The Ankle & Lower Leg Lecture 10

1. The Ankle & Lower LegLecture 10

2. Lower leg and ankle • ankle injuries most frequent in sports • tibia • is major weight bearing bone of the lower leg • fibula • assists minimally with weight bearing aprrox 2 % , serves as a site for muscle attachment and contributes to the stability of the ankle

3. Crural Bones • med / lat. malleolus and talus • Talocrural Joint (ankle joint) • is a uniaxial modified hinge joint - (talus, tibia and fibula) • plantar flexion and dorsiflexion occur here • talus wider ant vs post - stability

4. Lateral Ankle Support • ATF, PTF , CF (static) (AITF) b) peroneals (dynamic) • the lateral ligaments of the ankle joint are relatively weaker than the medial ligaments • hence the larger number of lateral ankle sprains

6. Medial Ankle a) Deltoid ligament (static) b) Tom, Dick and Harry (dynamic) • Dynamic • TA • TP

8. Distal Tib-Fib Joint a) ant & post tibiofibular lig b) interosseos membrane

9. Muscles • 4 compartments • anterior , deep , superficial and lateral i) anterior - tibialis anterior - extensor digitorum longus - extensor hallucis longus and peroneous tertius ii) deep - tibialis posterior - flexor digitorum longus - flexor hallicus longus

10. iii) superficial - gastrocnemius - soleus, plantaris iv) lateral - peroneus brevis , peroneus longus

12. Ankle Movements • Plantarflexion • Dorsiflexion • Inversion • Eversion

14. General Ligament Sprains • 1st, 2nd, 3rd degree

15. Common Lower Leg & Ankle Injuries

16. Inversion Ankle Sprain • more common than eversion because of ligament and bony support • stress is applied to the lateral side of the foot during plantar flexion and inversion • most often injuring the Anterior Talofibular ligament (ATF) • if stress is continued the Calcaneal Fibular Lig (CF) may be injured as well

17. individual will report cracking or tearing sound at time of injury • swelling and ecchymosis will be rapid and diffuse • point tenderness over ATF may extend over CF • Rx - PIER, modalities -horseshoe pad • Should probably xray to rule out any possible fractures

22. http://www.youtube.com/watch?v=SjprI020XQ0&feature=related

23. Eversion Ankle Sprain • less common than lateral ankle sprains because of strong deltoid ligament, thus many are associated with fibular fractures • mild to moderate pain with ankle eversion • slower and less evident swelling • point tenderness over deltoid ligament • Rx – X-ray, PIER, modalities -horse shoe

27. First Aid Care • Immediately apply ice, compression and elevate • Apply a horseshoe or doughnut pad, keep it in place with a elastic wrap. • Have athlete rest , use crutches • If needed refer to physician or hospital for x-rays .

28. Syndesmotic ankle sprain • AKA: high ankle sprain • Approximately 10 – 15% of all ankle sprains involve the syndesmosis • 30 % for collision sports ( football etc) • MOI – almost always involves a direct blow to the lateral aspect of the leg with foot planted in external rotation

30. s/s • Min lateral swelling • Possible med swelling • Pain in anterolateral lower leg • Point tenderness over the AITF lig , the interosseus membrane • Pont tenderness over the ATF and possibly the sup ATF lig • Disomfort /pain with DF ( AROM ) • Loss of ankle function

31. First Aid Care Immediately apply ice, compression and elevate Apply a horseshoe or doughnut pad, keep it in place with a elastic wrap. Have athlete rest , use crutches , may want to put in walking boot or cast for short period of time If needed refer to physician or hospital for xrays .

32. Achilles Tendon Strain or Rupture • probably the most severe acute muscular problem in lower leg • 75% seen in males between 30 - 50 years • mechanism of injury - usually pushing off of the forefoot while knee is extending (racquet sports )

33. most ruptures occur 1 to 2 inches proximal to the distal attachments of the tendon on the calcaneus • individual experiences sharp pain and hears or feels a POP in the tendon region - often described as a gun shot sound • a common sensation is one of being hit in the back of the leg • visible defect in the tendon

34. inability to actively extend the foot (especially against resistance) • swelling - bruising and a palpable defect in the tendon • immediate referral to physician • http://www.youtube.com/watch?v=AmDi08rlR3I&feature=fvw

35. First Aid Care Immediately apply ice, compression and elevate Immobilize the area in a splint or walking boot. Have athlete rest , use crutches Send to hospital or nearest medical facility.

36. AchillesTendinitis • most common in lower leg • tight heel cord – hyper-pronation - repetitive heel running - a recent change in shoes or running surfaces - increase in distance or intensity • pain present during and after activity

37. increases with passive dorsiflexion and resisted plantar flexion • point tenderness - diffuse or localized swelling • aching or burning in the posterior heel • occasionally fine crepitation can be palpated in the tendon with movement • Rx - PIER, Modalities, NSAIDS-heel lifts - reduced activity (rest) - especially running

38. Lower Leg Contusion • usually gastroc • results in immediate pain and weakness and loss of function • haemorrhage and muscle spasm quickly lead to a tender firm mass that is easily palpable • ice on a mild stretch • care must be taken for myositis ossificans

39. Exercise Induced Compartment Syndrome • 50-60% are anterior – characterised by exercise induced pain and swelling that is relieved by rest • exercise induced aching leg pain and a sense of fullness, both over the involved compartment • symptoms are almost always relieved with rest, usually with in 20 minutes

40. exercise will produce swelling and tenderness • to confirm a intra-compartmental pressure must be measured • RX involves stretching and strengthening , PIER, and NSAIDS • If symptoms persist , surgery is recommended

41. Muscle Spasms and Cramps • fatigue , loss of fluids or electrolyte, • acute treated with ice , pressure and slow static stretch • prevention - adequate water intake (electrolyte solution) - regular stretching program

42. Lower Leg Strain • may be acute or chronic • acute may be result of tearing followed by the inability to walk without pain • point tenderness, swelling and muscle weakness will be present • Rx - PIER, modalities, depends on severity

43. Medial Tibial Stress Syndrome • AKA : Shin splints • Microscopic tears in the muscle attachment site on posterior medial border • pain along the posterior-medial tibial border • usually in the distal third

44. Possible factors - excessive pronation , prolonged pronation , recent training changes (speed, form , running surface , distance) • pain usually present at start of activity ,but decreases with activity only to return after activity, later stages pain present at all times - may restrict activity • RX - PIER, NSAIDS, (modalities) activity modification (rest) - low impact - non impact - stretching and strengthening of intrinsic muscle of the foot • Real key is to find cause ….

45. http://www.youtube.com/watch?v=o5DXFVI6mTA&feature=related