Chronic Ankle Pain Research Articles

Can Subtle Syndesmotic Injury Be Assessed Using Weightbearing CT Scans?

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. Recently, weight-bearing computed tomography (CT) scans gained popularity with foot and ankle surgeons. This method is advantageous in that the distal tibio-fibular syndesmosis can be assessed in greater detail and under weight-bearing conditions. However, there are no studies investigating weight-bearing CT scans for assessment of subtle syndesmotic injury. 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) including external rotational torque (10 Nm). 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). Using coronal CT images, the width between the anterior tibia and fibula (A), distance between the anterior tibial incisura and anterior fibula (F), the tibio-fibular overlap (TFO), and the angle between the medial malleolus and the longitudinal axis of the fibula were assessed (a). 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 measurement A, a significant difference (p=0.046) was observed between Condition 2 and 3 vs. Native, independent of which ligament was dissected first. Measurement F was significantly different between Condition 2 and 3 vs. Native (p=0.011) if the AITFL was dissected first, but only reached significance for Condition 3 vs. Native if the deltoid ligament was dissected first (p=0.007). The TFO and a were significant in Conditions 1, 2, and 3 vs. Native if the deltoid ligament was dissected first (p=0.050). When the AITFL was dissected first, significance was reached for the same conditions (p=0.046) with the exception of the TFO for Condition 2 vs. Native. No differences were found when comparing the conditions of the AITFL with the same conditions of the deltoid group. Conclusion: With weight-bearing CT scans and applied external rotation torque, the TFO and angle between the tibia and fibula (a) may be used to assess subtle syndesmotic injury to either the AITFL or the deltoid ligament. When both ligaments (AITFL and deltoid) were injured, the tibio-fibular width (A) and distance between the anterior part of the tibia and fibula (F) could also be used for assessment. Weight-bearing CT scans cannot be used to distinguish between injuries to the AITFL or deltoid ligament. Further studies are needed to assess weight-bearing CT scans in the clinical setting.

Correction: Partial Hemiresurfacing of Osteochondral Defects of the Talus? Surgical Technique and Preliminary Report from Four Patients

Background: Osteochondral lesions of the medial talus (OLT) frequently lead to chronic ankle pain and osteoarthritis. Arthroscopic debridement, subchondral bone stimulation by drilling, and microfracturing are options for primary therapy in small lesions. In larger lesions, restoration of the talar dome contour seems to be a mandatory course of action. Methods: In a case series, we followed up four patients being treated with a focal resurfacing prosthetic due to large osteochondral talar lesions. In contrast to other studies, we can report on an off-label application to restore defects of the lateral talar dome with two patients for the first time. At follow-up, three patients reported a remarkable reduction in pain and were able to return to sports activities. One patient developed pseudarthrosis of the medial malleolar osteosynthesis. Conclusions: With selected patients, focal resurfacing appears to be an option for large osteochondral defects of the talus.

Ankle Arthroscopy versus Conservative Modalities in Management of Ankle Impingement Syndrome : A Systematic Review of Literature

Background: it has been well established that chronic ankle pain negatively affects the lives of patients. Surgical techniques for ankle pain have evolved dramatically over the past decade, as arthroscopic equipment has improved to allow excellent exposure to the ankle joint and surrounding anatomic areas. Soft- tissue and osseous impingement syndromes are now increasingly recognized as a significant cause of chronic ankle pain, The exact cause of this condition is debated but seems to involve osteophyte formation due to either repetitive microtrauma or macrotrauma associated with major injuries. Careful analyses of patient history and signs and symptoms at physical examination can suggest a specific diagnosis in most patients. Aim of the work: this systematic review aimed to assess the outcome of ankle arthroscopy versus conservative modalities in management of ankle impingement syndrome. Methods: a systematic literature search of the PubMed, Embase (classic), and Chochrane library databases, for articles that published from January 1990 to June 2017 was performed using the following inclusion criteria English language puplications, human clinical trials, studies that reported on at least one of the chosen outcome measures which are patient satisfaction, time to return to full activity, AOFAS score, visual analog scale (VAS) score for pain, and complications, we found 9 studies met our inclusion criteria, data extraction was done which is consisted of population characteristics, in addition to the outcome measures. Results: nine articles were included in this systematic review. Overall, good results were found for arthroscopic treatment in patients with ankle impingement syndrome, patient satisfaction rates was reported in 5 studies, we reported high percentages of good to excellent satisfaction rates, ranging 74% to 94%, especially in patients treated with arthroscopy, Complication rates were 14.1%, as regard to patients treated with arthroscopy the rate was 13.2%, on the other hand the rate was 17.6% in those patients treated with injection therapy technique, conventional conservative modalities reported to be ineffective in treating ankle impingement except injection therapy technique in case of ankle soft tissue impingement. Conclusion: our systematic review showed that Patients may respond to conservative treatment modalities, especially ultra-sound guided injection mainly in soft tissue impingement type, arthroscopic debridement is the treatment of choice for patients of ankle impingement syndrome of both osseous and soft tissue nature with least morbidity and early return to function, and also it is noted to be superior to conservative modalities.

