Ligamentous, Chondral, and Osteochondral Ankle Injuries in Athletes

James Linklater

doi:10.1055/s-2004-823016

Seminars in Musculoskeletal Radiology, Table of Contents

Semin Musculoskelet Radiol 2004; 8(1): 81-98
DOI: 10.1055/s-2004-823016

Ligamentous, Chondral, and Osteochondral Ankle Injuries in Athletes

James Linklater¹

¹Castlereagh Imaging, Crows Nest, Australia

Abstract

There is a broad spectrum of intra- and extra-articular pathologies that may result in chronic pain and loss of function after an ankle sprain in an athlete. Multiple concurrent intra- and extra-articular pathologies are common. The complex anatomy in the ankle and foot may result in overlap of the clinical features of these various conditions. Contemporary imaging modalities facilitate accurate diagnosis and appropriate and timely management. This review focuses on the particular mechanisms of injury in individual sports, the imaging manifestations of ankle ligament injuries, posttraumatic ankle synovitis, meniscoid lesions, soft-tissue impingement, and ankle joint chondral and osteochondral lesions, with an emphasis on their clinical relevance in athletes.

KEYWORDS

Ankle - ligaments - cartilage

Full Text

References

REFERENCES

1 Garrick J G, Requa R K. The epidemiology of foot and ankle injuries in sports. Clin Sports Med. 1988; 7 29-36
2 Frey C, Bell J, Teresi L et al.. A comparison of MRI and clinical examination of acute lateral ankle sprains. Foot Ankle Int. 1996; 17 533-572
3 Anzilotti Jr K, Schweitzer M E, Hecht P. Effect of foot and ankle MR imaging on clinical decision making. Radiology. 1996; 201 515-517
4 Garrick J G. Epidemiologic perspective. Clin Sports Med. 1982; 1 13-18
5 Usami N, Inokuchi S, Hiraishi E. Pathophysiology and treatment of subtalar instability. , Proceedings of AOFAS 1997 Annual Summer Meeting, Monterey, AL, USA
6 De Simoni C, Wetz H H, Zanetti M et al.. Clinical examination and magnetic resonance imaging in the assessment of ankle sprains treated with an orthosis. Foot Ankle Int. 1996; 17 177-182
7 Roder W, Hennes R, Grebe P et al.. MRI monitoring of reconstruction of ligaments of the upper ankle joint after injury. Unfallchirurg. 1994; 97 467-471
8 Mazur D W, Bartolozzi A R. Ankle Soft Tissue Injuries in Sports Medicine 2. Rosemont, IL; AAOS 1999: 375
9 Liu S H, Jason W J. Lateral ankle sprain and instability problems. Clin Sports Med. 1994; 13 793-804
10 Hertel J, Denegar C R, Monroe M M et al.. Talocrural and subtalar instability after lateral ankle sprain. Med Sci Sports Exerc. 1999; 31 1501-1508
11 Clark T W, Janzen D L, Ho K et al.. Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion. Am J Roentgenol. 1995; 164 1185-1189
12 Berg E E. The symptomatic os subfibulare. Avulsion fracture of the fibula associated with recurrent instability of the ankle. J Bone Joint Surg (Am). 1991; 73 1251-1254
13 Sugimoto K, Samoto N, Takakura Y et al.. Varus tilt of the tibial plafond as a factor in chronic ligament instability of the ankle. Foot Ankle Int. 1997; 18 402-405
14 Fortin P T, Guettler J, Manoli II A. Idiopathic cavovarus and lateral ankle instability: recognition and treatment implications relating to ankle arthritis. Foot Ankle Int. 2002; 23 1031-1037
15 Fujii T, Luo Z P, Kitaoka H B. The manual stress test may not be sufficient to differentiate ankle ligament injuries. Clin Biomech (Bristol, Avon). 2000; 15 619-623
