Propagation of Syndesmotic Injuries During Forced External Rotation in Flexed Cadaveric Ankles

Background: Forced external rotation of the foot is a mechanism of ankle injuries. Clinical observations include combinations of ligament and osseous injuries, with unclear links between causation and injury patterns. By observing the propagation sequence of ankle injuries during controlled experiments, insight necessary to understand risk factors and potential mitigation measures may be gained. Hypothesis: Ankle flexion will alter the propagation sequence of ankle injuries during forced external rotation of the foot. Study Design: Controlled laboratory study. Methods: Matched-pair lower limbs from 9 male cadaveric specimens (mean age, 47.0 ± 11.3 years; mean height, 178.1 ± 5.9 cm; mean weight, 94.4 ± 30.9 kg) were disarticulated at the knee. Specimens were mounted in a test device with the proximal tibia fixed, the fibula unconstrained, and foot translation permitted. After adjusting the initial ankle position (neutral, n = 9; dorsiflexed, n = 4; plantar flexed, n = 4) and applying a compressive preload to the tibia, external rotation was applied by rotating the tibia internally while either lubricated anteromedial and posterolateral plates or calcaneal fixation constrained foot rotation. The timing of osteoligamentous injuries was determined from acoustic sensors, strain gauges, force/moment readings, and 3-dimensional bony kinematics. Posttest necropsies were performed to document injury patterns. Results: A syndesmotic injury was observed in 5 of 9 (56%) specimens tested in a neutral initial posture, in 100% of the dorsiflexed specimens, and in none of the plantar flexed specimens. Superficial deltoid injuries were observed in all test modes. Conclusion: Plantar flexion decreased and dorsiflexion increased the incidence of syndesmotic injuries compared with neutral matched-pair ankles. Injury propagation was not identical in all ankles that sustained a syndesmotic injury, but a characteristic sequence initiated with injuries to the medial ligaments, particularly the superficial deltoid, followed by the propagation of injuries to either the syndesmotic or lateral ligaments (depending on ankle flexion), and finally to the interosseous membrane or the fibula. Clinical Relevance: Superficial deltoid injuries may occur in any case of hyper–external rotation of the foot. A syndesmotic ankle injury is often concomitant with a superficial deltoid injury; however, based on the research detailed herein, a deep deltoid injury is then concomitant with a syndesmotic injury or offloads the syndesmosis altogether. A syndesmotic ankle injury more often occurs when external rotation is applied to a neutral or dorsiflexed ankle. Plantar flexion may shift the injury to other ankle ligaments, specifically lateral ligaments.

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A Biomechanical Analysis of Ankle Instability in Supination External Rotation Ankle Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00062 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0006

Author(s):

Eric Hempen ◽

Bennet Butler ◽

Muturi Muriuki ◽

Anish Kadakia

Keyword(s):