Role of Ultrasound and Magnetic Resonance Imaging in Diagnosis of the Etiology of Chronic Ankle Pain

AbstractBackground: In patients with ankle and foot pain, it is crucial to detect the lesion responsible for the pain for deter-mining adequate treatment. MRI in combination with other radiologic images is currently regarded as the most appropriate diagnostic imaging of benign bone and soft tissue lesions in chronic ankle pain.Aim of Work: To evaluate the role of ultrasound and magnetic resonance imaging in diagnosis of the etiology of chronic ankle pain.Material and Methods: This study included ninety patients with chronic ankle pain. All patients were subjected to clinical evaluation, ultrasound examination and MRI.Results: Both ultrasound and MRI revealed nearly the same results in evaluation of tendon abnormalities. Ultra-sonography couldn't detect injuries of the posterior talo-fibular ligament as well as posterior tibio-fibular ligament while MRI could clearly detect them. Regarding other ligaments (anterior talo-fibular, anterior lower tibio-fibular and deltoid ligaments), MRI was slightly superior to ultrasound in evaluation of injuries of these ligaments. Ultrasonography could detect some cases of postero-medial impingement syndromes (caused by deltoid ligament injury), however it couldn't detect cases of posterior or anterior impingement (usually caused by bony abnormalities), these cases were better assessed by MRI examination. Cases of osteochondritis dessicans and bony tumors could be assessed by MRI examination however; ultrasonography was negative in detecting these lesions.Conclusion: Ultrasound and MRI showed similar results in evaluation of tendon and ligament injuries as well as entrapment neuropathy, MRI was superior to ultrasound in evaluation of impingement syndromes and osseous pathologies.

Imaging Features of Symptomatic Hypertrophic Tuberculum Peroneum.

Objective:The aim of this article is to review the clinical and imaging features of symptomatic hypertrophic (TP) in a cohort of symptomatic patients.Materials and Methods:Twenty-three patients with chronic lateral ankle pain were retrospectively included in our study group. Patients underwent ultrasound (US), (cone beam) computed tomography (CB)CT or magnetic resonance (MR) examination or a combination of these examinations with a standardized protocol. Patients with an underlying fracture were excluded. The following parameters were recorded: clinical history, size of the TP on different imaging modalities, presence and grade of peroneus brevis/longus tenosynovitis and the presence of bone marrow edema at the os calcaneus on magnetic resonance imaging (MRI).Results:The mean width of the hypertrophic TP was 5.6 mm. Combined tenosynovitis of the peroneus longus (PL) and brevis tendon (PB) was most common, followed by isolated PL and finally PB tenosynovitis. Grade 1 tenosynovitis was most common. BME was present in 53% of the cases.Conclusion:The width of the TP is may be evaluated on the (oblique) coronal US, (CB)CT or non-fat suppressed MR images. Both US and MRI may detect and grade involvement of the peroneal tendons. By the use of fluid sensitive sequences, MRI may be of additional value to detect bone marrow edema as result of repetitive friction.

Symptomatic os talus secundarius: a case report and review of the literature

Level IV.

MRI Utilization by Orthopaedic and Non-orthopaedic providers for acute or chronic ankle pain

