Comprehensive Overview of Ankle and Lower Leg Clinical Anatomy and Evaluation Techniques

1. Chapter 5 The Ankle and Lower Leg

2. Clinical Anatomy • VERY IMPORTANT! Pages 136-145 • Bones and bony landmarks • Articulations and ligamentous support • Muscles • Compartments • Bursae

3. Clinical Evaluation of the Ankle and Lower Leg • Bi-lateral comparison • Patient Positioning • Interrelated to foot and knee • Evaluation Map, page 146

4. History • Location of pain (Table 5-2, page 147) • Nature or type of pain • Onset • Injury Mechanism (Table 5-3, page 148) • Changes in activity and conditioning • Prior history of injury

5. Inspection • General Inspection • Weight-bearing status • Bilateral comparison • Swelling • Lateral Structures • Peroneal muscle group • Distal one third of fibula • Lateral Malleolus (Figure 5-15, page 149)

6. Inspection • Anterior Structures • Appearance of anterior lower leg • Contour of the malleoli • Talus • Sinus tarsi (Figure 5-16, page 149) • Medial Structures • Medial malleoli • Medial longitudinal arch

7. Inspection • Posterior Structures • Gastrocnemius-soleus complex • Achilles tendon • Bursae • Calcaneus

8. Palpation • Utilize textbook pages 150-154 • Refer to list of Clinical Proficiencies • Palpation of Pulses • Posterior tibial artery • Dorsalis pedis artery

9. Range of Motion Testing • Talocrural Joint • Affected by muscular tightness, bony abnormalities, or soft tissue constraints • 100 of dorsiflexion during walking • 150 of dorsiflexion during running • If DF is limited, the foot compensates by increasing pronation • Table 5-4, page 154 • Goniometry (Box 5-2, page 155)

10. Active Range of Motion • Plantarflexion and dorsiflexion • 700 of motion • Figure 5-17, page 155 • Inversion and eversion • 250 of motion • Figure 5-18, page 155

11. Passive Range of Motion • Plantarflexion and dorsiflexion • Measured with knee flexed and extended • Firm end-feel • Anterior capsule, deltoid lig, ATF lig (PF) • Achilles tendon (DF) • Inversion and Eversion • Stabilize lower leg • End-feel • Inversion – firm (lateral ankle ligs, peroneals) • Eversion – hard (fibula striking calcaneus) or firm (medial jt capsule and musculature)

12. Resistive Range of Motion • Box 5-3, page 156 • DF, PF, INV, EV • Toe-raise test (figure 5-19, page 157)

13. Tests for Ligamentous Stability • Specific testing for joint play and specific ligament tenderness and pain

14. Test for Anterior Talofibular Ligament Instability • ATF prevents anterior translation of the talus relative to ankle mortis • Combination of PF, INV, and SUP place strain on ATF • Anterior Drawer Test • Box 5-4, page 158

15. Test for Calcaneofibular Ligament Instability • Talar Tilt test (inversion stress test) • Box 5-5, page 159 • Also stresses anterior and posterior talofibular ligaments

16. Test for Deltoid Ligament Instability • Talar Tilt test (eversion stress test) • Box 5-6, page 160 • Kleiger’s test (external rotational test) • Box 5-7, page 161

17. Test for Ankle Syndesmosis Instability • Overpressure at end of DF • Ankle syndesmosis, anterior tibiofibular ligament, interosseous membrane, posterior tibiofibular ligament • Talus is wedged into talocrural joint, causing separation between tibia and fibula • Kleiger’s Test (external rotational test)

18. Neurologic Testing • Dysfunction can occur secondary to compartment syndrome or direct trauma • Common peroneal nerve • Table 5-5, page 162 • Figure 5-20, page 162 • Lower quarter screening (Chapter 1, page 16)

19. Pathologies and Related Special Tests • Ankle Sprains • Most occur secondary to supination and cause trauma to the lateral ligament complex, due to calcaneal inversion • Less commonly, the medial ankle ligaments and distal tibiofibular syndesmosis are sprained • Trauma to capsule

20. Lateral Ankle Sprains • Open-packed vs closed-packed position • Sudden forceful inversion; specific structures injured depends on talocrural joint position • ATF ligament – most commonly sprained • Calcaneofibular and posterior talofibular ligaments may also be injured

21. Lateral Ankle Sprains • Anatomic and physiologic predisposing conditions • Prophylactic devices • Re-incidence rates • Loss of ligament’s ability to protect and support joint • Decreased proprioceptive ability

22. Lateral Ankle Sprains • Evaluation Findings • Table 5-6, page 163 • Additional trauma may be overlooked • Medial structures, peroneals, achilles tendon, etc. • Figure 5-21, page 164 • Secondary conditions • Thickened connective tissue, bone bruises, blood accumulations, etc. • Figure 5-22, page 164

23. Lateral Ankle Sprains • Traction injuries to peroneal nerve • Evaluating ankle sprains in adolescents • Treatment

24. Syndesmosis Sprains • Only represent between 10% and 18% of all ankle sprains • Associated with significantly increased amounts of time loss • Excessive external rotation or forced dorsiflexion = talus placing pressure on fibula = spreading of syndesmosis • Figure 5-23,page 165

25. Syndesmosis Sprains • Factors contributing to occurrence • Evaluation Findings • Table 5-7, page 167 • Squeeze Test • Box 5-8, page 166 • Maisonneuve Fracture • Figure 5-24, page 167 • Treatment

26. Medial Ankle Sprains • Eversion is limited by: • Strength of deltoid ligament • Mechanical advantage - longer lateral malleolus • External rotation of talus in ankle mortis • Medial longitudinal arch and syndesmosis may also be involved

27. Medial Ankle Sprains • Evaluation Findings • Table 5-8, page 168 • Injuries to surrounding structures • “knock-off” fracture (Figure 5-25, page 168) • Pott’s fracture • Interarticluar trauma to talus and tibia