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Chapter 5

Chapter 5. The Ankle and Lower Leg Continued. Stress Fractures. Evaluation Findings Table 5-9, page 169 Predisposing factors Narrow tibial shaft, hip external rotation, pes cavus Diagnostic testing Bump Test (Box 5-9, page 170) Treatment (Figure 5-26, page 169) Table 5-10, page 171.

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Chapter 5

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  1. Chapter 5 The Ankle and Lower Leg Continued

  2. Stress Fractures • Evaluation Findings • Table 5-9, page 169 • Predisposing factors • Narrow tibial shaft, hip external rotation, pes cavus • Diagnostic testing • Bump Test (Box 5-9, page 170) • Treatment (Figure 5-26, page 169) • Table 5-10, page 171

  3. Os Trigonum Injury • Evaluation Findings • Table 5-11, page 173 • Steida’s process (figure 5-27,page 172) • Formation of an os trigonum (Fig 5-28, p172) • Os trigonum syndrome (talarcompression syndrome) • Inflammation of posterior joint • Inflammation of surrounding ligaments • Fracture of the os trigonum • Pathology involving Steida’s process

  4. Os Trigonum Injury cont. • Inversion/plantarflexion • posterior talocalcaneal ligament tightens against os trigonum or Steida’s process • Eversion of calcaneus • os trigonum or Steida’s process to become compressed between tibia and calcaneus • Treatment

  5. Achilles Tendon Pathology • Association with gastrocnemius and soleus • Decreased plantarflexion strength • Changes in gait; ability to walk, run, jump

  6. Achilles Tendinitis • Evaluation Findings • Table 5-12, page 174 • Poorly vascularized structure • Limited blood supply - posterior tibial artery • Distal avascularized zone – 2 to 6 cm proximal to insertion on calcaneus • Delayed healing

  7. Achilles Tendinitis cont. • Paratenon • Highly vascularized structure, surrounds tendon • Peritendinitis • Tendinosis • Degeneration of tendon’s substance • Peritendinitis Tendinosis Tendon Rupture

  8. Achilles Tendinitis cont. • Factors leading to achilles tendon pathology • Tibial varum • Calcaneovalgus • Hyperpronation • Tightness of triceps surae, hamstring groups • Running mechanics, duration and intensity of running, type of shoe, running surface • Biomechanics of foot and ankle • Acute Onset

  9. Achilles Tendinitis cont. • Age and gender • Pain characteristics • Treatment/Return to activity

  10. Achilles Tendon Rupture • Evaluation Findings • Table 5-13, page 176 • Forceful, sudden contraction = large amount of tension developing in tendon • Theories • Chronic degeneration of tendon • Failure of inhibitory mechanism of musculotendinous unit • Rupture tends to occur in distal 2-6 cm

  11. Achilles Tendon Rupture cont. • Age and gender • Previous or current tendinosis, age-related changes in tendon, deconditioning • Corticosteroid injections • Characteristics of rupture • Figure 5-29, page 175 • Thompson Test • Box 5-10, page 177 • Treatment

  12. Subluxating Peroneal Tendons • Evaluation Findings • Table 5-14, page 178 • Forceful, sudden DF/EV or PF/INV = stretch or rupture of superior peroneal retinaculum • Tendon alignment • Figure 5-30, page 176

  13. Subluxating Peroneal Tendons cont. • Predisposing factors • Flattened fibular groove • Pes planus • Hindfoot valgus • Recurrent ankle sprains • Laxity of peroneal retinaculum • Characteristics • Treatment

  14. Neurovascular Deficit • Disruption of blood or nerve supply to or from lower leg • Acute trauma • Overuse conditions • Congenital defects • Surgery • Dermatomes, reflexes, pulses

  15. Anterior Compartment Syndrome • Evaluation Findings • Table 5-15, page 179 • Increased pressure in compartment threatens integrity of lower leg, foot, and toes • Obstructs neurovascular network • Deep peroneal nerve • Anterior tibial artery

  16. Anterior Compartment Syndrome cont. • Bony posterolateral border and dense fibrous fascial lining = poor elastic properties • Cannot accommodate for expansion of intracompartmental tissues • Increased pressure = lack of oxygen to local tissues • Leads to ischemia and possibly cell death

  17. Anterior Compartment Syndrome cont. • 3 classifications • Traumatic • blow to anterior or anterolateral portion of lower leg • Exertional • acute or chronic; during or after exercise (or both) • Chronic (recurrent or intermittent claudication) • Occurs secondary to anatomic abnormalities obstructing blood flow to exercising muscles • Increased thickness of fascia inhibits venous outflow • Other anatomic factors – page 178

  18. Anterior Compartment Syndrome cont. • Associated with • Tibial fractures • Anticoagulant therapy • Diabetes • Knee braces • High-heeled shoes • Signs and Symptoms • 5 P’s • Pain, pallor, pulselessness, paresthesia, paralysis

  19. Anterior Compartment Syndrome cont. • Drop foot gait • Dorsalis pedis pulse (Figure 5-31, pg 180) • Most important clinical finding • Severe pain with passive muscle stretching • Medical emergency • Decreased pulse, paresthesia, paralysis • Compartmental pressure • Treatment

  20. Deep Vein Thrombophlebitis • Inflammation of veins with associated blood clots • Common in postsurgical patients • May be secondary to trauma to lower extremity • Pain and tightness in calf during walking • Inspection – swelling in calf • Palpation – warmth, tightness, pain • Homan’s sign • Box 5-11, page 181

  21. On-Field Evaluation of Lower Leg and Ankle Injuries • Goals • Rule out fractures and dislocations • Determine weight-bearing status • Removal methods

  22. Equipment Considerations • Footwear Removal • Rule out fracture/dislocation and then remove shoe • Figure 5-32, page 181 • Apprehensive athletes – remove themselves • If fracture is suspected – check pulses • Tape and Brace Removal • Similar to shoe removal • Tape is cut on opposite side of injury

  23. On-Field History • Mechanism of injury • Inversion • Eversion • Rotation • Dorsiflexion • Plantarflexion • Associated sounds and sensations

  24. On-Field Inspection • On-Field Palpation • Bony palpation • Soft tissue palpation • On-Field Range of Motion Tests • Willingness to move involved limb • Willingness to bear weight

  25. Initial Management of On-Field Injuries • Ankle Dislocations (talocrural joint) • Excessive rotation combined with INV or EV • Disruption of capsule/ligaments, fractures of malleoli, long bones, talus • Pain, loss of function, audible sounds • Figure 5-33, page 183 • Confirm presence of pulses • Lower Leg Fractures • Signs/symptoms (Figure 5-34, page 183) • Fibula – may be able to walk • Bump/squeeze tests

  26. Management of Lower Leg Fractures and Dislocations • Immediately immobilized • Moldable or vacuum splints • Leave shoe on until emergency room • Figure 5-35, page 183 • Compound fracture • Control bleeding • Treatment • Figure 5-36, page 184

  27. Anterior Compartment Syndrome • Avoid compression • Acute gross hemorrhage or absent dorsalis pedis pulse – immediate refer to physician • Educate athletes

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