

6

7

8

9

55.5

56

56.5

57

57.5

58

58.5

59

59.5

60

8

7 7 7

6

5

4

3

22

1 1

0 0

59.5

59.23

59.5 59.5

59.2

58.7

58.2558

57.6

57.257 57 57 57

Pain Vs Swellingpain Swelling( right/ left)

The most important phahse _ Phase I: includes resting, protecting and reducing

swelling of your injured ankle.

_ Phase II : includes restoring your ankle's flexibility, range of motion and strength.

_ Phase III: includes gradually returning to straight-ahead activity and doing maintenance exercises, followed later by more cutting sports such as tennis, basketball of football.

Joints flexibilty _ may it can have loss of joints flexibilty due to:Muscle spasm, pain, adherence

_when we restore ROM to within 80% of normal in the unaffected ankle , the rehabilitation emphasis moves to the development of muscular strength.

Muscular Strength and speed

_ Must perform a progressive resistive exercise on a regular basis.

_ Once strength in the injured side is 90% of the non-injured side, emphasis moves to the development of muscular endurance .

_ high intense rehab exercise

Muscular Endurance

– Stationary bike .

– Running when tolerated ,jogging gradually .

neuro muscular control

_ open kinetic chain

_ close kinetic chain

Taping_ As level 1 technique

After before

Take Home message

_ Treatment of ankle sprain should consist of an exercise program that is a varied and intense as possible to obtain optimal ankle functioning .

_ Medial ligaments injury take longer time than lateral In the treatment .

Thank you