CASE HISTORY PRESENTATION
HOUSSEM EDDINE MECHRI
NSMP STAFF
Ankle
• Anatomical Structures
– Tibia
– Fibular
– Talus
Tibia
• This is the strongest largest bone of the lower leg. It bears weight and
the bone creates the medial malleoli .
Tibia

The Tibia is the medial
bone and largest bone of
the lower leg.
Fibula
• This is a smaller lateral bone of the lower leg. It is not vital for weight
bearing yet it comprises the lateral ...
Fibula--->

_______________________

The fibula is longer
and non weight
bearing. It makes
up the lateral
aspect of the
mo...
Talus
• This bone transmits the forces from the calcaneus up into the tibia and
also allows the articulations of Plantar F...
------

Talus
Talocrural Joint
• The formation of the mortise (a hole) by the medial malleoli (Tibia)
and lateral malleoli (fibula) with...
________________

Talocrural Jt.

________________
Subtalar Joint
• The articulation between the talus and the calcaneus is referred to as
the subtalar joint.
Medial aspect of foo
Talus

---Subtalar Joint

calcaneus
Ankle Ligaments
• There are three lateral ligaments predominantly responsible for the
support and maintenance of bone appo...
Tibia

Fibula

A

t.
n

T

bi
i

fib
o

la
u

r

L

g.
i

Talus

Lig
r
ula
ofib
Tal
nt.
A

a

ent
m
<- Fibula
Post. Tibiofibular Lig.

<- Ant. Talofibular Lig

Calc
an e
ofib
Liga
ular
men
t
Calcaneus

<- Talus

 Subtalar...
Posterior
tibiofibular
Ligament

Peroneal
tendons

Talus

<-Fibular
head

Ach

or

ille
on
end
s T

ri lar
e
st ibu
Po lof...
The deltoid ligament
• This is located on the medial aspect of the foot. It is the largest
ligament but is actually compri...
X

al
bi
Ti

X
Navicular ---

Tibia

Deltoid
Ligament

is

An

t.

Te

nd

on

X

b
Ti

i

lis
a

P

st
o

e

rio

X

r

...
PLAYER INFORMATION
• NAME : NASSER

LAST NAME: NAIMI

• LENGTH : 1.68 CM

WEIGHT : 52.3 KG

• POSTION :MID-FILED

CATEGORY...
HISTORY
in the friendly game (Ramadan league) , in the second half-time
(65min) ,Nasser is was kicked by an opponent playe...
Assessing the Lower Leg and Ankle
• History
– Past history: no past history of ankle sprain
– Mechanism of injury : dorsi-...
• Observations
– Postural deviations : yes
– Is there difficulty with walking: yes ,he can”t
– Color and texture of skin, ...
Compression Test

Homan’s Test

Percussion Test

Thompson Test
• Ankle Stability Tests
– Anterior drawer test
• Used to determine damage to anterior talofibular ligament
primarily and o...
Anterior Drawer Test

Talar Tilt Test
– Kleiger’s test
• Used primarily to determine extent of damage to the
deltoid ligament and may be used to evaluate distal...
Kleiger’s Test

Medial Subtalar Glide Test
• Functional Tests
– While weight bearing the following should be performed
• Walk on toes (plantar flexion) : painful
• W...
Rapport of examination
There is little swelling around the medial and lateral malleolus .all
movement are painful and he i...
Radiography
MRI
INVESTIGATIONS
• X-ray were reviewed and appear normal
• MRI shows grade 3 ATFL tear ,high grade CFL tear and some DELTOID...
DIAGNOSIS AND MANAGEMENT
• He appears to have sustained a high grade tear of the lateral ligaments
with involvement of the...
Physical therapy and treatment
• The most important factors is swelling and pain
• If these factors are reduced ,you can t...
Swelling vs pain
Day

Swelling (right / left)

Pain /vas

Day 1

39/36

10

Day 3

38.75/36

10

Day 6

38.22/36

9

Day 9...
Chart
The most important phase
•

R.I.C.E.
12 to 72 hrs.
Grade II
• Immobilization
1 to 2 weeks
Grade II
• Splinting/Bracing
1 t...
Joint Flexibility
– Decreased joint flexibility results from:
• muscle spasm, pain (Therapeutic exercise with cold)
• conn...
Muscular Strength
– Must perform a progressive resistive exercise on a regular basis.
– Each side of the body should be wo...
Closed Chain
Ankle Strength Exercises
Muscular Endurance
– Stationary bike
– Running when tolerated (jog 400 meters first day and
increase by 400 meters each 1 ...
• Muscular Speed

