Chapter 19: The Ankle and Lower Leg

Anatomy of the Lower Leg and Ankle • Bones • Tibia: 2nd longest bone in the body, the “shin” bone • Medial side, triangular in upper 2/3rds and rounded and constricted in the lower third • Fibula: Lateral aspect of lower leg • Proximal end is under the tibia • Distal end articulates with tibia as a syndesmotic joint (bones are united by a ligament)

Bones con’t • Tibial and fibular malleoli: medial and lateral malleoli • Distal ends of the tibia and fibula • Lateral side is longer thus more stable • Talus: Main weight bearing bone • Rests on the calcaneus and articulates with the medial and lateral malleoli • Calcaneus: Heel bone • Many ligament attachments of the ankle and attachment of the achilles tendon

Articulations • Superior and Inferior Tibiofibular Joint: • Superior: diarthrotic (sliding) joint, tibia’s lateral condyle and head of fibula • Inferior: Lateral malleolus and distal end of the tibia • Talocrural Joint: Hinge joint aka the ankle mortise; dorsi and plantar flexion • Subtalar Joint: Talus and clacaneus; inversion, eversion, pronation and supination

Stabilizing Ligaments • Tibiofibular Ligament: • Strong interosseous membrane; helps diffuse the forces on the lower leg • Distal sometimes referred as the Syndesmotic ligaments • Lateral Ligaments: (Table 19-1) • Anterior Talofibular • Posterior Talofibular • Calcaneofibular • Medial Ligaments: Deltoid ligament • Resists eversion

Joint Capsule • Thin articular capsule that encases the joint and borders the bone

Ankle Musculature • Movements include: • Dorsiflexion: muscles on the anterior side • Plantarflexion: muscles on the posterior side • Inversion: muscle cross medially • Eversion: muscles cross laterally

Muscle Compartments • Anterior Compartment: • Dorsiflex the ankle and extend the toes • Tibialis anterior, extensor hallucis longus and extensor digitorum longus • Lateral Compartment: • Evert the ankle and assist with dorsiflexion • Peroneus longus and brevis and Peroneus tertius • Superficial Posterior Compartment: • Plantar flexion • Gastrocnemius and soleus • Deep Posterior Compartment: • Invert the ankle • Tibialis posterior, flexor digitorum longus and flexor hallucis longus

Nerve Supple • Anteriorly: Common peroneal nerve • Posterior: Tibial nerve

Blood Supply • Arteries: Anterior tibial and posterior tibial • Veins: Peroneal, Posterior tibial and Anterior Tibial

Functional Anatomy Ankle is a stable hinge joint Medial and lateral displacement is prevented by the malleoli Ligament arrangement limits inversion and eversion at the subtalar joint Square shape of talus adds to stability of the ankle Most stable during dorsiflexion, least stable in plantar flexion © 2011 McGraw-Hill Higher Education. All rights reserved.

Degrees of motion for the ankle range from 10 degrees of dorsiflexion to 50 degrees of plantar flexion Normal gait requires 10 degrees of dorsiflexion and 20 degrees of plantar flexion with the knee fully extended Normal ankle function is dependent on action of the rear foot and subtalar joint Critical link in kinetic chain © 2011 McGraw-Hill Higher Education. All rights reserved.

Preventing Injury in the Lower Leg and Ankle Achilles Tendon Stretching A tight heel cord may limit dorsiflexion and may predispose individual to ankle injury Should routinely stretch before and after practice Stretching should be performed with knee extended and flexed 15-30 degrees Strength Training Static and dynamic joint stability is critical in preventing injury While maintaining normal ROM, muscles and tendons surrounding joint must be kept strong © 2011 McGraw-Hill Higher Education. All rights reserved.

Neuromuscular Control Training Can be enhanced by training in controlled activities Uneven surfaces, BAPS boards, rocker boards, or Dynadiscs can also be utilized to challenge athlete Figure 19-39 © 2011 McGraw-Hill Higher Education. All rights reserved.

Footwear Can be an important factor in reducing injury Shoes should not be used in activities they were not made for Preventive Taping and Orthoses Tape can provide some prophylactic protection Improperly applied tape can disrupt normal biomechanical function and cause injury Lace-up braces have even been found to be superior to taping relative to prevention © 2011 McGraw-Hill Higher Education. All rights reserved.

Assessing the Lower Leg and Ankle History Past history Mechanism of injury When does it hurt? Type of, quality of, duration of pain? Sounds or feelings? How long were you disabled? Swelling? Previous treatments? © 2011 McGraw-Hill Higher Education. All rights reserved.

Observations- Bilateral Postural deviations? (toe in, pronation) Genu valgum or varum? Is there difficulty with walking? Deformities, asymmetries or swelling? Color and texture of skin, heat, redness? Patient in obvious pain? Is range of motion normal? Figure 19-9: Tibial Torsion © 2011 McGraw-Hill Higher Education. All rights reserved.

Palpation: Bones and Soft Tissue Fibular head and shaft Lateral malleolus Tibial plateau Tibial shaft Medial malleolus Dome of talus Calcaneus Sustentaculum tali Peroneus longus Peroneus brevis Peroneus tertius Flexor digitorum longus Flexor hallucis Posterior tibialis © 2011 McGraw-Hill Higher Education. All rights reserved.

Palpation: Soft Tissue (continued) Anterior tibialis Extensor hallucis longus Extensor digitorum longus Gastrocnemius Soleus Achilles tendon Anterior/posterior talofibular ligament Calcaneofibular ligament Deltoid ligament Anterior tibiofibular ligament Posterior tibiofibular ligament © 2011 McGraw-Hill Higher Education. All rights reserved.

