The Ankle and Lower Leg

1
Chapter 5

• The Ankle and Lower Leg

2
Clinical Anatomy

• VERY IMPORTANT! Pages 136-145
• Bones and bony landmarks
• Articulations and ligamentous support
• Muscles
• Compartments
• Bursae

3
Clinical Evaluation of the Ankle and Lower Leg

• Bi-lateral comparison
• Patient Positioning
• Interrelated to foot and knee
• Evaluation Map, page 146

4
History

• Location of pain (Table 5-2, page 147)
• Nature or type of pain
• Onset
• Injury Mechanism (Table 5-3, page 148)
• Changes in activity and conditioning
• Prior history of injury

5
Inspection

• General Inspection
• Weight-bearing status
• Bilateral comparison
• Swelling
• Lateral Structures
• Peroneal muscle group
• Distal one third of fibula
• Lateral Malleolus (Figure 5-15, page 149)

6
Inspection

• Anterior Structures
• Appearance of anterior lower leg
• Contour of the malleoli
• Talus
• Sinus tarsi (Figure 5-16, page 149)
• Medial Structures
• Medial malleoli
• Medial longitudinal arch

7
Inspection

• Posterior Structures
• Gastrocnemius-soleus complex
• Achilles tendon
• Bursae
• Calcaneus

8
Palpation

• Utilize textbook pages 150-154
• Refer to list of Clinical Proficiencies
• Palpation of Pulses
• Posterior tibial artery
• Dorsalis pedis artery

9
Range of Motion Testing

• Talocrural Joint
• Affected by muscular tightness, bony
  abnormalities, or soft tissue constraints
• 100 of dorsiflexion during walking
• 150 of dorsiflexion during running
• If DF is limited, the foot compensates by
  increasing pronation
• Table 5-4, page 154
• Goniometry (Box 5-2, page 155)

10
Active Range of Motion

• Plantarflexion and dorsiflexion
• 700 of motion
• Figure 5-17, page 155
• Inversion and eversion
• 250 of motion
• Figure 5-18, page 155

11
Passive Range of Motion

• Plantarflexion and dorsiflexion
• Measured with knee flexed and extended
• Firm end-feel
• Anterior capsule, deltoid lig, ATF lig (PF)
• Achilles tendon (DF)
• Inversion and Eversion
• Stabilize lower leg
• End-feel
• Inversion firm (lateral ankle ligs, peroneals)
• Eversion hard (fibula striking calcaneus) or
  firm (medial jt capsule and musculature)

12
Resistive Range of Motion

• Box 5-3, page 156
• DF, PF, INV, EV
• Toe-raise test (figure 5-19, page 157)

13
Tests for Ligamentous Stability

• Specific testing for joint play and specific
  ligament tenderness and pain

14
Test for Anterior Talofibular Ligament Instability

• ATF prevents anterior translation of the talus
  relative to ankle mortis
• Combination of PF, INV, and SUP place strain on
  ATF
• Anterior Drawer Test
• Box 5-4, page 158

15
Test for Calcaneofibular Ligament Instability

• Talar Tilt test (inversion stress test)
• Box 5-5, page 159
• Also stresses anterior and posterior talofibular
  ligaments

16
Test for Deltoid Ligament Instability

• Talar Tilt test (eversion stress test)
• Box 5-6, page 160
• Kleigers test (external rotational test)
• Box 5-7, page 161

17
Test for Ankle Syndesmosis Instability

• Overpressure at end of DF
• Ankle syndesmosis, anterior tibiofibular
  ligament, interosseous membrane, posterior
  tibiofibular ligament
• Talus is wedged into talocrural joint, causing
  separation between tibia and fibula
• Kleigers Test (external rotational test)

18
Neurologic Testing

• Dysfunction can occur secondary to compartment
  syndrome or direct trauma
• Common peroneal nerve
• Table 5-5, page 162
• Figure 5-20, page 162
• Lower quarter screening (Chapter 1, page 16)

19
Pathologies and Related Special Tests

• Ankle Sprains
• Most occur secondary to supination and cause
  trauma to the lateral ligament complex, due to
  calcaneal inversion
• Less commonly, the medial ankle ligaments and
  distal tibiofibular syndesmosis are sprained
• Trauma to capsule

20
Lateral Ankle Sprains

• Open-packed vs closed-packed position
• Sudden forceful inversion specific structures
  injured depends on talocrural joint position
• ATF ligament most commonly sprained
• Calcaneofibular and posterior talofibular
  ligaments may also be injured