– high intense stationary bike
– Cybex

• Muscular Power

– Isokinetic devices
– high- speed resistive w...
TAPING

heel and lace pads

Angle tape to avoid wrinkles

medial to lateral direction

First step of lateral heel lock

Se...
THANK YOU
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Ankle ppt

  1. 1. CASE HISTORY PRESENTATION HOUSSEM EDDINE MECHRI NSMP STAFF
  2. 2. Ankle • Anatomical Structures – Tibia – Fibular – Talus
  3. 3. Tibia • This is the strongest largest bone of the lower leg. It bears weight and the bone creates the medial malleoli .
  4. 4. Tibia The Tibia is the medial bone and largest bone of the lower leg.
  5. 5. Fibula • This is a smaller lateral bone of the lower leg. It is not vital for weight bearing yet it comprises the lateral (outside) aspect of the malleoli and makes up the lateral aspect of the mortise.
  6. 6. Fibula---> _______________________ The fibula is longer and non weight bearing. It makes up the lateral aspect of the mortise. The lateral malleoli lies inferior (below) the medial malleoli
  7. 7. Talus • This bone transmits the forces from the calcaneus up into the tibia and also allows the articulations of Plantar Flexion, Dorsiflexion or pulling the foot upward and Inversion and Eversion
  8. 8. ------ Talus
  9. 9. Talocrural Joint • The formation of the mortise (a hole) by the medial malleoli (Tibia) and lateral malleoli (fibula) with the talus lying in between them makes up the talocrural joint. This is a hinge joint and allows most of the motion with plantarflexion and dorsiflexion.
  10. 10. ________________ Talocrural Jt. ________________
  11. 11. Subtalar Joint • The articulation between the talus and the calcaneus is referred to as the subtalar joint.
  12. 12. Medial aspect of foo Talus ---Subtalar Joint calcaneus
  13. 13. Ankle Ligaments • There are three lateral ligaments predominantly responsible for the support and maintenance of bone apposition (best possible fit). These ligaments prevent inversion of the foot. • These ligaments are: – Anterior talofibular ligament – Calcaneofibular ligament – Posterior talofibular ligament
  14. 14. Tibia Fibula A t. n T bi i fib o la u r L g. i Talus Lig r ula ofib Tal nt. A a ent m
  15. 15. <- Fibula Post. Tibiofibular Lig. <- Ant. Talofibular Lig Calc an e ofib Liga ular men t Calcaneus <- Talus  Subtalar Joint Space Peroneal Tendons Cuboid
  16. 16. Posterior tibiofibular Ligament Peroneal tendons Talus <-Fibular head Ach or ille on end s T ri lar e st ibu Po lof ta g. li calcaneus
  17. 17. The deltoid ligament • This is located on the medial aspect of the foot. It is the largest ligament but is actually comprised of several sections all fused together. This ligament prevents (eversion) of the ankle. The deltoid ligament is triangular in shape and has superficial and deep layers. It is the most difficult ligament in the foot to sprain.
  18. 18. X al bi Ti X Navicular --- Tibia Deltoid Ligament is An t. Te nd on X b Ti i lis a P st o e rio X r en T on d -- Talus
  19. 19. PLAYER INFORMATION • NAME : NASSER LAST NAME: NAIMI • LENGTH : 1.68 CM WEIGHT : 52.3 KG • POSTION :MID-FILED CATEGORY; AL -NASHINE TEAM AGE : 14 YEARS • DOMINANT LEG : RIGHT • ALLERGIE : NO • MRN: 01152693 SURGERY: NO
  20. 20. HISTORY in the friendly game (Ramadan league) , in the second half-time (65min) ,Nasser is was kicked by an opponent player in the lateral face of his ankle (right) He was stopped directly the game ,and referred to Aspetar (emergency department ) he made a radiograph of the front and side of the ankle. has provide that "there is no fracture and the next day made a consultation with Dr target ​
  21. 21. Assessing the Lower Leg and Ankle • History – Past history: no past history of ankle sprain – Mechanism of injury : dorsi-flexion +inversion (kicked by other player ) – When does it hurt : directly after the kick – Type of, quality of, duration of pain : vas 10/10 , he feel pulse , functional dysfunction , he can't walk , no weight bearing, bruising . – Sounds or feelings: yes – Swelling : yes and painful
  22. 22. • Observations – Postural deviations : yes – Is there difficulty with walking: yes ,he can”t – Color and texture of skin, heat, redness;blue – Is range of motion normal: no,it”s painful
  23. 23. Compression Test Homan’s Test Percussion Test Thompson Test
