This document discusses various ligamentous and tendinous injuries around the ankle. It begins by describing the anatomy of the medial and lateral ankle ligaments, as well as the syndesmosis ligaments. It then discusses the evaluation and treatment of common ankle injuries like ankle sprains, syndesmotic injuries, Achilles tendon ruptures, and peroneal tendon dislocations. For many of these injuries, the summary includes the typical mechanisms of injury, physical exam findings, imaging studies, and both non-operative and surgical treatment options and their supporting evidence.

1. LLiiggaammeennttoouuss aanndd TTeennddoonn
IInnjjuurriieess AAbboouutt tthhee AAnnkkllee
UCMC Trauma Conference 5/2/12

2. Talus

3. Medial
 Superficial
Superficial
talotibial,
naviculotibial, and
calcaneotibial
fibers
 Deep
–Deep anterior
talotibial and
posterior talotibial
fibers from
posterior colliculus
to talus
–Strongest portion
of the Deltoid
ligament

4. Lateral Collateral
Ligaments
 Anterior Talofibular
Ligament
– First injured in
lateral sprain
with
plantarflexed
ankle
 Calcaneofibular
Ligament
– Strongest
lateral ligament
– First injured in
lateral sprain
with dorsiflexed
ankle
 Posterior Talofibular
Ligament

5. Syndesmosis
 Anterior inferior
tibiofibular
ligament
 Posterior inferior
tibiofibular
ligament
 Transverse
tibiofibular
ligament
 Interosseous
membrane

6. Ankle Sprains
 Most common ligamentous injury
 One sprain per day per 10,000 people
 40% will have intermittent chronic problems (Garrick, Am J Sports Med, 1977)
 More common on the lateral aspect of the ankle

7.  Physical Exam
– Palpation over medial and
lateral malleoli
– Palpation over deltoid ligament
– Palpation over ATFL, CFL, and
PTFL
– Neurovascular exam
– Anterior drawer test for ATFL
– Talar tilt to assess CFL
– Squeeze test to look for
syndesmotic injury
EXAM

8.  Most common mechanism of ankle
injury is inversion stress with
plantarflexion
– May lead to ankle fracture,
sprain, or syndesmotic injury
 Abduction or adduction are other
mechanisms

9.  AP of the Ankle
– Tibio-Fibular Clear
Space
 AB < 5mm is
normal
– Tibio-Fibular
Overlap
 BC > 10 mm is
normal

10.  Mortise View
– Ankle internally
rotated
– AB clear space
– BC overlap
– Talocrural angle (83
degrees)
– Medial clear space
<4 mm

11. Ankle Stress
Radiographs
 Talar tilt view
– Demonstrates complete
ligamentous instability
– Talar tilt <2 mm
 External rotation view
– Useful in identifying
syndesmotic injury

12. Ankle Stress
Radiographs
Anterior drawer
stress view
– No fracture seen
– >3 mm anterior
translation compared
to contralateral side
or >10 mm
translation
– Incongruency of
ankle joint present
– Ligamentous
instability present

13. Lateral Ankle Sprains
 Commonly missed diagnoses
– Peroneal tendon injuries
– Achilles injuries
– FX’s
 Lateral process of talus
 Anterior process of
calcaneus
 Fifth metatarsal
 Lisfranc injuries
– Osteochondral Lesion of the
Talus

14. Lateral Ankle Sprains
Lateral Process FX of the Talus
“Snowboarders” injury

15. Ankle Sprain Treatment
 RICE ROM exercises
 Peroneal strengthening and proprioceptive training

16. Ligament Reconstructions
 These procedures use the peroneal tendons to
reconstruct the lateral ligamentous complex
 Higher complication rates than Brostrom
 More restricted ankle and subtalar motion (Colville, JAAOS,
1998)

17. Medial Ankle
Sprain
 5% ankle sprains
 Forced eversion
 Injury to deltoid ligament
 May be associated with
syndesmotic injury
and/or Weber C fibula
FX

18. Syndesmotic (High) Ankle Sprains

19. Syndesmosis
Exam
 Squeeze Test
– Squeeze the
syndesmosis above the
ankle®pain
 Abduction-External Rotation
Stress Test
– Further instability with
external rotation (may be
shown with x-ray)
 Gravity Stress Test
– Foot hanging free in
lateral position with
mortise view taken

