By: Kelsey Showalter & Taylor Douglass The Ankle and Lower Leg By: Kelsey Showalter & Taylor Douglass

Anatomy of the ankle and lower leg Tibia- Serves as the principle weight bearing bone of the leg. Fibula- Main function is to provide for the attachment of muscles. Talus- Forms a link between the lower leg and the foot. Calcaneus- The bone that forms the heel.

Articulations Talocrural Joint- The ankle joint that is formed by the articular facet on the distal portion of the tibia. The ankle movements that occur at the talocrural joint are plantar flexion and dorsiflexion. Subtalar Joint- The subtalar joint consist of the articulation between the talus and the calcaneus. The ankle movements that occur here are inversion, eversion, pronation, and supination.

Stabilizing Ligaments Tibiofibular Ligaments- Joins the tibia and fibula with a strong interosseous membrane. Ankle Ligaments- Support of the ankle consist of three lateral ligaments and the medial, or deltoid, ligament. Lateral Ligaments-Anterior taliofibular, the posterior talofibular, and the calcaneofibular. Medial Ligaments- Is the primary resistance to foot eversion and helps maintain the inner longitudinal arch.

Nerve Supply- The lower leg is supplied by the common peroneal nerve anteriorly. The tibial nerve runs posteriorly and supplies the ankle and the foot. Blood Supply-The ankle and lower leg are supplied by the anterior tibial artery and posterior tibial arteries.

Preventing injury to the ankle and lower leg Achilles Tendon Stretching- It is critical for normal gait that the ankle dorsiflex at least 10 degrees or more. Strength training- It is important to achieve both static and dynamic joint stability. Neuromuscular Control Training- Involves adapting to uneven surfaces by controlling motion at the ankle joint. Footwear- Shoes should not be used in activites for which they were not intended. Preventive Ankle Taping and Orthoses- Properly applied tape can provide some prophylactic protection.

Assessing the Ankle and Lower Leg History- The athletic trainer should ask the patient questions about their ankle history. Observation- The athletic trainer should observe the injury. Palpation- The area of injury should be palpated to determine obvious structural deformities, areas of swelling, and points of tenderness.

Special Tests Lower Leg Lower leg alignment test- determining malalignment of the lower leg can reveal the causes of abnormal stress applied to the foot, ankle and lower leg. Percussion and compression test- A gentle percussive blow sets up a vibratory force that causes pain if fractured. Thompson Test- Used to determine whether there is a rupture of the Achilles tendon.

Special Test Ankle Stability Test Anterior Drawer Test- Used to determine the extent of injury to the anterior talofibular ligament and to the other lateral ligaments. Talar Tilt Test- Used to determine the extent of inversion or eversion injuries. Kleiger’s Test- Used to determine injury to the deltoid ligament. Functional Tests-Athletic trainers routinely have individuals with traumatic ankle sprains perform these test.

Ankle Injuries Inversion Ankle Sprains- Result in injury to the lateral ligaments. Grade I Ligament Sprain- Most common type of sprain. Symptoms and signs include, mild pain and disability. A sign is swelling. Grade II ligament Sprain- Moderate force on the ankle while it is in a position of inversion, plantar flexion, and/or adduction can cause a grade 2 sprain. Symptoms and signs include, patient feeling a pop or snap. They will also have moderate pain.

Ankle Injuries Grade 3 ligament sprain- Is relatively uncommon and caused by a significant inversion force to the ankle, usually combined with plantar flexion and adduction. Symptoms and signs include, severe pain and swelling. Eversion Ankle Sprains- Represents about 5 percent to 10 percent of all ankle sprains. A foot that excessively pronates, is hypermobile, or has a depressed medial longitudinal arch is more predisposed to eversion ankle injuries. Signs and symptoms include pain and unable to bear weight.

Ankle Injuries Chronic Ankle Instability- Develops following about one third of all acute ankle sprains. Ankle Fracture/Dislocation- A foot that is forcibly abducted can produce a transverse fracture of the distal tibia and fibula. In contrast, a foot that is planted in combination with a force internal rotation of the leg can produce a fracture to the distal and posterior tibia.