  24. 24. • Ankle Stability Tests – Anterior drawer test • Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarily • A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point – Talar tilt test • Performed to determine extent of inversion or eversion injuries • With foot at 90 degrees calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments • If the calcaneus is everted, the deltoid ligament is tested
  25. 25. Anterior Drawer Test Talar Tilt Test
  26. 26. – Kleiger’s test • Used primarily to determine extent of damage to the deltoid ligament and may be used to evaluate distal ankle syndesmosis, anterior/posterior tibiofibular ligaments and the interosseus membrane • With lower leg stabilized, foot is rotated laterally to stress the deltoid – Medial Subtalar Glide Test • Performed to determine presence of excessive medial translation of the calcaneus on the talus • Talus is stabilized in subtalar neutral, while other hand glides the calcaneus, medially • A positive test presents with excessive movement, indicating injury to the lateral ligaments
  27. 27. Kleiger’s Test Medial Subtalar Glide Test
  28. 28. • Functional Tests – While weight bearing the following should be performed • Walk on toes (plantar flexion) : painful • Walk on heels (dorsiflexion) : painful • Walk on lateral borders of feet : painful • Walk on medial borders of feet :painful • Hops on injured ankle : he can”t • Passive, active and resistive movements : painful
  29. 29. Rapport of examination There is little swelling around the medial and lateral malleolus .all movement are painful and he is able to dorsi-flex to neutral and plantar flex to about 45 degree All test are painful over the lateral and medial ankle It’s very tender over deltoid ligament ,anterior joint line distal tibio fibular joint as well as the lateral ligaments
  30. 30. Radiography
  31. 31. MRI
  32. 32. INVESTIGATIONS • X-ray were reviewed and appear normal • MRI shows grade 3 ATFL tear ,high grade CFL tear and some DELTOID ligament signal change • No bony injury and AITFL • SYNDESMOSIS is intact • There is a small osteochandral injury to the lateral talar dome
  33. 33. DIAGNOSIS AND MANAGEMENT • He appears to have sustained a high grade tear of the lateral ligaments with involvement of the deltoid ligament and possibly distal tibiofibular joint as well • No bone injury and injury to the distal tibiofibular joint which showed the • Review in two weeks above
  34. 34. Physical therapy and treatment • The most important factors is swelling and pain • If these factors are reduced ,you can take a faster results • The difference between the players are the reduced of swelling and the control of pain • 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
  35. 35. Swelling vs pain Day Swelling (right / left) Pain /vas Day 1 39/36 10 Day 3 38.75/36 10 Day 6 38.22/36 9 Day 9 38.00/36 9 Day 12 37.80/36 8 Day 15 37.55/36 7 Day 18 37.25/36 6 Day 21 37.00/36 5 Day 25 36.45/36 3
  36. 36. Chart
  37. 37. The most important phase • R.I.C.E. 12 to 72 hrs. Grade II • Immobilization 1 to 2 weeks Grade II • Splinting/Bracing 1 to 4 weeks Grade II • Physical Therapy 3 to 12 weeks Grade II
  38. 38. Joint Flexibility – Decreased joint flexibility results from: • muscle spasm, pain (Therapeutic exercise with cold) • connective tissue adhesions (Therapeutic exercise with heat) – When 80% of flexibility is restored rehabilitation emphasis moves to the development of muscular strength
  39. 39. Muscular Strength – Must perform a progressive resistive exercise on a regular basis. – Each side of the body should be worked independently. – Once strength in the injured side is 90% of the non-injured side, emphasis moves to the development
  40. 40. Closed Chain Ankle Strength Exercises
  41. 41. Muscular Endurance – Stationary bike – Running when tolerated (jog 400 meters first day and increase by 400 meters each 1 or 2 days) – When athlete can run 1 mile emphasis should move to next phase
  42. 42. • Muscular Speed – high intense stationary bike – Cybex • Muscular Power – Isokinetic devices – high- speed resistive work
  43. 43. TAPING heel and lace pads Angle tape to avoid wrinkles medial to lateral direction First step of lateral heel lock Second step of lateral heel lock First horseshoe Final step of lateral heel lock Figure of eight Completed tape job
  44. 44. THANK YOU
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