ANKLE AND

LOWER LEGChapter 17

WARM - UP

http://www.youtube.com/watch?v=4hCS1O2LP_c

FACTS ON THE ANKLE, AND FOOT 15% of all sports injuries involve the ankle

Ankle absorbs three times the force of the body during running and jumping

Estimated 20,000 ankle sprains every day in the US

Foot is responsible for some of the most minor yet potentially debilitating conditions if not treated

ANKLE BONY ANATOMY Talus (link between lower leg & foot)

TibiaMedial malleolus

FibulaLateral malleolus

MortiseThe bony arch formed by the tibial plafond and the two malleoli

Tibial tuberosity

Tibial condyles

BONY ANATOMY

FUNCTIONAL ANATOMY Ankle is a stable hinge joint Medial/lateral dislocation is prevented by malleoli Square shape of talus adds stability of ankle Most stable during dorsiflexion, least stable in plantar flexion

ANKLE MOTIONS Plantar Flexion Dorsiflexion Inversion Eversion

ANKLE ARTICULATIONS Talar Joint (Talocrural joint)Tibia & fibula with talus

Dome of talus articulates with mortise formed by tibia & fibula

Motions: dorsiflexion & plantar flexion

Subtalar JointArticulation of talus with calcaneus

Motions: inversion & eversion

MUSCLES OF THE LOWER LEG Flexor Hallucis Longus

Flexor Digitorum Longus

Anterior Tibialis

MUSCLES OF THE LOWER LEG

Peroneus tertius

Peroneus longus

Peroneus brevis

MUSCLES OF THE LOWER LEG

Gastrocnemius Soleus

MUSCLES OF THE LOWER LEG

MUSCLES OF THE LOWER LEG

COMPARTMENTS OF THE LOWER LEG

AnteriorTibialias anteriorExtensor digitorum longus

Peroneus tertiusExtensor hallucis muscles

PeronealPeroneus longusPeroneus brevis

Deep PosteriorPopliteusFlexor digitorum longusFlexor hallucis longusTibialis posterior

Superficial PosteriorGastrocnemiusSoleusPlantaris

COMPARTMENTS OF THE LOWER LEG

COMPARTMENTS OF THE LOWER LEG

LIGAMENTS

Lateral aspectAnterior talofibular (ATF)

Anterior tibiofibularCalcaneofibular (CF)Posterior talofibular

Medial aspectDeltoid Ligament

COMMON INJURIES TO THE

ANKLE & LOWER LEG

CONTUSIONS Occur most often on tibia

Can be painful and disabling

Complication

compartment syndrome

MUSCLE STRAINS Most common in calf

Result from: violent contractionOverstretchingContinued overuse

Usually occur in area of MTJ or insertion of Achilles tendon

Result from: Repetitive overuse Single violent contraction

Acute strain to Achilles have tendency to become chronic

CRAMPS A sudden, involuntary contraction of a muscle

Contributing factors include:FatigueFracturesDehydrationLack of nutrients in dietPoor flexibilityImproperly fitted equipment

CRAMPS—TREATMENT

Passive stretching

Fluid replacementWaterSports drink

Massage

Rest

Ice

ACHILLES TENDONITIS

Inflammation of Achilles tendon Tearing of tendon tissues caused by excessive stress Occurs at point where tendon attaches to heel

ACHILLES TENDONITIS Symptoms develop gradually

Repeated or continued overstress increases inflammation

Pain, crepitus, redness

Treatment Prevention Stretching Biomechanical problems? Ice/Rest NSAIDs Heel lift/Achilles taping

ACHILLES TENDON RUPTURE Rupture occurs w/in tendon, approx 1-2” proximal to insertion

Eccentric force applied to dorsiflexed foot Poor conditioning Overexertion

Direct trauma

Surgically repaired

Rehab = 1yr +

Thompson test

MEDIAL TIBIAL STRESS SYNDROME aka shin splints Catchall term for pain that occurs below kneeAnterior shinMedial shin

Result of doing too much too soon

Associated with:repetitive activity on hard surface

forcible excessive use of leg muscles (running, jumping)

tightness of gastroc and/or soleus muscles

improper footwearrunning biomechanics

MTSS TREATMENT

Ice

Reduce activity level

Gentle stretching

Biomechanical assessment

Orthotics

NSAIDs

Strengthening and flexibility program

STRESS FRACTURES Incomplete crack in bone

Microscopic fractures in bone that will eventually lead to full fracture if left untreated

