Ankle & Lower Leg

ANKLE AND LOWER LEG

KNR 387

Clicker Questions

Illinois State University

A pt comes to you complaining of pain in the arch and pain radiating to the toes and plantar aspect of the foot. What condition do you suspect?

1 2 3 4 5

6%

18%

0%6%

71%1. Metatarsalgia

2. Intermetatarsal neuroma

3. Plantar fasciitis

4. Pump bumps

5. MT fx


What condition is depicted here?

1 2 3 4

47%

6%6%

41%

1. Rearfoot varum

2. Rearfoot valgum

3. Forefoot varum

4. Forefoot valgum


Where would you palpate and find the dorsal pedal pulse?

1 2 3 4 5

6%

12%

18%

59%

6%

1. Posterior to the lateral malleolus

2. Anterior to the medial malleolus

3. Between the 1st and 2nd phalanges

4. Between the 1st and 2nd metatarsals

5. None of the above


Introduction

Ankle injuries among most common injury in athletics20-25% of all athletic time-lost

High re-injury rate Residual instabilityLoss of joint position sense

Trauma to lower leg can cause compression of neurovascular structures


Clinical Anatomy Ankle mortise

Tibia/fibula/talus

Weight BearingTibia ≈ 83-100%Fibula ≈ 0-17%

○ Muscle attachment○ Ligamentous attachment○ Lateral stability to mortise○ Pulley for muscles

posteriorly to it


Talocrural Joint

Dorsiflexion = closed-pack position

LigamentsATFCFPTFDeltoid


Interosseous Membrane & Syndesmosis Interosseous membrane

Strong, fibrous tissue fixating tibia to fibula

Distal Tibiofibular SyndesmosisAnterior/Posterior tib-fib ligamentsExtension of interosseous membrane

Damaged through excessive eversion or dorsiflexion


Muscles of Lower Leg Anterior Compartment

Tibialis anteriorExt Hallucis LongusExt Digitorum LongusPeroneus tertius

Dorsiflexors

Extensor retinaculum


Muscles of Lower Leg Lateral compartment

Peroneus longusPreoneus brevis

Superior & inferior peroneal retinacula

Superficial peroneal nerve

Peroneal artery


Muscles of the Lower Leg Superficial Posterior

CompartmentGastrocnemiusSoleusPlantaris

Triceps surae group


Muscles of the Lower Leg Deep Posterior

CompartmentTibialis posteriorFlexor digitorum longusFlexor hallucis longus

Tibial nerve Posterior tibial artery


Bursae

Subtendinous calcanealAKA:

retrocalcaneal

Subcutaneous calcaneal


This muscle is a dynamic restraint against excessive inversion at the ankle.

1 2 3 4

19%

56%

13%13%

1. Tibialis posterior

2. Tibialis anterior

3. Peroneus tertius

4. Peroneus longus


All of the following are muscles in the superficial posterior compartment EXCEPT:

1 2 3 4 5

0% 0% 0%

94%

6%

1. Plantaris

2. Gastrocnemius

3. Soleus

4. Tibialis posterior

5. All of the above are in the superficial post. compartment

Clinical Evaluation


History

Location of painReferred pain

○ Anterior compartment syndrome, Tarsal tunnel syndrome, or peroneal nerve, sciatic nerve root impingement

Type of painOnsetMechanismActivity/conditioning changesPrevious history


Inspection

Weight bearing status

General bilateral comparisonRedness, pallor, obvious deformity

SwellingGirth or volumetric measurements


Inspection Peroneal muscle group Distal ⅓ of fibula Medial/Lateral malleolus Malleoli Talus Sinus tarsi Medial Longitudinal Arch Gastroc/soleus complex Achilles tendon Bursae Calcaneous

