Footballer s ankle current management

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1 Footballer s ankle current management Sakari Orava professor,, MD, PhD 1

2 Ankle and football biomechanics Forced plantarflexions Forced eversions Rotations Landing from jumps Sudden stops Change of running directions Contusions, twistings 2

3 Footballer s ankle Classically end stage of soccer player s ankle after recurrent traumas and overuse Talo-tibial osteophytes Arthrosis Synovitis Instability Stiffness, swelling, nerve pains, tendon pains e.t.c 3

4 Ankle problems in soccer fractures, chondral lesions ligament injuries, late instability synovitis talotibial exostoses loose bodies, osteochondromatosis os trigonum tali problems meniscoidal lesions anomalous syndesmosis ligament rupture and pain of anterior sndesmosis differential dg stenosing tenosynovitis of FHL tendon tibialis post. tendon tibialis ant. tendon peroneal tendon problems OD or marginal fracture of talus posteror impingement ganglions tarsal canal syndrome and other nerve pains 4

5 Etiology: overuse, distorsion, direct blow, instability, spur formation, loose bodies, hemarthron anterior impingement DG: clinical examination, radiographs,, MRI Anterior synovitis 5

6 MENISCOIDAL LESIONS soft tissue impingement in the ankle joint ligamentous injuries flaps haemarthron fibrin clots, synovitis, foreign bodies joint debris at malleolar areas: impingement, friction, inflammation, pain 6

7 NSAIDS Rest Treatment of synovitis and meniscoidal lesions Cold, physiothrapay Corticosteroid injections Arthroscopic / open debridement Ligament plasty (unstable ankle) 7

8 Talo tibial exostoses Etiology: plantar-, dorsiflexion injuries, ligament instability,, sport (soccer( soccer) --- anterior impingement, associated synovitis, loose fragments may occur DG: radiographs (oblique views), MRI 8

9 Talotibial exostoses anterior impingement posterior impingement Therapy: -- corticosteroid injections -- a-scopic or open debridement 9

10 Loose bodies in the ankle joint ETIOLOGY: 1. TRAUMATIC ETIOLOGY - marginal fracture of talus or malleoli, - fracture of talotibial exostoses - bony ligament avulsions 2. CHRONIC STRAIN - talo tibial exostoses - os trigonum talii post. - OD with loose fragment(s) 3. OSTEOCHONDRO- MATOSIS - chronic synovitis - rheumatic disease 4. MENISCOIDAL LESIONS - soft tissue bodies 10

11 OD of the ankle: 1. juvenile osteochodrosis 2. marginal fracture after ankle injuries 11

12 Osteochondral OD lesions in the ankle joint 12

13 Os trigonum talii posterior - Os trig. talii post. - usually symptomfree - painful after ankle injuries - posterior impingement - FHL tenosynovitis - fibrotic, calcified posttraumatic scar - variation of sizes - in dancers, jumpers, soccer players TREATMENT: posterior arthroscopic removal syndrome 13

14 Flexor Hallucis Longus Tendon problems stenosing tenosynovitis tendinosis Partial / total tear Pain at the posteromed. ankle, swelling, stiffness, clicking, weakness TH: stretching, technique technique (dance, sports), physiotherapy, NSAIDs, corticosteroid injections, surgery (arthroscopic oper.) 14

15 Stress fractures around the ankle STRESS FRACTURE OF --- distal fibula --- medial malleolus --- distal tibia --- talus --- calcaneus --- cuboid bone --- navicular bone 15

16 Stress fracture of medial malleolus in jumpers, runners, sprinters, decathletes, soccer players diffuse medial ankle pain displaced fracture sometimes initial radiographs negative isotope scan + MRI + Treatment: rest, immobilization, surgery 16

17 Bone oedema in the ankle Posttraumatic overuse etiology Talus, calc., distal tibia, med. mall., fibula, cuboid. Before real stress fracture TH: rest, time, medic?, drilling 17

