1. Ankle and Lower Leg
Chapter 17

2. Warm - up

3. 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

4. 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

5. Bony Anatomy

6. 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

7. Ankle Motions
Plantar Flexion
Dorsiflexion
Inversion
Eversion

8. 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

9. 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

10. Muscles of the Lower Leg
Peroneus tertius
Peroneus longus
Peroneus brevis

11. Muscles of the Lower Leg
Gastrocnemius
Soleus

12. Muscles of the Lower Leg

13. Muscles of the Lower Leg

14. 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

15. Compartments of the Lower Leg

16. Compartments of the Lower Leg

17. Ligaments Lateral aspect Medial aspect Anterior talofibular (ATF)
Anterior tibiofibular
Calcaneofibular (CF)
Posterior talofibular
Medial aspect
Deltoid Ligament

20. Common Injuries to the Ankle & Lower Leg

21. Contusions Occur most often on tibia Can be painful and disabling
Complication
compartment syndrome

22. 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

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

24. Cramps—Treatment Passive stretching Fluid replacement Massage Rest Ice
Water
Sports drink
Massage
Rest
Ice

25. Achilles Tendonitis Inflammation of Achilles tendon
Tearing of tendon tissues caused by excessive stress
Occurs at point where tendon attaches to heel

26. 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

27. 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

29. 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

30. MTSS Treatment Ice Reduce activity level Gentle stretching
Biomechanical assessment
Orthotics
NSAIDs
Strengthening and flexibility program

31. 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

32. Stress Fractures—S/Sxs
“hot spot” of sharp, intense pain upon palpation
Shin-splint
Pain more generalized
Pain worse in am

33. 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

34. 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

35. 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

36. Ankle Sprains

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

38. 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

39. Ankle Sprain—Treatment
R.I.C.E.
Crutches
Boot
Splint, tape, brace
Compressive wrap
Horseshoe

40. Ankle Assessment

41. 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?

42. 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??

43. 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

44. 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

45. Special Tests & Rehabilitation

46. Anterior Drawer Talar Tilt
Tests integrity of anterior talofibular ligament
Tests integrity of calcaneofibular ligament

47. 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

48. 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

49. Ankle Rehab 4-way TheraBand® Heel walks/Toe walks 3-way heel raises
Unilateral Balance
3-way Tramp throw

50. 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