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IMO, clinical tibio-fibular seperation/instablility/subluxation is under-diagnosed and usually supplements significant ankle sprain. IMO, it can be the under-lying factor for a complex recalcitrant ankle and psuedo-impingement.


What is the standard for clinical diagnosis?


Is the xray view sensitive enough?


Have I overrated this as a frequently presented co-finding in significant ankle sprain/injury?





Furthermore, once you have clinically diagnosed it, how do you approach it conservatively?

 

FYI from Physician and Sports Medicine:

I usually find diagnosis, more often than not is one of excluding everything else. The above quote is the standard textbook one .... the ones I have dealt were not in acute stage and symptoms more subtle than that. .... invariably lunge test comparing the two sides and noting fibula motion as they go down into lunge position is helpful.

Initially get patient to just use lunge "test" as the intervention --- if that no work, then more aggressive mobs of distal and proximal tib-fib joints.

The "podiatric" mentaility is to use foot orthoses on any chronic foot pain, but IMHO, this not a good idea in these people....... as foot orthoses allegedly ;) supinate the rearfoot, a greater range of dorsiflexion is needed and due to problems with fibula mobility in these people, they just can't cope initially.

 

Have you ever seen what seems to be a posterior ankle impingement syndrome in concurrance with a syndesmosis injury/sprain? Insidious onset 3-4 months after eversion sprain(external rotation of leg on fixed foot). Ultrasound shows fluid extra-articular anterolateral ankle and possibly thickening posterior ankle joint capsule. CT shows sclerotic changes to tibia at posterior ankle. Ankle immob. strapping reduced symptoms until skin allergy occured!! Orthotics not helpful. Pain++ anterolateral ankle on lunge test. Deep posterior ankle pain on plantarflexion with reduced ROM. Tenderness on palpation anterior distal tib-fib jt. Any ideas in addition to tib-fib mobs?

 

That ankle is a 'pizza with the lot'. If tape was helpful, the logical next step is a brace.

I like your thinking though. You have just raised the things that matter IMO.



Ron
Physiotherapist (Masters) & Podiatrist