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Cedera Ankle
 Ankle injuries fall into the same basic 
categories as do all athletic injuries: 
• Contusions 
• Sprains 
• Strains 
• Fractures
 Lateral ankle sprains (85%) 
› Plantar flexion and inversion 
 Syndesmotic sprains (10%) 
› Dorsi-flexion and/or eversion 
 Medial ankle sprains (5%) 
› Eversion
Ankle 
Ecchymosis
Cedera Ankle
Cedera Ankle
 Lateral complex 
› Ant. talofibular 
› calcaneofibular 
› Post. talofibular 
 Syndesmosis 
› Ant. Inf. tibiofibular 
› Post.Inf. tibiofibular
 Syndesmosis: 
› Ant. Inf. Tibiofibular 
ligament 
› Post. Inf. Tibiofibular 
ligament 
› Transverse 
tibiofibular ligament 
› Interosseous 
membrane
 Major Ligament 
complex is called the 
Deltoid Ligament. 
 It is the strongest of 
the ankle ligaments 
 Navicular bone 
› post. Tibial tendon 
attaches
 Provide proprioceptive information for 
joint function 
 Provide static stability to the joint and 
prevent excessive motion 
 Act as guides to direct motion
 Peroneus brevis 
 Peroneus longus 
› Both serve as the 
major everters of 
the ankle 
› Also serve as plantar 
flexors
 Major tendons 
› Anterior tibialis 
(dorsi-flexor) 
› Achilles tendon 
(plantar flexor) 
› Medial tendons 
 Posterior tibialis 
(inverter and plantar 
flexor) 
 Flexor digitorum 
longus 
 Flexor hallucis longus
 Osseous Structures (bones) 
› Tibia, fibula, talus 
 Ligaments (static stabilizers) 
› Lateral, medial, syndesmotic 
 Muscles/Tendons (dynamic stabilizers) 
› Plantar & Dorsi-flexors 
› Everters (peroneals) 
› Inverters (post & ant tibialis)
 History is always good! 
› What happened? 
› Which way did it bend? 
› Could you walk? 
› How much swelling/ecchymosis? 
› When did it happen? 
› What have you done for it? 
› Have you sprained it before?
› Past history 
› Mechanism of injury 
› When does it hurt? 
› Type of, quality of, duration of pain? 
› Sounds or feelings? 
› How long were you disabled? 
› Swelling? 
› Previous treatments?
› Postural deviations? 
› Is there difficulty with walking? 
› Deformities, asymmetries or swelling? 
› Color and texture of skin, heat, redness? 
› Patient in obvious pain? 
› Is range of motion normal?
› Most helpful during the acute phase 
› Remember your anatomy! 
› Palpate the structures you know 
 Boney prominences 
 Ligaments 
 Tendon insertions
› Check Range of Motion 
 Plantar and Dorsi-flexion 
 Inversion and Eversion 
› Neurovascular status 
› Strength? 
 Not helpful in the acute setting 
› Ligamentous testing 
 May be very difficult to do in the acute setting
Cedera Ankle
Cedera Ankle
Cedera Ankle
 Anterior Drawer Test tes utk 
mengetahui integritas ligamen 
talofibular anterior
 Tes utk mengetahui integritas ligamen 
calcaneofibular
 Untuk mengetahui adanya cedera 
syndesmotic
› Xrays are indicated to r/o fx if: 
 Presents within 10 days of injury 
 Unable to bear weight at time of injury or in 
office 
 Tenderness of distal 6cm of malleoli on the 
post. Aspect. 
 Tenderness over the base of the 5th met or 
navicular bone
 Several Classifications Exist based on: 
› Ligamentous injury and evidence of 
instability 
› Classification based on functional 
impairment 
› Number of ligaments involved 
 Combination of the above
 Ligament status 
› partial tear of the ligament 
› mild tenderness and swelling 
› no instability on exam when stressing 
ligament 
 Functional status 
› Slight or no functional loss 
› able to bear weight and ambulate with 
minimal pain
 - The anterior talofibular ligament 
affected 
 - stress: minimal change on inversion, 
normal anterior drawer 
 - treatment by encouraging early active 
movement: 
 a) stationary cycling 
 b) walking with protective taping or 
semi-rigid brace ( Aircast splint )
 c) NSAIDS (anti-inflammatory medication) 
 d) physiotherapy: electrotherapy, 
strengthening exercises, proprioception. 
 e) functional progression to running, 
jumping, hopping, swerving, recovery 
into 6 weeks
• Ligament Status 
– Incomplete tear of the ligament 
– Moderate pain swelling and tenderness 
– Mild to mod. ecchymosis 
– Mild to moderate instability of the ligament 
• Functional status 
– Some loss of motion and function 
– patient has pain with weight-bearing and 
ambulation
 - Complete tear of anterior talofibular 
ligament with some damage of the 
calcaneofibular ligament 
 - laxity when inversion, anterior drawer 
present 
 - treatment: a) 1 week crutches, joint 
taped or in aircast splint 
 b) follow grade 1 rehabilitation
• Ligament Status 
– Complete tear and loss of integrity of a 
ligament. 
