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MOB TCD
Functional Anatomy ofthe Ankle Joint Complex
Professor Emeritus Moira OBrien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
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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.Brstrom, 1966
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Tennis
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Dorsiflexion and plantarflexion take place at the
ankle joint
In plantar flexion there
is some side-to-sidemovementLast, 1963
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The Ankle JointMOB TCD
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Inversion and Eversion
Initiated at the transversetarsal joint
A radiological term
Calcaneo-cuboid
Anterior portion of thetalocalcaneonavicular
Amputation at this joint,
no bones are cut
Last, 1963
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Main movement takeplace at the clinical
sub-talar joint i.e.:
Talocalcaneal
Inferior portion of thetalocalcaneonavicular
The pivot is the ligament
of the neck of the talus
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Inversion and Eversion
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A uniaxial, modifiedsynovial hinge joint
Proximally the articulation
depends on the integrity of
the inferior tibiofibular joint Close pack
DorsiflexionWilliams & Warwick, 1980
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In the anatomical positionthe axis of the ankle joint
is horizontal
But is set at 20-25
obliquely to the frontal
plane
Running posteriorly as it
passes laterallyPlastanga et al., 1990
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The Ankle JointMOB TCD
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In dorsiflexion the foot movesupwards and medially
Downwards and laterally in
plantar flexionPlastanga et al., 1990
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The Ankle JointMOB TCD
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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 inferiorlyWilliams & Warwick, 1980
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Proximal Articulation
The inferior transverse tibiofibularligament
Deepens it posteriorly
Passes from the lower margin of
the tibia To the malleolar fossa of the fibulaWilliams & Warwick, 1980
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Proximally the articulationdepends 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 SurfaceMOB TCD
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Distal Articular Surface
The superior surface of the bodyof 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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The talus has no musclesattached to it
Has a very extensive articular
surface
As a result fractures of the talusmay result in avascular necrosis
of either the body or the headOBrien et al., 2002
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Distal Articular Surface
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Posterior Aspect of Talus
Two tubercles Groove contains flexor
hallucis longus
Medial tubercle is smaller
Lateral is larger, posteriortalofibular ligament attached
7% separate ossification called os
trigonum
There is a triangular facet on theposterior surface which articulates with the inferior
transverse tibiofibular ligament
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Congenital Abnormalities
Congenital abnormalities includeos 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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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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Capsule
Is attached just beyond thearticular margin
Except anterior-inferiorly
Attached to the neck of the
talusWilliams & Warwick, 1980
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The capsule is thin and weakin 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 talusWilliams & Warwick,1980
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The Ankle JointMOB TCD
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The Posterior Ligament
The posterior ligament fibres passfrom: 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 ligamentsWilliams & Warwick,1980
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The Medial (Deltoid) Ligament
A strong triangularligament
Superiorly attached
The medial malleolus of
the tibiaWilliams & Warwick, 1980
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Medial Ligament
Inferiorly, ant-post The tuberosity of the
navicular
Neck of talus
The free edge of thespring ligament
The sustentaculum tali
The body of the talusLast, 1963
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Medial or Deltoid Ligament
(Superficial)
Crosses two joints
Anterior tibionavicular
pass to the tuberosity of
the navicular
The free edge of thespring ligament
The middle fibres, the
tibiocalcaneal are
attached to thesustentaculum tali
Williams & Warwick, 1980
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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 ligamentWilliams & Warwick, 1980
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Lateral Ligaments of Ankle
The anterior talofibularligament
(ATFL)
The calcaneofibular
(CFL) The posterior talofibular
(PTF)
They radiate like the spokes
of a wheelLiu & Jason, 1994
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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 inferiorborder 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
equinusLiu & Jason, 1994
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It is the weakest ligament Strain increases with
increasing plantar flexion
and inversion
The AFTL is a primarystabiliser against inversion
and internal rotation for all
angles of plantar flexionLiu & Jason, 1994
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The ATFL
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The anterior draw teststhe ATFL
Test should be done
with the ankle in 10o-20o
plantar flexion
Low loads
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Test for the ATFL
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A long rounded 20-25 mm
long, 6-8 mm in diameter
It contains the most
elastic tissue
It is attached in front ofthe 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
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It is separated from thecapsule by fibro-fatty tissue
Part of the medial wall of the
peroneal tendon sheath
Crossesboth the ankle andsubtalar joints
The CFL has the highest
linear elastic modulus of the
three ligamentsSiegler et al., 1988
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The CFL
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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
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The CFL
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The Lateral Ligament
The angle between theATFL 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 restraintHamilton, 1994; Peters, 1991
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O C
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ATFL and CFL
A difference of 10o
between the two ankles issignificant.
