Ch 19- The Ankle and Lower Leg

Mechanism of Ankle and Ligament Injury: -Mechanisms of Plantarflexion or inversion can injure what structure(s)?

-Anterior talofibular (ATF) ligament -Calcaneofibular (CF) ligament

What are the three stabilizing lateral ligaments of the ankle?

-Anterior talofibular ligament (ATF) -Calcaneofibular ligament (CF) -Posteriorfibular ligament (PTF)

What are the parts of the Deltoid ligament?

-Anterior tibiotalar and tibionavicular (anterior) -Tibiocalcaneal (medial) -Posterior tibiotalar (posterior)

Mechanism of Ankle and Ligament Injury: -Mechanisms of Inversion can injure what structure(s)?

-Calcaneofibular (CF) ligament

What two lateral ankle ligament may also be injured in inversion sprains as force of inversion is increased?

-Calcaneofibular (CF/CFL) -Posterior tibiofibular (PTF/PTFL)

Mechanism of Ankle and Ligament Injury: -Mechanisms of Eversion can injure what structure(s)?

-Deltoid ligament -Tibiofibular ligament (severe injury) -Interosseous membrane (ER increases) -Possible fibular fracture (proximal or distal)

What are the three articulations of the ankle complex?

-Distal tibiofibular syndesmosis -Talocrural joint -Subtalar joint

Tendons of muscle passing anterior to talocrural joint produce what movements?

-Dorsiflexion -Toes extension

Tendons of muscles that pass posterior to the medial malleoli produce what movements?

-Plantarflexion -Toes flexion

What are three tests that can be used to predict lower extremity injury?

-Star Excursion Balance test -Lower Quarter Y-Balance test -Functional tests

Mechanism of Ankle and Ligament Injury: -Mechanisms of Dorsiflexion can injure what structure(s)?

-Tibiofibular ligament

The most pronunced change of the Tibia occurs in the lower ____ of the shaft and produces an anatomical weakness that establishes this area as the site of most fractures occuring in the leg.

1/3

An ankle injury-prevention program focusing on balance and neuromuscular control should last how many months?

3 months

Recognition or Specific Injuries -Etiology: This may include tendinitis (inflammatory condition inovlving tendon), tenosynovitis (inflammation of tendon and sheath/paratenon), or tendinosis (no evidence of inflammation). Tendinosis is a soreness and stiffness that comes on gradually and continues to worsen until treated. The tendon is overloaded because of excessive tensile stress placed on it during movements of repetitive nature; the condition worsens with repetitive WB activities. Decreased gastroc-soleus complex flexibility can also increase symptoms. -Signs & Symptoms: Patient c/o generalized pain and stiffness about Achilles tendon region, that when localized, is usually just proximal to calcaneal insertion. Uphill running/hill workouts usually aggravate the condition. Reduced gastroc-soleus muscle flexibility in general that worsen as condition progresses. MMT may show deficit when performing toe raises. Symptoms may progress to morning stiffness and discomfort with walking after periods of prolonged sitting. Tendon may be warm and painful to palpation as well as thickened, which may indicate chronicity of condition. Crepitus may be palpated with active plantarflexion and dorsiflexion, and pain is elicited with passive stretching. Chronic inflammation of tendon may lead to thickening when compared to uninvolved side. -Management: Proper shoeware and foot orthotics should be work to address structural faults that may be causing irritation, and flexibility exercises should be performed for the heel cord complex. Modalities such as ice can help reduce pain and inflammation early on, and ultrasound can facilitate an increased blood flow to tendon in later stages. Eccentric exercises have a high level of evidence as treatment for these conditions. Cross-friction massage may be used to break down adhesions that may have formed during healing response and further improve gliding ability of paratenon. Strengthening gastroc-soleus complex must be progressed carefully so as not to cause recurrence of symptoms.

Achilles Tendinopathy

Recognition or Specific Injuries This injury is possible in activities that require stop-and-go action. Most common in athletes who are 30 years+. Usually occurs in individual with history of chronic inflammation and gradual degeneration caused by microtears. -Etiology: Inital insult normally result of a sudden pushing-off action of forefoot, with knee being forced into complete extension. -Signs & Symptoms: Patient c/o sudden snap that felt like something kicked them in the lower leg. Pain is immediate but rapidly subsides. Point tenderness, swelling, and discoloration are usually associated with trauma. Toe raising is impossible. Any acute injury should be suspected to be rupture. Obvious indentation at tendon site and positive Thompson test are indicative of this injury. This injury usually occurs 0.78-2.34 inches (2-6 cm) proximal to its insertion onto the calcaneus. -Management: Nonoperative treatment consists of POLICE, NSAIDs, and analgesics with NWB cast for 6 weeks, followed by short-leg walking cast for 2 weeks. Exercise rehab lasts for about 6 months and consists of ROM, PRE, and wearing a heel lift in both shoes.