Neurological Testing


DermatomesNerve Root Area

L4 Medial lower leg, medial foot

L5 Lateral lower leg, dorsal foot

S1 Lateral foot

Tibial Plantar calcaneus

Medial Plantar

Medial plantar aspect of foot

Lateral Plantar

Lateral plantar aspect of foot

Sural Lateral heel


Myotomes/Reflexes

Nerve Root

Testing Reflex

L4 Dorsiflexion Patellar tendon

L5 Toe extension

S1 Plantarflexion Achilles’

S2 Knee flexion

S3 Foot intrinsics

PalpationRefer to Microsoft Word document


Range of Motion Testing

AROMPlantarflexion ≈ 50°Dorsiflexion ≈ 20°Inversion ≈ 20°Eversion ≈ 5°

PROMPlantar/Dorsi w/ knee flexed & extended


Resisted ROM

PlantarflexionSingle-leg heel raiseStraight & bent knee

Dorsiflexion Inversion Eversion

Ligamentous Stability


Ligamentous Stress Tests

ATFLAnterior drawer test

CFLInversion stress test (Talar Tilt)

Deltoid ligamentEversion stress test (Talar Tilt)External Rotation Test (Kleiger’s Test)


Ligamentous Stress Tests

Syndesmosis InstabilityOverpressure w/ passive dorsi

External rotation of talus○ Kleiger’s test

http://orthoassessment.blogspot.com/2007/01/ankle-kleigers-test.html

http://orthoassessment.blogspot.com/2007/01/ankle-kleigers-test.html

Pathologies and Related Special Tests


Ankle Sprain Videos

Video 1

Video 2

Video 3

http://www.youtube.com/watch?v=f4Tk-ltF82o

http://www.youtube.com/watch?v=tre-vqmjgX4

http://www.youtube.com/watch?v=M5anH0fi4Lw


Lateral Ankle Sprain

Least stable in open-packed positionATFLCFPTFL

Predisposing factorsDecreased proprioceptionDecreased muscular strengthPes cavusTightness of the triceps surae


Lateral Ankle Sprain

High re-incidence rate (70%)60% experience residual effects

Why?Loss of static restraints & too slow of a reflex arcDecreased proprioceptive ability

Prophylactic devices


Clinical Findings

Mechanism of injury Sensation of “popping”

Localized pain along lateral ligament complexDiffuse swelling

Pt tenderness Painful inv, PF, and decreased ROM

Medial ankle pain


Diagnostic Tests

Bump & Squeeze/Compression TestMust rule out fx FIRST

Anterior drawer

Talar tilt

http://www.youtube.com/watch?v=4UzoP0PZfZg&feature=related

http://www.youtube.com/watch?v=2qF_DOe2jPE&feature=PlayList&p=E519389B31DF6020&playnext=1&playnext_from=PL&index=32

http://www.youtube.com/watch?v=2qF_DOe2jPE&feature=PlayList&p=E519389B31DF6020&playnext=1&playnext_from=PL&index=32


Chronic Ankle Instability (CAI) Etiology

Repeated lateral ankle sprainsLaxity in ligamentous structuresOften found in pes cavus individualsDecreased proprioception

ObjectivesStabilize calcaneous at heel strikeLimit rearfoot inversionExternal support


Syndesmosis Sprain 10-18% of all ankle sprains

Significant time lostPainful weight bearingImmobilization & non-weight bearing

Must rule out fx

Excessive ER of talus or forced DFCauses mortise to spreadCan involve ATF, PTF, interosseous membrane


Syndesmosis Sprain

AROM restrictedPain w/ DF, eversion, end range of PF & Inv

PROM pain in all directionsDF & eversion worst

RROM weakAll directions

Positive: Kleiger’s & squeeze tests


Medial Ankle Sprains Relatively stable deltoid ligament

Bony support from lateral malleolus○ Small amount of eversion

Mechanism typically external rotationSyndesmotic sprain

Pain along medial joint line Localized swelling Evaluate medial malleolus carefully for fx