– Severe swelling (more than 4cm around the 
fibula) 
– Severe ecchymosis 
– Significant mechanical instability with ligament 
stressing 
• Functional Status 
– Significant loss of function and motion 
– patient is unable to bear weight or ambulate.
 - Uncommon severe injuries, associated 
with fractures 
 - treatment: 10 days NWB in aircast 
brace, then PWB with the brace up to 6 
weeks. Aggressive rehabilitation follows 
 - surgical reconstruction must be 
considered
Cedera Ankle
Cedera Ankle
– PRICEM 
– Protection: (orthosis or brace) 
– Rest: limit wt. Bearing until non-painful 
– Ice, Compression, and Elevation 
• Most important component acutely 
• Limiting inflammation and swelling has been 
shown to speed recovery 
– Mobilize 
• early range of motion has also been shown to 
speed recovery
ACUTE 
 Major goals in the acute 
phase are to reduce 
swelling and pain 
 RICE 
 AROM as long as it is pain 
free. 
 U/S, Laser, Acupuncture 
 A brace can be used to 
prevent inversion of the 
foot 
 Research shows that early 
limited stress following the 
inflammation phase might 
promote faster, stronger 
healing as it helps to align 
the collagen fibers. 
SUBACUTE 
 U/S, laser, Acupuncture 
 AROM without brace 
starting with dorsiflexion 
and plantarflexion 
 Progressive isometric 
exercises 
 Cross fiber massage to the 
ligament in late rehab 
 Taping or tensor bandage 
 Build up to functional skills 
CHRONIC 
 Resisted exercise 
strengthening 
 Balance and agility 
 Proprioception training 
 Functional training
- Ice 
- Ultrasound 
- Rest/Activity Modification 
- Fix training errors 
- Fix biomechanical problems 
- Stretching 
- Strengthening 
- Taping
• PPhhaassee oonnee——IImmmmoobbiilliizzaattiioonn 
• PPhhaassee ttwwoo--EEaarrllyy mmoottiioonn 
• PPhhaassee tthhrreeee--SSttrreennggtthheenniinngg 
• PPhhaassee ffoouurr--FFuunnccttiioonnaall aaccttiivviittyy 
• PPhhaassee ffiivvee--RReettuurrnn ttoo ffuullll aaccttiivviittyy
Cedera Ankle
Cedera Ankle
Cedera Ankle
 Neuromuscular 
Control Training 
› Can be enhanced 
by training in 
controlled activities 
› Uneven surfaces, 
BAPS boards, rocker 
boards, or 
Dynadiscs can also 
be utilized to 
challenge athlete
Cedera Ankle
Cedera Ankle
Cedera Ankle
Cedera Ankle
Cedera Ankle
Cedera Ankle
Cedera Ankle
 Stretching of the Achilles tendon 
 Strengthening of the surrounding muscles 
 Proprioceptive training: balance 
exercises and agility 
 Wearing proper footwear and or tape 
when appropriate
 Reviewed anatomy and clinical exam 
 Ankle injuries are extremely common 
with high potential for long term sequele. 
 A through exam and early aggressive 
treatment including a rehabilitation 
program will lead to optimal results.
Cedera Ankle

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Cedera Ankle

  • 2.  Ankle injuries fall into the same basic categories as do all athletic injuries: • Contusions • Sprains • Strains • Fractures
  • 3.  Lateral ankle sprains (85%) › Plantar flexion and inversion  Syndesmotic sprains (10%) › Dorsi-flexion and/or eversion  Medial ankle sprains (5%) › Eversion
  • 7.  Lateral complex › Ant. talofibular › calcaneofibular › Post. talofibular  Syndesmosis › Ant. Inf. tibiofibular › Post.Inf. tibiofibular
  • 8.  Syndesmosis: › Ant. Inf. Tibiofibular ligament › Post. Inf. Tibiofibular ligament › Transverse tibiofibular ligament › Interosseous membrane
  • 9.  Major Ligament complex is called the Deltoid Ligament.  It is the strongest of the ankle ligaments  Navicular bone › post. Tibial tendon attaches
  • 10.  Provide proprioceptive information for joint function  Provide static stability to the joint and prevent excessive motion  Act as guides to direct motion
  • 11.  Peroneus brevis  Peroneus longus › Both serve as the major everters of the ankle › Also serve as plantar flexors
  • 12.  Major tendons › Anterior tibialis (dorsi-flexor) › Achilles tendon (plantar flexor) › Medial tendons  Posterior tibialis (inverter and plantar flexor)  Flexor digitorum longus  Flexor hallucis longus
  • 13.  Osseous Structures (bones) › Tibia, fibula, talus  Ligaments (static stabilizers) › Lateral, medial, syndesmotic  Muscles/Tendons (dynamic stabilizers) › Plantar & Dorsi-flexors › Everters (peroneals) › Inverters (post & ant tibialis)
  • 14.  History is always good! › What happened? › Which way did it bend? › Could you walk? › How much swelling/ecchymosis? › When did it happen? › What have you done for it? › Have you sprained it before?
