mohamed aouini - physiotherapist

1. Case review presentation
MEDIAL ANKLE SPRAIN
MOHAMED AOUINI
NSMP PHYSIOTHERAPIST

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

3. Ankle
Anatomical structure
Tibia
Fibula
Talus

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

6. 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 .

8. 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

10. 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

12. Ankle ligaments and roles
There are three lateral ligaments Responsible for the support
and maintenance of bone apposition
These 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.

14. 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-navicular
Middle tibio-calcanean
Psoterior tibio-talar
Deep part: it is also called as tibio-talar ligament attached on
the anterior part of the medial surface of talus

15. 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.

17. 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.

18. 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

19. 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.

20. 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

21. • Inspection
_ player walk with pain in the medial side
_ no deformity
_ there is swelling in the medial side

23. • Palpation
_ tenderness on the deltoid ligaments
_ no pain on the :malleoli, navicular bone ,fibula
head .

24. • R.O.M
_ Normal range of motion

25. • 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

27. 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

28. Recent investigation
_ X-Ray : there is no bony articular or soft tissue
abnormality
_ Ultrasound:
The ATFL and CFL are normal
There is no syndesmotic injury
There is thickening of the anterior superficial of
the deltoid ligament ( Grade 1 )
There is no tenosynovitis

29. DIAGNOSIS
_ There is thickening of the anterior superficial
of the deltoid ligament ( Grade 1 )
_ no bone injury

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

31. 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

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

33. 8
7 7 7
6
5
4
3
2
2
1 1
0 0
59.5
59.23
59.5 59.5
59.2
58.7
58.25
58
57.6
57.2
57 57 57 57
55.5
56
56.5
57
57.5
58
58.5
59
59.5
60
0
1
2
3
4
5
6
7
8
9
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
Pain Vs Swelling
pain Swelling( right/ left)

34. 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.

35. 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.

36. 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

37. Muscular Endurance
– Stationary bike .
– Running when tolerated ,jogging gradually .

38. neuro muscular control
_ open kinetic chain
_ close kinetic chain

39. Taping
_ As level 1 technique

40. After before

41. 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 .

42. Thank you