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Page 1: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

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Page 2: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

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MOB TCD

Functional Anatomy of the Ankle Joint Complex

Professor Emeritus Moira O’Brien

FRCPI, FFSEM, FFSEM (UK), FTCD

Trinity College

Dublin

Page 3: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

The Ankle Joint

• The ankle joint is one of the most common joints to be injured.

• The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured.

Bröstrom, 1966

MOB TCD

Page 4: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Tennis

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MOB TCD

Page 5: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• Dorsiflexion and plantar flexion take place at the ankle joint

• In plantar flexion there is some side-to-side movement

Last, 1963

5

The Ankle Joint MOB TCD

Page 6: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Inversion and Eversion

• Initiated at the transverse tarsal joint

• A radiological term• Calcaneo-cuboid• Anterior portion of the

talocalcaneonavicular• Amputation at this joint,

no bones are cutLast, 1963

6

MOB TCD

Page 7: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• Main movement take place at the clinical sub-talar joint i.e.:• Talocalcaneal

• Inferior portion of the talocalcaneonavicular

• The pivot is the ligament of the neck of the talus

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Inversion and Eversion

MOB TCD

Page 8: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• A uniaxial, modified synovial hinge joint

• Proximally the articulation depends on the integrity of the inferior tibiofibular joint

• Close pack• DorsiflexionWilliams & Warwick, 1980

8

The Ankle Joint MOB TCD

Page 9: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• In the anatomical position the axis of the ankle joint is horizontal

• But is set at 20-25º obliquely to the frontal plane

• Running posteriorly as it passes laterally

Plastanga et al., 1990

9

The Ankle Joint MOB TCD

Page 10: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• In dorsiflexion the foot moves upwards and medially

• Downwards and laterally in plantar flexion

Plastanga et al., 1990

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The Ankle Joint MOB TCD

Page 11: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Proximal Articular Surface

• The distal surface of the tibia • which is concave antero-

posteriorly and convex from side to side

• Medial malleolus (comma- shaped facet)

• Lateral malleolus (triangular facet is convex from above downwards apex inferiorly

Williams & Warwick, 1980

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MOB TCD

Page 12: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Proximal Articulation

• The inferior transverse tibiofibular ligament

• Deepens it posteriorly• Passes from the lower margin of

the tibia• To the malleolar fossa of the fibulaWilliams & Warwick, 1980

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MOB TCD

Page 13: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• Proximally the articulation depends on the integrity of the inferior tibiofibular joint

• A syndesmosis• Lateral malleolus is larger,

lies posteriorly• Extends more inferiorly

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Proximal Articular Surface MOB TCD

Page 14: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Distal Articular Surface

• The superior surface of the body of the talus is wider anteriorly

• Convex from before backwards • Concave from side to side • Medial comma-shaped facet• Lateral triangular facetFrazer, 1965

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MOB TCD

Page 15: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• The talus has no muscles attached to it

• Has a very extensive articular surface

• As a result fractures of the talus may result in avascular necrosis of either the body or the head

O’Brien et al., 2002

15

Distal Articular Surface

MOB TCD

Page 16: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Posterior Aspect of Talus

• Two tubercles• Groove contains flexor

hallucis longus• Medial tubercle is smaller• Lateral is larger, posterior

talofibular ligament attached• 7% separate ossification called os

trigonum• There is a triangular facet on the

posterior surface which articulates with the inferior transverse tibiofibular ligament

16

MOB TCD

Page 17: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Congenital Abnormalities

• Congenital abnormalities include os trigonum and tarsal coalition

• Os trigonum in 7% of normal population but in 32% of soccer players

• It is a problem in soccer players, ballet dancers and javelin

• Forced hyperplantar flexion compresses the posterior portion of the ankle and may fracture the lateral tubercle or an os trigonum

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MOB TCD

Page 18: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Articular Surfaces

• Articular surfaces are covered with hyaline or articular cartilage

• Synovial fold which may contain fat

• Fills the interval between tibia, fibula and inferior transverse tibiofibular ligament

