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Year |
2001 |
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Question Number |
259 |
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Category |
Select |
Question
A 44-year-old man has persistent anteromedial joint line pain after sustaining multiple ankle sprains. At the time of surgery, thickening of the deltoid ligament on its most anterior aspect is noted. What fascicle of the deltoid ligament is involved with this anterior impingement?
1- Anterior tibial
2- Anterior tibiotalar
3- Tibionavicular
4- Tibiocalcaneal
5- Talonavicular
Figures
Answer (click for answer)
Preferred response: 2
To answer this question, you need to know the fascicles that make up medial support of the ankle (deltoid ligament). These structures are, from anterior to posterior, the anterior tibiotalar fascicle (ATTF), the tibionavicular fascicle, the tibiocalcaneal ligament, and the posterior tibiotalar ligament. The ATTF and tibionavicular arise from a common origin on the anterior aspect of the medial malleolus, with the ATTF coursing deep to insert on the talar neck and the tibionavicular inserting on the dorsomedial aspect of the navicular. The tibiocalcaneal ligament arises from the medial malleolus to insert on the sustentaculum tali of the calcaneus and the posterior tibiotalar ligament arises from the posterior medial malleolus and inserts on the posterior process of the calcaneus (see Netter Plate 495 for a good representation).
Anterolateral ankle impingement syndrome from hypertrophic ligamentous tissue secondary to trauma is a well known entity. A similar process on the medial side of the ankle has recently been identified after inversion injury or fracture of the fibula or talus. This anteromedial impingement causes pain which localizes to the anteromedial ankle and worsens with dorsiflexion. The cause of this syndrome is hypertrophy of the ATTF. The thickened ligament impinges on the anteromedial corner of the articular surface of the talus with ankle dorsiflexion causing osteophyte formation and/or chondral abrasion. Partial excision/debridement of the ATTF has yielded good results.
Reference: Egol KA, Parisien JS: Impingement syndrome of the ankle caused by a medial meniscoid lesion. Arthroscopy 1997;13:522-525.
Mosier-La Clair SM, Monroe MT, Manoli A: Medial impingement syndrome of the anterior tibiotalar fascicle of the deltoid ligament on the talus. Foot Ankle Int 2000;21385-391.
Netter, FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, pp 495.