The Ankle & Lower LegLecture 10

Lower leg and ankle ankle injuries most

frequent in sports tibia is major weight bearing

bone of the lower leg fibula assists minimally with

weight bearing aprrox 2 % , serves as a site for muscle attachment and contributes to the stability of the ankle

Crural Bones

med / lat. malleolus and talus

Talocrural Joint (ankle joint)

is a uniaxial modified hinge joint - (talus, tibia and fibula)

plantar flexion and dorsiflexion occur here

talus wider ant vs post - stability

Lateral Ankle Support

a) ATF, PTF , CF (static)

(AITF)

b) peroneals (dynamic) the lateral ligaments

of the ankle joint are relatively weaker than the medial ligaments

hence the larger number of lateral ankle sprains

Medial Ankle

a) Deltoid ligament (static)

b) Tom, Dick and Harry (dynamic)

Dynamic TA TP

Distal Tib-Fib Joint

a) ant & post tibiofibular lig

b) interosseos membrane

Muscles

4 compartments anterior , deep , superficial and lateral

i) anterior - tibialis anterior - extensor digitorum longus - extensor hallucis longus and peroneous tertius

ii) deep - tibialis posterior - flexor digitorum longus - flexor hallicus longus

iii) superficial - gastrocnemius - soleus, plantaris

iv) lateral - peroneus brevis , peroneus longus

Ankle Movements

Plantarflexion Dorsiflexion Inversion Eversion

General Ligament Sprains

1st, 2nd, 3rd degree

Common Lower Leg & Ankle Injuries

Inversion Ankle Sprain

more common than eversion because of ligament and bony support

stress is applied to the lateral side of the foot during plantar flexion and inversion

most often injuring the Anterior Talofibular ligament (ATF)

if stress is continued the Calcaneal Fibular Lig (CF) may be injured as well

individual will report cracking or tearing sound at time of injury

swelling and ecchymosis will be rapid and diffuse

point tenderness over ATF may extend over CF

Rx - PIER, modalities -horseshoe pad Should probably xray to rule out any

possible fractures

http://www.youtube.com/watch?v=SjprI020XQ0&feature=related

Eversion Ankle Sprain

less common than lateral ankle sprains because of strong deltoid ligament, thus many are associated with fibular fractures

mild to moderate pain with ankle eversion slower and less evident swelling point tenderness over deltoid ligament Rx – X-ray, PIER, modalities -horse shoe

First Aid Care

Immediately apply ice, compression and elevate

Apply a horseshoe or doughnut pad, keep it in place with a elastic wrap.

Have athlete rest , use crutches

If needed refer to physician or hospital for x-rays .

Syndesmotic ankle sprain

AKA: high ankle sprain Approximately 10 – 15% of all ankle

sprains involve the syndesmosis 30 % for collision sports ( football etc) MOI – almost always involves a direct

blow to the lateral aspect of the leg with foot planted in external rotation

s/s

Min lateral swelling Possible med swelling Pain in anterolateral lower leg Point tenderness over the AITF lig , the

interosseus membrane Pont tenderness over the ATF and possibly the

sup ATF lig Disomfort /pain with DF ( AROM ) Loss of ankle function

First Aid Care Immediately apply ice, compression

and elevate Apply a horseshoe or doughnut pad,

keep it in place with a elastic wrap. Have athlete rest , use crutches , may

want to put in walking boot or cast for short period of time

If needed refer to physician or hospital for xrays .

Achilles Tendon Strain or Rupture probably the most severe

acute muscular problem in lower leg

75% seen in males between 30 - 50 years

mechanism of injury - usually pushing off of the forefoot while knee is extending (racquet sports )

most ruptures occur 1 to 2 inches proximal to the distal attachments of the tendon on the calcaneus

individual experiences sharp pain and hears or feels a POP in the tendon region - often described as a gun shot sound

a common sensation is one of being hit in the back of the leg

visible defect in the tendon

inability to actively extend the foot (especially against resistance)

swelling - bruising and a palpable defect in the tendon

immediate referral to physician

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

First Aid Care

Immediately apply ice, compression and elevate

Immobilize the area in a splint or walking boot.

Have athlete rest , use crutches Send to hospital or nearest medical

facility.

Achilles Tendinitis

most common in lower leg tight heel cord – hyper-pronation -

repetitive heel running - a recent change in shoes or running surfaces - increase in distance or intensity

pain present during and after activity

increases with passive dorsiflexion and resisted plantar flexion

point tenderness - diffuse or localized swelling

aching or burning in the posterior heel occasionally fine crepitation can be

palpated in the tendon with movement Rx - PIER, Modalities, NSAIDS-heel lifts -

reduced activity (rest) - especially running

Lower Leg Contusion

usually gastroc results in immediate pain and weakness

and loss of function haemorrhage and muscle spasm quickly

lead to a tender firm mass that is easily palpable

ice on a mild stretch care must be taken for myositis ossificans

Exercise Induced Compartment Syndrome 50-60% are anterior – characterised

by exercise induced pain and swelling that is relieved by rest

exercise induced aching leg pain and a sense of fullness, both over the involved compartment

symptoms are almost always relieved with rest, usually with in 20 minutes

exercise will produce swelling and tenderness

to confirm a intra-compartmental pressure must be measured

RX involves stretching and strengthening , PIER, and NSAIDS

If symptoms persist , surgery is recommended

Muscle Spasms and Cramps

fatigue , loss of fluids or electrolyte,

acute treated with ice , pressure and slow static stretch

prevention - adequate water intake (electrolyte solution) - regular stretching program

Lower Leg Strain

may be acute or chronic acute may be result of tearing followed by

the inability to walk without pain point tenderness, swelling and muscle

weakness will be present Rx - PIER, modalities, depends on

severity

Medial Tibial Stress Syndrome AKA : Shin splints Microscopic tears in the muscle

attachment site on posterior medial border

pain along the posterior-medial tibial border

usually in the distal third

Possible factors - excessive pronation , prolonged pronation , recent training changes (speed, form , running surface , distance)

pain usually present at start of activity ,but decreases with activity only to return after activity, later stages pain present at all times - may restrict activity

RX - PIER, NSAIDS, (modalities) activity modification (rest) - low impact - non impact - stretching and strengthening of intrinsic muscle of the foot

Real key is to find cause ….

http://www.youtube.com/watch?v=o5DXFVI6mTA&feature=related