Ankle and Lower Leg Chapter 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) Tibia Fibula Medial malleolus Fibula Lateral malleolus Mortise The 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 Subtalar Joint Talar Joint (Talocrural joint) Articulation of talus with calcaneus Motions: inversion & eversion Talar Joint (Talocrural joint) Tibia & fibula with talus Dome of talus articulates with mortise formed by tibia & fibula Motions: dorsiflexion & plantar flexion

Muscles of the Lower Leg Flexor Hallucis Longus Flexor Digitorum Longus Anterior Tibialis tibionavicular ligament, calcaneotibial ligament, anterior talotibial ligament, and the posterior talotibial ligament

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 Deep Posterior Popliteus Flexor digitorum longus Flexor hallucis longus Tibialis posterior Superficial Posterior Gastrocnemius Soleus Plantaris Anterior Tibialias anterior Extensor digitorum longus Peroneus tertius Extensor hallucis muscles Peroneal Peroneus longus Peroneus brevis

Compartments of the Lower Leg

Compartments of the Lower Leg

Ligaments Lateral aspect Medial aspect Anterior talofibular (ATF) Anterior tibiofibular Calcaneofibular (CF) Posterior talofibular Medial aspect Deltoid 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: 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 Muscle Strains Most common in calf Result from: violent contraction Overstretching Continued overuse

Cramps A sudden, involuntary contraction of a muscle Contributing factors include: Fatigue Fractures Dehydration Lack of nutrients in diet Poor flexibility Improperly fitted equipment

Cramps—Treatment Passive stretching Fluid replacement Massage Rest Ice Water Sports 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 knee Anterior shin Medial 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 footwear running 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: Contusion Fracture Crush injury Localized infection Excessive exercise Overstretching

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 General Symptoms: 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 swelling Local temperature increase Pain Point tenderness Skin discoloration

Ankle Sprains

Inversion Eversion Syndesmotic Anterior Talofibular Calcaneofibular Posterior Talofibular Eversion Deltoid Ligament Syndesmotic High ankle sprain

Ankle Sprain—S/SXS Grade 1 Grade 3 Grade 2 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 Talar Tilt Tests integrity of anterior talofibular ligament Tests integrity of calcaneofibular ligament

Kleiger’s Test Thompson Test Tests integrity of the deltoid ligament and syndesmosis If the gastrocnemius is squeezed and the foot should plantarflex. If it does not then there is a possible rupture of the Achilles tendon

Bump calcaneus Tap mallelous Squeezing the tibia and fibula together Squeeze Test Bump Test/Tap Test Squeezing the tibia and fibula together Can indicate fracture or high ankle sprain Bump calcaneus Indicate fracture to tibia/fibula Indicate high ankle sprain Tap mallelous Indicate 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 injury General definition – include anatomy MOI S/SX TX General Rehabilitation Exercises