Ankle and Lower Leg Exam Review

How to measure swelling

- Volumetric measure - girth measurements - pitting edema assessment

Chronic exertional compartment syndrome

- exercise exacerbates condition - muscle volume increases roughly 20% - tissue pressure remains high during contractions, impeding blood flow and causing muscle ischemia - pressure is not usually high enough to cause vascular collapse and rarely results in a medical emergency

Os trigonum sydrome

- inflammation of the posterior joint - inflammation of the ligaments surrounding os trigonum - fracture of the os trigonum - pathology involving the Stieda's process

5 Ps of compartment syndrome

- pain - pallor - pulselessness - paresthesia - paralysis

DVT risk factors

- recent surgery - fracture of the pelvis, femur, or tibia - spinal cord injury - use of contraceptives - recent pregnancy - cardiovascular disorders - periods of prolonged sitting (airplane travel)

Shin splints causes

- repetitive use - training errors - training on a hard surface - increasing load too quickly - incorrect shoe wear - muscle fatigue (dorsiflexor) - biomechanical factors (excessive pronation)

Acute exertional compartment syndrome

- represents a medical emergency - typically results from an acute trauma such as a fracture, kick to the leg, or other direct trauma - as a result of the acute trauma, vasodilation and bleeding within the compartment increases pressure and causes venous compromise and eventual collapse

Os trigonum fracture

- sudden onset of pain after forced plantarflexion or dorsiflexion - swelling lateral or medial to the Achilles tendon may be noted - patients report tenderness anterior to the Achilles tendon and posterior to the talus

Contributory factors for stress factors

- training errors - poor footwear - menstrual irregularities - diet - bone density - increased hip ER - tibial width - calf girth

Signs/symptoms of DVT

- unexplained warmth - tightness in the calf - pain during palpation

Rehab pyramid

1) correct deviations and decrease pain 2) flexibility and ROM 3) strength and endurance 4) balance, coordination, and agility 5) function 6) performance (sport-specific drills)

Ottawa ankle rules

1) patient is unable to weight bear for 4 steps 2) pain on medial malleolus and navicular 3) pain on lateral malleolus and base of the 5th MT

Anterior compartment

Contains the tibialis anterior, deep peroneal nerve/ anterior tibial vessels, extensor hallucis longus, and extensor digitorum longus

Anterior drawer test position

Foot position is slightly plantarflexed

Mechanical ankle instability

Gross laxity in one or more of the ankle's joints or insufficiency of the supporting structures - ROM beyond normal physiological limits - patient may also present with FAI - purely objective measure to joint displacement

Medial ankle sprain special tests

Talar tilt (eversion) and Kleiger (external rotation) test

Cotton test (lateral talar glide)

The Cotton test assesses the amount of lateral translation of the talus within the ankle mortise. Implications: Distal tibiofibular syndesmosis sprain.

Medial malleolar fracture

Usually an ankle Eversion injury, avulsion fracture - could be caused by compression of the medial malleolus or avulsion of the lateral malleolus

Deep vein thrombosis

a blood clot that has the risk of turning into a PE

Functional Ankle Instability

a self-reported finding that involves repeated ankle sprains in individuals who have normal findings during ligamentous stress tests and is associated with proprioceptive and neuromuscular deficits, decreased strength, and/or postural control - sensation of giving way - defined more subjectively

Lateral ankle sprain special tests

anterior drawer test ad medial talar tilt test (inversion)

Ligament involved in lateral ankle sprains

anterior talofibular ligament

Pitting edema assessment

based on the depth and duration of the indentation

Stress fracture imaging tools

bone scan (lots of radiation) or an MRI (better due to no radiation)

Ligament involved in medial ankle sprains

deltoid ligament

Shin splints pain

diffuse pain at the posteromedial tibial border - span of >5cm

Girth measurements

evaluated with a tape measure

Medial ankle sprain MOI

eversion, plantarflexed, pronated, abducted

Biggest cause for stress fractures

excessive pronation

High ankle sprain MOI

external rotation while foot is in dorsiflexion

Maisonneuve fracture

fibular fracture involving the interosseous membrane

Os Trigonum

formed when Stieda's process separates from the talus (looks like a snail shell)

Talus fracture

fracture typically seen in association with high ankle sprains due to the excessive dorsiflexion that crushes the talus

Athletes who are susceptible to Os Trigonum

gymnasts, dancers, and divers (due to prolonged periods or plantarflexion)

Medial tibial stress syndrome

inflammation of the periosteum along the posteromedial tibial border at or near the insertion of the long toe or ankle flexors

Lateral ankle sprain MOI

inversion and plantarflexion (supination as well), adduction

High ankle sprain special tests

modified Kleiger and the squeeze test

Homan's sign

pain in *calf upon dorsiflexion* of foot and may indicated thrombophlebitis

Stress fracture pain

pinpoint tenderness along the shaft of the bone

Compartment syndrome

results from increased pressure within the compartment (direct blow or exertional exercise)

Superficial posterior compartment

soleus, gastrocnemius, plantaris

Volumetric measurement

stick foot in water to see how high up the water rises; compare both segments

Lateral compartment

superficial peroneal nerve, peroneus longus, peroneus brevis, and fibula

Anterior drawer ligament test

talofibular and calcaneofibular ligament

Deep posterior compartment

tibialis posterior, flexor digitorum longus, peroneal vessels, flexor hallucis longus, tibial nerve and posterior tibial vessels

high ankle sprain structures

tibiofibular ligament and interosseous membrane (syndesmosis)

Location of tibial stress fractures

typically in the distal 1/3 of the tibia