20. Stress Radiograph -
Technique

21. Stress View
SER-2
+ Stress View
Negative Stress view
External Widened Medial rotation Clear
of foot
with ankle Space
in neutral
flexion (00)
Stable  Treatment
FWBAT

22. Syndesmosis Injury
 Surgical Treatment
– Maximally dorsiflex
hindfoot
– Reduce the syndesmosis
with a large clamp under
fluoro by internally
rotating the fibula and
compressing it to the
tibia
– Perform medial
arthrotomy if unable to
reduce in order to
debride medial ankle
joint

23. Fixation
Screws are not
lagged!

24. Syndesmosis Controversies
Number of Screws
– One vs. two, 3.5 mm screw vs. 4.5 mm
screw
Number of Cortices
– Three vs. four cortices
Ankle position during placement
– Classically dorsiflexion was advocated
– Tornetta showed no difference with
plantarflexion

25. EEnnddoobbuuttttoonn aanndd HHeeaavvyy SSuuttuurree
– PPootteennttiiaall BBeenneeffiittss
 fflleexxiibbllee ffiixxaattiioonn,, nnoo nneeeedd ffoorr iimmppllaanntt
rreemmoovvaall,, eeaarrlliieerr wweeiigghhtt bbeeaarriinngg
 IImmpprroovveedd ssuubbjjeeccttiivvee oouuttccoommeess ssiimmiillaarr
oobbjjeeccttiivvee oouuttccoommeess

26. Ankle Dislocations
 Isolated ankle dislocation is rare
 Mechanism is forced inversion
that results in a posteromedial
dislocation
 Anterolateral ligaments
damaged
 Commonly open 30 - 90%
 Rule out neurovascular injury

27. Tibiotalar
Dislocations
 Management closed
injury
– Check neurovascular
status
– Prompt closed
reduction
– Cast for 6 weeks in
plantigrade position
– Results generally
good
– Results not improved
with acute ligament
repair
– Late instability rare

28. Achilles Tendon Ruptures
 AAnnaattoommyy
– 1100-1122 ccmm lloonngg
– 00..55-11..00 ccmm ddiiaammeetteerr
– AAvvaassccuullaarr zzoonnee 22-66 ccmm pprrooxxiimmaall ttoo
iinnsseerrttiioonn
– FFiibbeerrss rroottaattee 9900 ddeeggrreeeess aatt iinnsseerrttiioonn

29. Achilles Tendon Rupture
– Acute pain in the back of the ankle with contraction, no antecedent history of calf or heal pain
– Average age 35
– Steroids, fluorquinolones, and chronic overuse may predispose to rupture
Pathology
– Rupture occurs 3-4 cm above the Achilles insertion in a watershed area

30. Achilles Tendon Rupture
 Physical Exam
– Tenderness over
achilles tendon
– Palpable defect
– Positive Thompson’s
test
– No evidence to support
routine use of MRI,
U/S, or Xray

31. Achilles Tendon Ruptures
 SSuurrggiiccaall rreeppaaiirr
– YYoouunnggeerr aaccttiivvee ppaattiieennttss
 NNoonnooppeerraattiivvee ttrreeaattmmeenntt
– OOllddeerr sseeddeennttaarryy ppaattiieennttss
– PPaattiieennttss wwiitthh iinnccrreeaasseedd rriisskk ooff ssoofftt ttiissssuuee ccoommpplliiccaattiioonnss
 IIDDDDMM
 SSmmookkeerrss
 VVaassccuullaarr ddiisseeaassee
 BBMMII >> 3300

32. Management of Non-Operative
Tx Short leg cast strategy (SLC)
– SLC is applied w/ ankle in plantarflexion
– Cast is brought out of equinus over 8-10
weeks
– Walking is allowed (in the cast) at 4-6 weeks
– Alternatively, consider using functional brace
starting in 45 degrees of flexion
– Following casting, a 2 cm heel lift is worn for
an additional 2-4 months
Long leg cast (LLC)
– Initial LLC in gravity equinus for 6 weeks,
followed by short leg cast for 4 weeks