Ankle Instability ◽

External Rotation ◽

Axial Rotation ◽

Injury Pattern ◽

Contact Forces ◽

Biomechanical Analysis ◽

Ankle Injuries ◽

Injury Patterns ◽

Supination External Rotation ◽

Rotation Stress

Category: Trauma Introduction/Purpose: Supination external rotation (SER) 2 and SER3 ankle injuries are thought to be stable whereas SER4 injuries are thought to be unstable. In other words, deltoid rupture is thought to be a necessary component of instability in SER injuries. However, biomechanical evidence has shown that as little as 1 mm talar shift results in 40% loss in contact area leading to increased contact forces. Additionally, the external rotation stress exam which is the typical test used to detect instability is poorly standardized in the literature limiting its ability to detect subtle instability. Therefore the purpose of this study is to analyze talar rotation and translation with external rotation stress specifically in SER2 and SER3 patterns in an effort to better define which injury patterns are unstable. Methods: 19 legs disarticulated below the knee were obtained. Optotrak optoelectronic 3D motion measurement system was used to determine positioning of the talus compared to the tibia. Specimens were first tested intact using a jig capable of exerting known axial and rotational forces through the hindfoot in line with the weightbearing axis of the tibia. Specimens were loaded with 150N to simulate physiologic load and sequentially stressed with 0, 1, 2, 3, and 4Nm of external rotation. SER2 injury was then created by creating a Weber B distal fibula fracture and AITFL rupture. The above testing was then repeated. Next the injury was converted to SER3 by rupturing the PITFL, and the above testing was repeated. In all conditions coronal and sagittal translation as well as axial and coronal angulation from the uninjured/unstressed state were recorded. The SER2 and SER3 conditions were compared to the intact condition using a paired t-test. Results: When compared to the uninjured state, the SER2 injury pattern demonstrated statistically significant differences in the following parameters: - axial rotation at 1Nm (11.0±4.2°, p<0.0005), 2Nm (12.8±4.4°, p<0.0005), 3Nm (14.4±4.9°, p<0.0005), and 4Nm (15.8±5.2°, p<0.0005) - sagittal translation at 1Nm (5.2±3.6 mm, p=0.007), and 2Nm (6.4±3.9 mm, p=0.02) - coronal translation at 3Nm(0.6±3.2 mm, p=0.004), and 4Nm (0.7±3.5 mm, p=0.003) When compared to the uninjured state, the SER3 injury pattern demonstrated statistically significant differences in the following parameters: - coronal rotation at 4Nm (-0.9±6.8°, p=0.03) - axial rotation at 1Nm (12.3±4.4°, p<0.0005), 2Nm (16.0±4.7°, p<0.0005), 3Nm (18.2±5.1°, p<0.0005), and 4Nm (20.4±5.7°, p<0.0005) - sagittal translation at 1Nm (5.0±3.9 mm, p=0.03), and 2Nm (6.4±3.9 mm, p=0.01) - coronal translation at 1Nm (0.7±1.9 mm, p=0.05), 2Nm (0.8±2.5 mm, p=0.01), 3Nm (1.1±3.0 mm, p<0.0005), and 4Nm (1.5±3.6 mm, p<0.0005) Conclusion: Current literature describes ankle instability in SER injury patterns in terms of coronal translation, and suggests that SER2 and SER3 injury patterns are stable. However, our data demonstrates that even SER2 and SER3 injury patterns with an intact deltoid ligament show signs of instability in sagittal translation and axial rotation as well as subtle signs of instability in coronal translation, especially at higher torques. As previously stated, subtle instability has been shown to significantly decrease contact forces, and therefore this data supports further study of long term clinical outcomes and reconsideration of our treatment algorithms for SER2 and SER3 fractures.

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Assessment of Functional End Ranges of Lower Limb Joints in Positions Commonly Used for ADLs in India

Journal of Pharmaceutical Research International ◽

10.9734/jpri/2021/v33i35a31873 ◽

2021 ◽

pp. 64-71

Author(s):

Niketa Patel ◽

Lavina Rajesh Khatri ◽

Lata Parmar

Keyword(s):

