1. Ankle and Lower Leg
Chapter 17

2. Ankle Bony Anatomy Talus (link between lower leg & foot) Tibia Fibula
Medial malleolus
Fibula
Lateral malleolus
Tibial tuberosity
Tibial condyles

3. Bony Anatomy

4. Bones of the Ankle Tibia Fibula
Tibia is the second longest bone in the body
Principle weight bearing bone of the lower leg
Anatomical weakness present in the lower third of the shaft
Fibula
Joins the tibia with an arthrodial articulation at the upper end, just below the knee and as a syndesmotic joint at the lower end
Main function is to provide for attachment of muscles

5. Tibial and Fibular Malleoli
Lateral malleolus extends further distally which creates stability on the lateral aspect of the ankle
Medial malleolus is part of the tibia

6. Bones of the Ankle Talus Calcaneous
Second largest tarsal, and main weight-bearing bone of the articulation, rests on the calcaneous and receives the articulating surfaces of the lateral and medial malleoli
Calcaneous
Forms the heel, attachment site for ligaments and the achilles tendon

7. Ankle Articulations Talar Joint (Talocrural joint)
Tibia & fibula with talus
Dome of talus articulates with mortise formed by tibia & fibula
Motions: dorsiflexion & plantar flexion
Subtalar Joint
Articulation of talus with calcaneus
Motions: inversion & eversion

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

9. Superior and Inferior Tibiofibular Joints
Inferior tibiofibular joint is a fibrous (Syndesmosis) articulation between the lateral malleolus and the distal end of the tibia
Superior tibiofibular joint formed by the tibia’s lateral condyle and the head of the fibula – allows for some gliding movements

10. Stabilizing Ligaments
Tibiofibular Ligaments
Anterior and posterior tibiofibular
hold the tibia and fibula together, form the distal portion of the interosseous membrane (syndesmotic ligaments)
Oblique arrangement aids in diffusing the forces on the lower leg

11. Ankle Ligaments Lateral Ligaments Medial Ligaments
Anterior Talofibular: restrains anterior displacement of talus
Calcaneofibular: restrains inversion of calcaneous
Posterior Talofibular: restrains posterior displacement of talus
Deltoid (anterior tibiotalar, tibionavicular, tibiocalcaneal and posterior tibiotalar):
Prevents abduction and eversion of the ankle and subtalar joint
Prevents eversion, pronation and anterior displacement of the talus

14. Articular Capsule
Encases the ankle joint, thick on the medial aspect and becomes thin at the back

15. Muscle Compartments
Anterior Compartment
Lateral Compartment
Contains the muscles that dorsiflex the ankle and extend the toes (tibialis anterior, extensor hallucis longus, extensor digitorum)
Contains muscles the evert the foot and ankle
Peroneus longus and brevis (evert ankle), peroneus tertius (assists dorsiflexion), superficial branch of the peroneal nerve

16. Muscle Compartments Muscles that plantarflex the foot and ankle
Superficial Posterior Compartment
Deep Posterior Compartment
Muscles that plantarflex the foot and ankle
Gastrocnemius, and soleus
Foot and ankle invertors
Tibialis Posterior, flexor digitorum longus and flexor hallucis longus Posterior tibial artery

17. Compartments of the Lower Leg
Anterior
Tibialias anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis muscles
Peroneal
Peroneus longus
Peroneus brevis
Deep Posterior
Popliteus
Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior
Superficial Posterior
Gastrocnemius
Soleus
Plantaris

18. Compartments of the Lower Leg

19. Compartments of the Lower Leg

20. Muscles of the Lower Leg
Flexor hallucis longus
Flexor digitorum longus
Anterior tibialis

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

22. Muscles of the Lower Leg
Gastrocnemius
Soleus

23. Muscles of the Lower Leg

24. Muscles of the Lower Leg

25. Nerve and Blood Supply
Major nerves of the lower leg are the tibial and common peroneal
Major arteries include the posterior and anterior tibial arteries
Primary veins consist of popliteal, peroneal and anterior and posterior tibial veins.

26. 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

27. Ankle Motions Plantar Flexion Dorsiflexion Inversion Eversion
Pronation
Supination

28. Common Injuries to the Ankle & Lower Leg

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

30. Muscle Strains Most common in calf Result from:
violent contraction
Overstretching
Continued overuse
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

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

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

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

34. 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

35. 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

37. 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

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

39. 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

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

41. 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

42. 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

43. Ankle Sprains 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

44. Ankle Sprains

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

46. Ankle Sprain—S/SXS Grade 1 Grade 2 Grade 3 Some pain Severe sprain
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

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

48. Special Tests & Rehabilitation

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

50. 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

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