Repeated stress placed on bone greater than body’s ability to heal it

STRESS FRACTURES—S/SXS

“hot spot” of sharp, intense pain upon palpation

Shin-splint

Pain more generalized

Pain worse in am

COMPARTMENT SYNDROME Swelling within one or more of the compartments of the lower leg Caused by:ContusionFractureCrush injuryLocalized infectionExcessive exerciseOverstretching

ANKLE SPRAINS

MOI: combo of excessive inversion and PF aka lateral ankle sprain

Anterior Talofibular Ligament (ATF) Calcaneofibular (CF) Posterior talofibular (PTF)

Eversion (medial) ankle sprain less common Deltoid ligament

Syndesmotic sprain High ankle sprain Syndesmosis and tibiofibular ligament

ANKLE SPRAINS

Injury to ligamentous and capsular tissue

Traumatic joint twist that results in stretching of total tearing of the stabilizing connective tissue

One of most common & disabling sports injuries

General Symptoms:Joint swellingLocal temperature increase

Pain Point tendernessSkin discoloration

ANKLE SPRAINS

Inversion Anterior TalofibularCalcaneofibularPosterior Talofibular

EversionDeltoid Ligament

SyndesmoticHigh ankle sprain

ANKLE SPRAIN—S/SXS Grade 1 Some pain Minimum LOF Mild point tenderness Little or no swelling No abnormal motion

Grade 2 Pain Moderate LOF Swelling Slight to moderate instability

Grade 3 Severe sprain Extremely painful initially

LOF Severe instability Tenderness Swelling

May represent subluxation that reduced spontaneously

ANKLE SPRAIN—TREATMENT

R.I.C.E.

Crutches

Boot

Splint, tape, brace

Compressive wrap

Horseshoe

ANKLE ASSESSMENT

HISTORY QUESTIONS – FOOT Always start with the general history questions first…. How, what, when, where, and who was involved

Where is the pain (ankle, heel, arches, toes)

Any sound – snapping, popping, crepitus

What type of surface has athlete been training on?

What type of footwear was worn during training? Is it appropriated for the type of training? Is discomfort increased when footwear is worn?

HISTORY QUESTIONS – ANKLE/LOWER LEG

Is there any sense of muscle weakness or difficulty walking?

How disabling is the injury? Could you walk right away or was there a period of time when you could not bear weight

Different questions will be asked if they have a chronic condition of the ankle/foot Past injuries??

OBSERVATION - FOOT

Always check for swelling, discoloration, bleeding, deformity

Walking with limp or unable to bear weight

Pes Planus and Pes Cavus

Everything aligned

2nd toe longer than big toe

OBSERVATION – ANKLE/ LOWER LEG

Postural deviations in foot and ankle

Difficulty walking

Are ankles symmetrical

Crepitus or abnormal sound

Normal range of motion

Able to walk with a normal walking pattern

SPECIAL TESTS&

REHABILITATION

Anterior Drawer

Tests integrity of anterior talofibular ligament

Talar Tilt

Tests integrity of calcaneofibular ligament

Kleiger’s Test

Tests integrity of the deltoid ligament and syndesmosis

Thompson Test

If the gastrocnemius is squeezed and the foot should plantarflex. If it does not then there is a possible rupture of the Achilles tendon

Squeeze Test

Squeezing the tibia and fibula together

Can indicate fracture or high ankle sprain

Bump Test/Tap Test

Bump calcaneusIndicate fracture to tibia/fibula

Indicate high ankle sprain

Tap mallelousIndicate fracture of particular bone

ANKLE REHAB

4-way TheraBand®

Heel walks/Toe walks

3-way heel raises

Unilateral Balance

3-way Tramp throw

ANKLE INJURY BROCHURE - TEST General Anatomy of the Ankle Bones and ligaments

Injuries: Ankle sprains (x3), Achilles Tendonitis, Achilles Tendon Rupture, Compartment Syndrome, and Medial Tibial Stress Syndrome.Include the following for each injuryGeneral definition – include anatomyMOIS/SXTX

General Rehabilitation Exercises