MOB TCD

Tibifibular and Ankle Joint Complex

Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin

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Superior and Inferior Tibio-Fibular Joints

Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament

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Ankle Joint
The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured
Brstrom, 1966

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Tennis

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Ankle Joint
Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement

Last, 1963

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Ankle Joint
Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion
Williams & Warwick, 1980

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Proximal Articular Surface

Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet
Williams & Warwick, 1980

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Proximal Articulation
Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula
Williams & Warwick, 1980

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Proximal Articular Surface

Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis

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Distal Articular Surface

The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet
Frazer, 1965

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Capsule
Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus
Williams & Warwick, 1980

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Ankle Joint
The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments
Williams & Warwick, 1980

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Medial (Deltoid) Ligament

A strong triangular ligament Superiorly attached The medial malleolus of the tibia
Williams & Warwick, 1980

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Medial Ligament
The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus
Last, 1963

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Medial or Deltoid Ligament (Superficial)

Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali
Williams & Warwick, 1980

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Medial or Deltoid Ligament (Deep)

The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus
Williams & Warwick, 1980

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Lateral Ligaments of Ankle

The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel
Liu & Jason, 1994

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Anterior Talofibular Ligament (ATFL)

Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick

Liu & Jason, 1994

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ATFL
The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus

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ATFL
It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion
Liu & Jason, 1994

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Calcaneofibular Ligament (CFL)

A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus
Williams & Warwick, 1980

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CFL
It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints

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CFL
The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL

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Lateral Ligament
The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament
Hamilton, 1994; Peters, 1991

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Ankle Stability
The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint

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ATFL and CFL

A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint
Liu & Jason, 1994

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Posterior Talofibular (PTL)

The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus

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PTL
During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion

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Ankle Joint
The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum

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Synovial Membrane
Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint

Plastanga et al., 1980

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Blood Supply of Ankle

Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries

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Nerve Supply of Ankle

Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2

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Anterior Aspect
Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius

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Postero-Medial Aspect of Ankle

Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus

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Posterior Aspect
Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk
Jaivin & Ferkel, 1994

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Lateral Aspect of Ankle

The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament

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Lateral Aspect of Ankle

Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius

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Nerves Related to Ankle Joint

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Ankle Joint
In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally
Plastanga et al., 1990

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Ankle Joint
The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt)

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Ankle Examination
Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test

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Ankle Examination
Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament

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Tests for Ankle Ligament Injury

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Ottawa Ankle Rules

Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury

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Tibialis Posterior / Superficial Peroneal Nerve

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Ankle Examination
ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal

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Inversion and Eversion

Inversion or supination Raising the medial border Sole faces medially Eversion or pronation Raising the lateral border Sole faces laterally

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Inversion and Eversion

Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular
Last, 1963

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Inversion and Eversion

Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus
Last, 1963

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Inversion and Eversion

Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus
Last, 1963

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Talocalcaneal
Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus

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Talocalcaneal Joint
Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus

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Tarsal Canal and Tarsal Sinus

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Inversion or Supination
Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior

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Eversion and Pronation

Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus

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Talocalcaneonavicular Joint
Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL

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Talocalcaneonavicular Joint
Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus

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Talocalcaneonavicular Joint
Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament

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Talocalcaneonavicular Joint
Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus

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Talocalcaneonavicular Joint
Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves

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Subtalar Interosseosus
Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint

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Ligaments of Subtalar Joint

Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament

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Ligament of Neck of Talus

Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion
Last, 1963

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Tarsal Canal and Tarsal Sinus

Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints

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Inferior Extensor Retinaculum

Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus
Klein & Spreitzer, 1993

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Ligament Attachments

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Bifurcate Ligament
Lateral calcaneonavicular ligament (CNL) Medial calcaneocuboid ligament (CCL)

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Bifurcate Ligament
Two individual ligaments Separate attachments Different fibre orientation Different histology

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Talocalcaneonavicular Joint
Invertors In dorsiflexion Tibialis anterior In plantarflexion Tibialis posterior

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Talocalcaneonavicular Joint
Evertor In dorsiflexion Peroneus tertius In plantarflexion Peroneus longus Peroneus brevis

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Calcaneo Navicular Ligament

Folded and twisted appearance Prominent medial and lateral edges / folds Three groups of fibres Medial Lateral (deep) Intra-articular

N A

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Calcaneocuboid Ligament
Intra-capsular CC joint Smaller than CNL, always present Hourglass shaped fibres, twisted medially

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Calcaneocuboid Joint
Plane synovial Ligaments Capsular Ligament of neck of talus Long and short plantar ligament Bifurcate ligament

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Calcaneocuboid Joint
The long and short plantar ligaments support the calcaneocuboids portion of the transverse tarsal joint

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