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Ankle & Lower Leg. HEAT 3685 Athletic Injury Assessment I Chapter 5, p. 136. Bones: tibia fibula talus Ligaments: ATFL PTFL CFL Deltoid. Clinical Anatomy-- p.136. Interosseous membrane Muscles: peroneals anterior tibialis posterior tibialis triceps surae Bursae.

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ankle lower leg
Ankle & Lower Leg
  • HEAT 3685
  • Athletic Injury Assessment I
  • Chapter 5, p. 136
clinical anatomy p 136
Bones:

tibia

fibula

talus

Ligaments:

ATFL

PTFL

CFL

Deltoid

Clinical Anatomy--p.136
  • Interosseous membrane
  • Muscles:
    • peroneals
    • anterior tibialis
    • posterior tibialis
    • triceps surae
  • Bursae
history p 145
History--p. 145
  • Onset of pain--
    • acute/gradual/chronic/ re-injury
  • PMH? (tx/rehab)
  • Mechanism:
    • INV
    • EV
    • DF
    • PF
    • Combination
  • Location of pain--
    • Table 5-2, p.147
    • medial/lateral:
      • probable sprain
      • avulsion fx
      • stress fx
      • muscle strain
  • Change in activity?
    • Position/requirements/ duration/frequency/ surface
observation inspection p 147 fig 5 15 p 149
Observation/Inspection--p.147Fig. 5-15, p. 149
  • WB status (antalgic?)
  • Bilateral comparison
    • malleoli
    • sinus tarsi (p.fig. 5-16, p149)
    • triceps surae
    • Achilles tendon
  • Inflammation
  • Swelling
  • Deformity
palpation p 150 151
Lateral ligaments (p.151)

ATFL

PTFL

CFL

Medial Ligaments

Deltoid group

Dorsalis pedis pulse

fig. 5-31, p. 180

Between 1st & 2nd mets.

Palpation-- p. 150-151
  • Tibio-fibular Ligaments (p.152)
    • Anterior
    • Posterior
functional testing p 154
AROM:

DF/PF:

landmarks

DF=20º

PF=~50º

fig. 4-24, p. 106

INV/EV:

