Does Foot Position and Local of Measurement Influence on Ankle Medial Clear Space?

Category: Ankle, Sports, Trauma Introduction/Purpose: The ankle Medial Clear Space (MCS) is frequently used in foot and ankle surgery for determining the competence of the deltoid ligament in Weber B ankle fractures. A widened MCS indicates deltoid ligament incompetence, requiring surgery to prevent lateral talar shift. Controversy still exists regarding Medial Clear Space (MCS) normal and abnormal values, and its possible variation in previously uncontrolled biases. Sex, height, foot position, and type of radiograph were all described as possible influencing factors. The objective of this study was to access how much different degrees of plantar flexion, all performed with and without stress, influence on MCS width. Methods: We submitted 30 volunteers to six different anteroposterior non-weight bearing digital radiographs of the ankle in the following positions: neutral, neutral with external rotation stress, physiologic plantar flexion (FPF), physiologic plantar flexion with external rotation stress, maximum plantar flexion (MPF) and maximum plantar flexion with external rotation stress. The medial clear space MCS oblique (MCSo) and perpendicular (MCSp) were measured in all images by an experienced foot and ankle surgeon. Results: The data analysis showed with statically significance that the position of the foot does influence in the value of both MCSp and MCSo (p<0,05), regardless of three exceptions. MCSo does not change statistically between FPF with stress and MPF with stress. On the other hand, MCSp did not change in two situations: between FPF and Neutral with stress and between MPF and FPF with stress. It is noteworthy that MCSo, on average, was 15% wider than MCSp in all positions tested. It is also noticeable that, from the neutral position, plantar flexing the ankle has a great impact on MCS than external rotation stress, increasing MCSp by 25% and 22% respectively. MCSo follows the same pattern, with 21% and 17% respectively. Conclusion: This study is unique on showing that many different ways of positioning the foot and making stress radiographs do result in completely different MCS values, and that these values differ depending on the anatomical site they are measured. All these data indicates that we need to establish a gold standard for measuring MCS, taking into account patient sex, height, local of measurement of MCS, position of the foot and type of radiograph (AP or Mortise). This study was not able to address all variables that influence directly on MCS and therefore did not intended to establish this new gold standard.

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Does Foot Position and Location of Measurement Influence Ankle Medial Clear Space?

Foot & Ankle Specialist ◽

10.1177/1938640017699918 ◽

2017 ◽

Vol 11 (1) ◽

pp. 32-36 ◽

Cited By ~ 2

Author(s):

Daniel Baumfeld ◽

Tiago Baumfeld ◽

João Cangussú ◽

Benjamim Macedo ◽

Thiago Alexandre Alves Silva ◽

...

Keyword(s):

External Rotation ◽

Plantar Flexion ◽

Anatomical Site ◽

Foot And Ankle ◽

Levels Of Evidence ◽

Stress Radiographs ◽

Clear Space ◽

Stress Maximum ◽

Foot Position ◽

Rotation Stress

Purpose. There is still controversy regarding normal and abnormal values of the medial clear space (MCS) of the ankle. The aim of this study was to assess how much different degrees of plantar flexion, with and without stress, influenced the MCS. Methods. We submitted 30 volunteers to 6 different anteroposterior ankle radiographs in the following positions: neutral, neutral with external rotation stress, physiologic plantar flexion (FPF), physiologic plantar flexion with external rotation stress, maximum plantar flexion (MPF), and maximum plantar flexion with external rotation stress. The MCS oblique (MCSo) and perpendicular (MCSp) were measured in all images by an experienced foot and ankle surgeon. Results. The data showed that the position of the foot does influence the value of MCSp and MCSo ( P < .05), except for 3 comparisons. MCSo did not change between FPF with stress and MPF with stress. MCSp did not change in 2 situations: between FPF and neutral with stress and between MPF and FPF with stress. Conclusions. This study is unique in showing that different ways of positioning the foot and performing stress radiographs results in different MCS values and that these values differ depending on the anatomical site where they are measured. Levels of Evidence: Diagnostic, Level IV

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Invisible Injuries in Ankle Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000121 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0001

Author(s):

Robin Blom ◽

Markus Knupp ◽

Beat Hintermann ◽

Sjoerd Stufkens

Keyword(s):