Achilles Tendon Rupture

Recognition or Specific Injuries -Etiology: Occur most often after ankle sprains or sudden excessive dorsiflexion of the ankle. -Signs & Symptoms: Most severe injury is a partial or complete avulsion or rupturing of the tendon. Patient feels acute pain and extreme weakness on plantarflexion. -Management: Initally, pressure is first applied with an elastic wrap together with the application of cold. Hemorrhage may be extensive, requiring POLICE over an extended period of time. Elastic wrap should be applied for continued pressure. Conservative approach to therapy is required. Patient should being stretching and strengthening the heel cord complex ASAP. A lift should be placed in the heel of each shoe to decrease stretching of the tendon and thus relieve some stress that contributes to chronic inflammation.

Achilles Tendon Strain

What may limit dorsiflexion and may predispose an individual to ankle injury?

Achilles tendon

Acute, Acute Exertional, or Chronic compartment syndrome: -This is a rare condition that occurs w/o any precipitatinig trauma and can evolve with minimal to moderate activity.

Acute Exertional compartment syndrome

Recognition of Specific Injuries -Etiology: This type of injury to the fibula has the highest incidence. Occurs principally in middle 1/3; injury to tibia occurs predominantly in lower 1/3. Crepitus and temporary loss of limb function usually present. -Signs & Symptoms: Causes soft-tissue insult and hemorrhaging. Patient c/o severe pain and disability. Leg appears hard and swollen, which may indicate the beginning of a Volkmann's contracture (result of internal tension cuased by hemorrhage and swelling within closed fascial compartments), which inhibits the blood supply and results in muscle necrosis and contractures. -Management: Fracture reduction and cast immobilization are applied up to 6 weeks, depending on extent of injury and any complications.

Acute Leg Fractures

Acute, Acute Exertional, or Chronic compartment syndrome: -Occurs ssecondary to direct trauma to the area, kicked in leg. Considered medical emergency because of possibility of compression of arterial and nerve supply.

Acute compartment syndrome

Recognition or Specific Injuries -Etiology: This occur when a chip of bone is pulled by the resistance of a ligament, and are common in grade 2 & 3 eversion or inversion sprains. -Signs & Symptoms: Swelling and pain are extreme. There may be some or no deformity; however, if a fracture is suspected, splinting is essential. -Management: Immobilization and POLICE are used as soon as possible to control hemorrhage and a walking cast or brace may be applied. Immobilization usually lasts for at least 7-9 weeks. Radiographs should be obtained. If a dislocation is present, after a radiograph, reduction and splinting should be performed ASAP preferably by an orthopedist for clinically deformed ankles.

Ankle Fracture/Dislocation

Preventing what can be accomplished via the following: -Achilles tendon stretching -Strength training -Neuromuscular control and balance training -Foowear -Bracing and taping

Ankle sprains

Anterior, Lateral, Superficial posterior, or Deep posterior compartment? -Contains muscles that dorsiflex the ankle and extend the toes including tibialis anterior, extensor hallucis & digitorum longus muscles; and the anterior tibial nerve and tibial artery.

Anterior Compartment

Recognition of Specific Injuries -Etiology: This is a common condition in individuals who run downhill for extended periods of time. -Signs & Symptoms: Patients c/o pain at front of ankle or medial midfoot. Pain when tendon is stretched or when muscle is contracted. -Management: Patient should be advised to rest (or at least decrease running time and distance) and to avoid hills. In more serious cases, ice packs, coupled with stretching before and after running, should help reduce the symptoms. Daily strengthening program also should be conducted. Oral anti-inflammatory meds may be required.

Anterior Tibialis Tendonitis

This test is used to determine the extent of injury to the ATF ligament primarily. Examiners apply anterior translation to the ankle; a positive test occurs when the foot slides forward, sometimes making a clunking sound as it reaches the end point.

Anterior drawer test

Of the three lateral ankle ligaments, what is the weakest of the three? It is injured in an inverted, plantarflexed, and IR position.