Category: Ankle Introduction/Purpose: The use of MRI poses a significant expense in the ever-increasing cost of healthcare. The American College of Radiology (ACR) recommends obtaining ankle radiographs within 6 months prior to MRI in the assessment of patients with acute or chronic ankle pain. In this retrospective utilization study, we examine the compliance rate of both orthopedic and non-orthopedic providers at two academic centers. We hypothesize that there is an over utilization of resources by non- orthopaedic surgeons. Methods: We retrospectively reviewed 721 patient charts (4/2015-11/2016) who had an ankle MRI. We analyzed the preceding conservative management and subsequent non-operative or surgical care of the patient, and made note of the ordering physician and whether or not radiographs were obtained prior to ordering an MRI. We also performed an analysis of diagnosis and identified common diagnoses that were associated higher levels of non-compliance to the ACR criteria. Results: Overall, we determined that 222 of the 259 (85.7%) of the orthopedic providers obtained radiographs prior to MRI while only 271of 462 (58.7%) non-orthopedic providers followed these criteria (p<0.0001). In total, we found that 493 out of 721 (68.4%) providers ordered ankle radiographs prior to MRI. Among orthopedic providers showing non-compliance with the ACR criteria, the most common patient diagnoses were tendinopathy and not obtaining new radiographs when radiographs were older than 6 months. Among non-orthopedic providers, the most common diagnoses were edema and tendinopathy. Conclusion: We found that orthopedic providers adhered much more closely to the ACR criteria, and that there is a significant over-utilization of resources by all providers, with an overall inappropriate use percentage of 32.1%. Increasing the compliance rate could prove to be an effective mechanism for decreasing the cost healthcare in the treatment of ankle pain.

Effect of Ankle Position and Noninvasive Distraction on Arthroscopic Accessibility of the Distal Tibial Plafond.

Osteochondral lesions of the tibial plafond (OLTPs) can lead to chronic ankle pain and disability. It is not known how limited ankle motion or joint distraction affects arthroscopic accessibility of these lesions. The purpose of this study was to determine the effects of different fixed flexion angles and distraction on accessibility of the distal tibial articular surface during anterior and posterior arthroscopy. Fourteen below-knee cadaver specimens underwent anterior and posterior ankle arthroscopy using a 30-degree 2.7-mm arthroscopic camera. Intra-articular working space was measured with a precision of 1 mm using sizing rods. The accessible areas at the plafond were marked under direct visualization at varying fixed ankle flexion positions. Arthroscopic accessibilities were normalized as percent area using a surface laser scan. Statistical analyses were performed to assess the relationship between preoperative ankle range of motion, amount of distraction, arthroscopic approach, and arthroscopic plafond visualization. There was significantly greater accessibility during posterior arthroscopy (73.5%) compared with anterior arthroscopy (51.2%) in the neutral ankle position ( P = .007). There was no difference in accessibility for anterior arthroscopy with increasing level of plantarflexion ( P > .05). Increasing dorsiflexion during posterior arthroscopy significantly reduced ankle accessibility ( P = .028). There was a significant increase in accessibility through the anterior and posterior approach with increasing amount of intra-articular working space (parameter estimates ± SE): anterior = 14.2 ± 3.34 ( P < .01) and posterior = 10.6 ± 3.7 ( P < .05). Frequency data showed that the posterior third of the plafond was completely inaccessible in 33% of ankles during anterior arthroscopy. The frequency of inaccessible anterior plafond during posterior arthroscopy was 12%. Intra-articular working space and arthroscopic accessibility were greater during posterior arthroscopy compared with anterior arthroscopy. Improved accessibility of OLTPs may be achieved from posterior arthroscopy. Arthroscopic accessibility was heavily dependent on the amount of intraoperative joint working space achieved and not on ankle position. OLTPs are often encountered in tandem with talar lesions, and safely achieving intra-articular working space through noninvasive distraction greatly improved arthroscopic accessibility.

Hidden Unicameral Bone Cyst of the Calcaneus; Case Report of a Military Soldier with Chronic Ankle Pain

Bone cysts are benign bone lesions that are quite uncommon in the calcaneus. Calcaneal cysts generally remain asymptomatic in most patients and are discovered incidentally but in some, they may cause localized bone pain that is progressive in intensity. If not picked on the conventional radiographs, the diagnosis is delayed and the patient remains distressed and dispirited. We, here, report a military soldier with calcaneal cyst who remained misdiagnosed for six months and had been treated as a case of ankle sprain. After correct diagnosis, his problems were finally settled following surgical intervention. The physicians should keep a high degree of suspicion of an alternative diagnosis in all cases where usual management is not beneficial in commonly expected pathologies. Keywords: Ankle Pain; Bone Cement; Calcaneus; Case Report; Surgical Curettage; Unicameral Bone Cyst

Radiologic findings for prediction of rehabilitation outcomes in patients with chronic symptomatic os subfibulare.