Ankle Instability ◽

External Rotation ◽

Plantar Flexion ◽

Axial Loading ◽

Ankle Fractures ◽

Deltoid Ligament ◽

Neutral Position ◽

Need For Treatment ◽

Ligament Rupture ◽

Fresh Frozen

Category: Ankle, Trauma, Biomechanical Introduction/Purpose: Ankle fractures are often associated with ligamentous injuries of the distal tibiofibular syndesmosis, the deltoid ligament and are predictive of ankle instability, early joint degeneration and long-term ankle dysfunction. Detection of ligamentous injuries and the need for treatment remain subject of ongoing debate. In the classic article of Boden it was made clear that injuries of the syndesmotic ligaments were of no importance in the absence of a deltoid ligament rupture. Even in the presence of a deltoid ligament rupture, the interosseous membrane withstood lateralization of the fibula in fractures up to 4.5 mm above the ankle joint. Generally, syndesmotic ligamentous injuries are treated operatively by temporary fixation performed with positioning screws. But do syndesmotic injuries need to be treated operatively at all? Methods: The purpose of this biomechanical cadaveric study was to investigate the relative movements of the tibia and fibula, under normal physiological conditions and after sequential sectioning of the syndesmotic ligaments. Ten fresh-frozen below-knee human cadaveric specimens were tested under normal physiological loading conditions. Axial loads of 50 Newton (N) and 700 N were provided in an intact state and after sequential sectioning of the following ligaments: anterior-inferior tibiofibular (AITFL), posterior-inferior tibiofibular (PITFL), interosseous (IOL), and whole deltoid (DL). In each condition the specimens were tested in neutral position, 10 degrees of dorsiflexion, 30 degrees of plantar flexion, 10 degrees of inversion, 5 degrees of eversion, and externally rotated up to 10 Nm torque. Finally, after sectioning of the deltoid ligament, we triangulated Boden’s classic findings with modern instruments. We hypothesized that only after sectioning of the deltoid ligament; the lateralization of the talus will push the fibula away from the tibia. Results: During dorsiflexion and external rotation the ankle syndesmosis widened, and the fibula externally rotated after sequential sectioning of the syndesmotic ligaments. After the AITFL was sectioned the fibula starts rotating externally. However, the external rotation of the fibula significantly reduced when the external rotation torque was combined with axial loading up to 700 N as compared to the external rotation torque alone. The most relative moments between the tibia and fibula were observed after the deltoid ligament was sectioned. Conclusion: Significant increases in movements of the fibula relative to the tibia occur when an external rotation torque is provided. However, axial pressure seemed to limit external rotation because of the bony congruence of the tibiotalar surface. The AITFL is necessary to prevent the fibula to rotate externally when the foot is rotating externally. The deltoid ligament is the main stabilizer of the ankle mortise.

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Analysis of Foot Position in Ankle Arthrodesis and Its Influence on Gait

Foot & Ankle ◽

10.1177/107110078000100115 ◽

1980 ◽

Vol 1 (1) ◽

pp. 44-49 ◽

Cited By ~ 48

Author(s):

Howard A. King ◽

Troy B Watkins ◽

Kent M. Samuelson

Keyword(s):

Plantar Flexion ◽

Ankle Arthrodesis ◽

Neutral Position ◽

Foot And Ankle ◽

Solid Fusion ◽

Foot Position

This study was carried out on 24 patients who underwent 25 ankle fusions. Twenty-four of 25 ankles operated upon by eight different surgeons achieved a solid fusion. A review showed that when the ankle was fused in a neutral position, the patient would, on the average, have 10° of plantar flexion occurring in the midfoot. This motion allowed him to wear most normal foot gear. In gait, the plantar flexion in the foot approximated the plantar flexion in the normal ankle, giving little difficulty. In contrast, those individuals whose ankle was fused in 10° of plantar flexion who also had 10° of plantar motion in the midfoot and no dorsiflexion motion in the midfoot were, in effect, in 10° of equinus. These patients showed a vaulting pattern while ambulating barefoot, but were usually able to accommodate this position while wearing shoes. The patient with a neutral position of the foot and ankle showed a very satisfactory gait in shoes and a much improved barefoot gait. It is concluded that fusion in a neutral position is indicated and that midtarsal motion occurs in the plantar direction but that no dorsiflexion is present in the midtarsal area.