landmarks

INV~20º

EV~5º

RROM: Box 5-3, p. 156

Functional Testing--p. 154
  • Other Tests:
    • Toe Raise
    • Heel Raises
    • Walking/Hopping/Jumping
on field functional testing
On-field Functional Testing
  • Willingness to:
    • Move joint
    • Bear weight
  • Contraindicated:
    • Obvious deformity
    • Be cautious when full AROM present
ligamentous testing p 157
Ligamentous Testing--p.157
  • Anterior Drawer
  • Posterior Drawer
  • Talar tilt
  • Kleiger test
anterior drawer p 158
Anterior Drawer--p.158
  • Box 5-4, p. 158
  • 2 methods
  • knee flexed/foot stabilized
  • Assesses laxity in ATFL
  • (+)= anterior movement of talus on mortise
anterior drawer testing
Anterior Drawer Testing
  • Knee flexed/foot stabilized
  • Assesses laxity in ATFL
  • (+)= anterior movement of talus on mortise
posterior drawer
Posterior Drawer
  • Similar to Anterior Drawer
  • Tests integrity of PTFL
  • (+) = Posterior movement of talus on mortise
talar tilt p 159
Talar Tilt—p.159
  • Inversion stress test
  • Box 5-5, p. 159
  • Stresses CFL
  • Always compare bilaterally
  • (+) = excessive PROM in INV
  • Also used in x-rays (WNL: <9º)
  • (EV talar tilt tests the deltoid ligament.—Box 5-6, p.160)
kleiger test p 161
Kleiger test—p. 161
  • Box 5-7, p.161
  • Syndesmosis test
  • External Rotation (ER) with plantar flex. (PF)
  • (+) Results: (2 possible)
    • Medial pain=deltoid sprain
    • Anterior pain=ant. tibiofibular sprain
lower leg special tests
Lower Leg Special Tests
  • Bump Test--p.170
  • Squeeze test--p.166
  • Thompson test--p.177
  • Homan’s sign--p.181
bump test p 170
Bump Test--p.170
  • Percussion test –Box 5-9
  • Ankle DF to neutral and tap calcaneus
  • (+) Results=
    • Pain proximally with distal percussion
    • Impression: lower leg fx. (tibia, fibula, or talus)
    • false positives common
squeeze test p 166 box 5 8
Squeeze test--p.166—Box 5-8
  • Compression test
  • Compress tibia & fibula together progressing distally
  • (+) Results:
    • Distal pain with proximal compression
    • Impression: lower leg fx (tibia or fibula)
    • Sometimes (+) with stress fx
thompson test p 177 box 5 10
Thompson test--p.177, Box 5-10
  • Athlete is prone
  • Squeeze the triceps surae belly and observe passive plantarflexion
  • (+)=Reduced motion at ankle
    • Impression: torn Achilles tendon
homan s sign p 181 box 5 11
Homan’s sign--p.181, Box 5-11
  • Assesses presence of deep vein thrombosis (DVT)
  • Findings must agree with other symptoms
  • Passive DF with full knee EXT.
  • (+) = intense pain in calf along with other signs of inflammation
  • Triceps surae strain may give false (+)
neurological testing p 162
Neurological Testing--p.162
  • Most common neuro. Trauma:
    • common peroneal nerve injury
      • Dec. in PF, EV, DF strength
    • secondary to other injuries (fx, contusions, LBP)
  • Signs/symptoms:
    • Decreased strength
    • Paresthesia/Anesthesia
    • Decreased reflexes
pathologies
Pathologies
  • Inversion ankle sprain
  • Eversion ankle sprain
  • Lower leg fractures
  • Stress fx
  • Ankle impingement
  • Achilles tendonitis
  • Subluxating Peroneal Tendons
  • Anterior compartment syndrome
  • Medial Tibial Stress Syndrome (Shin Splints)
inversion ankle sprain box 5 6 p 163
Inversion ankle sprain--Box 5-6, p. 163
  • More common than EV sprains
  • Mechanism: INV +/- rotation
  • Injured structures: ATFL/PTFL/ CFL
  • Symptoms:
    • lateral swelling/pain
    • hx of tight heel cord (HC)
  • Testing:
    • (+) Anterior Drawer
    • (+) Talar tilt
    • (-) Bump/Squeeze test
    • (-) Kleiger test
    • R/O fx’s in kids
eversion ankle sprain box 5 8 p 168
Eversion ankle sprain--Box 5-8, p. 168
  • Mechanism: EV +/- rotation or compression mechanism
  • Injured structures: Deltoid Ligament complex
  • Symptoms:
    • Medial swelling/pain
    • hx of tight heel cord (HC)
  • Testing:
    • (+)Kleiger test
    • (+) Talar tilt
    • (-) Bump/Squeeze test
    • R/O “knock-off” fx’s (p. 168)
syndesmosis sprains high ankle sprains
Syndesmosis Sprains(High Ankle sprains)
  • 10 – 18% of cases
  • Involves the Ant/Post. Tib/fib. Ligaments, interosseous membrane, crural interosseous ligament, possibly deltoid lig.
  • MOI – excessive ER of talus with associated DF
  • S/S – pain at anterior/dist aspect of lower leg. Inc with DF, ER and squeeze test
syndesmosis sprains high ankle sprains24
Syndesmosis Sprains(High Ankle sprains)
  • Eval – palpate entire shaft of fib for crepitus
  • FX – usually in distal 1/3 but can be in proximal 1/3 (Maisonneuve FX)
  • TX – splint & crutch
  • Recovery: usually 3 – 4 weeks
ankle impingement syndrome
Ankle Impingement Syndrome
  • Hx--recurrent ankle sprains
  • Symptoms:
    • Tenderness between Ant. Tib. Tendon and Med. Malleolus
    • chronic inflammation
    • Pain worsens with DF and decreases with PF
    • Ankle weakness in INV/EV
    • Anterior pain without laxity
stress fractures
Stress Fractures
  • History:
    • gradual onset
    • Usually accompanies a change in activity
    • c/o “burning” after activity in lower leg
  • Palpation:
    • point tenderness at site of fx
    • often confused with other injuries
  • Observation:
    • Swelling is minimal/absent
    • Altered gait/activities due to pain
    • Usually no discoloration/deformity
  • Special Tests:
    • (-) Bump test?
    • (-) Squeeze test?
    • (+) Tuning Fork sign
  • Tx: Minimum 2 wks rest
achilles tendinitis p 173
Achilles Tendinitis--p.173
  • History:
    • Poorly vascularized area
    • Usual mechanism= overuse
    • Sometimes acute (strain/trauma)
    • Check shoes, gait, and technique for risk factors
  • Palpation:
    • Usually point tender at musculotendonous junction
    • Crepitus possible with AROM
  • Observation:
    • Localized inflammation which worsens with activity
    • Over pronation/supination
  • Special Tests:
    • Thompson test painful
    • Limited AROM in DF/PF
  • If untreated, may lead to HC rupture
achilles tendinitis p 17329
Achilles Tendinitis--p.173

Treatment:

Eliminate cause(s)

Temporary heel lift

Gentle stretches (2)

Arch supports

Taping

Modalities & Medications

subluxating peroneal tendon p 178
Box 5-14

May be primary or secondary injury

Subluxation may be seen, felt, or heard

Easily palpated with AROM and RROM

Fig. 5-30: Biomechanical changes possible

May require surgical correction to prevent further injuries

Subluxating Peroneal Tendon—p. 178
anterior compartment syndrome p 179
Anterior compartment syndromep. 179
  • History:
    • Acute or chronic onset
    • Traumatic or overuse onset
    • C/O numbness/tingling in foot with decreased DF
  • Palpation:
    • Decreased dorsalis pedis pulse
    • Dec. RROM in DF
  • Observation:
    • Possible generalized swelling
    • Altered gait due to pain and weakness
  • Treatment:
    • Find/eliminate cause
    • Avoid ext. compression
    • Decrease int. compression
    • fasciotomy may be indicated
shin splints
Shin Splints
  • Medial tibial stress syndrome
  • Pain with activity in distal 1/3 of tibia
  • Initially pain only after activity
  • Two primary causes:
    • Overuse (Muscle imbalance)
    • Biomechanical (Overpronation)
medial tibial stress syndrome shin splints
Medial Tibial Stress Syndrome(Shin Splints)
  • Caused by Overuse:
  • Evaluate PROM in DF and PF
  • Evaluate Achilles flexibility
  • Treatment:
    • Improve circulation in lower leg
    • Reverse muscle strength imbalance
mtss cont
MTSS cont.
  • Caused by Poor Biomechanics:
  • Evaluate RROM in EV and INV
  • Evaluate Achilles flexibility
  • Assess arch integrity
  • Treatment:
    • Improve circulation in lower leg
    • Support arch
    • Strengthen post. tib.