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.