33. Clinical Evidence to Support Nonoperative Treatment
 Benefits: no wound complications, no scar, decreased patient cost.
 Disadvantage: up to 39% re-rupture rate, increased patient dissatisfaction, decreased power, strength and
endurance.
 Gillies and Chalmers-
– 80% vs. 84.3% return of strength compared to unaffected side, non-op and operative, respectively
 Wills, 775 patients the overall complication rate of surgically treated Achilles tendon ruptures was 20%.
– skin necrosis, wound infection, sural neuromas, adhesions of the scar to the skin, and the usual
anesthesia risks

34.  SSuurrggiiccaall ttrreeaattmmeenntt
– PPrreeffeerrrreedd ffoorr
aatthhlleetteess
– MMeeddiiaall iinncciissiioonn
aavvooiiddss tthhee ssuurraall
nneerrvvee
– PPeerrccuuttaanneeoouuss vvss..
OOppeenn ttrreeaattmmeennttss
ddeessccrriibbeedd
– IIssoollaattee tthhee
ppaarraatteennoonn aass aa
sseeppaarraattee layer

35. CClliinniiccaall RReessuullttss SSuurrggiiccaall
RReeccoonnssttrruuccttiioonn
 BBeenneeffiittss:: 00--55%% rree--rruuppttuurree rraattee,, >> ppeerrcceennttaaggee ppaattiieennttss
rreettuurrnn ttoo ssppoorrtt,, iimmpprroovveedd ppoowweerr,, ssttrreennggtthh,, aanndd eenndduurraannccee..
 DDiissaaddvvaannttaaggeess:: >> ppaattiieenntt ccoosstt aanndd wwoouunndd ccoommpplliiccaattiioonnss
 CClliinniiccaall sseerriieess:: mmaannyy tteecchhnniiqquueess
– MMoosstt BBuunnnneell oorr MMooddiiffiieedd KKeesssslleerr ssuuttuurree
– SSoommee wwiitthh aauuggmmeennttaattiioonn EEHHLL vvss.. GGaassttrrooccnneemmiiuuss

36. Operative Support
 Cetti et al. compared operative versus
non-operative treatment in a prospective
study with 111 patients
– In the operative group (56
patients), there were three re-ruptures
(5%) and two deep
infections, as compared with eight
re-ruptures (15%) in the non-operative
group (55 patients)
– The operative group had a
significantly higher rate of
resuming sports activities at same
level prior to rupture (57.1% vs
29.1% of pts), a lesser degree of
calf atrophy (1.6 cm vs 1.1 cm calf
circum.), significantly fewer
complaints at 1 year (29% vs 49%
of pts), and better ankle movement
at 1 year (82% vs 53% of pts, op
vs non-op, respectively)

37. Percutaneous Achilles Repair

38. Chronic Achilles Tendon
Rupture
 History
– Remote hx trauma, post
pain, gradual improvement
of symptoms, palpable
tendon defect.
– No hx trauma, gradual
thickening of tendon, AM
startup pain, pain
ascending/descending
stairs.
 Physical Exam
– “Hatchet” posterior calf at
site of defect at resolution of
swelling
– Positive Thompson test
– Weakened plantar flexion

39. MRI
 <3 cm gap, <3 months old—
primary repair
 >3cm gap—scar tissue
debridement and V-Y lengthening
of proximal gastroc tendon granted
that remaining tissue no evidence
inflammation
 Evidence chronic inflammation—
augmentation with FHL tendon

40. Chronic Achilles Rupture
Chronic rupture may
be reconstructed
with FHL, FDL, or
slip from
gastrocnemius

41. Achilles Tendon Ruptures
Reconstruction of neglected rruuppttuurree wwiitthh
ppeerroonneeuuss lloonngguuss aanndd ppllaannttaarriiss wweeaavvee

42. V-Y Lengthening: >3 cm
Debride necrotic tissue
Advance Tendon
Suture Repair

43. FHL Transfer: >3cm with
tendinopathy
•Reflect abductor
hallucis and flexor
hallucis brevis
•FHL medial to FDL

44. FHL Transfer
Tag each end
of tendon

45. FHL Transfer
Distal FHL sutured to FDL with
ankle and toes in neutral
Confirm full hallux MTP dorsiflexion, otherwise
retension and residual clawing