Anterior talofibular (ATF/ATFL) ligament

Anterior talofibular, Calcaneofibular, Posterior talofibular, or Deltoid ligament: -Restrains anterior displaement of the talus

Anterior talofibular ligament (ATF)

An injury caused by inversion causing both an avulsion of the lateral malleolus and a fracture of the medial malleolus is known as what?

Bimalleolar (Pott's) fracture

In this injury, both the medial mallelous of the distal tibia and lateral malleolus of the distal fibula are fractured.

Bimalleolar (Pott's) fracture

Increased inversion force is needed to tear what lateral ligament?

Calcaneofibular (CF/CFL) ligament

Anterior talofibular, Calcaneofibular, Posterior talofibular, or Deltoid ligament: -Restrains inversion of calcaneus

Calcaneofibular ligament (CF)

This is defined by the presence of residual symptoms following recurrent sprains and episodes of giving way at the ankle. It can either be mechanical or functional. Functional has been attributed to proprioceptive and/or neuromuscular deficits that negatively impact postural control and thus stability and balance. Both deficits may include but are not limited to increased laxity, imparied dorsiflexion ROM, deficient leg and hip strength, diminished postural control, and impaired movement strategies. Treatment focuses on improving balance, strength, and dynamic movements with changes in direction that can effectively reduce the risk of recurrent ankle sprains in patients with functional deficits.

Chronic Ankle Instability (CAI)

Clonic vs Tonic spasm: -Identified by intermittent contraction and relaxation. This has neurological basis and is seen less often in sports.

Clonic spasm

Recognition of Specific Injuries -Etiology: These are 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. Anterior and Deep posterior compartments are usually involved. They can either be Acute compartment, Acute exertional compartment, or Chronic compartment. -Signs & Symptoms: Athlete c/o deep, aching pain; tightness and swelling of the involved compartment; and pain with passive stretching of the involved muscles. Reduced circulation and sensory changes can be detected in the foot. If unrecognized, diagnosed, and treated properly, this can lead to poor functional outcome for the patient. -Management: Immediate first aid for acute syndrome should include application of ice and elevation; a compression wrap should not be used to control swelling because there is already a problem with increased pressure in the compartment. Using a compression wrap only increases the pressure. Measurement of intracompartmental pressures by a physician confirms the diagnosis, with emergency fasciotomy to release the pressure within that compartment being the definitive treatment. Anterior or Deep peroneal compartment fasciotomy may not RTP for 2-4 month. Management of chronic syndrome is initially conservative, with activity modification, icing, and stretching the anterior compartment musculature and heel cord complex. If conservative unsuccessful, measurement of intracompartmental pressure by physician is necessary to determine treatment.

Compartment Syndromes

This test is performed to determine if there is a sprain to the distal tibiofibular syndesmosis. Examiners cup the calcaneus and talus while attempting to translate the talus laterally. Test is positive if pain is increased and there is excessive lateral translation.

Cotton's test

Anterior, Lateral, Superficial posterior, or Deep posterior compartment? -Contains the Tibialis posterior, Flexor digitorum and hallicus longus muscles which invert the ankle, and the posterior tibial artery.

Deep posterior compartment

Anterior talofibular, Calcaneofibular, Posterior talofibular, or Deltoid ligament: -Prevents abduction and eversion of ankle and subtalar joint -Prevents eversion, pronation, and anterior displacement of talus

Deltoid ligament

What is the stabilizing ligament found on the medial side of the ankle? It is the primary resistance to foot eversion.

Deltoid ligament

Muscles that cross the ankle joint laterally cause what movement?

Eversion

Recognition or Specific Injuries -Etiology: This injury only represents about 3-4% of all ankle sprains. Less common due to bony and ligamentous anatomy. This type of injury may also involve a avulsion fracture of tibia before the deltoid ligament tears. This injury is more severe and may take longer to heal than its counterpart. -Signs & Symptoms: Depending on grade, patients c/o pain (sometimes severe) that only occurs over the foot and lower leg. Patient is usually unable to WB. Both abduction and adduction cause pain, but pressing directly upward against the bottom of the foot does not produce pain. -Management: X-rays necessary to rule out fracture. POLICE and NWB are recommended. NSAIDs given orally or topically minimize swelling, reduce pain, and improve function following injury. Management is the same as its injury counterpart. Patient engages in PRE program fo the posteromedial ankle muscles, engages in balance activites, and is fitted with an inner heel wedge shoe insert.

