Syndesmosis Injuries Manny Moore ATS Syndesmosis Injuries 11-18%

Syndesmosis Injuries Manny Moore ATS Syndesmosis Injuries 11-18%

Syndesmosis Injuries Manny Moore ATS Syndesmosis Injuries 11-18% of all ankle sprains Longer recovery v.s. Lateral sprains Men v.s. Women? Bone Anatomy Tibia Articular Surface Fibula

Articular Surface Talus Dome Articular Surface Provides Stability & Proper Ankle Function Snydesmosis Ligaments AIFL- Chaputs Tubercle

Most Vulnerable PIFL- Wagstaffes Tubercle Strongest ITFL- Thickening of PIFL IM- Fibrous tissue Transmit force IL-

Thickening of IM Biomechanics 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? Clinical Examination History ER with DF Contact None Contact

Acute v.s. Chronic Observation Edema Eccymosis Antalgic gait Possible Deformity? Clinical Examination Palpation Tenderness Length

Special Test Squeeze Test Dorsiflexion Test Kleigers Test Cross-leg Test Nussbaum et al. Imaging Techniques 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 Techniques X-RAY Tibiofibula overlap Tibiofibula clearance space Medial clear space Imaging Techniques X-RAY Tibiofibula overlap Tibiofibula clearance

space Medial clear space Imaging Techniques X-RAY Lateral View Imaging Techniques X-RAY AP View Heterotopic Ossification

Imaging Techniques 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 Techniques MRI Axial Views West Point Instability Scale Grade I Grade II Grade III

Edema & Ecchymosis Localized Mild Localized Moderate Diffuse Severe

Weight Bearing Ability Full or Partial Without Significant Pain Difficult Without Crutches Impossible Significant Pain

Ligament Stretch Partial Tear Complete Tear +AIFL +AIFL +IL Possible AD

+AIFL/PIFL +IL +AD Ligament Damage Ligament Involvement Treatment Criteria Based on Patients Goals Length of Symptoms

Severity of Injury Conservative Grade I Non-Fractures Stable Grade II Non Conservative Grade III Unstable Grade II Fractures Chronic Injury

Conservative Protocols Results vary patient to patient Grade I Injuries: 2-4 Weeks RTP Grade II Injuries: 6-8 Weeks RTP Without Instability or Fractures Conservative Protocols Phase I (0-5 Days) or (5-14Days) Immobilize Reduce Pain Reduce Inflammation

Cryotherapy E-Stim Increase ROM Manual 30* PF Stretch Ankle Pumps Toe Curls Towel Stretch Conservative Protocols Phase II (6-10 Days) or (2-4 weeks) Immobilize Grade II Reduce Pain

Reduce Inflammation Proprioception Increase Flexibility Increase ROM Increase Strength CV Endurance Conservative Protocols Phase III (18-25 Days) or (4-8 Weeks) Protect Injury Reduce Pain Increase Pain free Activity

Sports Specific Proprioception Increase Strength Increase Flexibility CV Endurance Conservative Protocols Phase III (18-25 Days) or (4-8 Weeks) Sports Specific Drill#1

Drill#2 Conservative Protocols Return To Play Criteria Full Strength Full ROM Functional Test Physician Clearance Protect Injury Operative Treatment Arthroscopy

Goal is to restore structures, and mobility Open Reduction & Internal Fixations Autographs Modified Brostrum Technique 4.5 mm Cortical Screws Complications Screw Breakage Screw Type Infection Calcification & Joint Stiffness

Operative Treatment Arthroscopy Before After Post-Operative Protocols 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 Protocols Phase I (1-3 Weeks) Phase I- Conservative Rehabilitation Immobilize & Non Weight Bearing Protect Wound Reduce Pain Reduce Inflammation Proprioception Increase ROM

Maintain Flexibility CV Endurance Post-Operative Protocols Phase II (3-8 Weeks) Phase I- Conservative Rehabilitation Immobilize & Partial Weight Bearing Protect Wound Reduce Pain Reduce Inflammation Increase ROM Increase Strength

Proprioception Increase Flexibility CV Endurance Post-Operative Protocols Phase III (8-12 Weeks) Phase II- Conservative Rehabilitation Full Weight Bearing & Cam-walker Remove Screws Reduce Pain Increase ROM Increase Strength

Proprioception Increase Flexibility Sports Specific CV Endurance Post-Operative Protocols Phase IV (4-8 Months) Phase III Conservative Rehabilitation Protect Injury Increase Pain Free Activity Increase ROM Increase Strength

Proprioception Increase Flexibility Sports Specific CV Endurance Post-Operative Protocols 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 References 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; 27:276284.

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