16 Rijke A M, Jones B, Vierhout P AM. Stress examination of traumatized lateral ligaments of the ankle. Clin Orthop. 1986; 210 143-151
17 Rijke A M, Vierhout P AM. Graded stress radiography in acute injury to the lateral ligaments of the ankle. Acta Radiol. 1990; 31 151-155
18 van Dijk C N, Molenaar A H, Cohen R H et al.. Value of arthrography after supination trauma of the ankle. Skeletal Radiol. 1998; 27 256-261
19 van Dijk C N, Mol B W, Lim L S et al.. Diagnosis of ligament rupture of the ankle joint. Physical examination, arthrography, stress radiography and sonography compared in 160 patients after inversion trauma. Acta Orthop Scand. 1996; 67 566-570
20 Campbell D G, Menz A, Isaacs J. Dynamic ankle ultrasonography. A new imaging technique for acute ankle ligament injuries. Am J Sports Med. 1994; 22 855-858
21 Friedrich J M, Schnarkowski P, Rubenacker S et al.. Ultrasonography of capsular morphology in normal and traumatic ankle joints. J Clin Ultrasound. 1993; 21 179-187
22 Milz P, Milz S, Steinborn M et al.. 13-MHz high frequency ultrasound of the lateral ligaments of the ankle joint and the anterior tibia-fibular ligament. Comparison and results of MRI in 64 patients. Radiologe. 1999; 39 34-40
23 Muhle C, Frank L R, Rand T et al.. Collateral ligaments of the ankle: high-resolution MR imaging with a local gradient coil and anatomic correlation in cadavers. Radiographics. 1999; 19 673-683
24 Lagalla R, Iovane A, Midiri M et al.. Comparison of echography and magnetic resonance in sprains of the external compartment of the ankle. Radiol Med (Torino). 1994; 88 742-748
25 Rijke A M, Goitz H T, McCue III F C et al.. Magnetic resonance imaging of injury to the lateral ankle ligaments. Am J Sports Med. 1993; 21 528-534
26 Gaebler C, Kukla C, Breitenseher M J et al.. Diagnosis of lateral ankle ligament injuries. Comparison between talar tilt, MRI and operative findings in 112 athletes. Acta Orthop Scand. 1997; 68 286-290
27 St Pierre R K, Rosen J, Whitesides T E et al.. The tensile strength of the anterior talofibular ligament. Foot Ankle. 1983; 4 83-85
28 Siegler S, Block J, Schneck C D. The mechanical characteristics of the collateral ligaments of the human ankle joint. Foot Ankle. 1988; 8 234-242
29 Freeman M A, Dean M R, Hanham I WF. The etiology and prevention of functional instability of the foot. JBJS. 1965; 47(A) 678-685
30 Freeman M A. Instability of the foot after injuries to the lateral ligament of the ankle. JBJS. 1965; 47(A) 669-677
31 Brostrum L, Sundelin P. Histologic changes in recent and “chronic” ligament ruptures. Acta Chir Scand. 1966; 132 248-253
32 Freiberger RH, Kaye JJ Arthrography. New York; Appleton-Century-Crofts 1979
33 Meislin R J, Rose D J, Parisien J S et al.. Arthroscopic treatment of synovial impingement of the ankle. Am J Sports Med. 1993; 21 186-189
34 Lahm A, Erggelet C, Steinwachs M et al.. Arthroscopic management of osteochondral lesions of the talus: results of drilling and usefulness of magnetic resonance imaging before and after treatment. Arthroscopy. 2000; 16 299-304
35 Bassett F, Gates H, Billys J et al.. Talar impingement by the anteroinferior tibiofibular ligament. JBJS. 1990; 72(A) 55-59
36 DeBerardino T M, Arciero R A, Taylor D C. Arthroscopic treatment of soft-tissue impingement of the ankle in athletes. Arthroscopy. 1997; 13 492-498
37 Liu S H, Nuccion S L, Finerman G. Diagnosis of anterolateral ankle impingement. Comparison between magnetic resonance imaging and clinical examination. Am J Sports Med. 1997; 25 389-393
