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

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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

17. 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

18. 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.

19. 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.

20. 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.

21. 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

22. 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.

23. 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

24. 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