  • 15. › Past history › Mechanism of injury › When does it hurt? › Type of, quality of, duration of pain? › Sounds or feelings? › How long were you disabled? › Swelling? › Previous treatments?
  • 16. › Postural deviations? › Is there difficulty with walking? › Deformities, asymmetries or swelling? › Color and texture of skin, heat, redness? › Patient in obvious pain? › Is range of motion normal?
  • 17. › Most helpful during the acute phase › Remember your anatomy! › Palpate the structures you know  Boney prominences  Ligaments  Tendon insertions
  • 18. › Check Range of Motion  Plantar and Dorsi-flexion  Inversion and Eversion › Neurovascular status › Strength?  Not helpful in the acute setting › Ligamentous testing  May be very difficult to do in the acute setting
  • 22.  Anterior Drawer Test tes utk mengetahui integritas ligamen talofibular anterior
  • 23.  Tes utk mengetahui integritas ligamen calcaneofibular
  • 24.  Untuk mengetahui adanya cedera syndesmotic
  • 25. › Xrays are indicated to r/o fx if:  Presents within 10 days of injury  Unable to bear weight at time of injury or in office  Tenderness of distal 6cm of malleoli on the post. Aspect.  Tenderness over the base of the 5th met or navicular bone
  • 26.  Several Classifications Exist based on: › Ligamentous injury and evidence of instability › Classification based on functional impairment › Number of ligaments involved  Combination of the above
  • 27.  Ligament status › partial tear of the ligament › mild tenderness and swelling › no instability on exam when stressing ligament  Functional status › Slight or no functional loss › able to bear weight and ambulate with minimal pain
  • 28.  - The anterior talofibular ligament affected  - stress: minimal change on inversion, normal anterior drawer  - treatment by encouraging early active movement:  a) stationary cycling  b) walking with protective taping or semi-rigid brace ( Aircast splint )
  • 29.  c) NSAIDS (anti-inflammatory medication)  d) physiotherapy: electrotherapy, strengthening exercises, proprioception.  e) functional progression to running, jumping, hopping, swerving, recovery into 6 weeks
  • 30. • Ligament Status – Incomplete tear of the ligament – Moderate pain swelling and tenderness – Mild to mod. ecchymosis – Mild to moderate instability of the ligament • Functional status – Some loss of motion and function – patient has pain with weight-bearing and ambulation
  • 31.  - Complete tear of anterior talofibular ligament with some damage of the calcaneofibular ligament  - laxity when inversion, anterior drawer present  - treatment: a) 1 week crutches, joint taped or in aircast splint  b) follow grade 1 rehabilitation
  • 32. • Ligament Status – Complete tear and loss of integrity of a ligament. – Severe swelling (more than 4cm around the fibula) – Severe ecchymosis – Significant mechanical instability with ligament stressing • Functional Status – Significant loss of function and motion – patient is unable to bear weight or ambulate.
  • 33.  - Uncommon severe injuries, associated with fractures  - treatment: 10 days NWB in aircast brace, then PWB with the brace up to 6 weeks. Aggressive rehabilitation follows  - surgical reconstruction must be considered
  • 36. – PRICEM – Protection: (orthosis or brace) – Rest: limit wt. Bearing until non-painful – Ice, Compression, and Elevation • Most important component acutely • Limiting inflammation and swelling has been shown to speed recovery – Mobilize • early range of motion has also been shown to speed recovery
  • 37. ACUTE  Major goals in the acute phase are to reduce swelling and pain  RICE  AROM as long as it is pain free.  U/S, Laser, Acupuncture  A brace can be used to prevent inversion of the foot  Research shows that early limited stress following the inflammation phase might promote faster, stronger healing as it helps to align the collagen fibers. SUBACUTE  U/S, laser, Acupuncture  AROM without brace starting with dorsiflexion and plantarflexion  Progressive isometric exercises  Cross fiber massage to the ligament in late rehab  Taping or tensor bandage  Build up to functional skills CHRONIC  Resisted exercise strengthening  Balance and agility  Proprioception training  Functional training
  • 38. - Ice - Ultrasound - Rest/Activity Modification - Fix training errors - Fix biomechanical problems - Stretching - Strengthening - Taping
  • 39. • PPhhaassee oonnee——IImmmmoobbiilliizzaattiioonn • PPhhaassee ttwwoo--EEaarrllyy mmoottiioonn • PPhhaassee tthhrreeee--SSttrreennggtthheenniinngg • PPhhaassee ffoouurr--FFuunnccttiioonnaall aaccttiivviittyy • PPhhaassee ffiivvee--RReettuurrnn ttoo ffuullll aaccttiivviittyy
  • 43.  Neuromuscular Control Training › Can be enhanced by training in controlled activities › Uneven surfaces, BAPS boards, rocker boards, or Dynadiscs can also be utilized to challenge athlete
  • 51.  Stretching of the Achilles tendon  Strengthening of the surrounding muscles  Proprioceptive training: balance exercises and agility  Wearing proper footwear and or tape when appropriate
  • 52.  Reviewed anatomy and clinical exam  Ankle injuries are extremely common with high potential for long term sequele.  A through exam and early aggressive treatment including a rehabilitation program will lead to optimal results.