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Stress vs. Non-Stress Radiographs in Subtle Syndesmotic Injuries

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00296 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0029

Author(s):

Nicola Krähenbühl ◽

Travis Bailey ◽

Nathan Davidson ◽

Heath Henninger ◽

Charles Saltzman ◽

...

Keyword(s):

Ankle Instability ◽

External Rotation ◽

Paired Comparison ◽

Weight Bearing ◽

Deltoid Ligament ◽

Ankle Sprains ◽

X Rays ◽

Syndesmotic Injury ◽

Stress Radiographs ◽

Clear Space

Category: Sports Introduction/Purpose: Between 1-18% of all ankle sprains and 23% of all ankle fractures involve injury to the distal tibio-fibular syndesmosis. Syndesmotic injuries can create a substantial diagnostic and therapeutic challenge for orthopaedic surgeons. While acute injuries can be assessed using conventional radiographs, subtle syndesmotic injuries may be misdiagnosed using X-rays. Misdiagnoses may result in chronic ankle instability, pain and post-traumatic osteoarthritis of the tibio-talar joint. The purpose of this study was to investigate whether syndesmotic injury was more easily diagnosed with stress vs. non-stress radiographs.radiographs.sed with stress vs. non-stress radiographs. Methods: Five pairs of cadavers (tibia plateau to toe-tip, mean 61 years, range 52-70 years) were scanned with weight-bearing CT (170 lb, w/ and w/o 10 Nm static external rotation torque). Digitally reconstructed radiographs (DRRs), which are comparable to conventional radiographs, were reconstructed from the 3D CT data. The following conditions were tested: First, intact ankles (Native) were tested. Second, one specimen from each pair underwent AITFL resection, while the contralateral underwent deltoid resection (Condition 1). Third, the remaining intact deltoid ligament or AITFL was resected in each ankle (Condition 2). Finally, the interosseous membrane (IOM) was resected in all ankles (Condition 3). Condition 3 was defined as acute syndesmotic injury. Using antero-posterior (AP) views, the tibio-fibular clear space (TFCS), tibiofibular overlap (TFO) and medial clear space (MCS) were assessed. Statistical analysis was performed using paired (comparison within groups) and unpaired (comparison between groups) t-test where p=0.05 was considered significant. Results: Regarding the TFCS, Native vs. Condition 3 in 10 Nm stress radiographs was significantly different in the deltoid group (p=0.021). Using TFO in stress and non-stressed radiographs, Native vs. Condition 2 and 3 was significantly different for the deltoid group (p=0.043), and Native vs. Condition 3 in the syndesmotic group (p=0.027). Regarding the MCS in non-stress radiographs, Native vs. Condition 3 was significantly different in the deltoid group (p=0.007), while in stress views, Native vs. Condition 2 was significant different in the syndesmotic (p=0.026) and Native vs. Condition 3 in the deltoid group (p=0.030). No differences were found comparing the conditions of the AITFL with the same conditions of the deltoid group. Conclusion: The TFCS cannot be used to assess subtle or acute syndesmotic injuries in stress and non-stress radiographs. The TFO can be used to assess a combined injury to the AITFL and deltoid ligament in stress and non-stress radiographs. The MCS can be used to assess acute syndesmotic injuries in stress and non-stress radiographs. Radiographs (stress or non-stress) cannot be used to distinguish between injuries to the AITFL or deltoid ligament. Therefore, stress and non-stress radiographs are not useful in assessment of subtle syndesmotic injuries. Stress-radiographs are not superior compared to non-stress radiographs in assessment of acute syndesmotic injuries.

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Varus External Rotation Stress Test for Radiographic Detection of Deep Deltoid Ligament Disruption With and Without Syndesmotic Disruption

Foot & Ankle International ◽

10.1177/1071100712465848 ◽

2013 ◽

Vol 34 (2) ◽

pp. 251-260 ◽

Cited By ~ 19

Author(s):

John E. Femino ◽

Tanawat Vaseenon ◽

Phinit Phistkul ◽

Yuki Tochigi ◽

Donald D. Anderson ◽

...