38 Ferkel R D, Karzel R P, Del Pizzo W et al.. Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med. 1991; 19 440-446
39 Lahm A, Erggelet C, Reichelt A. Ankle joint arthroscopy for meniscoid lesions in athletes. Arthroscopy. 1998; 14 572-575
40 Rubin D A, Tishkoff N W, Britton C A et al.. Anterolateral soft-tissue impingement in the ankle: diagnosis using MR imaging. Am J Roentgenol. 1997; 169 829-835
41 Farooki S, Yao L, Seeger L L. Anterolateral impingement of the ankle: effectiveness of MR imaging. Radiology. 1998; 207 357-360
42 Bagnolesi P, Carafoli D, Ortori S et al.. Anterolateral fibrous impingement of the ankle: discrepancy between MRI findings and arthroscopy. Eur Radiol. 1998; 8 1295 , Abstract
43 Jordan III L K, Helms C A, Cooperman A E et al.. Magnetic resonance imaging findings in anterolateral impingement of the ankle. Skeletal Radiol. 2000; 29 34-39
44 Skib R A. Anterolateral soft-tissue impingement of the ankle. Radiology. 1998; 209 885
45 Chandnani V P, Harper M T, Ficke J R et al.. Chronic ankle instability: evaluation with MR arthrography, MR imaging, and stress radiography. Radiology. 1994; 192 189-194
46 Hauger O, Moinard M, Lasalarie J C et al.. Anterolateral compartment of the ankle in the lateral impingement syndrome: appearance on CT arthrography. AJR Am J Roentgenol. 1999; 173 685-690
47 Robinson P, White L M, Salonen D C et al.. Anterolateral ankle impingement: MR arthrographic assessment of the anterolateral recess. Radiology. 2001; 221 186-190
48 Hopkinson W J, St Pierre P, Ryan J B et al.. Syndesmosis sprains of the ankle. Foot Ankle. 1990; 10 325-330
49 Scranton P E. Sprains and soft tissue injuries. In: Pfeffer GB Chronic Ankle Pain in the Athlete. Rosemont, IL; AAOS 2000: 3-20
50 Nussbaum E D, Hosea T M, Sieler S D et al.. Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med. 2001; 29 31-35
51 Gerber J P, Williams G N, Scoville C R et al.. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998; 19 653-660
52 Boytim M J, Fischer D A, Neumann L. Syndesmotic ankle sprains. Am J Sports Med. 1991; 19 294-298
53 Takao M, Ochi M, Naito K et al.. Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy. 2001; 17 836-843
54 Loren G J, Ferkel R D. Arthroscopic assessment of occult intra-articular injury in acute ankle fractures. Arthroscopy. 2002; 18 412-421
55 Taylor D C, Englehardt D L, Bassett III F H. Syndesmosis sprains of the ankle. The influence of heterotopic ossification. Am J Sports Med. 1992; 20 146-150
56 Harper M C. Delayed reduction and stabilization of the tibiofibular syndesmosis. Foot Ankle Int. 2001; 22 15-18
57 Beals T C, Manoli II A. Late syndesmosis reconstruction: a case report. Foot Ankle Int. 1998; 19 485-488
58 Ogilvie-Harris D J, Reed S C. Disruption of the ankle syndesmosis: diagnosis and treatment by arthroscopic surgery. Arthroscopy. 1994; 10 561-568
59 Veltri D M, Pagnani M J, O'Brien S J et al.. Symptomatic ossification of the tibiofibular syndesmosis in professional football players: a sequela of the syndesmotic ankle sprain. Foot Ankle Int. 1995; 16 285-290
60 Kennedy M A, Sama A E, Sigman M. Tibiofibular syndesmosis and ossification. Case report: sequelae of ankle sprain in an adolescent football player. J Emerg Med. 2000; 18 233-240
61 Pneumaticos S G, Noble P C, Chatziioannou S N et al.. The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int. 2002; 23 107-111
