Medial ankle ligament

Introduction

Medial Ankle Ligament

The deltoid muscle (or medial muscle of the talocrural joint) is a slender, strong triangular shaft. It consists of 4 triangular muscles that connect the tibia navicular the calcaneus and talus[1] .Attached to the upper and apex and anterior and posterior borders of the medial malleolus. The plantar calcaneonavicular ligament can be considered as part of the medial ligament complex.

The deltoid ligament consists of superficial and deep structures.

The superficial components:

• The tibiocalcaneal ligament descends vertically along almost the entire length of the sustentaculum tali to attach it inferiorly to the calcaneus
• The tibionavicular ligament advances to the navicular tuberosity (to attach anteriorly [1]) whereupon it fuses with the medial aspect of the plantar calcaneonavicular ligament
• The superior posterior tibiotalar ligament courses posteriorly to the medial portion of the talus and its medial tubercle
• The tibiospring ligament descends vertically and blends with the suture of the spring ligament

The deep components:

• The anterior tibiotalar ligament (ATTL) extends from the tip of the medial malleolus to the non-articular portion of the medial talar surface. The tibialis posterior is crossed by the flexor digitorum longus muscles
• The deep posterior tibiotalar ligament (PDTL) extends from the medial malleolus to the talus and is covered by the superficial posterior tibiotalar and tibiocalcaneal ligaments

The anterior and posterior tibiotalar ligaments attach the tibia to the talus [1].

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Clinically Relevant Anatomy

The deltoid ligament connects the medial malleolus to the multiple tarsal bones. Unlike the superficial layer of this ligament, the deep layer is intra-articular and covered by the synovium. In general anatomy, the superficial component originates from the anterior colliculus of the medial malleolus and The deep component arises from the intermalignant groove (ankle groove) and the posterior mound of the medial malleolus.

The superficial deltoid originates anteriorly and inferiorly on the medial malleolus, fans out and sends 3 bands to the navicular, and along the plantar-calcanoid (spring) ligament to the long shank and medial tubercle of the calcaneus. It is also partially covered by a tendon sheath & calf fascia. It primarily resists rearfoot eversion; the tibial portion suspends the spring beam and prevents inward displacement of the talar head, while the tibial portion prevents eversion displacement.

The deep deltoid arises from the anterior intercolliculus and the posterior border of the posterior colliculus. It is oriented laterally and inserts over the entire non-articular surface of the medial talus. The function of the deep deltoid muscle to extend the medial malleolus and prevent external rotation Displacement and external rotation of the talus (this is most pronounced in plantarflexion, when the deep deltoid tends to pull the talus into internal rotation).

Medial ankle stability is provided by the strong triangular ligament, anterior tibiofibular ligament, and tenon. Because of the bony joint between the medial malleolus and the talus, medial ankle sprains are less common than lateral sprains. Mechanism of Sprains in the Medial Ankle The injury is excessive valgus and dorsiflexion. [3][3]

Isolated deltoid ligament injuries are extremely rare and usually occur concurrently with lateral malleolus fractures. These are treated by identifying the damage complex and stabilizing the lateral side to ensure mortis reduction. [4]

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Physical Examination

Valgus Test – In a neutral state, it evaluates the superficial deltoid ligament complex. external rotation stress test to assess the syndesmosis, additionally – the deep deltoid ligament;

This test is performed by everting and abducting the heel with one hand while stabilizing the tibia (and fibula) with the other. Increased laxity or pain indicates a positive test [6].

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Radiographic Diagnosis of Injury

The deltoid muscle is usually torn away from its attachment to the tibia, with small pieces of bone visible on x-rays;

• A deltoid ligament rupture can be diagnosed with relative confidence when the medial space between the talus and the middle malleolus increases
• Lateral displacement of the talus with increased medial joint space (>3 mm), but this may only be apparent on stress views or post-cast films after swelling subsides;
• Presence of medial tenderness & > 5 mm of visible space indicates severe damage to the deltoid ligament;

Treatment of Deltoid Tear

• Such injuries should be treated as bimallear fractures with lateral malleolus ORIF;
• Routine exploration of the medial ankle is not necessary unless there is evidence that part of the deltoid ligament has entered the joint and is preventing reduction of the talus.

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Physical Therapy Management

To avoid ankle sprains or ankle instability, rehabilitation exercises can be performed to strengthen or retrain the medial ligaments of the ankle. These ligaments are important because they prevent the ankle from everting too much (valgus trauma).

First and second degree sprains are usually managed with conservative treatment. In the early stages, conservative treatment includes RICE (rest ice elevation) and mobilization to prevent loss of range of motion. When pain and inflammation are under control, we can begin treatment Exercises increase range of motion stability strength proprioception and function.

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With third-degree sprains, structural damage will most likely require surgical intervention. The ankle is immobilized after surgery. If pain or edema occurs after immobilization, the first treatment option is to manage the pain and edema. This will follow the same guidelines As for the conservative treatment of first and second degree sprains, it is the same as above.

After two weeks or when the pain and swelling allow for exercises that strengthen the muscles and ligaments on the inside of the ankle. Strengthening programs can begin with low-resistance exercises. For example, the patient sits on a chair or massage table with his/her legs Prolonged (sedentary). The physical therapist stabilizes the leg with one hand just below the knee. Hold the outside of the ankle with the other hand. A physical therapist moves the foot into an inversion and provides some manual resistance. The patient must then perform eversion movements this resistance. Hold the resistance for 3 to 5 seconds. Do 10 to 12 repetitions of the exercise. [10]

The above exercises can also be performed without resistance from a physical therapist. The patient sits on a chair. Put the elastic tube or resistance band over the foot and place the other foot on the elastic tube while holding the elastic tube with the opposite hand. same movement Do the exercise, but use a band as resistance. The patient pushes the foot outward with the pad away from the midline of the body.

[11] Proprioception exercises can be included after 5 weeks. To make these exercises more difficult, the therapist can vary the surface – on the floor/balance board or any other unstable surface. For example, have the patient sit in a chair with their feet on a kinesthetic ankle board (KAB). Ask the patient to keep their knees at a 90° angle while maintaining contact with the top of the KAB with their respective extremities. Once in position, the patient rotates the slide to the left and then to the right (=clockwise and counterclockwise) while maintaining Every time they move the board to the left or right, the board makes contact with the floor. This is done for 25 reps x 3 sets. [12]. The progression of this exercise is to stand on one leg on a balance board, hold the position first, eyes open and closed, 30 seconds at a time exercise. [13].

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Another way to increase the difficulty is to close your eyes while performing the exercise and try to do it without visual input. For example, the patient performs a single-leg stand on a flat surface, then opens and then closes the eyes. progress of the matter The workout can perform the same movements, but on a balance/wobble board with and without visual input. Perform 15 reps x 3 sets of each exercise. Another advancement with the wobble board can be to stand on the board with both feet and do a circular motion, as this will not only train Valgus also includes inverted dorsiflexion and plantarflexion.

The physical therapist can also further improve the skill level of the various exercises described above by introducing slight perturbations while the subject is balancing on the balance board.

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