Keyword(s):

External Rotation ◽

Stress Test ◽

Deltoid Ligament ◽

Ligament Disruption ◽

Rotation Stress

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Operative Treatment of Syndesmotic Disruptions Without Use of a Syndesmotic Screw: A Prospective Clinical Study

Foot & Ankle International ◽

10.1177/107110079401500801 ◽

1994 ◽

Vol 15 (8) ◽

pp. 407-414 ◽

Cited By ~ 87

Author(s):

Ken Yamaguchi ◽

Christopher H. Martin ◽

Scott D. Boden ◽

Panos A. Labropoulos

Keyword(s):

External Rotation ◽

Clinical Results ◽

Cadaveric Study ◽

Deltoid Ligament ◽

Prospective Clinical Study ◽

Fibular Fracture ◽

Static View ◽

Pronation External Rotation ◽

Rotation Stress

A new protocol for the selected omission of transsyndesmotic fixation in Weber class C ankle fractures was prospectively evaluated in 21 consecutive patients. As proposed in a previous cadaveric study ( J. Bone Joint Surg., 71A:1548–1555, 1989), the protocol suggested that transsyndesmotic fixation was not required if (1) rigid bimalleolar fracture fixation was achieved or (2) lateral without medial fixation was obtained (i.e., with accompanying deltoid tears) if the fibular fracture was within 4.5 cm of the joint. According to this protocol, only 3 of 21 patients (14%) required transsyndesmotic fixation. Ten of the patients who did not receive transsyndesmotic fixation underwent pronation-external rotation stress radiographs in a fashion analogous to the previous cadaveric study. At 1- to 3-year follow-up, no stress (N = 10) or static view (N = 18) widening of the mortise or syndesmosis was seen in any patient, which supports (with the above guidelines) a limited, rather than routine, use of supplemental transsyndesmotic fixation. Clinical results from this prospective study seem to substantiate previously proposed biomechanical guidelines for the selected omission of transsyndesmotic fixation. Given these guidelines, transsyndesmotic fixation was unnecessary in many cases and the need can be determined before surgery by assessing the integrity of the deltoid ligament and level of the fibular fracture.

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Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000320 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0003

Author(s):

Young-Uk Park ◽

Youngwook Seo ◽

Hyuk Jegal ◽

Kyung-Tai Lee

Keyword(s):

Ankle Fracture ◽

External Rotation ◽

Ligament Injury ◽

Deltoid Ligament ◽

Stability Assessment ◽

Stress Radiography ◽

X Ray ◽

Malleolar Fractures ◽

The Stability ◽

Rotation Stress

Category: Ankle, Trauma Introduction/Purpose: Isolated Lateral malleolus fracture, like any other fractures can be treated by operative or conservative treatment. Stability of ankle joint is the most important factor in deciding the type of treatment. Unstable ankle joints present superior clinical outcomes with surgical management. There are many methods to assess the stability of ankle joint such as plain x- ray films, stress radiographies and physical examination. Many studies have suggested the usage of ultrasound for diagnosis of ankle ligament injury. But, there are no reports about its use for stability assessment of isolated lateral malleolar ankle fracture. Therefore, the purpose of this study is to evaluate the value of ultrasound for stability assessment of isolated lateral malleolar fractures, compared to simple x-ray, stress radiography and arthroscopy. Methods: We have conducted a prospective study which included 13 consecutive patients who underwent arthroscopic exam and subsequent open reduction and internal fixation for isolated lateral malleolar ankle fracture. Before operation simple x-ray, external rotation stress radiographs were done. Stress ultrasound was performed to assess the anterior inferior tibiofibular ligament (AITFL) and medial deltoid ligament prior to operation. The arthroscopic findings were used as the reference standard. A standardized physical examination (tenderness and ecchymosis, external rotation stress test), simple radiography, stress radiography and ultrasound images were compared to assess the stability. Results: Deltoid ligament injury and or syndesmosis injury were verified arthroscopically in 12 cases with a clinical diagnosis (92.3%). There were 9 cases who showed unstable ankle fracture on the simple radiography. (69.2%). There were all cases who showed unstable ankle fracture on the external rotation stress radiography. (100%) In addition, for 12/13, there were acute tear of the deltoid ligament or AITFL injury on the ultrasound (92.3%). Conclusion: The results suggest that ultrasound could be used for the assessment of the instability of isolated lateral malleolar fracture.