Eversion ankle sprain

Muscle of Ankle/Lower Leg -Origin: Lateral condyle of the tibia, proximal 3/4 of anterior surface of fibula, and interosseous membrane -Insertion: Dorsal surface of the phalanges of 2nd-5th toes -Muscle action: Dorsiflexion and eversion of foot; extension of toes -Nerve/Nerve root: Deep peroneal (L5 & S1) -Compartment: Anterior

Extensor digitorum longus

Muscle of Ankle/Lower Leg -Origin: Anterior surface of the middle of the fibula and the interossueous membrane -Insertion: Dorsal surface of the distal phalanx of the great toe -Muscle action: Dorsiflexion and inversion of foot; extension of great toe -Nerve/Nerve root: Deep peroneal (L5 & S1) -Compartment: Anterior

Extensor hallicus longus

What is the long and slender bone of the lower leg that is located on the lateral side of the lower leg? The main function of this bone is to provide attachments for muscles.

Fibula

Muscle of Ankle/Lower Leg -Origin: Posterior surface of the tibia -Insertion: Distal phalanx of the 2nd-5th toes -Muscle action: Plantarflexion and inversion of foot; flexion of toes -Nerve/Nerve root: Tibial (L5 & S1) -Compartment: Deep posterior

Flexor digitorum longus

Muscle of Ankle/Lower Leg -Origin: Lower 2/3 of the fibula -Insertion: Distal phalanx of the great toe -Muscle action: Plantarflexion and inversion of the foot; flexion of great toe -Nerve/Nerve root: Tibial (L5 & S1) -Compartment: Deep posterior

Flexor hallicus longus

What is the most stable position of the ankle?

Foot in dorsiflexion

Inversion-eversion occur in what plane?

Frontal/Coronal plane

Function or Mechanical Instability: -A sensation that the ankle is unstable as a result of recurrent ankle sprains.

Functional Instability

Muscle of Ankle/Lower Leg -Origin: Medial and lateral condyles of the femur -Insertion: Calcaneus via the Achilles tendon -Muscle action: Flexes the leg and plantarflexion of the foot -Nerve/Nerve root: Tibial (L5 & S1) -Compartment: Superficial posterior

Gastrocnemius

Recognition of Specific Injuries -Etiology: The medial head is particularly susceptible to this near its musculotendinous attachment. Activities that require quick starts and stops or occasional jumping can cause this gastroc strain. Patient makes a quick stop with the foot planted flat and suddenly extends the knee, placing stress on the medial head. "Tennis leg" is a rupture or tear at the musculotendinous juncture of the gastroc and Achilles. -Signs & Symptoms: Depending on grade, there is variable amount of pain, swelling, and muscle disability. Patient may c/o sensation of having been "hit in the calf with a stick". Edema, point tenderness, and functional strength loss will be revealed. -Management: Initially POLICE, NSAIDs, and analgesics are given as needed. Grade 1 should be given gentle, gradual stretch after muscle cooling. WB can take place as tolerated. Heel wedge may help reduce stretching of calf muscle during walking. Appropriate elastic wrap may support the muscle while active. Gradual program of ROM exercises and PRE should be instituted.

Gastrocnemius Strain

Recognition or Specific Injuries This is the most common type of sprain. -Etiology: This can occur when an individual is walking or running on an uneven surface or suddenly steps in hole that causes a plantarflexion and inversion force. -Signs & Symptoms: Mild pain and disability occur. Weight bearing is minimally impaired. Signs are point tenderness and swelling over the ligament with no joint laxity. The ATF is the most common ligament injured in this injury. -Management: PRICE to minimize swelling (30-60mmin ever 2 hours for 1-2 days). E-stim can also help minimize swelling. Horseshoe pads and compression may help control edema. Some form of immobilization to assist with walking and protect the ligament/allow for healing may be needed during the first 1-2 days of acute phase. Patient may also be advised to limit WB for 24-48 hours. Rehab should include comprehensive ROM, flexibility, and strengthening surrounding muscles. Early functional rehab is more effective than immobilization. ROM, isometric, isotonic exercises should be included. Neuromuscular control and balance should occur before sport specific activites. Passive joint mobs can increase ankle dorsiflexion and improve flexion. Patients usually RTP in 7-10 days.