18 Os trigonum talii post Accessory navicular Apophysis of MT V TH: removal, refixation of tendon Excessive bones 18

19 ANOMALOUS ANTEROR SYNDESMOSIS LIGAMENT = anterior syndesmosis ligament causes friction on the anterior lateral talar corner structural anomaly posttraumatic fibrosis diffuse anterior later. pain, swelling, clicking TREATMENT: mobilization, corticosteroid inj., arthroscopic excision (similarity with medial plica of knee joint) 19

20 Peroneal tendon problems peroneus tenosynovitis stenosing tenosynovitis (at lat.calc.exost.).) partial tendon tear (split tear, longitudinal) tendon rupture subluxation, luxation anomalies (accessory peron. tendon) TREATMENT: NSAIDs, corticoster. Inj. SURGERY: - division of tenosynovia - suturation of tendon - plastic repair, tenodesis to fibula (Evans) 20

21 Surgical treatment of peroneal tendon split tears - suturation of longitudinal split tear - tenodesis with half or whole peroneus brevis tendon (a.m.. Evans) - suturation of the tendons together proximally 21

22 TIBIALIS POSTERIOR TENDON partial tear and dysfunction sdr overuse (f.ex. high jump) tendinosis partial tear dysfunction together with deltoid and talo-navicular ligament insufficiency stress microtear subluxation luxation tenosynovitis problems related to accessory navicular bone - dg with clinical,, US echo,, MRI examinations - Treatment: technique, orthosis, NSAIDs, costicoster., surgery 22

23 ANTERIOR TIBIAL TENDON 1. Chronic overuse tenosynovitis 2. Crepitating acute and chronic tenosynovitis 3. Extension to anterior tibial syndrome 4. Partial tear 5. Total tear or distal avulsion TREATMENT: NSAIDs, immobilization, rest, stretching, strength training.. SURGERY: division of tendon sheath / fascia, repair of the tendon, refixation, tendon graft 23

24 Ankle ligament injuries Lateral Medial - uncommon, but typical to soccer players TH: : ICE, rest, rehab, follow up, late surgery 24

25 Tarsal canal / tunnel syndrome pain on medial aspect of ankle radiation proximally and distally Tinell sign + ENMG + or TREATMENT: antivalgus orthosis, local NSAID, corticoster.inj.,., surgery: division of flexor retinaculum / tendon sheaths good hemostasis, liberation of nerve(s) 25

26 Other nerve entrapments around Etilogy: - injuries - immobilization - surgery - overuse - microtrauma - individual tendency (diabetes, fragile nerve syndrome ) SURAL, SUPERFICIAL and DEEP PERONEAL nerves TREATMENT: mobilization, nerve stretching, silicone pad, NSAID locally, corticoster.inj.,., surgical release or excision ankle 26

27 Entrapment or stretch tear of superficial peroneal nerve proximal lesion at the fascial opening direct trauma or overuse distal lesion after ankle inversion plantar flexion inury or direct trauma 27

28 Entrapment of deep peroneal nerve anterior tarsal canal syndrome lesion due to direct trauma, overstretching or irritation by osteophytes 28

29 Entrapment of suralis nerve lateral to achilles tendon over peroneal tendons distally on lateral foot Caused by direct trauma, overuse or surgery - Neuromas possible 29

30 GANGLIONS OF ANKLE anterior / anterolateral ganglions inside peroneal tendon sheaths posterior deep ganglion (often( associated with os trig. talii sdr) TREATMENT: - NSAIDs, corticosteroid injections, compressive orthosis, tape, surgical removal 30

31 Conservative treatment of ankle Manual mobilization and treatment Local trigger point treatments US-, electrotherapy LPG-, lymphatic oedema treatments Balance training Strength training, especially toes and peroneii Mobility stability exercises Tape, support, orthosis Shoe-, sole corrections 31

32 Prevention of ankle injuries and pains in athletes ankle and foot mobility ankle and foot stability balance coordination lower leg, ankle, foot muscle training good footwear correction of malpositions pre-sports carieer evaluation (?) 32

33 MANY THANKS 33

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