Syndesmosis InjuriesInjuriesManny Moore ATS
Syndesmosis InjuriesInjuries
11-18% of all ankle sprains
Longer recovery v.s. Lateral sprains
Men v.s. Women?
BoneBone Anatomy Anatomy
• TibiaArticular Surface
• FibulaArticular Surface
• Talus Dome
Articular Surface
Provides Stability & Proper Ankle Function
SnydesmosisSnydesmosis Ligaments Ligaments
• AIFL- Chaput’s Tubercle Most Vulnerable
• PIFL- Wagstaffe’s Tubercle Strongest
• ITFL- Thickening of PIFL
• IM- Fibrous tissue Transmit force
• IL- Thickening of IM
BioBiomechanicsmechanics• Mechanism of Injury Eversion Dorsiflexion Pronation
• Closed Pack Position Forces the talus against the fibula Widening of mortise
1mm lateral shift increases joint surface pressure by 42%
Associated injuries?
ClinicalClinical Examination Examination
• History ER with DF Contact None Contact
Acute v.s. Chronic
• Observation Edema Eccymosis Antalgic gait Possible Deformity?
ClinicalClinical Examination Examination•Palpation Tenderness Length
•Special Test
Nussbaum et al.
Squeeze TestDorsiflexion Test Kleigers Test Cross-leg Test
Imaging Imaging TechniquesTechniques
X-RAY• Radiographs
AP, Lateral, Mortise Views
• AP View Fractures Tibiofibular clear space widening of 6 mm Tibiofibular overlap > 42% Fibula Width
Medial clear space widening > 4mm• Lateral View
Non weight bearing ER Fractures
Imaging Imaging TechniquesTechniques
X-RAY
Tibiofibula clearance space
Tibiofibula overlap
Medial clear space
Imaging Imaging TechniquesTechniques
X-RAY
Tibiofibula clearance space
Tibiofibula overlap
Medial clear space
Imaging Imaging TechniquesTechniques
X-RAY
• Lateral View
Imaging Imaging TechniquesTechniques
X-RAY
•AP View
Heterotopic Ossification
Imaging Imaging TechniquesTechniques
MRI & CT• MRI (Magnetic Resonance Imaging)
Frontal, Axial, Saggital Views High sensitivity and specificity More reliable detecting disruptions
• CT (Computed Tomography) More effective detecting minor disruptions Less Cost v.s. MRI
Imaging Imaging TechniquesTechniques
MRI
• Axial Views
West PointWest Point Instability ScaleInstability Scale
Edema &Ecchymosis
LocalizedMild
LocalizedModerate
DiffuseSevere
Weight Bearing Ability
Full or Partial Without Significant Pain
Difficult Without Crutches
Impossible Significant Pain
Ligament DamageLigament Stretch Partial Tear Complete Tear
Ligament Involvement
+AIFL +AIFL+ILPossible AD
+AIFL/PIFL+IL+AD
Grade IGrade I Grade IIGrade II Grade IIIGrade III
TreatmentTreatment CriteriaCriteria
• Conservative • Non ConservativeGrade INon-FracturesStable Grade II
Grade IIIUnstable Grade IIFracturesChronic Injury
Based on Patients GoalsLength of SymptomsSeverity of Injury
ConservativeConservative ProtocolsProtocols
Results vary patient to patient
• Grade I Injuries: 2-4 Weeks RTP
• Grade II Injuries: 6-8 Weeks RTP WithoutWithout Instability or Fractures
ConservativeConservative ProtocolsProtocols •Phase I (0-5 Days) or (5-14Days)Phase I (0-5 Days) or (5-14Days)
•ImmobilizeImmobilize•Reduce PainReduce Pain•Reduce InflammationReduce Inflammation•Cryotherapy Cryotherapy •E-StimE-Stim•Increase ROMIncrease ROM•Manual 30* PF StretchManual 30* PF Stretch•Ankle PumpsAnkle Pumps•Toe CurlsToe Curls•Towel StretchTowel Stretch
ConservativeConservative ProtocolsProtocols •Phase II (6-10 Days) or (2-4 weeks)Phase II (6-10 Days) or (2-4 weeks)
•Immobilize Grade IIImmobilize Grade II•Reduce PainReduce Pain•Reduce InflammationReduce Inflammation•ProprioceptionProprioception•Increase FlexibilityIncrease Flexibility•Increase ROMIncrease ROM•Increase StrengthIncrease Strength•CV EnduranceCV Endurance
ConservativeConservative ProtocolsProtocols •Phase III (18-25 Days) or (4-8 Weeks)Phase III (18-25 Days) or (4-8 Weeks)
•Protect InjuryProtect Injury•Reduce PainReduce Pain•Increase Pain free ActivityIncrease Pain free Activity•Sports Specific Sports Specific •ProprioceptionProprioception•Increase StrengthIncrease Strength•Increase FlexibilityIncrease Flexibility•CV EnduranceCV Endurance