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MOB TCD

Page 19: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Capsule

• Is attached just beyond the articular margin

• Except anterior-inferiorly• Attached to the neck of the

talusWilliams & Warwick, 1980

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MOB TCD

Page 20: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• The capsule is thin and weak in front and behind

• The anterior and posterior ligaments are thickenings of the joint capsule

• The anterior runs obliquely from the tibia to the neck of the talus

Williams & Warwick,1980

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The Ankle Joint MOB TCD

Page 21: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

The Posterior Ligament

• The posterior ligament fibres pass from: the tibia and fibula and converge to be attached to the medial tubercle of the talus

• Transverse ligament fibres form the lower part of the posterior part of the capsule, blend with the inferior transverse ligament

• The posterior ligament is thicker laterally

• Capsule is strengthened on either side by the collateral ligaments

Williams & Warwick,1980

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MOB TCD

Page 22: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

The Medial (Deltoid) Ligament

• A strong triangular ligament

• Superiorly attached • The medial malleolus of

the tibiaWilliams & Warwick, 1980

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MOB TCD

Page 23: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Medial Ligament

• Inferiorly, ant-post• The tuberosity of the

navicular• Neck of talus• The free edge of the

spring ligament• The sustentaculum tali • The body of the talusLast, 1963

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MOB TCD

Page 24: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Medial or Deltoid Ligament (Superficial)

Crosses two joints• Anterior tibionavicular

pass to the tuberosity of the navicular

• The free edge of the spring ligament

• The middle fibres, the tibiocalcaneal are attached to the sustentaculum tali

Williams & Warwick, 1980

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MOB TCD

Page 25: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Medial or Deltoid Ligament (Deep)

• The anterior tibio-talar to the nonarticular part of the medial surface of the talus

• The posterior tibiotalar to the medial side of the talus

• The medial tubercle of the talus

• Tibialis posterior and flexor digitorum longus cross ligament

Williams & Warwick, 1980

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MOB TCD

Page 26: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Lateral Ligaments of Ankle

• The anterior talofibular ligament (ATFL)

• The calcaneofibular (CFL)

• The posterior talofibular (PTF)

• They radiate like the spokes of a wheel

Liu & Jason, 1994

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MOB TCD

Page 27: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

The ATFL

• Is part of the capsule • An upper and lower bands• It is cylindrical, 6-10 mm

long and 2 mm thick• The anterior inferior

border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion

• More perpendicular to the talus when the foot is equinus

Liu & Jason, 1994

27

MOB TCD

Page 28: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• It is the weakest ligament• Strain increases with

increasing plantar flexion and inversion

• The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion

Liu & Jason, 1994

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The ATFL MOB TCD

Page 29: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• The anterior draw tests the ATFL

• Test should be done with the ankle in 10o-20o

plantar flexion• Low loads

29

Test for the ATFL MOB TCD

Page 30: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• A long rounded 20-25 mm long, 6-8 mm in diameter

• It contains the most elastic tissue

• It is attached in front of the apex of the fibular malleolus

• Passes downwards and backwards

• To a tubercle on the lateral aspect of the calcaneusWilliams & Warwick, 1980

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The CFL MOB TCD

Page 31: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• It is separated from the capsule by fibro-fatty tissue

• Part of the medial wall of the peroneal tendon sheath

• Crosses both the ankle and subtalar joints

• The CFL has the highest linear elastic modulus of the three ligaments

Siegler et al., 1988

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The CFL MOB TCD

Page 32: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• When the ankle is in the neutral or dorsiflexion, the CFL is perpendicular to the long axis of the talus

• Dorsiflexion and inversion result in an increased strain

• Talar tilt tests the CFL

32

The CFL MOB TCD

Page 33: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

The Lateral Ligament

• The angle between the ATFL and CFL varies between 100o and 135o

• Increasing the potential instability of the lateral ligament

• The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint

Hamilton, 1994; Peters, 1991

33

MOB TCD

Page 34: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

ATFL and CFL

• A difference of 10o between the two ankles is significant.

