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Ankle Ligament Injury

  1. The most common site of ligament injury is ankle joint.
  2. The most common mode of ankle injury is inversion of planter flexed foot.
  3. Over 90% of the ankle ligament injury involves lateral collateral ligament usually the anterior talofibular ligament.
  1. Achilles Tendonosis/Tendonitis/Tendinopathy
    1. Achilles tendonitis, tendonopathy or tendonosis (insertional) is an overuse disorder usually caused by sudden increase of a repetitive activity involving tendo Achilles. Excessive repetitive strain usually resulting from overuse associated with a change in playing surface, foot wear or intensity of activity is thought to be a major influence in the etiology.
    2. Achilles Tendonosis / Tendonitis / Tendinopathy
    3. It is inflammation followed by degeneration of tendon or paratenon of tendo achiles.
  2. Patho-anatomy  
    1. Tendo -Achilles is the largest and most powerful tendon formed from gastrocnemius and soleus muscle. It rotates 900 towards insertion into the calcaneal tuberosity, with gastrocnemius fibers lying lateral and soleus lying medial to the insertion point.
    2. There is a zone of relative avascularity 2—6 cm proximal to its insertion into the calcaneus k/a watershed zone.
  3. Pathophysiology
    1. Vascular arrangement for Achilles tendon is satisfactory for low demand normal activities. However increased demand from excessive use or oversue may l/t inadequate vascular supply and subsequent degeneration & fibrosis of involved segment of tendon
    2. Sudden increase in repetitive activity puts too much stress on tendon too quickly l/t microinjury that the body is unable to repair
  4. Predisposing Factor  
    1. Excessive repetitive strain d/t overuse (most common) associated with a change in intensity of activity, playing surface, or foot wear.
    2. Also common in individuals whose work put stress on their ankles & feet such as labours and weekend warriors — those who are less conditioned and participate in athelitics on weekends infrequently.
    3. People with excessive pronation (flattening of arch), corticosteroid and fluroquinolone use.
  5. Type  
    1. Acute
    2. Chronic
    3. Insertional
      1. Involve insertion site and is due to oiveruse.
      2. May be a/w retrocalcaneal bursitis, and large exostosis on postero superior aspect of calcaneal tuberosity – Haglund deformity
    4. Non-insertional
      1. Involves water shed area above retrocalcaneal bursa.
      2. It is seen in athletes.
  6. Tendon Rupture 
    1. Most frequent cause of partial or complete rupture of a muscle or tendon is eccentric overload of the muscle tendon unit. One factor contributing to muscle overload is fatigue (due to over use, which makes the muscle unable to absorb as much as eccentric force before overload.)
    2. Strains most commonly occur in muscles that cross two joints, muscles that have higher % of type II fast twitch muscle fibers, and weaker muscle of an agonist antagonist muscle group. eg hamstring, gastrocnemius & rectus femoris.
    3. Achiles tendon rupture commonly occurs to otherwise healthy men b/w the ages of 30 & 50 years who have no previous injury or problem reported in affected leg; typically “weekened warrious” who are active intermittently.
    4. Most TA tears occurs in left leg in the substance of TA, - 2-6 cm — the watershed zone — above the caleaneal insertion of tendon (d/t right handed more commonly push off with left foot)
    5. The most common mechanism of injury include sudden forced plantar flexion of foot unexpected dorsiflexion of foot, & violent dorsiflexion of planter flexed foot.
    6. Other mechanism indude direct trauma & less commonly, attrition of the tendon as a result of long standing peritenositis with or without tendinosis that body is unable to repair.
    7. Thompson or Simmonds test is used.

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