Palpation Lab

Special Test - Lower Leg Lower Leg Alignment Tests Mal-alignment can reveal causes of abnormal stresses applied to foot, ankle, lower leg, knees and hips Anteriorly, a straight line can be drawn from ASIS, through patella and between 1st and 2nd toes Laterally, a straight line can go from greater trochanter through center of patella and just behind the lateral malleolus Posteriorly, a line can be drawn through the center of the lower leg, midline to the Achilles and calcaneus Internal or external tibial torsion is also a common mal-alignment © 2011 McGraw-Hill Higher Education. All rights reserved.

Percussion and compression tests for fracture Percussion test is a blow to the tibia, fibula or heel to create vibratory force that resonates w/in fracture Compression test involves compression of tibia and fibula either above or below site of concern Tuning forks can also be used to create vibration at point of injury Thompson test Squeeze calf muscle, while foot is extended off table to test the integrity of the Achilles tendon Positive tests results in no movement in the foot Homan’s test Test for deep vein thrombophlebitis With knee extended and foot off table, ankle is moved into dorsiflexion Pain in calf is a positive sign and should be referred © 2011 McGraw-Hill Higher Education. All rights reserved.

Ankle Stability Tests Anterior drawer test: ATF primarily and other lateral ligaments secondarily Tibia is pushed backward as calcaneus is drawn forward A positive test occurs when foot slides forward and /or makes a clunking sound as it reaches the end point Talar tilt test: Inversion or eversion With foot at 90 degrees calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments If the calcaneus is everted, the deltoid ligament is tested © 2011 McGraw-Hill Higher Education. All rights reserved.

Kleiger’s test Used primarily to determine extent of damage to the deltoid ligament and may be used to evaluate distal ankle syndesmosis, anterior/posterior tibiofibular ligaments and the interosseus membrane With lower leg stabilized, foot is rotated laterally to stress the deltoid Medial Subtalar Glide Test Performed to determine presence of excessive medial translation of the calcaneus on the talus Talus is stabilized in subtalar neutral, while other hand glides the calcaneus, medially A positive test presents with excessive movement, indicating injury to the lateral ligaments © 2011 McGraw-Hill Higher Education. All rights reserved.

Functional Tests While weight bearing the following should be performed Walk on toes (plantar flexion) Walk on heels (dorsiflexion) Walk on lateral borders of feet (inversion) Walk on medial borders of feet (eversion) Hops on injured ankle Passive, active and resistive movements should be manually applied to determine joint integrity and muscle function If the patient has difficulty with bearing weight these tests should not be utilized. © 2011 McGraw-Hill Higher Education. All rights reserved.

Special Tests Lab • Percussion and Compression • Thompson Test • Homan’s Sign • Anterior Drawer • Talar Tilt (inversion and eversion) • Klieger’s • Medial Subtalar Glide • Functional

Chapter 18: The Ankle and Lower LegPart II

ASSIGNMENT: • Pick one ankle/ lower leg injury and do a SOAP note on it.

Specific Injuries Sprains Single most common injury in the active caused by sudden inversion or eversion moments Inversion Sprains Most common and result in injury to the lateral ligaments Anterior talofibular ligament is injured with inversion, plantar flexion and internal rotation Occasionally the force is great enough for an avulsion fracture to occur w/ the lateral malleolus © 2011 McGraw-Hill Higher Education. All rights reserved.

Figure 19-21

Severity of ligament sprains is classified according to grades Grade I, II, II With inversion sprains the foot is forcefully inverted or occurs when the foot comes into contact w/ uneven surfaces Figure 19-19 © 2011 McGraw-Hill Higher Education. All rights reserved.

Ottawa Ankle Rules • Used for determining need for radiograph • Most often used in emergency room • Indicates that • Required if pain in malleolar or midfoot area • Inability to bear weight for 4 steps (2 on each foot) at time of injury and examination • Tenderness over inferior or posterior pole of either malleoli • Inability to bear weight (4 steps taken independently, even if limping) at time of injury and/or evaluation • Tenderness along base of 5th metatarsal or navicular bone © 2011 McGraw-Hill Higher Education. All rights reserved.

Grade 1 Inversion Ligament Sprain Etiology Occurs with inversion plantar flexion and adduction Causes stretching of the anterior talofibular ligament Signs and Symptoms Mild pain and disability; weight bearing is minimally impaired; point tenderness over ligaments and no laxity Management RICE for 1-2 days; limited weight bearing initially and then aggressive rehab Tape may provide some additional support Return to activity in 7-10 days © 2011 McGraw-Hill Higher Education. All rights reserved.

Grade 2 Inversion Ligament Sprain Etiology Moderate inversion force causing great deal of disability with many days of lost time Signs and Symptoms Feel or hear pop or snap; moderate pain w/ difficulty bearing weight; tenderness and edema Positive talar tilt and anterior drawer tests Management RICE for at least first 72 hours; X-ray exam to rule out fx; crutches 5-10 days, progressing to weight bearing © 2011 McGraw-Hill Higher Education. All rights reserved.

Management (continued) Will require protective immobilization but begin ROM exercises early to aid in maintenance of motion and proprioception Taping will provide support during early stages of walking and running Long term disability will include chronic instability with injury recurrence potentially leading to joint degeneration Must continue to engage in rehab to prevent against re-injury © 2011 McGraw-Hill Higher Education. All rights reserved.

Grade 3 Inversion Ligament Sprain Etiology Relatively uncommon but is extremely disabling Caused by significant force (inversion) resulting in spontaneous subluxation and reduction Causes damage to the anterior/posterior talofibular and calcaneofibular ligaments as well as the capsule Signs and Symptoms Severe pain, swelling, hemarthrosis, discoloration Unable to bear weight Positive talar tilt and anterior drawer © 2011 McGraw-Hill Higher Education. All rights reserved.

Chapter 19: The Ankle and Lower Leg