External Rotation ◽

Plantar Flexion ◽

Cultural Practice ◽

Lower Limbs ◽

Rural And Urban ◽

Ankle Joints ◽

Hip Abduction ◽

Hip Flexion ◽

Age Range ◽

Ankle Plantar Flexion

Background: In many countries of Asian continent, floor sitting is preferred instead of chair supported sitting. Indian population differs noticeably in its cultural practice and daily tasks which involves squatting and cross-legged sitting on the ground. Aim: The purpose of the study was to assess the functional end-ranges of the hip, knee and ankle joints in healthy Indian subjects in positions commonly used for ADLs in India which includes squatting and cross-legged sitting. Methods: 66 healthy subjects were recruited from rural and urban populations with age range 30-50 years. Joint ROM of the lower extremities was measured using Universal Goniometer. All the subjects were asked to acquire squat and cross legged positions which were graded. Results: Our results finding showed that the subjects in cross leg sitting grade 2 (independent CLS) had hip flexion ranges ≥1150, hip abduction ≥ 410, hip external rotation ≥ 420, ankle plantar flexion ≥ 460, p<0.005. For squatting, grade 2 (independent squat) had hip flexion ranges ≥ 1130,p>0.005, Knee flexion ≥1200, p>0.005 and ankle dorsiflexion ≥150, p<0.005. Conclusion: From the results, it is suggested that squatting and cross-leg sitting multiple times a day can prevent the early closer of end ranges of the lower limbs.

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Syndesmotic Behavior after Sequential Sectioning: Simulation of Ligamentous Ankle Injuries in Vitro

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00012 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0001

Author(s):

Robin P. Blom ◽

Kaj S. Emanuel ◽

Markus Knupp ◽

Inger N. Sierevelt ◽

Gino M.M.J. Kerkhoffs ◽

...

Keyword(s):

External Rotation ◽

Lower Limbs ◽

Ankle Injuries ◽

Deltoid Ligament ◽

Active Motion ◽

Need For Treatment ◽

Ligament Rupture ◽

Fresh Frozen ◽

Rotation Stress

Category: Ankle, Trauma, Distal Tibiofibular Joint Introduction/Purpose: Ankle fractures are often associated with ligamentous injuries of the distal tibiofibular syndesmosis and the deltoid ligament. These injuries may predispose to instability, early joint degeneration and long-term ankle dysfunction. In the classic article of Boden it was made clear that injuries of the syndesmotic ligaments were of no importance in absence of a deltoid ligament rupture. Even in the presence of a deltoid ligament rupture, the interosseous membrane withstood lateralization of the talus in fixated fibula fractures up to 4.5 mm above the ankle joint. However, detection of ligamentous injuries and the need for treatment remain subject of ongoing debate. Syndesmotic injuries are often treated operatively by temporary fixation performed with positioning screws. But do isolated syndesmotic injuries need to be treated operatively at all? Methods: Ten fresh-frozen, exarticulated through the knee, human cadaveric lower limbs were tested under axial compressive loads of 50 and 700 N, simulating non-weightbearing and weightbearing conditions. All specimens were tested with different foot positions (plantigrade, dorsiflexion, inversion, eversion, and 10 Nm external rotational torque) during sequential sectioning of the syndesmotic ligaments and the deltoid ligament. We triangulated Boden’s classic findings with an active motion capture system (0.1 mm accuracy) to track the translations and rotations of the fibula relative to the tibia. Results: Isolated sectioning of the AITFL resulted in an increase of external fibula rotation up to 8.9 degrees (doubling the physiological 4.0 degrees) with an external rotation stress of 10 Nm in non-weightbearing conditions. However, weightbearing appeared somewhat protective, reducing the external rotation to 7.9 degrees. Sectioning of all syndesmotic ligaments with an intact deltoid ligament resulted in a syndesmotic widening of 0.9 mm in weightbearing conditions with a plantigrade foot. Dorsiflexion of the foot resulted in a significant increase of syndesmotic widening for all conditions of the syndesmotic ligaments. Sectioning of the deltoid ligament resulted in a significant increase of all fibula translations in all foot positions during weightbearing conditions. Conclusion: The results of our study have implications for common ligamentous ankle injuries and their treatment. In isolated syndesmotic injuries with a plantigrade foot, weightbearing seemed protective and limiting syndesmotic widening probably due to the saddle shape of the tibiotalar surface. Conservative treatment in a cast seems justifiable. External rotation stress causes the “open-book-phenomenon” in isolated AITFL injuries, especially in non-weightbearing conditions. Protection with cast or surgery is necessary. The deltoid ligament prevents lateralization of the talus but allows increased syndesmotic widening and external rotation of the fibula in dorsiflexion and external rotation stress due to the shape of the talus.

