Syndesmosis Injuries Manny Moore ATS Syndesmosis Injuries 11

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- Chaput’s Tubercle Most Vulnerable • PIFL- Wagstaffe’s 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 1 mm 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 > 4 mm • 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 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 +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 -14 Days) • 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: 228233. • 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.