62 Harper M C. An anatomic and radiographic investigation of the tibiofibular clear space. Foot Ankle. 1993; 14 455-458
63 Bozic K J, Jaramillo D, DiCanzio J et al.. Radiographic appearance of the normal distal tibiofibular syndesmosis in children. J Pediatr Orthop. 1999; 19 14-21
64 Ebraheim N A, Lu J, Yang H et al.. Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study. Foot Ankle Int. 1997; 18 693-698
65 Semaan H B, Elgafy H K, Ebraheim N A et al.. Computed tomography of normal and injured tibiofibular syndesmosis (Ab). Radiology. 2002; 225(Suppl) 462
66 Milz P, Milz S, Putz R et al.. 13 MHz high-frequency sonography of the lateral ankle joint ligaments and the tibiofibular syndesmosis in anatomic specimens. J Ultrasound Med. 1996; 15 277-284
67 Milz P, Milz S, Steinborn M et al.. Lateral ankle ligaments and tibiofibular syndesmosis. 13-MHz high-frequency sonography and MRI compared in 20 patients. Acta Orthop Scand. 1998; 69 51-55
68 van Holsbeeck M, Powell A. Ankle and foot. In: Fornage BD Musculoskeletal Ultrasound. New York; Churchill Livingstone 1995: 221-237
69 Fessell D P, van Holsbeeck M T. Sonography of the ankle and foot. In: Musculoskeletal Ultrasound. St Louis; Mosby 2001: 610
70 Wuest T K. Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg. 1997; 5 172-181
71 Paterson R S, Brown J N. The posteromedial impingement lesion of the ankle. A series of six cases. Am J Sports Med. 2001; 29 550-557
72 Harrington K D. Degenerative arthritis of the ankle secondary to longstanding lateral ligament instability. J Bone Joint Surg. 1979; 61-A 354-361
73 Feldman M D. Evaluation of intra-articular damage in displaced extra-articular ankle fractures. , Presented at the Annual Meeting of the Eastern Orthopedic Association, Scottsdale, AZ 1997;
74 Harper M. The deltoid ligament: an evaluation of need for surgical repair. Clin Orthop. 1988; 226 156-168
75 Liu S H, Mirzayan R. Posteromedial impingement. Arthroscopy. 1993; 9 709-711
76 Egol K A, Parisien J S. Impingement syndrome of the ankle caused by a medial meniscoid lesion. Arthroscopy. 1997; 13 522-525
77 Mosier-La Clair S M, Monroe M T, Manoli A. Medial impingement syndrome of the anterior tibiotalar fascicle of the deltoid ligament on the talus. Foot Ankle Int. 2000; 21 385-391
78 van Dijk C N, Bossuyt P M, Marti R K. Medial ankle pain after lateral ligament rupture. J Bone Joint Surg (Br). 1996; 78 562-567
79 Robinson P, White L M, Salonen D et al.. Anteromedial impingement of the ankle: using MR arthrography to assess the anteromedial recess. Am J Roentgenol. 2002; 178 601-604
80 Koenig F. Uber freie Korper in den elenken. Dtsch Z Chir. 1888; 27 90-109
81 Kappis M. Weitere Beitrage zur traumatisch-mechanischen Entstehumg der “spontanen” Knorpelablosungen (sog. Osteochondritis dissecans). Dtsch Z Chir. 1922; 171 13-29
82 Berndt A L, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg. 1959; 41 988-1020
83 Taga I, Shino K, Inoue M et al.. Articular cartilage lesions in ankles with lateral ligament injury. An arthroscopic study. Am J Sports Med. 1993; 21 120-126
84 Loomer R, Fisher C, Lloyd-Smith R et al.. Osteochondral lesions of the talus. Am J Sports Med. 1993; 21 13-19
85 Lantz B A, McAndrew M, Scioli M et al.. The effect of concomitant chondral injuries accompanying operatively reduced malleolar fractures. J Orthop Trauma. 1991; 5 125-128