21
Lateral Ankle Sprains

• Anatomic and physiologic predisposing conditions
• Prophylactic devices
• Re-incidence rates
• Loss of ligaments ability to protect and support
  joint
• Decreased proprioceptive ability

22
Lateral Ankle Sprains

• Evaluation Findings
• Table 5-6, page 163
• Additional trauma may be overlooked
• Medial structures, peroneals, achilles tendon,
  etc.
• Figure 5-21, page 164
• Secondary conditions
• Thickened connective tissue, bone bruises, blood
  accumulations, etc.
• Figure 5-22, page 164

23
Lateral Ankle Sprains

• Traction injuries to peroneal nerve
• Evaluating ankle sprains in adolescents
• Treatment

24
Syndesmosis Sprains

• Only represent between 10 and 18 of all ankle
  sprains
• Associated with significantly increased amounts
  of time loss
• Excessive external rotation or forced
  dorsiflexion talus placing pressure on fibula
  spreading of syndesmosis
• Figure 5-23,page 165

25
Syndesmosis Sprains

• Factors contributing to occurrence
• Evaluation Findings
• Table 5-7, page 167
• Squeeze Test
• Box 5-8, page 166
• Maisonneuve Fracture
• Figure 5-24, page 167
• Treatment

26
Medial Ankle Sprains

• Eversion is limited by
• Strength of deltoid ligament
• Mechanical advantage - longer lateral malleolus
• External rotation of talus in ankle mortis
• Medial longitudinal arch and syndesmosis may also
  be involved

27
Medial Ankle Sprains

• Evaluation Findings
• Table 5-8, page 168
• Injuries to surrounding structures
• knock-off fracture (Figure 5-25, page 168)
• Potts fracture
• Interarticluar trauma to talus and tibia

28
Stress Fractures

• Evaluation Findings
• Table 5-9, page 169
• Predisposing factors
• Narrow tibial shaft, hip external rotation, pes
  cavus
• Diagnostic testing
• Bump Test (Box 5-9, page 170)
• Treatment (Figure 5-26, page 169)
• Table 5-10, page 171

29
Os Trigonum Injury

• Evaluation Findings
• Table 5-11, page 173
• Steidas process (figure 5-27,page 172)
• Formation of an os trigonum (Fig 5-28, p172)
• Os trigonum syndrome (talarcompression syndrome)
• Inflammation of posterior joint
• Inflammation of surrounding ligaments
• Fracture of the os trigonum
• Pathology involving Steidas process

30
Os Trigonum Injury cont.

• Inversion/plantarflexion
• posterior talocalcaneal ligament tightens against
  os trigonum or Steidas process
• Eversion of calcaneus
• os trigonum or Steidas process to become
  compressed between tibia and calcaneus
• Treatment

31
Achilles Tendon Pathology

• Association with gastrocnemius and soleus
• Decreased plantarflexion strength
• Changes in gait ability to walk, run, jump

32
Achilles Tendinitis

• Evaluation Findings
• Table 5-12, page 174
• Poorly vascularized structure
• Limited blood supply - posterior tibial artery
• Distal avascularized zone 2 to 6 cm proximal to
  insertion on calcaneus
• Delayed healing

33
Achilles Tendinitis cont.

• Paratenon
• Highly vascularized structure, surrounds tendon
• Peritendinitis
• Tendinosis
• Degeneration of tendons substance
• Peritendinitis Tendinosis Tendon Rupture

34
Achilles Tendinitis cont.

• Factors leading to achilles tendon pathology
• Tibial varum
• Calcaneovalgus
• Hyperpronation
• Tightness of triceps surae, hamstring groups
• Running mechanics, duration and intensity of
  running, type of shoe, running surface
• Biomechanics of foot and ankle
• Acute Onset

35
Achilles Tendinitis cont.

• Age and gender
• Pain characteristics
• Treatment/Return to activity

36
Achilles Tendon Rupture

• Evaluation Findings
• Table 5-13, page 176
• Forceful, sudden contraction large amount of
  tension developing in tendon
• Theories
• Chronic degeneration of tendon
• Failure of inhibitory mechanism of
  musculotendinous unit
• Rupture tends to occur in distal 2-6 cm

37
Achilles Tendon Rupture cont.

• Age and gender
• Previous or current tendinosis, age-related
  changes in tendon, deconditioning
• Corticosteroid injections
• Characteristics of rupture
• Figure 5-29, page 175
• Thompson Test
• Box 5-10, page 177
• Treatment