To retrospectively evaluate the radiologic findings for predicting rehabilitation outcomes in patients with chronic symptomatic os subfibulare. 38 patients with chronic lateral ankle pain and os subfibulare underwent a standardized rehabilitation program. Rehabilitation outcome was evaluated after ≥3months of intervention as the following: good response group (n=20) without the need for further treatment and poor response group (n=18) who underwent surgery after rehabilitation. Size, shape and location of os subfibulare, anterior talofibular ligament abnormality and attachment to the os subfibulare, interposition of fluid signal intensity between the os subfibulare and the fibula, and bone marrow edema in the os subfibulare on radiographs and MRI were evaluated by two radiologists blinded to rehabilitation outcomes and were compared between the two groups. The mean size of os subfibulare was significantly different between good and poor response groups: 7 versus 12mm (p<0.01), respectively. The prevalence of interposition of fluid signal intensity between the os subfibulare and the fibula and bone marrow edema in the os subfibulare on MRI was significantly different between the two groups (p<0.01). However, other radiologic findings were not significantly different (p≥0.08). The optimal size to classify the two groups was 9mm with sensitivity of 83.3% and specificity of 80%. Inter-observer reliability was good to excellent (ICC=0.991 for size and kappa=0.735-0.923 for others). MRI may be used to predict rehabilitation outcome in patients with chronic symptomatic os subfibulare.

Ultrasound-Guided Percutaneous Needle Fenestration and Corticosteroid Injection for Anterior and Anterolateral Ankle Impingement.

Ankle impingement is a common cause of chronic ankle pain. We retrospectively studied the effectiveness of ultrasound-guided percutaneous needle fenestration of the pathological soft tissues combined with corticosteroid injection to treat this condition. We administered a telephone survey to patients who underwent the procedure. Patients were asked questions on the Foot Function Index and queried about their overall satisfaction with the procedure on a scale of 0 (completely unsatisfied) to 10 (very satisfied). Forty-nine patients participated in the survey: 26 women and 23 men, mean age 42.7 years (range, 19-65 years). Impingement was anterior in 26/49 (53.1%), anterolateral in 14/49 (28.6%), and both in 9/49 (18.4%). Mean pain level before the procedure was 6.76 ± 1.84 and after the procedure was 2.73 ± 2.21. Reported pain scale levels declined by 4.02 ± 2 units after the procedure (P < .0001). Patient's overall satisfaction was 7.9 ± 2.44. Ultrasound-guided percutaneous needle fenestration and corticosteroid injection appears to be an effective nonoperative alternative for treatment of anterior and/or anterolateral ankle impingement. Level IV.

Osteochondral Lesions of the Talus: Osteochondral Allograft Transplantation

Talar osteochondral lesions (OCLs) are common causes of ankle pain. When symptomatic, they may cause significant pain and affect function and quality of life. OCLs may be due to acute trauma or atraumatic, repetitive overuse. Lateral lesions are almost always traumatic, secondary to axial loading of the ankle in inversion and dorsiflexion and relative talar external rotation. Medial lesions are frequently caused by loading the ankle with inversion and plantarflexion. Medial lesions are more common than lateral. The extensive coverage of the talar surface area with articular cartilage limits talar vascular supply and creates multiple watershed areas compromising healing potential. As such, early diagnosis and management of talar OCLs are critical to prevent functional impairment and chronic ankle pain. Asymptomatic or incidentally identified talar lesions may be closely observed. Nonoperative management of symptomatic lesions includes rest, ice, oral nonsteroidal anti-inflammatories, immobilization, and intra-articular injections. In patients who fail nonoperative treatment or have an acute displaced osteochondral fragment, surgery is the treatment of choice. Arthroscopic and open surgical approaches are options. Lesion debridement, loose body removal, marrow stimulation techniques (microfracture, drilling, and abrasion), osteochondral autograft, and autologous chondrocyte implantation may result in excellent outcomes in smaller lesions. For larger defects, osteochondral allograft transplantation is the gold standard surgical treatment.