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Kinematics after Syndesmotic Injury: Assessing the Magnitude of Talus and Fibula Rotation and Displacement

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00114 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0011

Author(s):

Jonathan Bartolomei ◽

Mark W. Bowers ◽

Kenneth J. Hunt

Keyword(s):

Repeated Measures ◽

External Rotation ◽

Deltoid Ligament ◽

Ankle Sprains ◽

Syndesmotic Injury ◽

Suture Button ◽

Clear Space ◽

Lateral Translation ◽

Radiographic Measurements

Category: Ankle; Sports; Other Introduction/Purpose: High ankle sprains, or injuries to the distal tibiofibular syndesmosis, are predictive of long-term ankle dysfunction. Our objectives were to evaluate ankle mortise stability, radiographically, and kinematically, using a cadaveric model with a simulated syndesmotic injury. We also measured the ability of a suture-button system to restore natural joint motion. Methods: Eight cadaveric specimens underwent serial sectioning of the anterior-inferior tibiofibular (AITFL), interosseous (IOL), posterior-inferior tibiofibular (PITFL), and deltoid ligaments. Specimens underwent external rotation and lateral translation testing after ligament release to obtain kinematic data (using a validated infrared LED motion capture system) and radiographic measurements. We then repeated external rotation and lateral translation testing after implementing a suture-button system. Repeated measures ANOVA with a Bonferroni/Dunn post-hoc test calculated the interspecimen comparisons. Results: Sectioning of each ligament, beginning with the AITFL, significantly increased talar external rotation. After releasing the AITFL and IOL, fibular external rotation increased significantly. Posterior displacement of the fibula began following the release of AITFL. Significant radiographic widening of the medial clear space and the syndesmosis occurred only after the release of the deltoid ligament. Syndesmotic and medial clear space widening was not significantly different from the intact state under lateral translation until after the release of the deltoid ligament. Placement of the suture-button system successfully reduced the medial clear space but was unable to restore the native stability of the ankle joint. Conclusion: This project addresses rotational and kinematic changes in the ankle after syndesmotic injury by quantifying the effect of ligamentous disruption on the tibiotalar articulation. The change in joint kinematics may explain why patients with moderate-to-severe syndesmosis injuries take longer to heal and develop long-term dysfunction. Significant talar rotation and posterior fibular displacement occur during external rotation, even with moderate syndesmosis injury, and before the disruption of the deltoid ligament. Stress radiography does not appear to be a reliable indicator of mild or moderate syndesmosis injuries.

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Ankle Joint Pressure in Supination–External Rotation Injuries: A Biomechanical Study in an Unrestrained Cadaver Model

Foot & Ankle Specialist ◽

10.1177/1938640020950183 ◽

2020 ◽

pp. 193864002095018

Author(s):

Andreas C. Fösel ◽

Angela Seidel ◽

Marc C. Attinger ◽

Ivan Zderic ◽

Boyko Gueorguiev ◽

...

Keyword(s):

Ankle Joint ◽

Contact Area ◽

Peak Pressure ◽

External Rotation ◽

Axial Loading ◽

Biomechanical Study ◽

Deltoid Ligament ◽

Neutral Position ◽

Joint Reaction Forces ◽

Supination External Rotation

Background Previous biomechanical studies simulating supination–external rotation (SER) IV injuries revealed different alterations in contact area and peak pressure. We investigated joint reaction forces and radiographic parameters in an unrestrained, more physiological setup. Methods Twelve lower leg specimens were destabilized stepwise by osteotomy of the fibula (SER II) and transection of the superficial (SER IVa) and the deep deltoid ligament (SER IVb) according to the Lauge-Hansen classification. Sensors in the ankle joint recorded tibio-talar pressure changes with axial loading at 700 N in neutral position, 10° of dorsiflexion, and 20° of plantarflexion. Radiographs were taken for each step. Results Three of 12 specimen collapsed during SER IVb. In the neutral position, the peak pressure and contact area changed insignificantly from 2.6 ± 0.5 mPa (baseline) to 3.0 ± 1.4 mPa (SER IVb) ( P = .35) and from 810 ± 42 mm2 to 735 ± 27 mm2 ( P = .08), respectively. The corresponding medial clear space (MCS) increased significantly from 2.5 ± 0.4 mm (baseline) to 3.9 ± 1.1 mm (SER IVb) ( P = .028). The position of the ankle joint had a decisive effect on contact area ( P = .00), center of force ( P = .00) and MCS ( P = .01). Conclusion Simulated SER IVb injuries demonstrated radiological, but no biomechanical changes. This should be considered for surgical decision making based on MCS width on weightbearing radiographs. Levels of Evidence: Not applicable. Biomechanical study

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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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