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 ofthe AFTL and CFL occur in 20%
The CFL is a major stabiliser of the subtalar jointLiu & Jason, 1994
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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
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During plantar flexion theposterior 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
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The PTL
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In 7% of normal populationthe 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
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The Ankle Joint
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Synovial Membrane
Lines the capsule and thenon articular areas
It is reflected on to the neck
Extends upwards between
the tibia and fibula to theinterosseous ligament of the
inferior tibiofibular joint
Covers the fatty pads that
lie in relation to the anterior
and posterior parts of the
capsulePlastanga et al.,1980
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Ankle Stability
The ankle is most stable indorsiflexion, 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
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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
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Ankle Stability
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Blood Supply of the Ankle
Malleolar branches of the
anterior tibial
Perforating peroneal and
posterior tibial arteries
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Nerve Supply of the Ankle
Nerve supply is via articular
branches of the deep
peroneal
Tibial nerve from L4 - S2
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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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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 medialmalleolus
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Anterior Aspect
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Postero-Medial Aspect of the Ankle
Tibialis posterior
Flexor digitorum longus
Posterior tibial vessels
Posterior tibial nerve
Flexor hallucis longus
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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 flexorretinaculum to supply the skin of
the heel
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Postero-Medial Aspect of the Ankle
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Posterior Aspect
Achilles tendon separated bya bursa and pad of fat
Posterolateral portal is lateral
to achilles tendon, sural
nerve and short saphenousvein at risk
Postero-medial not used;
flexor retinaculum structures
at riskJaivin & Ferkel, 1994
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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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Plantar flexion andeversion
Peroneus longus
Peroneus brevis
Dorsi-flexion andeversion
Peroneus tertius
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Lateral Aspect of the Ankle
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Nerves Related to Ankle Joint
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Tibialis Posterior
Superficial Peroneal Nerve
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Movements of Ankle joint
Dorsiflexion is close
packed or stable position
Wider portion of body of
talus between malleoli
Range of 30o
Need 10 o dorsiflexion to
run
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Dorsiflexion
Dorsiflexion is produced by the tibialis
anterior
Extensor hallucis longus
Extensor digitorum longus
The peroneus tertius Deep peroneal nerve
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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
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Plantar Flexion
During plantar flexion
The dorsal capsule
The anterior fibres of the
deltoid
The anterior talofibularligaments 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
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The ankle is most stable
in dorsiflexion, with
increasing plantar flexion
there is more anterior talar
translation (drawer) and
talar inversion (tilt)
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The Ankle Joint
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Examination of Ankle
ATFL
CFL
Distal tibiofibular
Syndesmosis
Deltoid ligament Lateral malleolus
Medial malleolus
Base 5th metatarsal
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Achilles tendon Peroneal tendons
Posterior tibial tendon
Anterior process of calcaneus
Talar dome Sinus tarsi
Bifurcate ligament
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Examination of Ankle
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Ankle Examination
Anterior drawer
Talar tilt
Inversion stress
Squeeze test
External rotation test
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Tests for Ankle Ligament Injury
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Ottawa Ankle Rules
Anteroposterior Oblique
Lateral views
Bone tenderness
Medial or lateral malleolus Unable to weight bear
Four steps post injury
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A F S i i
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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
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Basketball Statistics
53% of basketball injuriesare ankle injuries
30.4 ankle injuries/1000
games
10.0 ankle injuries/seasonfor a squad of twelveGarrick, 1977
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Ri k F t
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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
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Ri k F t
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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
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Risk Factors
A kl I j i
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Ankle Injuries
Lateral ligament sprain
Medial ligament sprain
Peroneal dislocation
Fractures
Dislocations
Tendon rupture
Tibialis posterior
Peroneal tendons
Ruptured syndesmosis
Superficial peronealnerve lesion
Reflex sympathetic
dystrophy
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A kl S i
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Ankle Sprains
Grade one
Stretch of ATFL; mild swelling; no instability
Grade two
Partial macroscopic tear; pain; swelling; mild-
moderate instability
Grade three
Complete tear; severe swelling; unable to weight
bear; limited function; and instability
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Proprioception Theory
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Proprioception Theory
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R d i I j
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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
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