Ankle & Lower Leg HEAT 3685 Athletic Injury Assessment I Chapter 5, p. 136

Clinical Anatomy-- p.136 Bones: –tibia –fibula –talus Ligaments: –ATFL –PTFL –CFL –Deltoid Interosseous membrane Muscles: –peroneals –anterior tibialis –posterior tibialis –triceps surae Bursae

History-- p. 145 Onset of pain-- –acute/gradual/chronic/ re-injury PMH? (tx/rehab) Mechanism: –INV –EV –DF –PF –Combination Location of pain-- –Table 5-2, p.147 –medial/lateral: probable sprain avulsion fx stress fx muscle strain Change in activity? –Position/requirements/ duration/frequency/ surface

Observation/Inspection --p.147 Fig. 5-15, p. 149 WB status (antalgic?) Bilateral comparison –malleoli –sinus tarsi (p.fig. 5-16, p149) –triceps surae –Achilles tendon Inflammation Swelling Deformity

Palpation-- p Lateral ligaments (p.151) –ATFL –PTFL –CFL Medial Ligaments –Deltoid group Dorsalis pedis pulse –fig. 5-31, p. 180 –Between 1st & 2nd mets. Tibio-fibular Ligaments (p.152) –Anterior –Posterior

Functional Testing-- p. 154 AROM: –DF/PF: landmarks DF=20º PF=~50º fig. 4-24, p. 106 –INV/EV: landmarks INV~20º EV~5º RROM: Box 5-3, p. 156 Other Tests: –Toe Raise –Heel Raises –Walking/Hopping/Jumping

On-field Functional Testing Willingness to: – Move joint – Bear weight Contraindicated: –Obvious deformity –Be cautious when full AROM present

Ligamentous Testing-- p.157 Anterior Drawer Posterior Drawer Talar tilt Kleiger test

Anterior Drawer-- p.158 Box 5-4, p methods knee flexed/foot stabilized Assesses laxity in ATFL (+)= anterior movement of talus on mortise

Anterior Drawer Testing Knee flexed/foot stabilized Assesses laxity in ATFL (+)= anterior movement of talus on mortise

Posterior Drawer Similar to Anterior Drawer Tests integrity of PTFL (+) = Posterior movement of talus on mortise

Talar Tilt— p.159 Inversion stress test Box 5-5, p. 159 Stresses CFL Always compare bilaterally (+) = excessive PROM in INV Also used in x-rays (WNL: <9º) (EV talar tilt tests the deltoid ligament.—Box 5-6, p.160)

Kleiger test— p. 161 Box 5-7, p.161 Syndesmosis test External Rotation (ER) with plantar flex. (PF) (+) Results: (2 possible) –Medial pain=deltoid sprain –Anterior pain=ant. tibiofibular sprain

Lower Leg Special Tests Bump Test--p.170 Squeeze test--p.166 Thompson test--p.177 Homan’s sign--p.181

Bump Test-- p.170 Percussion test –Box 5-9 Ankle DF to neutral and tap calcaneus (+) Results= –Pain proximally with distal percussion –Impression: lower leg fx. (tibia, fibula, or talus) –false positives common

Squeeze test-- p.166—Box 5-8 Compression test Compress tibia & fibula together progressing distally (+) Results: –Distal pain with proximal compression –Impression: lower leg fx (tibia or fibula) –Sometimes (+) with stress fx

Thompson test-- p.177, Box 5-10 Athlete is prone Squeeze the triceps surae belly and observe passive plantarflexion (+)=Reduced motion at ankle –Impression: torn Achilles tendon

Homan’s sign-- p.181, Box 5-11 Assesses presence of deep vein thrombosis (DVT) Findings must agree with other symptoms Passive DF with full knee EXT. (+) = intense pain in calf along with other signs of inflammation Triceps surae strain may give false (+)

Neurological Testing-- p.162 Most common neuro. Trauma: –common peroneal nerve injury Dec. in PF, EV, DF strength –secondary to other injuries (fx, contusions, LBP) Signs/symptoms: –Decreased strength –Paresthesia/Anesthesia –Decreased reflexes

