Chapter 15: The Ankle and Lower Leg

Eversion force resulting in damage to deltoid ligament is likely to

cause fracture to the fibula

Ankle fractures/dislocations

caused by a number of mechanisms, often similar to those seen in ankle sprains.

shin contusion

caused by direct blow to lower leg (impacting periosteum anteriorly)

Stress fracture of tibia or fibula

common overuse condition, particularly in those with structural and biomechanical insufficiencies. Results of repetitive loading during training and conditioning

neuromuscular control training

includes training in controlled activities on uneven surfaces or a balance board; this training increases coordination of muscles collectively.

Achilles tendinitis/tendinosis

inflammatory condition involving tendon, tendon is overloaded due to extensive stress, presents with gradual onset and worsens with continued used. Decreased flexibility exacerbates condition

Syndesmotic sprain

injury to the distal tibiofemoral joint (anterior/posterior tibiofibular ligament), torn with increased external rotation or dorsiflexion

signs of shin contusion

intense pain, rapidly forming hematoma with jelly like consistency, and increased warmth

The anterior talofibular ligament is injured with these moments

inversion, plantar flexion and internal rotation

Inversion sprains

most common and results in injury to lateral ligaments. Occur when the foot is forcefully inverted or occurs when the foot comes into contact with uneven surfaces

Grade 2 ankle sprain

( ligaments partially torn) feel or hear pop or snap; moderate pain with difficulty bearing weight; tenderness and edema. You get a positive talar tilt and anterior drawer tests, and possible tearing of the anterior talofibular and calcaneofibular ligaments.

Grade 3 ankle sprain

(ligaments completely torn) severe pain, swelling, bleeding in joint spaces, discoloration, unable to bear weight, positive tala tilt and anterior drawer, instability due to complete ligamentous rupture.

Grade 1 ankle sprain

(ligaments stretched or slightly torn) mild pain and disability; weight bearing is minimally impaired; point tenderness over ligaments and no laxity

immobilization for ankle fractures/dislocations should last

6-8 weeks

Medial tibial stress syndrome (shin splints)

Caused by repetitive microtrauma. patient experiences pain in anterior portion of shin, may be caused by stress fractures, muscles strains, chronic anterior compartment syndrome, periosteum irritation. Can also be caused by biomechanic errors

Tendinosis

Chronic tendinitis, caused by a singular case or collection of mechanisms, including footwear, mechanics, trauma, overuse, limited flexibility

muscles that compose the posterior-deep compartment of the leg and function

FDL, FHL, popliteus, tibialis posterior, tibial a. n. and v. : inverters

These tests should be the final tests before return to play or return to activity

Functional tests

muscles that compose the posterior-superficial compartment of the leg and function

Gastrocnemius, Soleus, plantaris: Plantar flexion

Signs of tendinosis

Pain and inflammation, crepitus, pain with active(AROM) and Passive (PROM) range of motion

Ottawa ankle rules for medial ankle

Pain in posterior edge or tip of medial malleolus, and navicular

Ottawa ankles rules for lateral ankle

Pain in the posterior edge or tip of lateral malleolus, and base of 5th metatarsal

care for shin contusion

RICE and NSAIDS and analgesics as needed, maintain compression for hematoma, sometimes fit with doughnut pad

This ligament is the weakest and most likely to get torn out of the 3 lateral ankle ligaments

The anterior talofibular ligament (ATFL)

Reason why care time for syndesmotic sprains is so long

This injury occurs when the talus is driven up and splits the fibula and tibia. This movement occurs during walking.

these can be used for preventing injuries in the lower leg and ankle

achilles tendon stretching and strength training.

Following a stress fracture of the tibia or fibula, athletes can gradually return to activity

after 2 weeks of being pain free

Tests should always be done

bilaterally to establish a baseline for comparison

ankle stability tests

include anterior drawer test, talar tilt test, and thompson test

Bony protection and ligament strength

decreases the likelihood of injury

signs of shin splints (medial tibial stress syndrome)

diffuse pain about disto-medial aspect of lower leg, as condition worsens ambulation may be painful, morning pain and stiffness may also increase.