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Deltoid ligament injury patterns in external rotation ankle injuries: A cadaveric study

Foot and Ankle Surgery ◽

10.1016/j.fas.2017.07.1120 ◽

2017 ◽

Vol 23 ◽

pp. 26-27

Author(s):

M. Cooper ◽

A. Mait ◽

B. Nie ◽

J.P. Donlon ◽

A. Mane ◽

...

Keyword(s):

External Rotation ◽

Cadaveric Study ◽

Ankle Injuries ◽

Ligament Injury ◽

Deltoid Ligament ◽

Injury Patterns ◽

Deltoid Ligament Injury

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IDENTIFYING ANKLE INJURY PATTERNS OF NETBALL PLAYERS FOR MAINTAIN THEIR HEALTH AND WELLBEING

GLADI JURNAL ILMU KEOLAHRAGAAN ◽

10.21009/gjik.122.12 ◽

2021 ◽

Vol 12 (02) ◽

pp. 207-215

Author(s):

D.M.D.N Bandara ◽

A.W Suraj Chandana

Keyword(s):

Disease Transmission ◽

Lower Leg ◽

Ankle Injury ◽

Ankle Injuries ◽

Research Articles ◽

Ankle Sprains ◽

Injury Patterns ◽

Health And Wellbeing ◽

Course Of Action ◽

Basic Course

Netball is a ball game played by two groups of seven players. Its improvement, got from early forms of ball, started in England during the 1890s. By 1960, universal playing guidelines had been institutionalized for the game. The ankle joint is a pivot joint framed between the tibia and fibula and the bone and enables the foot to twist upwards and downwards. The joint likewise permits a modest quantity of pivot. The joint's dependability originates from the basic course of action of the bones and the encompassing tendons. Ankle injuries can transpire at any age. This article surveys epidemiological investigations on ankle injuries in netball, and what are the sorts of ankle injuries, how it's happen and also survey how counteractive action from ankle injuries and aversion strategies. Furthermore, talk about around a few activities that can use for prevent from ankle injuries in netball. The purpose of the study was to investigate the several Ankle injuries of netball players in different countries. The methodology used for this review was based on previously published guidelines. It included research articles, journals, research publications, reviews and books. Collect all the findings and add the references. Of 47 articles are found and 18 are included in this review essay. Results demonstrate that the ankle injury was the most widely recognized harmed body site in netball and an Ankle sprain was the real lower leg damage happen in Netball. Ankle sprains represent an enormous level of wounds supported in netball. This efficient survey gives a synopsis of the study of disease transmission of ankle damage in Netball.

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Differences in Ankle ROM Between Young Men and Women With a History of Ankle Sprain

Sportverletzung · Sportschaden ◽

10.1055/a-0753-7953 ◽

2018 ◽

Vol 33 (02) ◽

pp. 82-86

Author(s):

Jung-Hyun Kim ◽

Eun-Sook Sung

Keyword(s):

Sex Differences ◽

Ankle Sprain ◽

Plantar Flexion ◽

Ankle Injury ◽

Ankle Injuries ◽

Control Group ◽

Men And Women ◽

Ankle Joints ◽

History Of ◽

Male Subjects

Abstract Background Ankle injuries are the most common injuries in sports. However, very little is known about sex differences in ankle range of motion (ROM) between ankle joints with an episode of ankle sprain (ASE) and those without an episode of ankle sprain (non-ASE). This study aimed to investigate the differences of ankle ROM between men and women with and without ASE. Methods 26 ASE had at least one episode of ankle injury in the last 6 to 12 months. 35 non-ASE served as a control group. All subjects were examined in supine position and the ankle ROM was calculated by the sum of inversion (IV), eversion (EV), plantar flexion (PF) and dorsiflexion (DF) in both ankles. Results Subjects with ASE had a significantly smaller ROM regarding EV than non-ASE subjects in both ankles. The male subjects with ASE had a significantly higher EV and IV compared with the female subjects. However, ROM in PF was significantly lower among men compared with women who had ASE. Conclusions Our findings suggest that the ROM after ASE affects PF in male and EV in female patients. This could point to sex-based prevention and rehabilitation after ankle injury.