• A talar tilt of more than 10o is a lateral ligament injury in 99% of cases

• The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20%

• The CFL is a major stabiliser of the subtalar joint

Liu & Jason, 1994

34

MOB TCD

Page 35: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

The Posterior Talar Fibular (PTL)

• The PTL is the strongest part of the lateral ligament

• It runs almost horizontally from malleolar fossa to lateral tubercle of talus

35

MOB TCD

Page 36: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge

• They separate during dorsiflexion• The greatest strain on the

ligament is when the foot is plantar flexed and everted

36

The PTL MOB TCD

Page 37: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• In 7% of normal population the lateral tubercle has a separate ossification and is called an os trigonum

• It occurs in 32% of soccer players

• Tarsal coalition is another congenital abnormality

37

The Ankle Joint MOB TCD

Page 38: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Synovial Membrane

• Lines the capsule and the non articular areas

• It is reflected on to the neck• Extends upwards between

the tibia and fibula to the interosseous ligament of the inferior tibiofibular joint

• Covers the fatty pads that lie in relation to the anterior and posterior parts of the capsule

Plastanga et al.,1980

38

MOB TCD

Page 39: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Ankle Stability

• The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt)

• The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint

39

MOB TCD

Page 40: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• The tibiocalcaneal and the tibionavicular control abduction of the talus

• The calcaneofibular controls adduction• The anterior tibiotalar and the anterior talofibular

ligament control plantar flexion• Posterior tibiotalar and the posterior talar fibular

ligament resist dorsiflexion• Both the anterior tibiotalar and the tibionavicular

control external rotation and with the anterior talofibular internal rotation of the talus

• The anterior talofibular is the primary stabilizer of the ankle joint

40

Ankle Stability MOB TCD

Page 41: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Blood Supply of the Ankle

• Malleolar branches of the anterior tibial

• Perforating peroneal and posterior tibial arteries

41

MOB TCD

Page 42: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Nerve Supply of the Ankle

• Nerve supply is via articular branches of the deep peroneal

• Tibial nerve from L4 - S2

42

MOB TCD

Page 43: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Anterior Aspect

• Dorsi-flexors• Tibialis anterior• Extensor hallucis longus• Anterior tibial becomes the

Dorsalis pedis artery• Deep peroneal nerve • Extensor digitorum longus• Peroneus tertius

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MOB TCD

Page 44: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• The medial branch of the superficial peroneal nerve is superficial to the retinaculum

• The long saphenous vein and the saphenous nerve lie anterior to the medial malleolus

44

Anterior Aspect MOB TCD

Page 45: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Postero-Medial Aspect of the Ankle

• Tibialis posterior• Flexor digitorum longus• Posterior tibial vessels• Posterior tibial nerve • Flexor hallucis longus

45

MOB TCD

Page 46: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• The tibial nerve gives off the medial calcaneal nerve then divides into the medial and lateral plantar nerves

• The medial calcaneal vessels and nerve pierce the flexor retinaculum to supply the skin of the heel

46

Postero-Medial Aspect of the Ankle MOB TCD

Page 47: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Posterior Aspect

• Achilles tendon separated by a bursa and pad of fat

• Posterolateral portal is lateral to achilles tendon, sural nerve and short saphenous vein at risk

• Postero-medial not used; flexor retinaculum structures at risk

Jaivin & Ferkel, 1994

47

MOB TCD

Page 48: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Lateral Aspect of the Ankle

• The inferior extensor retinaculum

• Extensor digitorum brevis• Peroneus longus and

brevis• Peroneal retinaculum• Ligament of the neck of

talus• Bifurcate ligament• Sural nerve• Short saphenous vein

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MOB TCD

Page 49: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• Plantar flexion and eversion• Peroneus longus• Peroneus brevis

• Dorsi-flexion and eversion• Peroneus tertius

49

Lateral Aspect of the Ankle MOB TCD

Page 50: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Nerves Related to Ankle Joint

50

MOB TCD

Page 51: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Tibialis Posterior Superficial Peroneal Nerve

51

MOB TCD

Page 52: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Movements of Ankle joint