Grade 1 Inversion/Lateral Ankle Sprain

Recognition or Specific Injuries -Etiology: Moderate force on the ankle while in a position of inversion, plantarflexion, and/or adduction can cause this. -Signs & Symptoms: Patient usually c/o feeling a pop or snap on the lateral side of ankle. Moderate pain and disability, WB is difficult, and there is tenderness and edema with blood in the joint. Ecchymosis may occur, as well as a positive talar tile test. Anterior drawer also elicits slight to moderate abnormal motion. -Management: POLICE should be used intermittently for at least 72 hours. Anterior/posterior mobilization of the talus should begin as soon as tolerable following injury. Patient should use crutches for 5-10 days, gradually progressing to FWB during that period. Patient will need to wear some type of protective immobilization device for 1-2 weeks. Plantarflexion/dorsiflexion exercises in pain free ROM should begin 48 hours after injury occurs. PNF exercises improve strength, ROM, and proprioception (progressing from isometrics while immobilized, to ROM exercises, PRE, and balance activites to reduce risk of recurrent sprains lasting at least 4 weeks). Patient should be instructed to avoid walking or running on uneven surfaces for 2-3 weeks after WB has begun.

Grade 2 Inversion/Lateral ankle sprain

Recognition or Specific Injuries This injury is relatively uncommon, but when it does happen it is extremely disabling. -Etiology: This is caused by significant inversion force to the ankle, usually combined with plantarflexion and adduction. May involve tears of all three ligaments on the lateral ankle. -Signs & Symptoms: Patient c/o severe pain in region of lateral malleolus. WB not possible becuase of great amount of swelling, w/ or w/o pain. Hemarthrosis, discoloration, positivie talar tilt, and positive anterior drawer test present. If ATF/ATFL is completely disrupted, rotation of talus about its long axis in transverse plane results in rotary ankle instability. -Management: POLICE used intermittenly for at least 3 days. Should be immobilized for at least 10 days with rigid stirrup brace or below-knee cast followed by controlled therapeutic exercise. Not uncommon to see dorsiflexion cast or WB walking boot for 3-6 weeks, followed by taping for 3-6 weeks. Crutches usualy given when cast or walking boot is removed. Isometric exercise is carried out while cast is on, followed by ROM, PRE, and balance exercises. Surgery may be warranted to stabilize athlete's ankle.

Grade 3 Inversion/Lateral ankle sprain

This test is used to indicate the presence of a deep vein thrombophlebitis (DVT). When the patient is supine with the knee extended; the examiner will passively dorsiflex the ankle to stretch the calf. Pain in the calf is a postive test.

Homan's sign

Muscles that cross the ankle joint medially cause what movement?

Inversion

This type of ankle sprain represents 90% of all ankle sprains and is an injury to lateral ligaments. The ATF/ATFL, CF/CFL, or PFT/PTFL are the most commonly injured ligaments.

Inversion/Lateral ankle sprains

This test is primarily used to determine injury to the structures that support the dista ankle syndesmosis. ATC externally rotates the talus while applying pressure to the lateral malleolus. Pain in the anterolateral ankle may indicate injury to the syndesmosis, whereas pain over the deltoid ligament may indicate sprain of the deltoid.

Kleiger's (External Rotation) test

Anterior, Lateral, Superficial posterior, or Deep posterior compartment? -Contains Peroneus/Fibularis longus and brevis which every the ankle, Peroneus/Fibularis tertius muscle which assists in dorsiflexion, and the superficial branch of the peroneal nerve.

Lateral Compartment

Recognition of Specific Injuries -Etiology: Fatigue, excess loss of fluid through sweating, and inadquate reciprocal muscle coordination are some factors. -Signs & Symptoms: Patient has considerable muscle cramping and pain with tonic contraction of the calf muscle. -Management: A firm grasp of the contracted muscle, together with mild, gradual stretching, relieves most acute spasms. An ice pack or gentle ice massage may also be helpful in reducing spasm. If recurrent, ATC should make certain that fatigue or abnormal water or electrolyte loss is not a factor.

Leg cramps and spasms

Functional or Mechanical Instability: -Essentailly laxity that physically allows for movement beyond the physiologic limit of the ankle's ROM.

