The document provides details on a case history presentation for a 14-year-old soccer player named Nasser Naimi who injured his right ankle. It describes the anatomy of the ankle bones including the tibia, fibula, and talus. It outlines Nasser's injury occurring from being kicked on the outside of his ankle during a game. On examination, he had swelling, bruising, pain on all ankle movements and stability tests. Imaging showed a grade 3 tear of the ATFL ligament and high grade CFL tear. The diagnosis was lateral ligament tears and he was prescribed physical therapy including RICE treatment, bracing, and exercises to restore flexibility, strength, and function over 12 weeks.

1. CASE HISTORY PRESENTATION
HOUSSEM EDDINE MECHRI
NSMP STAFF

2. Ankle
• Anatomical Structures
– Tibia
– Fibular
– Talus

3. Tibia
• This is the strongest largest bone of the lower leg. It bears weight and
the bone creates the medial malleoli .

4. Tibia
The Tibia is the medial
bone and largest bone of
the lower leg.

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. 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. 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. ------
Talus

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. ________________
Talocrural Jt.
________________

11. Subtalar Joint
• The articulation between the talus and the calcaneus is referred to as
the subtalar joint.

12. Medial aspect of foo
Talus
---Subtalar Joint
calcaneus

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. 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. <- Fibula
Post. Tibiofibular Lig.
<- Ant. Talofibular Lig
Calc
an e
ofib
Liga
ular
men
t
Calcaneus
<- Talus
 Subtalar Joint
Space
Peroneal
Tendons
Cuboid

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. 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. 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. 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. 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. 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. • 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. Compression Test
Homan’s Test
Percussion Test
Thompson Test

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. Anterior Drawer Test
Talar Tilt Test

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. Kleiger’s Test
Medial Subtalar Glide Test

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. 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. Radiography

31. MRI

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. 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. 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. 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. Chart

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. 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. 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. Closed Chain
Ankle Strength Exercises

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. • Muscular Speed
– high intense stationary bike
– Cybex
• Muscular Power
– Isokinetic devices
– high- speed resistive work

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. THANK YOU