Chronic ankle instability: Arthroscopic anatomical repair

IntroductionAnkle sprains are one of the most common injuries. Despite appropriate conservative treatment, approximately 20–40% of patients continue to have chronic ankle instability and pain. In 75–80% of cases there is an isolated rupture of the anterior talofibular ligament. Material and methodA retrospective observational study was conducted on 21 patients surgically treated for chronic ankle instability by means of an arthroscopic anatomical repair, between May 2012 and January 2013.There were 15 men and 6 women, with a mean age of 30.43 years (range 18–48). The mean follow-up was 29 months (range 25–33). All patients were treated by arthroscopic anatomical repair of anterior talofibular ligament.Four (19%) patients were found to have varus hindfoot deformity. Associated injuries were present in 13 (62%) patients. There were 6 cases of osteochondral lesions, 3 cases of posterior ankle impingement syndrome, and 6 cases of peroneal pathology. All these injuries were surgically treated in the same surgical time. ResultsA clinical-functional study was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) score. The mean score before surgery was 66.12 (range 60–71), and after surgery it increased up to a mean of 96.95 (range 90–100). All patients were able to return to their previous sport activity within a mean of 21.5 weeks (range 17–28). Complications were found in 3 (14%) patients. ConclusionsArthroscopic anatomical ligament repair technique has excellent clinical-functional results with a low percentage of complications, and enables patients to return to their previous sport activity within a short period of time.

Chronic progressive ankle pain

Chronic progressive ankle pain

Role of magnetic resonance imaging in the diagnosis of ankle impingement

Objectives This study aimed to a ssess the role of MRI in the diagnosis of ankle impingement. Background Ankle pain is a common and frequently disabling clinical complaint that may be caused by a broad spectrum of osseous or soft-tissue disorders. Chronic ankle pain is a common complaint in orthopedic practice. Impingement syndromes are considered one of the most important causes of chronic ankle pain, which occur due to friction of the joint tissues. Patients and methods This prospective study included 86 patients (M/F = 60/26) with chronic ankle pain and clinically suspected to have impingement. MRI acquired on a 1.5 T scanner was applied for all cases. Results Different types of ankle impingement were observed: posterior ankle impingement (n = 34/90), anterolateral ankle impingement (n = 18/90), anterior ankle impingement (n = 8/90), anteromedial ankle impingement (n = 4/90), posteromedial ankle impingement (n = 2/90), entrapment neuropathy (n = 12/90), and sinus tarsi syndrome (n = 4/90). Conclusion With the advent of MRI, detailed examination of the osseous and soft-tissue structures of the ankle is possible. Thus, MRI has opened a new horizon in diagnosis and hence in the treatment of most ankle joint lesions.

PERONEAL TENDON LESIONS IN ATHLETES (REVIEW)

The authors analyzed scientific literature in respect of various issues in treatment of athletes with peroneal muscles lesions starting from 1987 till 2016. Key search and publications selection was made in PubMed and russian national electronic scientific library eLIBRARY. Peroneal tendons pathology is not the major but the underestimated cause of pain in lateral and hindfoot as well as of foot dysfunction which is difficult to distinguish from lesions of lateral ligaments of the ankle joint. Untreated lesions of peroneal tendons can result in chronic ankle pain and significant functional disorders. The purpose of the present paper is to improve the current comprehension of anatomy, to identify factors contributing to pathology, to perform diagnostic evaluation of peroneal tendons and to review current treatment options of such lesions.

Inestabilidad crónica de tobillo: reparación anatómica artroscópica

IntroductionAnkle sprains are one of the most common injuries. Despite appropriate conservative treatment, approximately 20-40% of patients continue to have chronic ankle instability and pain. In 75-80% of cases there is an isolated rupture of the anterior talofibular ligament. Material and methodA retrospective observational study was conducted on 21 patients surgically treated for chronic ankle instability by means of an arthroscopic anatomical repair, between May 2012 and January 2013.There were 15 men and 6 women, with a mean age of 30.43 years (range 18-48). The mean follow-up was 29 months (range 25-33). All patients were treated by arthroscopic anatomical repair of anterior talofibular ligament.Four (19%) patients were found to have varus hindfoot deformity. Associated injuries were present in 13 (62%) patients. There were 6 cases of osteochondral lesions, 3 cases of posterior ankle impingement syndrome, and 6 cases of peroneal pathology. All these injuries were surgically treated in the same surgical time. ResultsA clinical-functional study was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) score. The mean score before surgery was 66.12 (range 60-71), and after surgery it increased up to a mean of 96.95 (range 90-100). All patients were able to return to their previous sport activity within a mean of 21.5 weeks (range 17-28). Complications were found in 3 (14%) patients. ConclusionsArthroscopic anatomical ligament repair technique has excellent clinical-functional results with a low percentage of complications, and enables patients to return to their previous sport activity within a short period of time.