ConservativeConservative ProtocolsProtocols •Phase III (18-25 Days) or (4-8 Weeks)Phase III (18-25 Days) or (4-8 Weeks)
•Sports Specific Sports Specific
Drill#1 Drill#2
ConservativeConservative ProtocolsProtocols
Return To Play Criteria
•Full Strength•Full ROM•Functional Test•Physician Clearance•Protect Injury
Operative Operative TreatmentTreatment
Arthroscopy• Goal is to restore structures, and mobility
Open Reduction & Internal FixationsAutographsModified Brostrum Technique4.5 mm Cortical Screws
• Complications
Screw BreakageScrew TypeInfectionCalcification & Joint Stiffness
Operative Operative TreatmentTreatment
Arthroscopy
Before After
Post-Operative Post-Operative ProtocolsProtocols
Arthroscopy
Results vary patient to patient
• Grade III Injuries: 4-8 Months RTP
• Non Weight Bearing 6-8 Weeks
• Screw Removal @ 3 Months
• Follow-up Imaging every 2 weeks
Post-Operative Post-Operative ProtocolsProtocols
•Phase I (1-3 Weeks)Phase I (1-3 Weeks)
•Phase I- Conservative RehabilitationPhase I- Conservative Rehabilitation•Immobilize & Non Weight BearingImmobilize & Non Weight Bearing•Protect WoundProtect Wound•Reduce PainReduce Pain•Reduce InflammationReduce Inflammation•ProprioceptionProprioception•Increase ROMIncrease ROM•Maintain FlexibilityMaintain Flexibility•CV EnduranceCV Endurance
Post-Operative Post-Operative ProtocolsProtocols
•Phase II (3-8 Weeks)Phase II (3-8 Weeks)
•Phase I- Conservative RehabilitationPhase I- Conservative Rehabilitation•Immobilize & Partial Weight BearingImmobilize & Partial Weight Bearing•Protect WoundProtect Wound•Reduce PainReduce Pain•Reduce InflammationReduce Inflammation•Increase ROMIncrease ROM•Increase StrengthIncrease Strength•ProprioceptionProprioception•Increase FlexibilityIncrease Flexibility•CV EnduranceCV Endurance
Post-Operative Post-Operative ProtocolsProtocols
•Phase III (8-12 Weeks)Phase III (8-12 Weeks)
•Phase II- Conservative RehabilitationPhase II- Conservative Rehabilitation•Full Weight Bearing & Cam-walkerFull Weight Bearing & Cam-walker•Remove ScrewsRemove Screws•Reduce PainReduce Pain•Increase ROMIncrease ROM•Increase StrengthIncrease Strength•ProprioceptionProprioception•Increase FlexibilityIncrease Flexibility•Sports SpecificSports Specific•CV EnduranceCV Endurance
Post-Operative Post-Operative ProtocolsProtocols
•Phase IV (4-8 Months)Phase IV (4-8 Months)
•Phase III Conservative RehabilitationPhase III Conservative Rehabilitation•Protect InjuryProtect Injury•Increase Pain Free ActivityIncrease Pain Free Activity•Increase ROMIncrease ROM•Increase StrengthIncrease Strength•ProprioceptionProprioception•Increase FlexibilityIncrease Flexibility•Sports SpecificSports Specific•CV EnduranceCV Endurance
Post-Operative Post-Operative ProtocolsProtocols
Return To Play Criteria
•Full Strength•Full ROM•Functional Test•Physician Clearance•Protect Injury
Conclusion
• Early Recognition• Determine Extent of Injury• Rule out Associated Injuries• Conservative Treatment (2-8 Weeks)• Surgical Intervention (4-8 Months)• Complications
Questions
ReferencesReferences• Eric Nussbaum, Timothy M. Hosea, Shawn Sieler, Brian Incremona, Donald Kessler.
Prospective Evaluation of Syndesmotic Ankle Sprains Without Diastasis. American Journal of Sports Medicine. 2001; 29:31-35.
• David A. Porter. Evaluation and Treatment of Ankle Syndesmosis Injuries. [Editorial]. 2009; 58:575-581.
• Cyrus M. Press, Asheesh Gupta, Mark R. Hutchinson Management of Ankle Syndesmosis Injuries in the Athlete. American Academy of Sports Medicine.2009; 8:228-233.
• Marc L Wagener, Annechien Beumer, Bart A Swierstra. Chronic instability of the anterior tibiofibular syndesmosis of the ankle. Arthroscopic Findings and Results of Anatomical Reconstruction. Bio Med Central Musculoskeletal disorders 2011; 12:1-7.
• Albert Alonso, Lynette Khoury, Roger Adams. Clinical Tests for Ankle Syndesmosis Injury: Journal of Sports and Physical Therapy. 1998; 27:276-284.