The Ankle & Lower Leg

Anatomy

Bony anatomy: tibia, fibula, talus Joints: talocrural and subtalar

– Talocrural joint is the true “ankle joint” and ROM includes dorsiflexion (DF) and plantarflexion (PF)

– Subtalar joint ROM includes inversion and eversion.

Ligaments: – Medial ligaments: deltoid– Lateral ligaments: anterior

talofibular (ATF), posterior talofibular (PTF), calcaneofibular (CF)

Muscles: muscle action is divided up by 4 compartments

Anatomy

Ligaments: – Medial ligaments: deltoid– Lateral ligaments:

anterior talofibular (ATF), posterior talofibular (PTF), calcaneofibular (CF)

Muscles: muscle action is divided up by 4 compartments

Prevention of Lower Leg & Ankle Injuries Heel cord stretching

– Athletes with a tight achilles tendon should stretch before and after practice/competition.

Strength training– A balance of strength must be developed and maintained in each of the four

muscle groups that surround the ankle joint.– Exercises should be done through complete ROM.

Neuromuscular control– Key in injury prevention.– Neuromuscular control relies on the CNS to interpret/integrate

proprioceptive/kinesthetic information. Appropriate footwear

– Shoes should be used for intended activity. Ankle tape and bracing

– Debate about the effectiveness of using prophylactic taping/bracing.

Heel Cord Stretching & Neuromuscular Control

Ankle Assessment Principles: HHistory

What trauma or mechanism occurred? What was heard when the injury occurred? Intensity of pain? How disabling is the injury? Has a similar injury happened before? Is there any feeling of warmth; numbness or

tingling? Is there any swelling? Where did the swelling

occur?

Ankle Assessment Principles: OObservation Is there obvious deformity? Is there any discoloration? Is there crepitus or abnormal sound in the

joint? Is heat, swelling, or redness present? Is the athlete in obvious pain? Does the athlete have normal range of

motion? Is there a normal walking pattern?

Ankle Assessment Principles: PPalpation and SSpecial Tests Palpation over bony landmarks and then soft tissue. Special Tests:

– Bump test– Compression/squeeze test– Anterior drawer test– Talar tilt test

Functional Exam:– Walk on toes/heels– Hop on affected foot– Start or stop running motion– Change direction quickly– Run figure-8’s

Specific Injuries to the Lower Leg & Ankle Ankle sprains Ankle fractures Tendinitis Tibial and fibular fractures Shin splints Compartment syndrome Achilles tendon rupture/tendinitis Shin contusions

Ankle Sprains http://www.youtube.com/watch?v=KjJi_FCRhl0&feature=related

Cause of injury:– Inversion ankle sprain– Eversion ankle sprain– High ankle sprain

Signs of injury:– Grade 1 sprain: some

stretching/tearing of ligament fibers; mild pain; mild swelling; and joint stiffness.

– Grade 2 sprain: some tearing/separation of the ligament fibers; some instability; pain; swelling; and joint stiffness.

– Grade 3 sprain: total rupture of ligament fibers; gross instability; severe pain; major swelling; and joint stiffness; may require surgery and/or immobilization.

Treatment of injury:– LIMIT SWELLING; PRICE;

horseshoe with compression; remove/reduce weight bearing.

Ankle Fractures http://www.youtube.com/watch?v=alMRX5wQWEs&feature=fvw

Cause of injury:– Mechanisms of ankle fracture are similar to those

of ankle sprains.

Signs of injury:– Immediate swelling; point tenderness over bone;

athlete is apprehensive to bear weight.

Treatment of injury: – Splint and refer ASAP for x-rays.

Tendinitis Cause of injury:

– Tendons most commonly inflamed is the posterior tibialis tendon, anterior tibialis tendon, and peroneal tendons.

– May be a result of faulty mechanics, poor footware, acute trauma, tightness is the achilles tendon, and/or training errors.

Signs of injury:– Pain with active movement/passive stretching; swelling

around tendon; crepitus; stiffness/pain followed by periods of inactivity.

Treatment of injury: – Eliminate inflammation; rest; ice; NSAIDS; orthotic

devices/taping.

Lower Leg Assessment Principles: HHistory

How long has it been hurting? Where is the pain and/or discomfort? Has the feeling changed or is there

numbness? Is there any feeling of warmth? Is there any sense of muscle weakness

or difficulty in walking? How did the problem occur?

Lower Leg Assessment Principles: OObservation, PPalpation, & SSpecial Tests

Observation – Are there any postural deviations?– Any walking difficulty, leg deformities, and/or

swelling present? Palpation

– Bony palpation.– Musculature of the four lower leg compartments.

Special tests – Compression/squeeze test– Heel pound

Tibial and Fibular Fractures

Cause of injury:– Direct trauma; indirect/rotary/compressive

trauma. Signs of injury:

– Immediate pain; swelling; deformity. Treatment of injury:

– Splint and refer ASAP for x-rays.

Shin Splints Cause of injury:

– Strain of posterior tibialis muscle/fascial sheath at its attachment to the periosteum of distal tibia during running activities.

Signs of injury:– Pain around distal medial tibia and surrounding tissues.– May only hurt after activity then progresses to pain with

ambulation. Treatment of injury:

– Referral to MD to rule out a stress fracture; activity modification; correction of faulty mechanics; ice; stretching; taping.

Compartment Syndromes Cause of injury:

– Increased pressure within one of the four compartments of the lower leg causes compression of muscular/neurovascular structures within that compartment.

• Acute compartment syndrome• Acute exertional compartment syndrome• Chronic compartment syndrome

Signs of injury: – Deep aching pain, tightness, and swelling in compartment;

pain with passive stretching; reduced circulation and sensory changes.

Treatment of injury: – Application of ice and elevation; NO COMPRESSION; refer

to MD for further evaluation.

Achilles Tendinitis Cause of injury:

– Occurs because of repetitive stresses and strains placed on the tendon (running/jumping).

Signs of injury:– Generalized pain and

stiffness in Achilles tendon area; gradual onset; warm/painful to touch; tendon may thicken.

Treatment of injury: – Aggressive stretching;

heel lift; taping; NSAIDS

Shin Contusion

Cause of injury:– Due to the lack of muscular/adipose tissue, force

from direct trauma is not dissipated; therefore, periosteum receives the impact.

Signs of injury:– Intense pain, swelling, and warmth; bulging

hematoma. Treatment of injury:

– Compressive wrap with ice and elevation; protective donut to protect from additional injury.