Mechanical Instability

Recognition of Specific Injuries -Etiology: Referred to as shinsplints, caused by repetitive microtrauma. Weakness of leg muscles, shoes that provide little support or cushioning, and training errors (running on hard surfaces and overtaining) are factors that can contribute. BMI, navicular drop, ankle plantarflexion ROM, ankle dorsiflexion ROM, ankle eversion ROM, ankle inversion ROM, quad angle, hip IR ROM, and hip ER ROM are other biomechanical risk factors. This invovles either a tibial stress fracture or an overuse syndrome that can progress to an irreversible, exertional compartment syndrome. -Signs & Symptoms: Grade 1 is pain occuring after activity; Grade 2 is pain occuring before and after activity, but not affecting performance; Grade 3 is pain occurring before, during, and after activity and affecting performance; and Grade 4 is pain, so severe that activity is impossible. -Management: Referral may be necessary to rule out stress fracture. Activity modification along with meausres to maintain cardiovascular fitness should be set in place immediately. Correction of abnormal pronation during walking and running must also be addressed with shoes and, if needed, custom foot orthoics. Ice massage to area may be helpful in reduction of localized pain and inflammation. Flexibility program for gastroc-soleus complex musculature should be initiated. Arch taping and circumferential tape applied around the area of pain may also be used.

Medial Tibial Stress Syndrome (MTSS)

Recognition of Specific Injuries -Etiology: Common in area of gastroc muscle. -Signs & Symptoms: Brise in area can produce extremely handicapping injury to patient. Pain, weakness, and parital loss of use of limb. Palpation may reveal a hard, rigid, and somewhat inflexible area because of internal hemorrhage and muscle guarding. -Management: Advisable to stretch the muscle in region immediately to prevent spasm and then apply compression wrap and ice to control internal hemorrhaging. If cold therapy or other superficial therapy (massage/whirlpool) don't return the athlete to normal activity within 2-3 days, ultrasound may be warranted. Elastic wrap or tape support will stabilize that part and permit the athlete to participate without aggravating the injury.

Muscle contusions

Recognition or Specific Injuries -Etiology: These can occur in the superior medial articular surface of the talar dome. One or several fragements of articular cartilage and its underlying subchondral bone are either partially detached or completely detached and moving within joint space. MOI may be a single trauma, in which case it may be diagnosed as an osteochondral fracture, or may be due to repeated episodes of ankle sprain. -Signs & Symptoms: Initally, c/o pain and effusion with signs of progressing atrophy. May also be c/o catching, locking, or giving way, particularly if fragment is detached. -Management: Incomplete and nondisplaced injuries can be immobilized with early motion and delayed WB until there is evidence of healing. If fragement is displaced, surgery is recommended to excise the fragement and minimize the risk of nonunion.

Osteochondritis Dissecans

This was developed to determine the need for radiographs after acute ankle injury secondary to the risk of fracture. Radiographs are required if there is any pain and any of the following: -Inabiltiy to WB for 4 steps (2 on each foot) at the time of injury and time of exam -Tenderness over zone A or B -Tenderness over zone C or D

Ottawa Ankle Rules

This special test is used when a fracture is suspected. It is performed by adding gentle percussive blow to the heel or squeezing/compressing the tibia and fibula above/below the suspected fractrue site. A positive test is increased pain over the area of point tenderness.

Percussion (bump) and Compression (Squeeze) tests

Muscle of Ankle/Lower Leg -Origin: Distal 2/3 of the fibula -Insertion: Lateral surface of the 5th MT -Muscle action: Plantflexion and eversion of the foot -Nerve/Nerve root: Superficial peroneal (L4, L5, S1) -Compartment: Lateral

Peroneus/Fibularis Brevis

Muscle of Ankle/Lower Leg -Origin: Proximal 2/3 of the lateral surfae of fibula -Insertion: Ventral surface of the 1st MT and 1st medial cuneiform -Muscle action: Plantflexion and eversion of foot -Nerve/Nerve root: Superficial peroneal (L4, L5, S1) -Compartment: Lateral

Peroneus/Fibularis Longus

Recognition of Specific Injuries -Etiology: Even though this injury is not particularly common, this can be a problem in individuals with pes cavus, in which the foot tends to supinate excessively, which causes WB on the outside of the foot; placing stress on the peroneal tendon. -Signs & Symptoms: Patient c/o pain behind lateral malleolus when rising on the ball of the foot during joggin, running, cutting, or turning activities. Tenderness is noted over the tendon located at the lateral aspect of the calcaneuous distally to beneath the cuboid bone. -Management: Initially, POLICE and NSAIDs as required, taping with elastic tape, and appropriate warm-up and flexibility exercises. LowDye taping or an orthosis to help support the foot and prevent excessive supination my help.

