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So let's begin our discussion by talking about the pattern

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of movement that we see in the ankle in hin foot in orange.

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You can see some of the terms

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that have been applied in the literature with regard

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to the types of movements that we see.

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Typically, in fact, at the level of the ankle,

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the major movement is dorsiflexion

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and plantar flexion with minimal movements in other planes.

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When we get to the level of the sub Taylor joints,

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movements become, uh, a little bit more complicated.

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They occur in more than one plane.

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We use a variety of terms,

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but they're very, very similar as to what they mean.

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Supination, pronation is the major term

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that I'll be using during my lecture.

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It's just about equivalent to inversion aversion

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and even abduction and abduction.

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So those are multiplanar movements

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and they are the responsibility, not so much of the ankle,

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but of the hind foot and particularly the subular joint.

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Now, I wanted to give you an overview of the point

1:06

or the anatomy of the ankle joint.

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We'll look at the lower picture.

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First, you're looking from the point of view of the, uh,

1:13

tus looking up toward the tibia and fibula.

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And I'll point out a little bit of this anatomy.

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You can see there is a slight elevated rim.

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We call it a lip, both anteriorly and posteriorly.

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The anatomy of the medial malayali is a bit complicated.

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I'll talk about that in a, in a moment or so.

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We can see here, in fact the fibula

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and we see one of the grooves that can be apparent.

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We see it well on mr.

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This is a ular groove that houses, of course,

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the perineal tendons.

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There's also a depression

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that we can see in the distal fibula.

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These are the major things we can see an anterior posterior

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tubercle and a second groove, which will be intimate

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with the tibials posterior tendon.

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Now as we look at the upper images,

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I'm showing you the very front aspect here with this arrow

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and showing you what a coronal image looks like at the very

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anterior aspect where we're cutting into that anterior lip.

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And there is a normal notch known as the notch of heart T

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that occurs in that region.

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I wanna call your attention to it

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because it can simulate an abnormality

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and you might mistake that in fact

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for an osteochondral injury, which it is not.

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Now let's look at the anatomy of the male eye first,

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realizing they are not of the same length,

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the lateral males,

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the fibular tip shown on the right is longer than

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the medial males.

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Beyond that, let's deal with the anatomy

2:52

of the medial malali.

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Okay? Anterior is this way, posterior is this way.

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There's a large

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Anulus and an interocular groove.

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And as we'll talk about later today, we will talk about

3:08

that particular region being involved

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with the attachment site of the deep

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deltoid ligament fibers.

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And then we have a smaller prominence,

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the posterior colliculus, uh, shown here.

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So let me, I think I misstated that.

3:23

This is the area of the deep deltoid ligament.

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This is the area of the superficial deltoid ligament.

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So that is the particular shape of the medial maus.

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Now there's another interesting aspect of the tailored dome.

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It's not a square, it's not a rectangle.

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It has unusual anatomy,

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but in general, the anterior width of

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that tailored dome is wider than the posterior width.

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And that is why the most stable position

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of the ankle joint is extension.

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Okay? Or dorsi flexion.

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Because in that position, the wider anterior surface enters

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this particular joint.

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And that is why in such sports as running

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and sprinting, you will see this particular, uh, picture,

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the start of the race.

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Now let's also talk a little bit more about

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the tailored dome.

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It is not flat.

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It has elevated areas that we can call shoulders.

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This is the medial shoulder.

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It is more prominent than the lateral shoulder

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and it engages a concavity

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on the distal articular surface of the medial maus

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and tibial hon,

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this is an area in which compression may occur,

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which will become important

4:44

as we talk about the pathogenesis

4:46

of osteochondral abnormalities involving the tailored dome.

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Here you have a picture, coronal image

4:55

coronal section showing you the medial

4:58

and lateral shoulders of the tailored dome.

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One other point that I want

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to emphasize relates to joint motion.

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Here I'm showing you

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what the tibial articular surface looks like

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and we can measure that as approximately 80 degrees.

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When we look at the tailor articular surface,

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the measurement is closer to 120 degrees.

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So there is a 40 degree difference in the articular

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dimensions of the tibia with regard to the Alis.

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And that explains why.

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Typically in most normal ankles,

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you can do approximately 20 degrees as you try to dorsi flex

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and 20 degrees as you try to plant

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or flex the foot, small shifts in the position

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of the T will produce dramatic changes in the contact

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regions between the tibia and talis.

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This is what the normal contact

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Region looks like on the Taylor Dome.

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This is only a two millimeter lateral Taylor shift

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and look at the difference in the contact point.

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And that is why following injuries

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that involve the ankle joint with ligament problems

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or fractures or both accurate reduction

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of the tails back

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to somewhat normal position becomes critical.

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Now, there are a number of courses of impingement

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where ankle movement or motion is diminished.

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I'm not gonna be talking in great deal about those today,

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but I wanted to emphasize this one.

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I'll have you look at a moment at at those

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images at the bottom.

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They were shared with me with a previous

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uh, Brazilian scholar.

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And this is a pattern of abnormality that is known

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as antral medial ankle impingement seen in soccer players

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and often called footballers ankle.

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It's associated with a pattern

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of bone proliferation involving the anterial medial aspect

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and the superior surface of the tails.

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And you can imagine an outgrowth like this could certainly

7:09

produce restricted motion in the ankle.

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Now, if you were go ahead

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and put fluid in the joint,

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here I'm showing you an arthrogram involving the

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uh, ankle joint.

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You're gonna identify a number of recesses

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as you distend the joint.

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There are medial recesses, lateral anterior posterior.

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But I wanted to call your attention

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to this particular recess, which is the

7:36

syndesmotic recess in this area,

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which typically will extend 10 to 20 millimeters

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above the level of the cleon and ankle joint.

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That particular region is a tight region of the ankle joint.

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So if you could think of a process,

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perhaps a synovial inflammatory process

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or synovial proliferative process,

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the one I illustrate on the right is what we used

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to call pigmented vi nodular synovitis.

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Now it's a form of teno synovial giant cell tumor,

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but when you get those processes within that

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syndesmotic recess, you can get extensive erosions of bone.

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As in the case I am showing you

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when we fill the ankle joint with contrast material.

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As we've done here, we can illustrate some

8:29

of the normal areas of communication In 10

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to 20% of normal persons, there is communication

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of the ankle joint with one of the subtalar joints.

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This is the posterior subor joint.

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And in addition, there may be communication

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of the ankle joint with some

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of the tendon sheets about the medial flexor tendons,

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particularly the flexor lysis longest.

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That's a common pattern of communication.

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Rarely the flexor digitorum longest tendon sheet,

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but not the tendon sheet of the tibials posterior tendon.