Ankle Anterior Draw Sign: Assessing the stability of the Anterior Talofibular Ligament

Stability is a central theme at the Centeno-Schultz Clinic as discussed in Ortho 2.0.

The anterior talofibular ligament provides critical lateral support to the ankle and has been discussed in prior blogs.

Stability of the anterior talofibular ligament is evaluated by the anterior draw sign whereby the distal part of the leg is stabilized with one hand while the other hand cups the heel.  An anterior pull is applied to the heel attempting to move the talus forward from beneath the tibia.

The anterior drawer test has demonstrated high accuracy in the determination of lateral ankle instability and in the diagnosis of a ligament rupture.

Stem cell therapy is an alternative to traditional ankle surgery and a clinical case has been previously discussed.

At the Centeno-Schultz Clinic the anterior drawer sign can be performed under MSK ultrasound which can distinguish a partial from a complete tear.  The patient is place in the prone position with the foot hanging off the exam table in plantar flexion.  The forefoot is then pulled forward while the tibia is stabilized.  If the ATF is torn the gap between the talus and the tibia/fibula will widen when anterior force is applied which is depicted below.

Deltoid Ligament: Medial Ankle Pain

At the Centeno-Schultz Clinic stability is a central theme as outlined in Ortho 2.0.

The lateral ankle ligaments have been discussed in prior blog. Treatment of ankle sprains at the Centeno-Schultz Clinic includes a diagnostic MSK ultrasound where the ligaments visualized and their integrity assessed.  Treatment options for loose, partially torn or degenerative ligaments include prolotherapy, PRP and autolgous bone marrow derived stem cells.

A video discusses the use of stem cells as an alternative to ankle surgery.

15-20 % of all athletic injuries involve the ankle.  20-40% of ankle injuries will lead to chronic instability.

The deltoid ligament supports the medial side of the ankle joint and is composed of 3 principle ligaments.  They all attach at the medial malleolus.

Tibionavicular Ligament is the most anterior and inserts upon the navicular bone.

Tibiocalcaneal ligament is the middle ligament and inserts upon the sustentaculum tali of the calcaneus.

Posterior Tibiotalus are posterior fibers that connect to the talus.

An eversion sprain is a tear in the deltoid ligaments.  It occurs with excessive inward rotation and is often accompanied by a fracture of the fibula.

An ultrasound image of the tibiotalar  ligament is displayed below.

Lateral Knee Pain: Iliotibial Band Syndrome

At the Centeno-Schultz Clinic we acknowledge that there are many causes of lateral knee pain.  An important case report was discussed in a previous blog.  Ortho 2.0 outlines the four key concepts: stabilization, articulation, neurological functions and alignment.

The iliotibial band (ITB) is a longitudinal fibrous reinforcement of one of the lateral leg muscles, the fascia lata.  It  originates from the anterior superior iliac spine region and extends down the lateral portion of the thigh to the knee.

Proximally it inserts into the lateral epicondyle of the femur and then passes to insert distally on the lateral aspect of tibia tubercle (gerdy’s tubercle).

When the knee is extended, the ITB is anterior to the lateral femoral condyle. When the knee is flexed the ITB is posterior to the lateral femoral condyle.

Actions of the iliotibial band include thigh flexion at the hip, abduction, medial rotation and  lateral stabilization the knee.

Iliotibial Band syndrome is an overuse phenomenon which is common in runners.  Typically pain occurs over lateral femoral epicondyle, which is caused by irritation and inflammation of the distal iliotibial band as it rubs against the lateral femoral condyle.

Differential diagnosis includes lateral meniscus tear,  popliteus,tendinitis, and patellofemoral pain syndrome.

The iliotibial band is a standard part of the diagnostic knee ultrasound conducted at the Centeno-Schultz Clinic.  In the ultrasound image below a normal  iliotibial band is identified by the white arrows.

Stem Cell Success in Ballet Dancer with Ankle Instability

Ankle instability can mean the end of a career or passion.

Micro motion in the ankle can led to additional injuries and accelerate the degenerative process as discussed in Ortho 2.0.

Stem cell treatments are an alternative to ankle surgery.  CK is a case in point.

CK is active equestrian and ballet dancer who sustained a severe ankle sprain who presented to the Centeno-Schultz with a 4 month history of ankle instability and pain. Her  symptoms were progressive in  nature , exclusively located over the lateral aspect of the ankle and refractory to conservative care.  MRI was signficant for complete rupture of the anterior talofibular ligament and Grade 2 sprain of the calcaeofibular ligament.

The importance of the anterior talofibular and calcaneal fibular ligament has been discussed in a prior blog.

CK underwent ultrasound  guided injections of both prolotherapy and  Regenexx PL and SCP with significant improvement.  Initial MRI of ankle noted a complete rupture of ATF whereas followup studies demonstrated  a thick and wavy ATF ligament.  Pre and post MRI images will be posted at a later time.    Most importantly CK avoided a surgery and is back to her passions: dancing and riding.   Congratulations!!