86 Hintermann B, Boss A, Schafer D. Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med. 2002; 30 402-409
87 Lundeen R O. Medial impingement lesions of the tibial plafond. J Foot Surg. 1987; 26 37-40
88 Ogilvie-Harris D J, Gilbart M K, Chorney K. Chronic pain following ankle sprains in athletes: the role of arthroscopic surgery. Arthroscopy. 1997; 13 564-574
89 Stone J W. Osteochondral lesions of the talar dome. J Am Acad Orthop Surg. 1996; 4 63-73
90 Sijbrandij E S, van Gils A P, Louwerens J W et al.. Posttraumatic subchondral bone contusions and fractures of the talotibial joint: occurrence of “kissing” lesions. Am J Roentgenol. 2000; 175 1707-1710
91 Alanen V, Taimela S, Kinnunen J et al.. Incidence and clinical significance of bone bruises after supination injury of the ankle. A double-blind, prospective study. J Bone Joint Surg (Br). 1998; 80 513-515
92 Pinar H, Akseki D, Kovanlikaya I et al.. Bone bruises detected by magnetic resonance imaging following lateral ankle sprains. Knee Surg Sports Traumatol Arthrosc. 1997; 5 113-117
93 Anderson I F, Crichton K J, Grattan-Smith T. Osteochondral fractures of the dome of the talus. J Bone Joint Surg (Am). 1989; 71 1143-1152
94 Lahm A, Erggelet C, Reichelt A. Ankle joint arthroscopy for meniscoid lesions in athletes. Arthroscopy. 1998; 14 572-575
95 Guhl J F. Arthroscopic treatment of osteochondritis dissecans. Clin Orthop. 1982; 167 65-74
96 Potter H G, Linklater J M, Allen A A et al.. Magnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging. J Bone Joint Surg Am. 1998; 80-A(9) 1276-1284
97 Bredella M A, Tirman P F, Peterfy C G et al.. Accuracy of T2-weighted fast spin-echo MR imaging with fat saturation in detecting cartilage defects in the knee: comparison with arthroscopy in 130 patients. Am J Roentgenol. 1999; 172 1073-1080
98 Disler D G, McCauley T R, Kelman C G et al.. Fat-suppressed three-dimensional spoiled gradient-echo MR imaging of hyaline cartilage defects in the knee: comparison with standard MR imaging and arthroscopy. Am J Roentgenol. 1996; 167 127-132
99 Tan T C, Wilcox D M, Frank L. MR imaging of articular cartilage in the ankle: comparison of available imaging sequences and methods of measurement in cadavers. Skeletal Radiol. 1996; 25 749-755
100 Ba-Ssalamah A, Schibany N, Puig S. Imaging articular cartilage defects in the ankle joint with 3D fat-suppressed echo planar imaging: comparison with conventional 3D fat-suppressed gradient echo imaging. J Magn Reson Imaging. 2002; 16 209-216
101 Mintz D N, Tashjian G S, Connell D A, Deland J T, O'Malley M, Potter H G. Osteochondral lesions of the talus: a new magnetic resonance grading system with arthroscopic correlation. Arthroscopy. 2003; 19 353-359
102 Lo L D, Schweitzer M E, Hecht P et al.. Ankle pain: MR/arthroscopic correlation of cartilage defects (Ab). Radiology. 1997; 205(Suppl) 542
103 Miller T T, Bucchieri J S, Joshi A et al.. Pseudodefect of the talar dome: an anatomic pitfall of ankle MR imaging. Radiology. 1997; 203 857-858
104 Fritschy D. A rare injury of the ankle in competition skiers. Schweiz Z Med Traumatol.. 1994; 1 13-16
105 Wolin I, Glassman F, Sideman S et al.. Internal derangement of the talofibular component of the ankle. Surg Gynecol Obstet. 1950; 91 193-200

James LinklaterM.D.

Castlereagh Imaging, North Sydney Orthopaedic and Sports Medicine Centre

Level 1, 286 Pacific Highway, Crows Nest, 2093 Australia

Email: linkj@bigpond.com