Chapter 15: The Ankle and Lower Leg

How do you care for compartment syndrome if acute or chronic? 1. 2. 3. Hwo long of a recovery after surgery? What is required is conservative management fails?

1. May present as a medical emergency that requires surgery to reduce pressure or release fascia. 2. RICE, NSAIDs, and analgesics as needed; avoid compression wrap = increased pressure 3. 2-4 month recovery surgery!

How can you prevent injury in the lower leg and ankle? 1. 2. 3.

1. achilles tendon stretching 2. routinely stretch before and after practice 3. performed with knee flexed and extended 15-30 degrees 4. strength training - specifically static and dynamic joint training

While weight bearing the following should be performed: 1. 2. 3. 4. 5 6.

1. walk on your toes (plantarflex) 2. walk on your heels (dorsiflexion) 3. hops on injured ankle 4. start and stop running 5. changing direction rapidly 6. Run figure eights

What causes a shin contusion? What are the signs? Care?

A direct blow to the lower leg! Intense pain, rapidly forming hematoma with a jelly like consistency. NSAIDs, RICE, compression for the hematoma, and donut pad

What is the single most common injury in athletics caused by sudden inversion or eversion moments? What is the most common and results in injury to lateral ligaments?

Ankle sprains! Inversion sprains, anterior talofibular ligament is injuring with inversion, plantarflexion and internal rotation.

What decreases the likely hood of injury? Eversion force leads to damage of what?

Bony protection and strong ligaments. Leads to damage of deltoid ligament and possibly the fibula.

Neuromuscular control training can be enhanced by

Can be enhanced by training in controlled activities on uneven surfaces or a balance board.

How do you care for an Achilles rupture? What msut you do with this injury?

Care for achille's rupture by surgical repair, non-operative treatment is NSAIDs, RICE, analgesics, non-weight bearing cast for 6 weeks. Must work to regain normal range of motion following by gradual strengthening program.

What is the cause of injury in the achilles tendinitis/tendinosis? Achilles tendinitis/tendinosis presents with a gradual onsent and gets worse over time. True/false Explain the flexibility role in this condition. Signs of the injury?

Cause is inflammation of tendon, tendon is overloaded due to extensive stress True! The flexibility role is in this condition is that the more decreased someone's flexibility is, the more it'll make the condition worse. Signs of this injury is: generalized pain and stiffness, localized proximal to calcaneal insertion, warmth and painful with palpation

Stress Fracture of tibia or Fibula cause: signs: care:

Cause: Repetitive loading during training and conditioning. Signs: pain with activity, pain more intense after exercise than before, point tenderness; difficult to discern bone and soft tissue pain, bone scan results care: eliminate offending activity Discontinue stress inducing activity 14 days Use crutch for walking After pain free for 2 weeks athletes can return to play

Tibial and Fibular fractures Cause: Signs: Care:

Cause: result of direct blow or indirect trauma Signs of injury: pain, swelling soft tissue insult, leg will appear hard and swollen Care: immediate treatment should be include splinting to immobolize and ice, followed by medical referal - Restricted weight bearing for weeks/months depending on severity

If the calcaneus is everted, what is tested?

Deltoid ligament

What are the signs of a fracture? How do you care for an ankle fracture?

Extreme swelling, deformity - You care for an ankle fracture by splinting and referring to a physician for X-ray and examination. - RICE to control hemorrhaging and swelling - Walking cast or brace may be applied, with immobilization lasting 6-8 weeks - rehabilitation is similar to that of ankle sprains once range of motion is normal

What bone is the most commonly fractured?

Fibula is most commonly fractured.

What is a syndesmotic sprain? When can you return to play?

Injury to the distal anterior tibiofibular joint. (anterior/posterior tibifibular ligament) which then gets torn with increased dorsiflexion and external rotation. May require an extensive amount of time.

What rules should you go by when you want to refer for an xray?

Ottawa - Ankle Rules

What kind of tests are you gonna use if you detect that a person has a fracture?

Percussion/bump and compression tests!

Percussion/bump test what? Compression test what?