Special Tests: Talar tilt, Kleiger’s


Medial Tibial Stress Syndrome “Shin Splints” Etiology

Overuse or weakness of posterior tibial, flexor hallicus/digitorum, or soleus muscles

Abnormal biomechanicsImproper shoesPes planus/hyperpronated footFrequency, intensity, & duration of activityPractice/playing surfaceDistance runners, jumpersCan be caused by direct blow


MTSS

Pain at posterior, medial aspect of tibiaDistal 2/3 most commonIncreased pain w/ activity

ObjectivesControl pronationRest, ice, stretchingMay require orthotics


Stress Fx

Affects tibia, fibula, and talusPersistent microtrauma

Pain w/ activity Better w/ restMay report decreased muscle strength or

cramping May present w/ crepitus

Squeeze & bump tests—likely negative


Achilles Tendon Pathology

Achilles tendonitisInflammation of the tendonPoorly vascularized

Achilles tendon ruptureForceful sudden contraction Tends to occur in distal 2 to 6 cm (avascular)


Achilles tendonitis

Poor vascular supplyInflammatory process possible?Paratenon: surrounds tendon—highly vascular

○ Inflammation: PeritendinitisProduces pain and forms adhesions with underlying

tendon

Tendinosis: Degeneration of tendon

Peritendinits Tendinosis Tendon rupture


Associated Factors

Age & gender strongest predictor

Running mechanics Duration/Intensity of training Type of shoe Running surface Biomechanics of foot/ankle

Also can be caused by direct blow


Achilles Tendon Rupture

Most prominent in men over 30

Episodic strenuous activityDeconditioning

Feeling of being kicked—audible pop

Positive Thompson test

http://www.youtube.com/watch?v=MLT5-Wnu594&feature=related

http://www.youtube.com/watch?v=AmDi08rlR3I&feature=fvw


Management

ConservativeCasting for minimum of 8 weeks

○ Pros: absence of wound problems○ Cons: increased risk of re-rupture, decreased

muscle function, pt dissatisfaction w/ outcome

SurgicallyArthroscopic or open surgery

○ Pros: less than 5% re-rupture rate, greater return to pre-injury level, good strength, power, endurance

○ Cons: surgical complications & wound healing


Subluxing Peroneal Tendon

CauseTear of superior peroneal

retinaculum○ Forceful, sudden dorsi &

eversion or plantar & invTendons become

dorsiflexors

Surgery required for recurrent subluxations

http://www.youtube.com/watch?v=VMRCb8k3FSI


Anterior Compartment Syndrome Cause

Increased pressure in ant compartment

Obstructs neurovascular network of lower leg

Compartment doesn’t accommodate swelling well○ Lack of oxygen leads to

ischemia and cell death

Never apply compression


Type of Compartment Syndrome

Traumautic Anterior Compartment Syndrome Blow to ant or anteriolateral lower leg

○ Edema causes increase pressure ○ Pressure obstructs neurovascular network

Chronic Exertional Compartment SyndromeOccurs secondary to anatomic abnormalities

○ Increased thickness of fascia

Acute Exertional Compartment SyndromeNo prior symptoms or history of traumatic injury


Signs & Symptoms “Five P’s”

Pain○ Localized within affected area○ Increased during active, passive, or resistive ROM

Pallor (redness) Pulselessness

○ Dorsal pedal pulse (only very severe cases) Paresthesia

○ Webspace between 1st & 2nd toes Paralysis

○ Drop foot gait

Pain w/ passive stretching of muscles within compartment

http://www.youtube.com/watch?v=llpfBP8cVVE&NR=1


Deep Vein Thrombophlebitis (DVT)

Thrombophlebitis: inflammation of veins with associated blood clots

Most common in post-surgical patients

Symptoms:Pain, tightness in calfPossible swellingWarmth, tightness of musculature

Positive Homan’s sign

On-Field Evaluations


Equipment Removal

Footwear

Tape & Brace

Questions?

Ankle & Lower Leg

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