Care for stress fractures of tibia or fibula

eliminate offending activity, discontinue stress inducing activity for 14 days, use crutch for walking, weight bearing may return when pain subsides, after pain free for 2 weeks athlete can gradually return to activity, biomechanics must be addressed.

signs of compartment syndrome

excessive swelling compresses muscles, blood supply and nerves, deep aching pain and tightness , weakness with foot and toe extension and occasionally numbness in dorsal region of foot

Ottawa ankle rules

general rules for when to send for ankle injury radiography

Signs of achilles tendinitis/tendinosis

generalized pain and stiffness, localized proximal to calcaneal insertion, warmth and painful with palpation, as well as thickened. May progress to morning stiffness

Surgical release of pressure in compartment syndrome is

generally used for recurrent conditions of compartment syndrome

Positive thompson test

identified if the ankle does not plantar flex when the muscle belly of the gastroc-soleus complex is squeezed when compared bilaterally.

Care for compartment syndrome

if severe acute or chronic case, may present as medical emergency that requires surgery to reduce pressure or release fascia. RICE, NSAIDs and analgesics as needed, avoid compression wrap because they increase pressure.

Care for tibial and fibular fractures

immediate treatment should include splinting to immobilize and ice, followed by medical referral. Restrict weight bearing for weeks/months depending on severity

Care for ankle sprains

must manage pain and swelling, apply horseshoe-shaped foam pad for focal compression, keep foot elevated as much as possible, avoid weight bearing for at lease 24 hours (Depending on severity), return to activity should be gradual and dictated by healing process.

A positive anterior drawer test

occurs when foot slides forward and/or makes a clunking sound as it reaches the end point. May also occur without instability but with pain.

Achilles tendon rupture

occurs with sudden stop and go; forceful plantar flexion with knee moving into full extension, commonly seen in athletes 30 years or older, generally patient has history of chronic inflammation.

Signs of stress fractures of tibia or fibula

pain with activity, pain more intense after exercise, point tenderness

Signs of tibial and fibular fractures

pain, swelling, soft tissue insult, leg will appear hard and swollen deformity, may be open or closed.

Talar tilt test

performed to determine extent of inversion or eversion injuries.

muscles that compose the lateral compartment of the leg and function

peroneus longus and brevis, peroneal n. : extend and evert

Care for shin splints

physician referral for X-rays and bone scan, activity modification, correction of abnormal biomechanics, ice massage to reduce pain and inflammation, flexibility program for gastroc-soleus complec, arch taping and orthotics.

Compartment syndrome

rare acute traumatic syndrome due to direct blow or excessive exercise, may be classified as acute, acute exertional or chronic

Care for achilles tendinitis/tendinosis

resistant to quick resolution due to slow healing nature of tendon, must reduce stress on tendon, address structural faults, aggressive stretching and use of heel lift may be beneficial. Use of anti-inflammatory medication is suggested.

Care for tendinosis

rest, NSAIDS, modalities, and orthotics for foot mechanics.

Tibial and fibular fractures

result of direct blow or indirect trauma

Eversion ankle sprains

results in injury to Deltoid ligaments (medial ligaments of the ankle)

Ankle injuries: sprains

single most common injury in athletics caused by sudden inversions or eversion moments

care for ankle fractures/dislocations

splint and refer to physician for X-ray and examination, RICE to control hemorrhaging and swelling, once swelling is reduced, a walking cast or brace may be applied, pulse should be checked to ensure blood supply, rehabilitate similar ankle sprains once range of motion is normal

if not treated, shin splints may progress to

stress fracture

Signs of achilles tendon rupture

sudden snap (kick in the leg) with immediate pain which rapidly subsides, point tenderness, swelling, discoloration; decreased range of motion. Obvious indentation and positive thompson test

Signs of ankle fractures/dislocations

swelling and pain may be extreme with possible deformity

Dynamic restraints in joints

tendons

If the calcaneus is everted in the talar tilt test

the deltoid ligament is tested

This side of the ankle is more stable

the medial side of the ankle

excessive motion during inversion of the calcaneus in the talar tilt test

this indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments

fibular fractures typically seen with

tibial fractures or as the result of direct trauma

muscles that compose the anterior compartment of the leg and function

tibialis anterior, EDL, EHL, peroneus: dorsi flexion

Anterior drawer test

used to assess anterior talofibular ligament primarily and other lateral ligaments secondary.

Thompson test

used to assess the integrity of the achilles tendon. You squeeze the Gastroc-soleus complex to cause plantar flexion

compression test

used when fracture is suspected; involves compression of tibia and fibula either above or below site of concern

Percussion test/bump test

used when fracture is suspected; it is a blow to the tibia, fibula, or heel to create vibratory force that resonates within fracture causing pain

Care for achilles tendon rupture

usual management involves surgical repair for serious injuries. Non-operative treatment consists of RICE, NSAIDs, analgesics, and a non-weight bearing cast for 6 weeks to allow proper tendon healing. Must work to regain normal range of motion followed by gradual and progressive strengthening program