Medial ankle sprain

1. Case review presentation MEDIAL ANKLE SPRAIN MOHAMED AOUINI NSMP PHYSIOTHERAPIST

2. Case Load plan Anatomy History Assessment Management Take Home Message

3. Ankle Anatomical structure Tibia Fibula Talus

4. Tibia This is the strongest largest bone of the lower and it is bears weight the bones creates the medial malleoli

5. Fibula This is lateral bone of the lower leg is not vital for weight bearing it comprises the lateral outside aspect of the lateral malleoli and makes up the lateral aspect of the mortise .

6. Talus This bone transmits the force from the calcaneus up into the tibia and also allows the articulation of palantar flexion, dorsiflexion or pulling the foot upward and inversion and eversion

7. Joints of the Ankle/Foot Talocrural Joint in the ankle found between the tibia ,fibula, and talus. Subtalar Joint-joint in the ankle found between the talus and calcaneus . Transverse tarsal joint It is formed of 2 joints: talo-navicular joint calcaneo-cuboid joint

8. Ankle ligaments and roles There are three lateral ligaments Responsible for the support and maintenance of bone apposition These ligaments are: _ anterior talofibular ligament: prevents anterior subluxation of talus when ankle is in plantar flexion _ calcaneofibular ligament: primarily to stabilize sub- talar joint and limit inversion, it is lax in normal standing position due to relative valgus orientation of calcaneus . _ posterior talofibular ligament: prevents posterior and rotatory subluxation of the talus. 

9. The deltoid ligaments _ This is locates on medial aspect of the foot it is the largest ligament triangular in shape _ prevents eversion of the ankle _ deep and superficial part : Superfical part : Anterior tibio-navicular Middle tibio-calcanean Psoterior tibio-talar Deep part : it is also called as tibio-talar ligament attached on the anterior part of the medial surface of talus

10. Superficial deltoid: resist talar abduction and primarily resists eversion of hind foot. Tibionavicular portion prevents inward displacement of head of talus, while tibiocalcaneal portion prevents valgus displacement.    Deep deltoid ligament : _ prevents lateral displacement and external rotation of the talus. _ latter effect is pronounced in plantar flexion, when deep deltoid tends to pull talus into internal rotation. 

11. KINEMATICS OF ANKLE & FOOT 1 . Primary plane motions defined a. Sagittal plane motion is dorsiflexion (15°) and plantarfiexion (55°). b. Frontal plane motion is inversion (35°) and eversion (20°) c. Transverse plane motion is abduction and adduction . 2. Triplanar motions occurring about oblique axes defined: a. Pronation (20°) is a combination of dorsiflexion , eversion , and abduction. b. Supination (35°) is a combination of plantarfiexion , inversion, and adduction.

12. Player information NAME: Hassan Last name: Elsaafady Length: 1.83 cm Weight: 76kg Age: 16 years Position: player maker Category: Naachine Allergy: no previous injury: left big toe injury 2013 surgery : no MRN: 01366624

13. History During game on 9/03/2014 in the second half he injured his right ankle when he changed directions and sustained An eversion injury, he complete full game without any first treatment, the day after his coach called me about the injury of his player, we went to aspetar he made an X_RAY and there is no fracture.

14. Assessing the Lower Leg and Ankle History _ past history: no past history of ankle sprain _ Mechanism of injury: eversion of the foot _ NRS was 8/10 on the time of the injury _ currently pain on walking 7/10 on the medial side _ Aggravating factor: walk _ Easy factor: Rest _ sound or feeling: no _ swelling was immediate _ No Red flags and there is no other health issue

15. Inspection _ player walk with pain in the medial side _ no deformity _ there is swelling in the medial side

16. Palpation _   tenderness on the deltoid ligaments _ no pain on the : malleoli , navicular bone ,fibula head .

17. R.O.M _ Normal range of motion

18. Special tests _ Thompson's test: - ve _ compression test : - ve _ reverse talar tilt : + ve _   Kleiger’s test: - ve _ anterior drawer (ATFL): - ve _ Talar tilt (CFL) : - ve

19. Functional tests _ Single leg balance: painfull _ walk Heel raise (bi-lat/ uni -lat): paifull _ Step up/down: painfull _ Jump/hop: unable _ Jog/run/lat movement: unable _ walk on toe : painfull _ walk on lateral borders : painfull _ walk on medial borders: painfull

20. Recent investigation _ X-Ray : there is no bony articular or soft tissue abnormality _ Ultrasound: The ATFL and CFL are normal There is no syndesmotic injury There is thickening of the anterior superficial of the deltoid ligament ( Grade 1 ) There is no tenosynovitis

21. DIAGNOSIS   _ There is thickening of the anterior superficial of the deltoid ligament ( Grade 1 ) _ no bone injury

22. PROBLEM LIST Swelling Pain 8 over 10 Treatment Plan and Goals Eliminate swelling Eliminate pain Increase muscle strength Increase neuro muscular control

23. Physical therapy and treatment _ The most important factors in this case swelling and pain . _ If these factors are reduced ,you can take a faster results . _ That’s why the exercise who decreased the swelling is too much important. _ In the most case , the pain and swelling are synchronized in all phase

24. Swelling vs pain Day pain /NRS Swelling( right/ left) Day 1 8 59.50/57 Day3 7 59.23 /57 Day 5 7 59.50/57 Day 8 7 59.50 /57 Day 11 6 59.20 /57 Day 15 5 58.70 / 57 Day 18 4 58.25/57 Day 21 3 58/57 Day 24 2 57.60/57 Day 28 2 57.20/ 57 Day 31 1 57/57 Day 33 1 57/57 Day 35 57/57 Day 38 57 / 57

25. The most important phahse _ Phase I: includes resting, protecting and reducing swelling of your injured ankle. _ Phase II : includes restoring your ankle's flexibility, range of motion and strength. _ Phase III: includes gradually returning to straight-ahead activity and doing maintenance exercises, followed later by more cutting sports such as tennis, basketball of football.

26. Joints flexibilty _ may it can have loss of joints flexibilty due to: Muscle spasm, pain, adherence _when we restore ROM to within 80% of normal in the unaffected ankle , the rehabilitation emphasis moves to the development of muscular strength.

27. Muscular Strength and speed _ Must perform a progressive resistive exercise on a regular basis.  _ Once strength in the injured side is 90% of the non-injured side, emphasis moves to the development of muscular endurance . _ high intense rehab exercise

28. Muscular Endurance – Stationary bike . – Running when tolerated ,jogging gradually .

29. neuro muscular control _ open kinetic chain _ close kinetic chain

30. Taping _ As level 1 technique

31. After before

32. Take Home message _ Treatment of ankle sprain should consist of an exercise program that is a varied and intense as possible to obtain optimal ankle functioning . _ Medial ligaments injury take longer time than lateral In the treatment .

33. Thank you