Chapter 19: The Ankle and Lower Leg

1. Chapter 19: The Ankle and Lower Leg

4. 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

5. 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 rearfoot and subtalar joint

6. Preventing Injury in the Lower Leg and Ankle • Achilles Tendon Stretching • A tight heel cord may limit dorsiflexion and may predispose athlete 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

7. 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 • However, 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

8. 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?

9. Percussion and compression tests • Used when fracture is suspected • Percussion test is a blow to the tibia, fibula or heel to create vibratory force that resonates w/in fracture causing pain • Compression test involves compression of tibia and fibula either above or below site of concern • 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

10. Compression Test Percussion Test Homan’s Test Thompson Test

11. Ankle Stability Tests • Anterior drawer test • Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarily • A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point • Talar tilt test • Performed to determine extent of inversion or eversion injuries • 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

12. Anterior Drawer Test Talar Tilt Test

13. 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 any of these are painful they should be avoided

14. Specific Injuries • Ankle Injuries: Sprains • Single most common injury in athletics 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

15. Syndesmotic Sprain • Etiology • Injury to the distal tibiofemoral joint (anterior/posterior tibiofibular ligament) • Torn w/ increased external rotation or dorsiflexion • Injured in conjunction w/ medial and lateral ligaments • Signs and Symptoms • Severe pain, loss of function; passive external rotation and dorsiflexion cause pain • Pain is usually anterolaterally located • Management • Difficult to treat and may requires months of treatment • Same course of treatment as other sprains, however, immobilization and total rehab may be longer

16. Achilles Tendon Rupture • Etiology • Occurs w/ sudden stop and go; forceful plantar flexion w/ knee moving into full extension • Commonly seen in athletes > 30 years old • Generally has history of chronic inflammation • Signs and Symptoms • Sudden snap (kick in the leg) w/ immediate pain which rapidly subsides • Point tenderness, swelling, discoloration; decreased ROM • Obvious indentation and positive Thompson test • Occurs 2-6 cm proximal the calcaneal insertion

18. Achilles Tendon Rupture (continued) • Management • Usual management involves surgical repair for serious injuries (return of 75-80% of function) • Non-operative treatment consists of RICE, NSAID’s, analgesics, and a non-weight bearing cast for 6 weeks, followed up by a walking cast for 2 weeks (75-90% return to normal function) • Rehabilitation lasts about 6 months and consists of ROM, PRE and wearing a 2cm heel lift in both shoes

19. Medial Tibial Stress Syndrome (Shin Splints) • Etiology • Pain in anterior portion of shin • Catch all for stress fractures, muscle strains, chronic anterior compartment syndrome • Accounts for 10-15% of all running injuries, 60% of leg pain in athletes • Caused by repetitive microtrauma • Weak muscles, improper footwear, training errors, varus foot, tight heel cord, hypermobile or pronated feet and even forefoot supination can contribute to MTSS • May also involve, stress fractures or exertional compartment syndrome

20. Shin Splints (continued) • Signs and Symptoms • Four grades of pain • Pain after activity • Pain before and after activity and not affecting performance • Pain before, during and after activity, affecting performance • Pain so severe, performance is impossible • Management • Physician referral for X-rays and bone scan • Activity modification • Correction of abnormal biomechanics • Ice massage to reduce pain and inflammation • Flexibility program for gastroc-soleus complex • Arch taping and or orthotics

21. Compartment Syndrome • Etiology • Rare acute traumatic syndrome due to direct blow or excessive exercise • Signs and Symptoms • Excessive swelling compresses muscles, blood supply and nerves • Increase in fluid accumulation could lead to permanent disability • Chronic cases appear as gradual build-up that dissipates following activity; generally bilateral and becomes predictable; can remain elevated producing ischemia and pain or ache w/ rare neurological involvement; increased pressure involvement • Weakness with foot and toe extension and occasionally numbness in dorsal region of foot

22. Compartment Syndrome (continued) • Management • If severe acute or chronic case, may present as medical emergency that requires surgery to reduce pressure or release fascia • RICE, NSAID’s and analgesics as needed • Surgical release is generally used in recurrent conditions • Return to activity after surgery - light activity- 10 days later

23. Functional Progressions • Severe injuries require more detailed plan • Introduction of weight bearing activities (partial vs. full) is critical to progress • Progression must occur based on pain and level of function • Running can begin when ambulation is pain free (transition from pool  even surface  changes of speed and direction)

24. Return to Activity • Must have complete range of motion and at least 80-90% of pre-injury strength before return to sport • If full practice is tolerated w/out insult, athlete can return to competition • Return to activity must involve gradual progression of functional activities, slowly increasing stress on injured structure • Specific sports dictate specific drills