Arthroscopic Plafond Access for Osteochondral Lesions- The Effect of Limited Ankle Range of Motion on Anterior and Posterior Arthroscopic Accessibility

Category: Arthroscopy. Introduction/Purpose: Osteochondral lesions of the tibial plafond (OLTPs) can lead to chronic ankle pain and disability. Arthroscopic treatment has been described after failure of initial nonoperative treatment. However, the ideal appropriate approach for OLTPs is controversial, and it is not known if ankle positioning or joint distraction affects the accessibility of these lesions. The purpose of this study was to determine the effects of predetermined ankle flexion angles on arthroscopic accessibility of the distal tibial articular surface through either the anterior or posterior approach. The effects of non- invasive joint distraction were also analyzed. Methods: Fourteen below-knee cadaver specimens were subjected to pre-operative range of motion measurements. Joint distraction was measured using sizing rods with the precision of 1 mm. The accessible areas at the tibial plafond were marked using a curette at predetermined ankle positions. Arthroscopy was performed using a 30-degree 2.7 mm camera via standard anterior and posterior approaches in randomized fashion in all specimens. Following arthroscopic accessibility, each cadaveric ankle was disarticulated and arthroscopic accessibility was quantified using a surface laser scan. Statistical analyses were performed to determine the correlation between pre-operative ankle range of motion and amount of distraction on arthroscopic accessibility of the tibial plafond. Results: The average accessibility of the tibial plafond was 56 percent and 68 percent for the anterior and posterior approaches, respectively (p = 0.056). There was no difference in accessibility from the anterior approach with increasing level of plantarflexion (p &gt;0.05). Increasing dorsiflexion during the posterior approach significantly reduced ankle accessibility (p = 0.028). There was a significant increase in accessibility through either anterior or posterior approach with increasing level of ankle distraction; (parameter estimates ±SE): anterior= 14.2±3.34, p &lt; 0.01 and posterior= 10.6±3.7, p &lt; 0.05). Conclusion: Arthroscopic accessibility for the treatment of OLTPs was vastly dependent on the amount of intra-operative joint distraction achieved. Posterior approach had more joint distraction and wider plafond accessibility. Increasing ankle distraction significantly improved arthroscopic plafond accessibility for both anterior and posterior approaches while ankle joint position did not influence accessibility from either approach.

Anatomy of the ankle ligaments: a pictorial essay.

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.

Prevalence of the accessory deep peroneal nerve: A cadaveric study and meta-analysis

ObjectivesThe accessory deep peroneal nerve (ADPN) is a common anatomical variant arising from the superficial peroneal nerve (SPN) and, when present, is often responsible for partial or complete innervation of the extensor digitorum brevis muscle (EDBM). The nerve lies posterior to the peroneus brevis muscle, traveling posterior to the lateral malleolus to terminate in the ankle by giving off sensory branches to the ankle and joints. Although the EDBM is usually supplied by the deep peroneal nerve (DPN), in the presence of an ADPN, electrodiagnostic procedures may be complicated. Due to the lack of detailed anatomical knowledge on the topography of the ADPN, its presence posterior to the lateral malleolus can be iatrogenically injured during surgical procedures on the ankle using a lateral approach. Therefore, this meta-analysis aimed to provide a comprehensive, evidence-based assessment of the anatomical characteristics of the ADPN, supplemented with data from our own cadaveric dissection. Patients and methodsA comprehensive search of all major electronic databases, including Pubmed, Embase, Scopus, Web of Science, ScienceDirect, SciELO, and BIOSIS was performed. All articles with data on prevalence, symmetry and innervation of the EDBM by the ADPN were included. The anatomical data was then extracted and pooled into a meta-analysis using MetaXL 2.0. In addition, we dissected 21 cadavers (n=42 lower limbs) bilaterally to find the ADPN. ResultsA total of 19 studies (n=6070 lower limbs) were included in the meta-analysis. The pooled prevalence of the ADPN was 18.8% (95%CI:14.2–24.0) with a 39.3% prevalence rate for cadaveric studies. The ADPN was present more commonly unilaterally (67.0%) and when it was present, provided branches to the EDBM in 79.5% of cases. In our cadaveric study, the ADPN was identified in 5 of the 42 lower limbs dissected (11.9%); on the right side in 3 lower limbs and on the left side in 2 lower limbs. ConclusionsThe ADPN is a clinically important nerve and has been inculpated in unexplained cases of chronic ankle pain and EDBM atrophy. The variability in detection of the ADPN using electrophysiological techniques can lead to misdiagnoses of peroneal nerve lesions and increase the risk for iatrogenic injury to the ADPN, especially in laterally approaching ankle procedures and sural nerve biopsies.