Peroneus/Fibularis Tendinitis

Muscle of Ankle/Lower Leg -Origin: Distal 1/3 of the anterior surface of the fibula and the interosseus membrane -Insertion: Dorsal surface of the 5th MT -Muscle action: Dorsiflexion and eversion of foot -Nerve/Nerve root: Deep peroneal (L5 & S1) -Compartmen: Lateral

Peroneus/Fibularis tertius

Muscle of Ankle/Lower Leg -Origin: Posterior surface of the femur above the lateral condyle -Insertion: Calcaneus via the Achilles tendon -Muscle action: Flexes the leg and Plantarflexes the foot -Nerve/Nerve root: Tibial (L5 & S1) -Compartment: Superficial posterior

Plantaris

Muscle of Ankle/Lower Leg -Origin: Lateral condyle of the femur -Insertion: Proximal portion of the tibia -Muscle action: Flexes and rotates the leg medially -Nerve/Nerve root: Tibial (L5 & S1) -Compartment: Deep posterior

Popliteus

Recognition of Specific Injuries -Etiology: Most common form is degeneration of the tendon beginning with tenosynovitis and gradually progressing to a collapse of the medial arch. It is a repetitive microtrauma occuring during pronation in movements such as jumping, running, and cutting. -Signs & Symptoms: Patients c/o pain and swelling in area just posterior and distal of medial mallelous or in the medial midfoot. Inspection reveals edema and point tenderness directly behind the medial malleolus. In serious cases, pain becomes more intense during resistive inversion and plantarflexion. -Management: Initally, POLICE, NSAIDs, and analgesics are given as needed. NWB short-leg cast with foot in inversion may be used. Management consists of correcting the problem of pronation with LowDye taping or an orthotic device.

Posterior Tibialis Tendinitis

Anterior talofibular, Calcaneofibular, Posterior talofibular, or Deltoid ligament: -Restrains posterior displacement of talus

Posterior talofibular ligament (PTF)

A complete rupture of the talofibular ligament allows the talus to rotate about it's longitudinal axis in the transverse plane is referred to as what?

Rotary ankle instability

Plantarflexion-dorsiflexion occur in what plane?

Sagittal plane

Recognition of Specific Injuries -Etiology: The periosteum, which is a membrane that surrounds all bony surfaces except articulating surfaces (which are covered by hyaline cartilage) recieves the full force of any impact delievered. The periosteum is composed of two fibrous layers that adhere closely to the bone and act as a bed for nerves blood vessles, and bone-formating osteoblasts. -Signs & Symptoms: Patient c/o intense pain when the skin is contused. Hematoma forms rapidly and tends to exhibit a jellylike consistency. Could also be an associated compartment syndrome, particularly in the anterior compartment, as well as a potential tibial fracture. -Management: POLICE, NSAIDs, and analgesics are administered as needed. Maintaining compression in the area of a hematoma is critical. Hematomas may need to be aspirated in some cases. Patient should perform ROM and PRE exercises within pain limitations. Patient should be fitted with a doughnut padding under an orthoplast shell for protection. Inappropriately managed injury to the periosteum may develop into osteomyelitis, a serious condition that results in the destruction and deterioration of bone.

Shin contusion

Muscle of Ankle/Lower Leg -Origin: Posterior surface of the proximal 1/3 of the fibula and middle 1/3 of the tibia -Insertion: Calcaneus via the Achilles tendon -Muscle action: Plantarflexes the foot -Nerve/Nerve root: Tibial (L5 & S1) -Compartment: Superficial posterior

Soleus

This articulation consists of the articulation between the talus and the calcaneus. Subtalar inversion-eversion and pronation-supination occur at this joint.

Subtalar joint

Anterior, Lateral, Superficial posterior, or Deep posterior compartment? -Contains Gastrocnemius and Soleus muscle that plantarflex the ankle.