Pathologies Inversion ankle sprain Eversion ankle sprain Lower leg fractures Stress fx Ankle impingement Achilles tendonitis Subluxating Peroneal Tendons Anterior compartment syndrome Medial Tibial Stress Syndrome (Shin Splints)

Inversion ankle sprain-- Box 5-6, p. 163 More common than EV sprains Mechanism: INV +/- rotation Injured structures: ATFL/PTFL/ CFL Symptoms: –lateral swelling/pain –hx of tight heel cord (HC) Testing: –(+) Anterior Drawer –(+) Talar tilt –(-) Bump/Squeeze test –(-) Kleiger test –R/O fx’s in kids

Eversion ankle sprain-- Box 5-8, p. 168 Mechanism: EV +/- rotation or compression mechanism Injured structures: Deltoid Ligament complex Symptoms: –Medial swelling/pain –hx of tight heel cord (HC) Testing: –(+)Kleiger test –(+) Talar tilt –(-) Bump/Squeeze test –R/O “knock-off” fx’s (p. 168)

Syndesmosis Sprains (High Ankle sprains) 10 – 18% of cases Involves the Ant/Post. Tib/fib. Ligaments, interosseous membrane, crural interosseous ligament, possibly deltoid lig. MOI – excessive ER of talus with associated DF S/S – pain at anterior/dist aspect of lower leg. Inc with DF, ER and squeeze test

Syndesmosis Sprains (High Ankle sprains) Eval – palpate entire shaft of fib for crepitus FX – usually in distal 1/3 but can be in proximal 1/3 (Maisonneuve FX) TX – splint & crutch Recovery: usually 3 – 4 weeks

Ankle Impingement Syndrome Hx--recurrent ankle sprains Symptoms: –Tenderness between Ant. Tib. Tendon and Med. Malleolus –chronic inflammation –Pain worsens with DF and decreases with PF –Ankle weakness in INV/EV –Anterior pain without laxity

Ankle Impingement Syndrome

Stress Fractures History: –gradual onset –Usually accompanies a change in activity –c/o “burning” after activity in lower leg Palpation: –point tenderness at site of fx –often confused with other injuries Observation: –Swelling is minimal/absent –Altered gait/activities due to pain –Usually no discoloration/deformity Special Tests: –(-) Bump test? –(-) Squeeze test? –(+) Tuning Fork sign Tx: Minimum 2 wks rest

Achilles Tendinitis-- p.173 History: –Poorly vascularized area –Usual mechanism= overuse –Sometimes acute (strain/trauma) –Check shoes, gait, and technique for risk factors Palpation: –Usually point tender at musculotendonous junction –Crepitus possible with AROM Observation: –Localized inflammation which worsens with activity –Over pronation/supination Special Tests: –Thompson test painful –Limited AROM in DF/PF If untreated, may lead to HC rupture

Achilles Tendinitis-- p.173 Treatment:Eliminate cause(s) Temporary heel lift Gentle stretches (2) Arch supports Taping Modalities & Medications

Subluxating Peroneal Tendon— p. 178 Box 5-14 May be primary or secondary injury Subluxation may be seen, felt, or heard Easily palpated with AROM and RROM Fig. 5-30: Biomechanical changes possible May require surgical correction to prevent further injuries

Anterior compartment syndrome p. 179 History: –Acute or chronic onset –Traumatic or overuse onset –C/O numbness/tingling in foot with decreased DF Palpation: –Decreased dorsalis pedis pulse –Dec. RROM in DF Observation: –Possible generalized swelling –Altered gait due to pain and weakness Treatment: –Find/eliminate cause –Avoid ext. compression –Decrease int. compression –fasciotomy may be indicated

Shin Splints Medial tibial stress syndrome Pain with activity in distal 1/3 of tibia Initially pain only after activity Two primary causes: –Overuse (Muscle imbalance) –Biomechanical (Overpronation)

Medial Tibial Stress Syndrome (Shin Splints) Caused by Overuse:Evaluate PROM in DF and PF Evaluate Achilles flexibility Treatment: –Improve circulation in lower leg –Reverse muscle strength imbalance

MTSS cont. Caused by Poor Biomechanics: Evaluate RROM in EV and INV Evaluate Achilles flexibility Assess arch integrity Treatment: –Improve circulation in lower leg –Support arch –Strengthen post. tib.