• Dorsiflexion is close packed or stable position

• Wider portion of body of talus between malleoli

• Range of 30 o

• Need 10 o dorsiflexion to run

52

MOB TCD

Page 53: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Dorsiflexion

• Dorsiflexion is produced by the tibialis anterior

• Extensor hallucis longus• Extensor digitorum longus • The peroneus tertius• Deep peroneal nerve

53

MOB TCD

Page 54: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Movements of Ankle joint

• Plantar flexion• Some side to side

movement• Narrow portion of body

between malleoli, 50-60 o

• Least pack, unstable position

• Wide variation

54

MOB TCD

Page 55: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Plantar Flexion

• During plantar flexion• The dorsal capsule• The anterior fibres of the

deltoid• The anterior talofibular

ligaments are under maximum tension

• Plantar flexion is caused mainly by the action of the achilles tendon

• Assisted by the tibialis posterior

• Flexor digitorum longus• Flexor hallucis longus• Peroneus longus and

brevis

55

MOB TCD

Page 56: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt)

56

The Ankle Joint MOB TCD

Page 57: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Examination of Ankle

• ATFL• CFL• Distal tibiofibular• Syndesmosis• Deltoid ligament• Lateral malleolus• Medial malleolus• Base 5th metatarsal

57

MOB TCD

Page 58: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• Achilles tendon• Peroneal tendons• Posterior tibial tendon• Anterior process of calcaneus• Talar dome• Sinus tarsi• Bifurcate ligament

58

Examination of Ankle MOB TCD

Page 59: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Ankle Examination

• Anterior drawer• Talar tilt• Inversion stress• Squeeze test• External rotation test

59

MOB TCD

Page 60: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Tests for Ankle Ligament Injury

60

MOB TCD

Page 61: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Ottawa Ankle Rules

• Anteroposterior• Oblique• Lateral views

• Bone tenderness• Medial or lateral malleolus

• Unable to weight bear• Four steps post injury

61

MOB TCD

Page 62: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

A Few Statistics

• Basketball 5.5 ankle injuries/1000 player hours• Netball 3.3 ankle injuries/1000 player hours• Volleyball 2.6 ankle injuries/1000 player hours• Soccer 2.0 ankle injuries/1000 player hoursHopper et al., 1999

62

MOB TCD

Page 63: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Basketball Statistics

• 53% of basketball injuries are ankle injuries

• 30.4 ankle injuries/1000 games

• 10.0 ankle injuries/season for a squad of twelve

Garrick, 1977

63

MOB TCD

Page 64: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Risk Factors

Extrinsic• Training error• Type of sport• Playing time• Level of competition• Equipment• Environmental

Intrinsic

• Malalignment• Strength deficit• Reduced ROM• Joint instability• Joint laxity• Foot type• Height/weight

64

MOB TCD

Page 65: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

• Previous ankle injury Ekstrand & Gillquist, 1983; Milgrom et al., 1991

• Competition Ekstrand & Gillquist, 1983

• Muscle Imbalance Baumhauer et al., 1995

• Mass moment of inertia Milgrom et al., 1991

65

Risk Factors MOB TCD

Page 66: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Ankle Injuries

• Lateral ligament sprain• Medial ligament sprain• Peroneal dislocation• Fractures• Dislocations

• Tendon rupture• Tibialis posterior• Peroneal tendons• Ruptured syndesmosis• Superficial peroneal

nerve lesion• Reflex sympathetic

dystrophy

66

MOB TCD

Page 67: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Ankle Sprains

• Grade oneStretch of ATFL; mild swelling; no instability

• Grade twoPartial macroscopic tear; pain; swelling; mild-moderate instability

• Grade threeComplete tear; severe swelling; unable to weight bear; limited function; and instability

67

MOB TCD

Page 68: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Proprioception Theory

68

MOB TCD

Page 69: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

Reducing Injury

• Proprioceptive • Agility and Flexibility training Ekstrand & Gillquist, 1983

• Taping • Loosens in 10 minutes Garrick, 1977

• Nil effect in 30 minutes? Tropp et al., 1985; Rovere et al., 1988; Sitler et al., 1994

• Bracing

69

MOB TCD

Page 70: 1. 2 MOB TCD Functional Anatomy of the Ankle Joint Complex Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.

“BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

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