”Footballer´s ankle –
current management ”
Sakari Orava
professor, MD, PhD
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Ankle and football biomechanics
Forced plantarflexions
Forced eversions
Rotations
Landing from jumps
Sudden stops
Change of running directions
Contusions, twistings
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”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
Ankle problems in soccer –
differential dg
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
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
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Anterior synovitis
Etiology:
overuse, distorsion,
direct blow, instability,
spur formation, loose
bodies, hemarthron
- --- ”anterior
impingement”
DG: clinical
examination,
radiographs, MRI
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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
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Treatment of synovitis and
meniscoidal lesions
NSAIDS
Rest
Cold,
physiothrapay
Corticosteroid injections
Arthroscopic / open debridement
Ligament plasty (unstable ankle)
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Talo – tibial exostoses
Etiology: plantar-, dorsiflexion injuries,
ligament instability, sport (soccer) --”anterior impingement” , associated
synovitis, loose fragments may occur
DG: radiographs
(oblique views), MRI
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Talotibial exostoses
”anterior
impingement”
”posterior
impingement”
Therapy:
-- corticosteroid
injections
-- a-scopic or open
debridement
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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. OSTEOCHONDROMATOSIS
chronic synovitis
rheumatic disease
4. MENISCOIDAL LESIONS
- soft tissue bodies
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OD of the ankle:
1. juvenile osteochodrosis
2. marginal fracture … after ankle
injuries
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Osteochondral – OD – lesions in the
ankle joint
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Os trigonum talii posterior syndrome
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
-
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Flexor Hallucis Longus Tendon
problems
stenosing tenosynovitis
tendinosis
Partial / total tear
Pain at the posteromed.
ankle,
swelling, stiffness,
clicking, weakness
TH: stretching, technique (dance,
sports), physiotherapy, NSAIDs,
corticosteroid injections, surgery
(arthroscopic oper.)
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Stress fractures around the ankle
STRESS FRACTURE OF…
--- distal fibula
--- medial malleolus
--- distal tibia
--- talus
--- calcaneus
--- cuboid bone
--- navicular bone
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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
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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
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Excessive bones
Os trigonum talii
post
Accessory navicular
Apophysis of MT V
TH: removal,
refixation of tendon
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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)
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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)
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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
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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
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ANTERIOR TIBIAL TENDON
1.
2.
3.
4.
5.
Chronic overuse tenosynovitis
Crepitating acute and chronic tenosynovitis
Extension to anterior tibial syndrome
Partial tear
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
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Ankle ligament injuries
Lateral
Medial
- uncommon, but typical to soccer
players
TH: ICE, rest, rehab, follow – up,
late surgery
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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)
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Other nerve entrapments around
ankle
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
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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
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Entrapment of deep peroneal nerve –
”anterior tarsal canal syndrome”
lesion due to direct trauma, overstretching or
irritation by osteophytes
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Entrapment of suralis nerve
lateral to achilles tendon
over peroneal tendons
distally on lateral foot
Caused by direct trauma,
overuse or surgery
- Neuromas possible
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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
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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
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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 (?)
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MANY THANKS
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