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Gender Differences in Kinematic Analysis of the Lower Limbs during the Chasse Step in Table Tennis Athletes

Healthcare ◽

10.3390/healthcare9060703 ◽

2021 ◽

Vol 9 (6) ◽

pp. 703

Author(s):

Xiaoyi Yang ◽

Yuqi He ◽

Shirui Shao ◽

Julien S. Baker ◽

Bíró István ◽

...

Keyword(s):

Female Athletes ◽

External Rotation ◽

Rotational Velocity ◽

Knee Extension ◽

Lower Limbs ◽

Table Tennis ◽

Male Athletes ◽

Analysis System ◽

Hip Flexion ◽

Hip Internal Rotation

The chasse step is one of the most important footwork maneuvers used in table tennis. The purpose of this study was to investigate the lower limb kinematic differences of table tennis athletes of different genders when using the chasse step. The 3D VICON motion analysis system was used to capture related kinematics data. The main finding of this study was that the step times for male athletes (MA) were shorter in the backward phase (BP) and significantly longer in the forward phase (FP) than for female athletes (FA) during the chasse step. Compared with FA, knee external rotation for MA was larger during the BP. MA showed a smaller knee flexion range of motion (ROM) in the BP and larger knee extension ROM in the FP. Moreover, hip flexion and adduction for MA were significantly greater than for FA. In the FP, the internal rotational velocity of the hip joint was significantly greater. MA showed larger hip internal rotation ROM in the FP but smaller hip external rotation ROM in the BP. The differences between genders can help coaches personalize their training programs and improve the performance of both male and female table tennis athletes.

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Evaluation of Strength and Irradiated Movement Pattern Resulting from Trunk Motions of the Proprioceptive Neuromuscular Facilitation

Rehabilitation Research and Practice ◽

10.1155/2012/281937 ◽

2012 ◽

Vol 2012 ◽

pp. 1-6 ◽

Cited By ~ 3

Author(s):

Luciana Bahia Gontijo ◽

Polianna Delfino Pereira ◽

Camila Danielle Cunha Neves ◽

Ana Paula Santos ◽

Dionis de Castro Dutra Machado ◽

...

Keyword(s):

Plantar Flexion ◽

Movement Pattern ◽

Lower Limbs ◽

Trunk Flexion ◽

Average Force ◽

Proprioceptive Neuromuscular Facilitation ◽

Muscular Activation ◽

Flexion And Extension ◽

Regional Muscle ◽

Dorsal Flexion

Introduction. The proprioceptive neuromuscular facilitation (PNF) is a physiotherapeutic concept based on muscle and joint proprioceptive stimulation. Among its principles, the irradiation is the reaction of the distinct regional muscle contractions to the position of the application of the motions.Objective. To investigate the presence of irradiated dorsiflexion and plantar flexion and the existing strength generated by them during application of PNF trunk motions.Methods. The study was conducted with 30 sedentary and female volunteers, the PNF motions of trunk flexion, and extension with the foot (right and left) positioned in a developed equipment coupled to the load cell, which measured the strength irradiated in Newton.Results. Most of the volunteers irradiated dorsal flexion in the performance of the flexion and plantar flexion during the extension motion, both presenting an average force of 8.942 N and 10.193 N, respectively.Conclusion. The distal irradiation in lower limbs became evident, reinforcing the therapeutic actions to the PNF indirect muscular activation.