46. FHL Transfer

47.  PPeerroonneeaall tteennddoonnss ccoouurrssee bbeehhiinndd tthhee ddiissttaall
Peroneal TTeennddoonn DDiissllooccaattiioonn
ffiibbuullaa
 TThhee ppeerroonneeuuss bbrreevviiss mmaayy hhaavvee
ddeeggeenneerraattiivvee cchhaannggeess iiff tthhee iinnjjuurryy iiss nnoott
iiddeennttiiffiieedd iinn aa ttiimmeellyy ffaasshhiioonn

48. Peroneal Tendon Dislocation
X-ray
– May show avulsion of retinaculum from
fibula
Conservative treatment
– Casting in slight plantarflexion and
inversion for 6 weeks non weight bearing
– Allows the retinaculum to heal if the
tendons can be reduced closed
– Successful if the injury is identified early

49. PPeerroonneeaall TTeennddoonn DDiissllooccaattiioonn  SSuurrggeerryy
– OORRIIFF rreettiinnaaccuullaarr ppiieeccee iiff ppoossssiibbllee
– RReeppaaiirr rreettiinnaaccuulluumm iiff ppoossssiibbllee
– SSoofftt ttiissssuuee rreeccoonnssttrruuccttiioonn wwiitthh sslliinngg ffoorr
rreettiinnaaccuulluumm

50. Peroneal Tendon Dislocation

51. Peroneal Tendon Dislocation

52. Posterior Tibial Tendon Rupture
 AAnnaattoommyy
– AArriisseess ffrroomm ppoosstteerriioorr aassppeecctt iinntteerrmmuussccuullaarr sseeppttuumm
– IInnsseerrttss oonn ttaarrssaall bboonneess
– AAvvaassccuullaarr zzoonnee ppoosstteerriioorr ttoo mmeeddiiaall mmaalllleeoolluuss
– HHiigghh ffrriiccttiioonnaall llooaadd ppoosstteerriioorr ttoo mmeeddiiaall mmaalllleeoolluuss

53. Posterior Tibial Tendon Rupture
 Function
– Inverter of hindfoot
– Locks transverse tarsal joint
– Maintains height longitudinal arch
– Maintains neutral position of hindfoot at degrees

54. Posterior Tibial Tendon
 History
– More commonly an attritional rupture over time than an acute rupture
– Patient may complain of flat foot and midfoot pain
– Sports with quick changes of direction may put increased force on tendon
 X-ray
– Foot x-ray may show medial talar displacement

55. AP Radiograph
 Talonavicular
coverage- as arch
collapses the talarhead
coverage by the
navicular is lost
Talus-1st MT
diverges or angle
increases
Anterior
talocalcaneal
angle increases

56. Lateral Radiograph
A. Increased Talus-forefoot
angle
B. Increased Talus
Calcaneous angle
- plantarflexed talus
C. Decreased Calcaneal
Pitch
Negative Med Cun-5th MT
- normally the 5th MT is
more plantar than the
medial cuneiform
A
B
C

57. Talus-1st MT and Calcaneal
Pitch
Colinear Talus-1st
MT
Normal calcaneal
pitch
Divergent Talus-
1st MT
Loss of calcaneal
pitch

58. Posterior Tibialis Reconstruction
Surgery for the
flexible deformity
– Reconstruction of the
posterior tibial
tendon with FDL or
FHL
– Medial calcaneal
wedge osteotomy or
lateral column
lengthening through
the calcaneus
– Fig 14, page 1705 from “Acquired adult
flatfoot deformity” in Orthopaedics, 2002

59. Posterior Tibial Tendon Rupture
Chronic rupture
– Develop gradually
– Women over 40
– Tenderness/swelling
over tendon
– Forefoot abduction
– “too many toes” sign
– Absent single heel
raise
–Loss
of
height
of arch
–Hindfoot valgus

60. Posterior Tibial Tendon Rupture
 Chronic rupture
– Stage I
 Pain, weakness, no
deformity
– Stage II
 Flexible flatfoot deformity
– Stage III
 Rigid flatfoot deformity
 Radiographic
subluxation/arthritis

61. Posterior Tibial Tendon Rupture
Management
– Chronic rupture
Stage I
– Nonop (NSAID, arch support, AFO)
– Tenosynovectomy if SXs persist
Stage II
tenosynovectomy
– nonop (medial wedge, arch support, or AFO)
– Surgical TX controversial
– Reconstruction utilizing FDL or split anterior tibial tendon
– Deformity frequently recurs
– Calcaneal osteotomies hold promise

62. Thanks!