38
Subluxating Peroneal Tendons

• Evaluation Findings
• Table 5-14, page 178
• Forceful, sudden DF/EV or PF/INV stretch or
  rupture of superior peroneal retinaculum
• Tendon alignment
• Figure 5-30, page 176

39
Subluxating Peroneal Tendons cont.

• Predisposing factors
• Flattened fibular groove
• Pes planus
• Hindfoot valgus
• Recurrent ankle sprains
• Laxity of peroneal retinaculum
• Characteristics
• Treatment

40
Neurovascular Deficit

• Disruption of blood or nerve supply to or from
  lower leg
• Acute trauma
• Overuse conditions
• Congenital defects
• Surgery
• Dermatomes, reflexes, pulses

41
Anterior Compartment Syndrome

• Evaluation Findings
• Table 5-15, page 179
• Increased pressure in compartment threatens
  integrity of lower leg, foot, and toes
• Obstructs neurovascular network
• Deep peroneal nerve
• Anterior tibial artery

42
Anterior Compartment Syndrome cont.

• Bony posterolateral border and dense fibrous
  fascial lining poor elastic properties
• Cannot accommodate for expansion of
  intracompartmental tissues
• Increased pressure lack of oxygen to local
  tissues
• Leads to ischemia and possibly cell death

43
Anterior Compartment Syndrome cont.

• 3 classifications
• Traumatic
• blow to anterior or anterolateral portion of
  lower leg
• Exertional
• acute or chronic during or after exercise (or
  both)
• Chronic (recurrent or intermittent claudication)
• Occurs secondary to anatomic abnormalities
  obstructing blood flow to exercising muscles
• Increased thickness of fascia inhibits venous
  outflow
• Other anatomic factors page 178

44
Anterior Compartment Syndrome cont.

• Associated with
• Tibial fractures
• Anticoagulant therapy
• Diabetes
• Knee braces
• High-heeled shoes
• Signs and Symptoms
• 5 Ps
• Pain, pallor, pulselessness, paresthesia,
  paralysis

45
Anterior Compartment Syndrome cont.

• Drop foot gait
• Dorsalis pedis pulse (Figure 5-31, pg 180)
• Most important clinical finding
• Severe pain with passive muscle stretching
• Medical emergency
• Decreased pulse, paresthesia, paralysis
• Compartmental pressure
• Treatment

46
Deep Vein Thrombophlebitis

• Inflammation of veins with associated blood clots
• Common in postsurgical patients
• May be secondary to trauma to lower extremity
• Pain and tightness in calf during walking
• Inspection swelling in calf
• Palpation warmth, tightness, pain
• Homans sign
• Box 5-11, page 181

47
On-Field Evaluation of Lower Leg and Ankle
Injuries

• Goals
• Rule out fractures and dislocations
• Determine weight-bearing status
• Removal methods

48
Equipment Considerations

• Footwear Removal
• Rule out fracture/dislocation and then remove
  shoe
• Figure 5-32, page 181
• Apprehensive athletes remove themselves
• If fracture is suspected check pulses
• Tape and Brace Removal
• Similar to shoe removal
• Tape is cut on opposite side of injury

49

• On-Field History
• Mechanism of injury
• Inversion
• Eversion
• Rotation
• Dorsiflexion
• Plantarflexion
• Associated sounds and sensations

50

• On-Field Inspection
• On-Field Palpation
• Bony palpation
• Soft tissue palpation
• On-Field Range of Motion Tests
• Willingness to move involved limb
• Willingness to bear weight

51
Initial Management of On-Field Injuries

• Ankle Dislocations (talocrural joint)
• Excessive rotation combined with INV or EV
• Disruption of capsule/ligaments, fractures of
  malleoli, long bones, talus
• Pain, loss of function, audible sounds
• Figure 5-33, page 183
• Confirm presence of pulses
• Lower Leg Fractures
• Signs/symptoms (Figure 5-34, page 183)
• Fibula may be able to walk
• Bump/squeeze tests

52
Management of Lower Leg Fractures and Dislocations

• Immediately immobilized
• Moldable or vacuum splints
• Leave shoe on until emergency room
• Figure 5-35, page 183
• Compound fracture
• Control bleeding
• Treatment
• Figure 5-36, page 184

53
Anterior Compartment Syndrome

• Avoid compression
• Acute gross hemorrhage or absent dorsalis pedis
  pulse immediate refer to physician
• Educate athletes