The Ankle and Lower Leg

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The Ankle and Lower Leg
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Functional Anatomy

• Ankle is a stable hinge joint
• Medial and lateral displacement is prevented by
  the malleoli
• Ligament arrangement limits inversion and
  eversion at the subtalar joint
• Square shape of talus adds to stability of the
  ankle
• Most stable during dorsiflexion, least stable in
  plantar flexion

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Special Tests

• Lower Leg
• Percussion and compression tests
• Thompson test
• Squeeze calf muscle, while foot is extended off
  table to test the integrity of the Achilles
  tendon
• Positive tests results in no movement in the foot

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Compression Test
Percussion Test
Thompson Test
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• Ankle Stability Tests
• Anterior drawer test
• Used to determine damage to anterior talofibular
  ligament primarily and other lateral ligament
  secondarily
• A positive test occurs when foot slides forward
  and/or makes a clunking sound as it reaches the
  end point
• Talar tilt test
• Performed to determine extent of inversion or
  eversion injuries
• With foot at 90 degrees calcaneus is inverted and
  excessive motion indicates injury to
  calcaneofibular ligament and possibly the
  anterior and posterior talofibular ligaments
• If the calcaneus is everted, the deltoid ligament
  is tested

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Anterior Drawer Test
Talar Tilt Test
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Special Tests

• Kleigers test
• Used primarily to determine extent of damage to
  the deltoid ligament and may be used to evaluate
  distal ankle syndesmosis, anterior/posterior
  tibiofibular ligaments and the interosseus
  membrane
• With lower leg stabilized, foot is rotated
  laterally to stress the deltoid

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Inversion Sprains

• Anterior talofibular ligament is injured with
  inversion, plantar flexion and internal rotation
• Ankle Sprain
• Grade 1-most common
• Inv/PF mechanism
• Injury to ATF
• Grade 2- greater time loss
• Moderate force
• Inv/PF/Add
• Injury to ATF/ CF
• Grade 3- relatively uncommon
• Probable dislocation
• Injury to ATF, CF, PTF, joint capsule

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• Syndesmotic Sprain
• Etiology
• Injury to anterior/posterior tibiofibular
  ligament
• Torn w/ increased external rotation or
  dorsiflexion
• Injured in conjunction w/ medial and lateral
  ligaments
• Signs and Symptoms
• Severe pain, loss of function passive external
  rotation and dorsiflexion cause pain
• Pain is usually anterolaterally located
• Management
• Difficult to treat and may requires months of
  treatment

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• Ankle Fractures/Dislocations
• Etiology
• Number of mechanisms
• Signs and Symptoms
• Swelling and pain may be extreme with possible
  deformity
• Management
• RICE to control hemorrhaging and swelling
• Once swelling is reduced, a walking cast or brace
  may be applied, w/ immobilization lasting 6-8
  weeks

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Due to the GRAPHIC NATURE OF THE NEXT
SLIDE (X-rays of Ankle fracture/dislocation) VIEW
ER DISCRETION IS ADVISED
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Achilles Tendonitis

• Etiology
• Tendon is overloaded due to extensive stress
• Presents with gradual onset and worsens with
  continued use
• Decreased flexibility exacerbates condition
• Signs and Symptoms
• Generalized pain and stiffness, thickening
• May limit strength
• May progress to morning stiffness

• Management
• Resistant to quick resolution due to slow healing
  nature of tendon
• Must reduce stress on tendon, address structural
  faults (orthotics, mechanics, flexibility)
• Use antiinflammatory modalities and medications
• Cross friction massage

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• Achilles Tendon Rupture
• Etiology
• Occurs w/ sudden stop and go forceful plantar
  flexion w/ knee moving into full extension
• Commonly seen in athletes gt 30 years old
• Generally has history of chronic inflammation
• Signs and Symptoms
• Sudden snap (kick in the leg) w/ immediate pain
  which rapidly subsides
• Point tenderness, swelling, discoloration
  decreased ROM
• Obvious indentation and positive Thompson test
• Occurs 2-6 cm proximal the calcaneal insertion

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• Achilles Tendon Rupture (continued)
• Management
• Usual management involves surgical repair for
  serious injuries (return of 75-90 of function)
• Non-operative treatment consists of RICE,
  NSAIDs, analgesics, and a non-weight bearing
  cast for 6 weeks, followed up by a walking cast
  for 2 weeks (75-80 return to normal function)
• Rehabilitation last about 6 months and consists
  of ROM, PRE and wearing a 2cm heel lift in both
  shoes

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• Peroneal Tendon Subluxation/Dislocation
• Etiology
• Occurs in sports with dynamic forces being
  applied to the ankle
• May also be caused by dramatic blow to posterior
  lateral malleolus, or moderate/severe inversion
  ankle sprain resulting in tearing of peroneal
  retinaculum
• Signs and Symptoms
• Complain of snapping in and out of groove with
  activity
• Eversion against manual resistance replicates
  subluxation
• Recurrent pain, snapping and instability
• Present with ecchymosis, edema, tenderness, and
  crepitus over the tendon

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• Peroneal Subluxation (continued)
• Management
• Conservative approach should be used first,
  including compression with felt horseshoe
• Reinforce compression pad with rigid plastic or
  plaster until acute signs have subsided
• RICE, NSAIDs and analgesics
• Conservative treatment time 5-6 weeks followed by
  gradual rehab program
• Surgery if conservative plan fails

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• Gastrocnemius Strain
• Etiology
• Susceptible to strain near musculotendinous
  attachment
• Caused by quick start or stop, jumping
• Signs and Symptoms
• Depending on grade, variable amount of swelling,
  pain, muscle disability
• May feel like being hit in leg with a stick
• Edema, point tenderness and functional loss of
  strength
• Management
• RICE, NSAIDs and analgesics as needed
• Grade 1 should apply gentle stretch after cooling
• Weight bearing as tolerated
• Gradual rehab program should be instituted

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• Medial Tibial Stress Syndrome (Shin Splints)
• Etiology
• Pain in anterior portion of shin
• Stress fractures, muscle strains, chronic
  anterior compartment syndrome
• Accounts for 10-15 of all running injuries, 60
  of leg pain in athletes
• Caused by repetitive microtrauma
• Signs and Symptoms
• Four grades of pain
• Pain after activity
• Pain before and after activity and not affecting
  performance
• Pain before, during and after activity, affecting
  performance
• Pain so severe, performance is impossible

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• Management
• Physician referral for X-rays and bone scan
• Activity modification
• Correction of abnormal biomechanics
• Ice massage to reduce pain and inflammation
• Flexibility program for gastroc-soleus complex
• Arch taping and or orthotics

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• Stress Fracture of Tibia or Fibula
• Etiology
• Runners tends to develop in lower third of leg,
  dancers middle third
• Often occur in unconditioned, non-experienced
  individuals
• Often training errors are involved
• Component of female athlete triad
• Signs and Symptoms
• Pain more intense after exercise than before
• Point tenderness
• Bone scan results (stress fracture vs.
  periostitis)

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• Management
• Discontinue stress inducing activity 14 days
• Use crutch for walking
• Weight bearing when pain subsides
• After pain free for 2 weeks athlete can gradually
  return to running