Deltoid Ligament Injection

Indications and Clinical Considerations

The deltoid ligament is susceptible to strain from acute injury from sudden overpronation of the ankle or from repetitive microtrauma to the ligament from overuse or misuse, such as in long-distance running on soft or uneven surfaces ( Fig. 179.1 ). Patients with strain of the deltoid ligament experience pain just below the medial malleolus. Plantarflexion and eversion of the ankle joint exacerbate the pain. On physical examination, there is point tenderness over the medial malleolus. With acute trauma, ecchymosis over the ligament may be noted. Passive eversion and plantarflexion of the ankle joint exacerbate the pain. Coexistent bursitis and arthritis of the ankle and subtalar joint also may be present and may confuse the clinical picture.

FIG. 179.1, The deltoid ligament is frequently injured by eversion injuries that occur when tripping while wearing high heels, landing hard on uneven surfaces, and during dancing, soccer, and American football.

Plain radiographs are indicated for all patients with ankle pain ( Fig. 179.2 ). On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and/or ultrasound imaging of the ankle is indicated if disruption of the deltoid ligament, joint instability, occult mass, or tumor is suggested ( Fig. 179.3 ).

$FIG. 179.2, Anteroposterior radiograph of a severe acute eversion ankle injury. There is an oblique fracture of the distal fibula. Disruption of the ankle mortise with widening of the medial joint line (double-headed arrow) indicates a tear of the deltoid ligament. This pattern of injury is less common than an avulsion fracture of the entire medial malleolus with an intact ligament.$

$FIG. 179.3, A, Sagittal fast spin (FS) T2-weighted magnetic resonance (MR) image of an athlete with a subacute eversion ankle sprain. There is marrow edema in the tip of the medial malleolus (white arrow) and a possible small bony avulsion injury (broken white arrow). B, The coronal FS T2-weighted MR image also shows the marrow edema (white arrow), and there is high signal intensity within the deltoid ligament (curved white arrow) as a result of partial tearing. C and D, Consecutive axial FS T2-weighted MR images more clearly demonstrate the deltoid ligament edema (curved white arrow) anterior to the flexor tendons (white arrows). The bony avulsion fragment is demonstrated as a small round area of low signal intensity (broken white arrow). E, Coronal computed tomography scan confirms the presence of an avulsion fracture of the tip of the medial malleolus.$

Clinically Relevant Anatomy

The ankle is a hinge-type articulation among the distal tibia, the 2 malleoli, and the talus. The articular surface is covered with hyaline cartilage, which is susceptible to arthritis. The joint is surrounded by a dense capsule that helps strengthen the ankle. The joint capsule is lined with a synovial membrane that attaches to the articular cartilage. The ankle joint is innervated by the deep peroneal and tibial nerves.

The major ligaments of the ankle joint include the deltoid, anterior talofibular, calcaneofibular, and posterior talofibular ligaments, which provide the majority of strength to the ankle joint ( Fig. 179.4 ). The deltoid ligament is exceptionally strong and is not as subject to strain as the anterior talofibular ligament, and it has 2 layers ( Fig. 179.5 ). Both layers attach above to the medial malleolus ( Fig. 179.6 ). A deep layer attaches below to the medial body of the talus, with the superficial fibers attaching to the medial talus, the sustentaculum tali of the calcaneus, and the navicular tuberosity.