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Essentials of Human Anatomy and Physiology12th EditionElaine N. Marieb, Suzanne M. Keller 642 solutions
Hole's Human Anatomy and Physiology14th EditionDavid N. Shier, Jackie L. Butler, Ricki Lewis 2,027 solutions
Essentials of Human Anatomy and Physiology9th EditionElaine N. Marieb 622 solutions
Hole's Essentials of Human Anatomy and Physiology12th EditionDavid N. Shier, Jackie L. Butler, Ricki Lewis 1,633 solutions Original Editors - Rick Wetherald, Hannah Duncan, Hilary Zachary and James Passmore as part of the Texas State University Evidence-based Practice Project Top Contributors - James Passmore, Hilary Zachary, Rick Wetherald, Hannah Duncan, , Rachael Lowe, Kai A. Sigel, Admin, Patrick Bales, Laure Leyers, Khloud Shreif, Tarina van der Stockt, Simisola Ajeyalemi, Rucha Gadgil, Wanda van Niekerk, Evan Thomas, Naomi O'Reillyand WikiSysopDefinition/Description[edit | edit source]A syndesmotic, or ‘high’ ankle sprain is one that involves the ligaments binding the distal tibia and fibula at the Distal Tibiofibular Syndesmosis. Injuries can occur with any ankle motion, but the most common motions are extreme external rotation or dorsiflexion of the Talus. The dome of the Talus is wider in the anterior than in the posterior, and these movements force apart the medial and lateral aspects of the mortise, respectively the tibial and fibular malleoli. Sufficient distraction of the distal fibula from the tibia can cause strain or rupture of one or more of the following ligaments: the anterior inferior tibiofibular ligament, superficial posterior inferior tibiofibular ligament, transverse tibiofibular ligament, interosseous membrane, interosseous ligament and inferior transverse ligament.[1] Rupture injuries also commonly present with concomitant fractures of either malleolus (lateral being more common) or proximal fibular spiral fracture known as a Maissonneuve fracture. [2] Epidemiology/Etiology[edit | edit source]Syndesmotic ankle sprains commonly occur to athletes participating in American football and downhill skiing. Football injuries are usually a result of forced external rotation of the foot while the athlete is prone, as in at the bottom of the pile. The injuries can also result from a blow to the lateral knee while the foot is planted and dorsiflexed, resulting in an eversion or external rotation moment at the talocrural joint. Characteristics/Clinical Presentation[edit | edit source]Observationally the Syndesmotic will show significantly less swelling than a lateral ankle sprain, as well as demonstrate a loss of full plantar flexion and an inability to bear weight[2]. Ecchymosis may appear several days post-injury due to the injury of the intereosseuos membrane. A difficulty or inability to toe walk are often noted. History includes chronic pain, prolonged recovery, recurrent sprains, and the formation of heterotopic ossification within the interosseous membrane. [4]The most common MOI is when the foot is in external rotation with excessive dorsiflexion[5]. Differential Diagnosis[edit | edit source]Because of the occult nature of the high ankle sprain during clinical evaluation it is important to rule out pathologies with a similar mechanism of injury (MOI). First and foremost fractures of the tibia, fibula and/or the talus should be ruled out [6]. Secondly, the clinician should address concerns of a lateral ankle sprain as the mechanism of injury between the two injuries are very similar. Norwig writes “Syndesmotic ankle sprains can usually be distinguished from inversion ankle sprains by a history of an external rotation component.” Other possible pathologies are medial ankle sprain, compartment syndrome, severe joint laxity[2], severe contusion, dystrophic calcification, infection, or tumor. These pathologies should be preferentially ruled out before tx of a syndesmotic ankle sprain begins. Outcome Measures[edit | edit source]
Examination[edit | edit source]Hx and MOI: see clinical presentation
Special Testing[edit | edit source]1. Dorsiflexion External Rotation Stress Test (Kleiger's Test)
2. Squeeze Test
3. Cotton Test
4. Fibular Traslation Test
Medical Management[edit | edit source]Imaging is still
considered the diagnostic standard and should be sought as quickly as possible to rule out any expected fractures and to aid in restoring normal anatomy. A one millimeter lateral displacement of the fibula results in a reduction in the available area of tibiotalar contact in weight bearing by 42%[12] One can easily see how such a “minor” yet misdiagnosed injury
can lead to a lifetime of chronic sprains. Plain films are the bare minimum suggested, but due to the complexity of the structures and tissues, a CT scan is recommended for bony detail, MRIs give an accurate picture of the ligamentous injury, and they are the imaging gold standard for this injury. They are surpassed in accuracy only by arthroscopy.
[2] Images should be done in a bilateral fashion to better determine an injury from a natural joint gap or overlap. Syndesmotic ankle sprains without diastasis are considered to be stable and are treated symptomatically. These patients are told to weightbear as tolerated. Those patients who exhibit a sprain with latent diastasis, where the reduction
of the tibiofibular joint can be documented with CT or MRI, do not necessarily need surgery. Patients with these findings are often treated with immobilization in a non-weightbearing cast or walking boot for 4 to 6 weeks. Patients with a high syndesmotic ankle sprain that demonstrate diastasis of the syndesmosis without a fibular fracture require surgery. Surgical stabilization should be performed immediately. Surgical repair that includes open repair of torn ligaments and closed treatment of
the ligaments with open or percutaneous insertion of a transverse syndesmosis screw has been shown to have favorable results.[2] Physical Therapy Management[edit | edit source]
1.) Calf Stretch with Step 2.) Calf Strengthening Exercise 3.) Lunging Calf Stretch Goals:
Patient Education:
Assistive Devices:
Modalities:
Therapeutic Exercise/ Neuromuscular Re-education:
Ex: Single-leg stance, disk or balance pad training, aquatic therapy
Manual Therapy:
**The recovery for Syndesmotic Ankle Sprain is often twice that of a typical ankle sprain!** Theraband Ankle Composite.jpg 1.) Theraband Plantarflexion 2.) Theraband Dorsiflexion 3.) Theraband Inversion 4.) Theraband Eversion Clinical Bottom Line[edit | edit source]Syndesmotic ankle sprains, while less common than other ankle pathology, are an important consideration during the evaluation of leg pain. This injury is more common in athletes after forced external rotation and dorsi flexion of the foot. It may present with concomitant bony and ligamentous injury. While surgical intervention is rarely indicated in the absence of fracture, conservative PT management can aide in a faster recovery. References[edit | edit source]
Which term indicates the tearing of ligaments at a joint?Sprains are injuries where a ligament is stretched or torn within a joint.
What joint actions may take place at the elbow?Two or more bones form hinge joints that move along an axis, rather than rotate like the hip joint. The distal humerus and proximal ulna are the primary elbow joint bones. The hinge joint allows the elbow to bend and straighten. It also helps with hand motion by allowing the forearm to rotate.
Which joint allows a side to side?Ball and socket joints: This type of joint allows side to side, back and forth, and rotational movement. Examples of these joints are the hip or shoulder joints, where the head (ball) of one bone fits into the cavity (socket) of another.
Which of the following joints have a joint cavity?Synovial joints are the only joints that have a space between the adjoining bones (Figure 19.25). This space is referred to as the synovial (or joint) cavity and is filled with synovial fluid. Synovial fluid lubricates the joint, reducing friction between the bones and allowing for greater movement.
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