Chapter 5 The Ankle and Lower Leg

Clinical Anatomy  VERY IMPORTANT! Pages  Bones and bony landmarks  Articulations and ligamentous support  Muscles  Compartments  Bursae

Clinical Evaluation of the Ankle and Lower Leg  Bi-lateral comparison  Patient Positioning  Interrelated to foot and knee  Evaluation Map, page 146

History  Location of pain (Table 5-2, page 147)  Nature or type of pain  Onset  Injury Mechanism (Table 5-3, page 148)  Changes in activity and conditioning  Prior history of injury

Inspection  General Inspection Weight-bearing status Weight-bearing status Bilateral comparison Bilateral comparison Swelling Swelling  Lateral Structures Peroneal muscle group Peroneal muscle group Distal one third of fibula Distal one third of fibula Lateral Malleolus (Figure 5-15, page 149) Lateral Malleolus (Figure 5-15, page 149)

Inspection  Anterior Structures Appearance of anterior lower leg Appearance of anterior lower leg Contour of the malleoli Contour of the malleoli Talus Talus Sinus tarsi (Figure 5-16, page 149) Sinus tarsi (Figure 5-16, page 149)  Medial Structures Medial malleoli Medial malleoli Medial longitudinal arch Medial longitudinal arch

Inspection  Posterior Structures Gastrocnemius-soleus complex Gastrocnemius-soleus complex Achilles tendon Achilles tendon Bursae Bursae Calcaneus Calcaneus

Palpation  Utilize textbook pages  Refer to list of Clinical Proficiencies  Palpation of Pulses Posterior tibial artery Posterior tibial artery Dorsalis pedis artery Dorsalis pedis artery

Range of Motion Testing  Talocrural Joint Affected by muscular tightness, bony abnormalities, or soft tissue constraints Affected by muscular tightness, bony abnormalities, or soft tissue constraints 10 0 of dorsiflexion during walking 10 0 of dorsiflexion during walking 15 0 of dorsiflexion during running 15 0 of dorsiflexion during running If DF is limited, the foot compensates by increasing pronation If DF is limited, the foot compensates by increasing pronation  Table 5-4, page 154  Goniometry (Box 5-2, page 155)

Active Range of Motion  Plantarflexion and dorsiflexion 70 0 of motion 70 0 of motion Figure 5-17, page 155 Figure 5-17, page 155  Inversion and eversion 25 0 of motion 25 0 of motion Figure 5-18, page 155 Figure 5-18, page 155

Passive Range of Motion  Plantarflexion and dorsiflexion Measured with knee flexed and extended Measured with knee flexed and extended Firm end-feel Firm end-feel Anterior capsule, deltoid lig, ATF lig (PF)Anterior capsule, deltoid lig, ATF lig (PF) Achilles tendon (DF)Achilles tendon (DF)  Inversion and Eversion Stabilize lower leg Stabilize lower leg End-feel End-feel Inversion – firm (lateral ankle ligs, peroneals)Inversion – firm (lateral ankle ligs, peroneals) Eversion – hard (fibula striking calcaneus) or firm (medial jt capsule and musculature)Eversion – hard (fibula striking calcaneus) or firm (medial jt capsule and musculature)

Resistive Range of Motion  Box 5-3, page 156  DF, PF, INV, EV  Toe-raise test (figure 5-19, page 157)

Tests for Ligamentous Stability  Specific testing for joint play and specific ligament tenderness and pain

Test for Anterior Talofibular Ligament Instability  ATF prevents anterior translation of the talus relative to ankle mortis  Combination of PF, INV, and SUP place strain on ATF  Anterior Drawer Test Box 5-4, page 158 Box 5-4, page 158

Test for Calcaneofibular Ligament Instability  Talar Tilt test (inversion stress test) Box 5-5, page 159 Box 5-5, page 159 Also stresses anterior and posterior talofibular ligaments Also stresses anterior and posterior talofibular ligaments