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Predisposing factors to lateral ankle injury in male comrades marathon runners

South African Journal of Physiotherapy ◽

10.4102/sajp.v65i1.75 ◽

2009 ◽

Vol 65 (1) ◽

Cited By ~ 1

Author(s):

J. Hiemstra ◽

N. Naidoo

Keyword(s):

Correlation Coefficient ◽

Undergraduate Research ◽

The United States ◽

Ankle Injury ◽

Ankle Injuries ◽

Distance Runners ◽

Marathon Runners ◽

Lateral Ankle ◽

Ankle Ligament ◽

Lateral Ankle Ligament

Introduction: More than two million people experience ankle ligament traumaeach year in the United States. Half of these are severe ligament sprains, however verylittle is known about the factors that predispose individuals to these injuries. The purpose of this study, (which was conducted as an undergraduate research project),was to find a correlation between the characteristics of height, weight and limbdominance and lateral ankle ligament injuries. Method: A retrospective study was conducted on 114 ultra distance runners whoparticipated in the 2006 Comrades Marathon. During race registration, the runners’ height and weight were measuredafter answering a questionnaire regarding their training. Results: 114 runners responded to the questionnaire. From this cohort, 38 (33.3%) had sustained previous lateral ankle injuries. Of these 38 injuries, 47.4% of the injuries occurred on the runner’s dominant limb and 36.8% occurred on thenon-dominant side. 15.8% of the runners sustained previous ankle injuries to both ankles. There was a low negative correlation coefficient of 0.24 with regards to weight as a risk factor. This indicated that the power of the correlationwas 5.93%. The study demonstrates that there is no correlation between an increase in weight and an increase in theincidence of ankle injury. The correlation coefficient indicated a low correlation between an increase in height and the incidence of ankle injury. However, the power of the correlation at 18.37% makes inaccurate any attempt to predict the height at which a runner would be at most risk for lateral ankle injury. Conclusion: Height and weight are not risk factors predisposing subjects to lateral ankle injury. In addition, the studyillustrated that there was no effect of limb dominance on the incidence of lateral ankle injury.

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Injury patterns of South African international cricket players over a two-season period

South African Journal of Sports Medicine ◽

10.17159/2078-516x/2011/v23i2a350 ◽

2011 ◽

Vol 23 (2) ◽

pp. 45 ◽

Cited By ~ 8

Author(s):

RA Stretch ◽

RP Raffan

Keyword(s):

South African ◽

Exposure Time ◽

Lower Limbs ◽

Anatomical Site ◽

Injury Incidence ◽

International Level ◽

Mechanism Of Injury ◽

Injury Patterns ◽

Prevalence Data ◽

Acute Injuries

Objective. The aim of the study was to determine the incidence and nature of injury patterns of South African international cricket players. Methods. A questionnaire was completed for each cricketer who presented with an injury during the 2004 - 2005 (S1) and 2005 - 2006 (S2) cricket seasons to determine the anatomical site, month, diagnosis and mechanism of injury. Results. The results showed that 113 injuries were sustained, with a match exposure time of 1 906 hours for one-day internationals (ODIs) and 5 070 hours for test matches. The injury prevalence was 4% per match, while the incidence of injury was 90 injuries per 10 000 hours of matches. Injuries occurred mostly to the lower limbs, back and trunk, upper limbs and head and neck. The injuries occurred primarily during test matches (43%), practices (20%) and practices and matches (19%). Acute injuries comprised 87% of the injuries. The major injuries during S1 were haematomas (20 %), muscle strains (14%) and other trauma (20%), while during S2 the injuries were primarily muscle strains (16%), other trauma (32%), tendinopathy (10%) and acute sprains (12%). The primary mechanisms of injury occurred when bowling (67%), on impact by the ball (batting – 65%, fielding – 26%) and when sliding for the ball (19%). Conclusion. The study provided prospective injury incidence and prevalence data for South African cricketers playing at international level over a two-season period, high-lighting the increased injury prevalence for away matches and an increased match injury incidence for test and ODI matches possibly as a result of increased match exposure time.

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