Ankle Injuries Osteochondritis Dissecans – Occurs in the superior medial articular surface of the talar dome. One or several fragments of articular cartilage and its underlying subchondral bone are either partially or completely detached and moving within the joint space.

Lower Leg Injuries Achilles Tendon Strain – common in sports and occur most often after ankle sprains or sudden excessive dorsiflexion of the ankle Achilles Tendinosis (Achilles Tendinoapathy) – no evidence of inflammation. Injured areas of the achilles tendon have lost their normal appearance and the collagen fibers that make up the achilles tendon are disorganized, scarred and degenerated. Achilles tendinosis is a soreness and stiffness that comes on gradually and continues to worsen.

Lower leg injuries Achilles Tendon Rupture – Common in “stop and go” activities and athletes who are 30 years of age or older. It usually occurs in an individual with history of chronic inflammation and microtears. Anterior Tibialis Tendinitis – Common condition in individuals who run downhill for an extended period of time. Posterior Tibialis Tendinitis – Overuse condition among runners with hypermobility or pronated feet.

Lower Leg Injuries Fibularis Tendinitis – Can be a problem in individuals with pes cavus. In pes cavus, the foot tends to supinate excessively. Shin Contusion – because of the absence of muscular or adipose padding, the periosteum receives the full force of any impact delivered to the shin. Muscle Contusions – common in sports, particularly to the gastrocnemius muscle

Lower Leg Injuries Leg Cramps and Spasms – sudden, violent, involuntary contractions of one or several muscles and may be either clonic or tonic. Clonic – intermittent contraction and relaxation Tonic- constant muscles contraction without an intervening period of relaxation

Lower Leg Injuries Gastrocnemius Strains – the medial head of the gastrocnemius is particularly susceptible to muscle strain. Activities that require quick starts and stops or occasional jumping can cause this strain. Acute Leg Fractures – the fibular fracture has the highest incidence. Fractures of both the tibia and fibula result from either direct or indirect trauma. Medial Tibial Stress Syndrome (MTSS) – has in the past been referred to as shinsplints. Conditions such as stress fractures, muscle strains, and chronic anterior compartment syndrome have all been termed shinsplints.

Lower Leg Injuries Compartment Syndromes – conditions in which increased pressure within one of the four compartments of the lower leg causes compression of muscular and neurovascular structures within that compartment. 3 Categories: Acute Compartment Syndrome, Acute Exertional Compartment Syndrome, and Chronic Compartment Syndrome.

Lower Leg Injuries Stress fracture of the Tibia or Fibula – are a common overuse stress condition, especially among distance runners. Like many other overuse syndromes, these are more likely to occur in individuals with structural deformities of the foot.

Rehabilitation Techniques for the ankle and lower leg General Body Conditioning Injured patient should maintain cardiorespiratory conditioning during the entire rehab process Weight Bearing Minimum or non-weight bearing immediately following injury Early limited stress following initial period of inflammation may promote faster and stronger healing

Rehabilitation Techniques for the ankle and lower leg Joint Mobilizations Movement of an injured joint can be improved my manual joint mobilization techniques Flexibility Early stages of rehab, inversion and eversion should be avoided Stretching plantar flexors and dorsiflexors may improve range of motion Neuromuscular Control Exercises performed on unstable surfaces (BAPS Board, wedge board, or Dynadisk) may be beneficial for range of motion and for regaining neuromuscular control.

Rehabilitation Techniques for the ankle and lower leg Balance and Postural Stability BAPS Board, Bosu Balance Trainer, Rocker Board, Tremor box, Ployback, and Dynadisk are all useful in regaining balance. Strengthening Should concentrate on achieving a balance in muscle groups surrounding the ankle As healing progresses, athlete may begin strengthening exercises in all

Rehabilitation Techniques for the ankle and lower leg Taping and Bracing May prevent further injury Functional Progressions Can be as complex or as simple as needed More severe injuries need a more detailed functional progression