Test for Deltoid Ligament Instability  Talar Tilt test (eversion stress test) Box 5-6, page 160 Box 5-6, page 160  Kleiger’s test (external rotational test) Box 5-7, page 161 Box 5-7, page 161

Test for Ankle Syndesmosis Instability  Overpressure at end of DF Ankle syndesmosis, anterior tibiofibular ligament, interosseous membrane, posterior tibiofibular ligament Ankle syndesmosis, anterior tibiofibular ligament, interosseous membrane, posterior tibiofibular ligament Talus is wedged into talocrural joint, causing separation between tibia and fibula Talus is wedged into talocrural joint, causing separation between tibia and fibula  Kleiger’s Test (external rotational test)

Neurologic Testing  Dysfunction can occur secondary to compartment syndrome or direct trauma  Common peroneal nerve Table 5-5, page 162 Table 5-5, page 162 Figure 5-20, page 162 Figure 5-20, page 162  Lower quarter screening (Chapter 1, page 16)

Pathologies and Related Special Tests  Ankle Sprains Most occur secondary to supination and cause trauma to the lateral ligament complex, due to calcaneal inversion Most occur secondary to supination and cause trauma to the lateral ligament complex, due to calcaneal inversion Less commonly, the medial ankle ligaments and distal tibiofibular syndesmosis are sprained Less commonly, the medial ankle ligaments and distal tibiofibular syndesmosis are sprained Trauma to capsule Trauma to capsule

Lateral Ankle Sprains  Open-packed vs closed-packed position  Sudden forceful inversion; specific structures injured depends on talocrural joint position  ATF ligament – most commonly sprained  Calcaneofibular and posterior talofibular ligaments may also be injured

Lateral Ankle Sprains  Anatomic and physiologic predisposing conditions  Prophylactic devices  Re-incidence rates Loss of ligament’s ability to protect and support joint Loss of ligament’s ability to protect and support joint Decreased proprioceptive ability Decreased proprioceptive ability

Lateral Ankle Sprains  Evaluation Findings Table 5-6, page 163 Table 5-6, page 163  Additional trauma may be overlooked Medial structures, peroneals, achilles tendon, etc. Medial structures, peroneals, achilles tendon, etc. Figure 5-21, page 164 Figure 5-21, page 164  Secondary conditions Thickened connective tissue, bone bruises, blood accumulations, etc. Thickened connective tissue, bone bruises, blood accumulations, etc. Figure 5-22, page 164 Figure 5-22, page 164

Lateral Ankle Sprains  Traction injuries to peroneal nerve  Evaluating ankle sprains in adolescents  Treatment

Syndesmosis Sprains  Only represent between 10% and 18% of all ankle sprains  Associated with significantly increased amounts of time loss  Excessive external rotation or forced dorsiflexion = talus placing pressure on fibula = spreading of syndesmosis  Figure 5-23,page 165

Syndesmosis Sprains  Factors contributing to occurrence  Evaluation Findings Table 5-7, page 167 Table 5-7, page 167  Squeeze Test Box 5-8, page 166 Box 5-8, page 166  Maisonneuve Fracture Figure 5-24, page 167 Figure 5-24, page 167  Treatment

Medial Ankle Sprains  Eversion is limited by: Strength of deltoid ligament Strength of deltoid ligament Mechanical advantage - longer lateral malleolus Mechanical advantage - longer lateral malleolus  External rotation of talus in ankle mortis  Medial longitudinal arch and syndesmosis may also be involved

Medial Ankle Sprains  Evaluation Findings Table 5-8, page 168 Table 5-8, page 168  Injuries to surrounding structures “knock-off” fracture (Figure 5-25, page 168) “knock-off” fracture (Figure 5-25, page 168) Pott’s fracture Pott’s fracture Interarticluar trauma to talus and tibia Interarticluar trauma to talus and tibia