Superficial posterior compartment

Recognition or Specific Injuries -Etiology: This injury is more common in high-speed collision sports, that involve high-torque cutting and jumping forces. Ligaments are torn with increased ER or forced dorsiflexion and are often injured in conjunction with a severe sprain of the medial and lateral ligament complexes. Inital rupture of ligaments occurs distally above ankle mortise. Grade 1 involves mild sprain and rupture of anterior inferior tibfib ligament w/o instability. Grade 2 involves rupture of anterior inferior tibfib ligament and interosseous ligament w/ significant instability. Grade 3 is grossly unstable and results from disruption of all syndesmotic ligaments. -Signs & Symptoms: Patients c/o severe and prolonged pain and loss of function in the ankle region about the talocrural joint, and heterotopic ossification. When passively ER or dorsiflexion of ankle, there is pain in lower leg, indicating syndesmotic sprain or possibly a lateral malleolar fracture. Pain normally occurs along anterolateral leg. -Management: This injury is extremely hard to treat and often take months to heal. Treatment includes an extended period of immobilization (NWB, walking boot, casting, or bracing) for a time period sufficient to allow healing and functional return. Functional activities may be delayed. Common to see surgical fixation in which there is widening of the ankle mortise greater than 2 mm or joint incongruity on standard or stress radiographs.

Syndesmotic/High Ankle sprain

This test is used to determine the extent of an inversion or eversion ankle sprain. If there is an increase in ROM during passive inversion, this indicates an injury to the CF ligament; while passive eversion with increase ROM indicates injury to the deltoid ligament.

Talar tilt test

This articulation is a hinge joint that is formed by the articular facet on the distal tibia (superior surface of trochlea of talus), the medial malleolus (medial surface of trochlea of talus), and lateral malleolus (lateral surface of trochlea of talus). It is referred to as the ankle mortise. Dorsiflexion-plantarflexion occur at this joint.

Talocrural joint

This talocrural joint bone is the second largest tarsal and the main WB bone of the articulation, it rests on the calcaneus and receives the articulating surfaces of the lateral and medial malleoli.

Talus

This test is used to determine if there is a rupture of the Achilles tendon. The examiner will squeeze the calf and look for the foot to plantarflex. A positive test is indicative if the foot does not plantarflex.

Thompson test

What bone of the lower leg is the prinicpal WB bone of the leg, and with the exception of the Femur, is the longest bone in the body? This bone is the medial bone of the lower leg.

Tibia

What are the two bones that make up the lower leg?

Tibia and Fibula

What are the three bones that make up the talocrural joint (ankle)?

Tibia, Fibula, and Talus

Muscle of Ankle/Lower Leg -Origin: Lateral condyle and proximal 2/3 of shaft of tibia and interosseous membrane. -Insertion: Medial surface of the 1st cuneiform and 1st MT -Muscle action: Dorsiflexion and inversion -Nerve/Nerve root: Deep peroneal (L5 & S1) -Compartment: Anterior

Tibialis anterior

Muscle of Ankle/Lower Leg -Origin: Posterior surface of the interosseus membrane, tibia, and fibula -Insertion: Navicular, cuneiforms, cuboid; 2nd-5th MT -Muscle action: Plantarflexion and inverison of foot -Nerve/Nerve root: Tibial (L5 & S1) -Compartment: Deep posterior

Tibialis posterior

This articulation is a diarthrotic joint, allowing for some gliding movements. It is formed superiorly (stronger of two) by the tibia's lateral condyle and the head of the fibula; and inferiorly by the lateral malleolus and distal end of the tibia.

Tibiofibular joint

This stabilizing ligament is a strong interosseous membrane that holds the tibia and fibula together (form distal portion of membrane and referred to as syndesmotic ligaments).

Tibiofibular ligament

Clonic vs Tonic spasm: -Identified by constant muscle contraction without an intervening period of relaxation.

Tonic spasm

Internal-External rotation occur in what plane?

Transverse/Horizontal plane

Supination and pronation occuring at the subtalar joint are considered to be what type of movement?

Triplanar (occuring in all three plane simultaneously)

Ottawa Akle Rules zone A, B, C, or D: -This zone is the 6 cm posterior edge or tip of the lateral malleolus

Zone A

Ottawa Ankle Rules: -Ankle radiographs should be ordered if pain is elicited in what two zones?

Zone A or B

Ottawa Akle Rules zone A, B, C, or D: -This zone is 6 cm posterior edge or tip of medial mallelous

Zone B

Ottawa Akle Rules zone A, B, C, or D: -This zone is the base of the 5th MT

Zone C

Ottawa Ankle Rules: -Foot radiographs should be ordered if pain is elicited in what two zones?

Zone C or D

Ottawa Akle Rules zone A, B, C, or D: -This zone is the Navicular

Zone D