Percussion/bump test is when you have a blow to the tibia, fibula, or heel to create vibratory force that resonates w a fracture. Compression test involves compression of tibia and fibula above or below the site addressed.

What does the talar tilt test assess?

Performed to assess to the inversion or eversion of a fracture. Calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly anterior and posterior talofibular.

Cause of achilles tendon rupture? Currently seen in what kind of athletes? Generally patient has what? Signs of achilles tendon rupture?

Sudden stop and go; forceful plantar flexion with knee moving into full extension. Athletes 30 years old or greater. Generally patient has history of chronic inflammation. Signs: sudden snap (kick in the leg) with immediate pain, point tenderness, swelling, discoloration; decreased ROM. --> positive thompson test

What is compartment syndrome?

Swelling of muscles causing compression against nerves and blood vessels.

What does the anterior drawer test assess? What does a positive test occurs?

That test assess' anterior talofibular ligament primarily and other lateral ligament secondarily. When the foot slides forward and/or makes a clunking sound as it reaches the end point.

What is the problem with healing of the tendon in achilles tendinitis/tendinosis? How do you care for achille's tendinitis/tendinosis?

The problem is that the tendon is very slow with the healing process! You care for this condition by reduces the stress placed on the tendon, address structural faults, aggressive stretching and heal lifts, use of anti-inflamatroy medicine is suggested

What does the Thompson test assess? What does a positive test show?

This is used to assess achilles tendon. Positive test will show that the ankle does not properly plantarflex when you squeeze the muscle belly when compared bilaterally.

Tight heel cord may limit dorsiflexion. True/False

True

Deltoid ligament can be impinged and contused with inversion sprains. True/false

True.

How to care for an ankle sprain?

- Must manage the pain and swelling - Apply horseshoe-shaped foam pad for focal compression - Apply ice for 20 minutes and repeat every hour for 24 hours - Continue to apply ice over the next 3 days - Keep foot elevated as much as possible - Avoid weight bearing for at least 24 hours - Begin weight bearing as soon as tolerated - Return to participation should be gradual and dictated by healing process.

What is the weakest ligament on the ankle complex?

Anterior talofibular ligament

What are the causes of injury in Medial Tibial Stress Syndrome (Shin Splits)? Signs? Care?

Causes; repetitive micro-trauma, improper footwear, tight heel cord, training errors, varus foot, hypermobile or pronated feet Signs: pain in disto-medial aspect of lower leg, morning pain and stiffness, can progress to a stress fracture if not treated Care: physician referral for X-rays and bone scan, acitivity modification, correction of abnormal biomechanics, ice massage, flexilibity program for gastroc-soleus complex, arch taping and orthotics

Tendinosis Cause: Signs of injury: Care:

Footwear, mechanics, trauma, overuse, limited flexibility Signs of injury: pain and inflammation, crepitus, pain with AROM and PROM Care: rest, NSAIDS, modalities, orthotics

What is the first thing to do when assessing the lower leg and ankle? What do you begin with?

Go through the history, mechanism of history, when does it hurt?, sounds or feelings? Begin with palpation of bony landmarks and progress to soft tissue, also attemtp to locate areas of deformity, swelling and localized tenderness!

Explain all of the ankle sprains Grade 1 Grade 2 Grade 3

Grade 1 = mild pain and disability, point tenderness of ligament and no laxity Grade 2 = feel or hear pop or snap, moderate pain with difficulty bearing weight, tenderness and edema, positive talar tilt and anterior drawer test, possible tearing of anterior talofibular ligaments and calcaneofibular ligaments. Grade 3= sever pain, swelling, bleeding in joint spacings, discoloration, unable to bear weight, positive talar tilt and anterior drawer, instability due to complete rupture of the ligament

What is the cause of injury with a compartment syndrome? What can this be classified as? Signs of injury:

Rare acute traumatic syndrome due to direct blow or excessive exercise Can be classified as acute, acute exertional or chronic Signs of injury: excessive swelling compresses muscles, blood supply and nerves, deep aching pain and tighness experienced, weakness with foot and toe extension, dorsal region of foot will be tight too.

What is a common overuse injury?

Stress fracture of tibia or fibula