Ankle

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Ankle Low Leg Evaluation
http//www.csmfoundation.org/Educational_Lower_Ext
remity.html
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Common Injuries

• Ankle sprains lateral, medial, syndesmosis
  (high)
• Fractures
• Tendinitis
• Subluxating Peroneal Tendons
• Compartment Syndromes (Anterior)
• Achilles Tendon Rupture
• Deep Vein Thrombosis (Thrombophlebitis)

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Ankle Anatomy

• Bony
• Calcaneus, Talus, Tibia (Medial Malleolus),
  Fibula (Lateral Malleolus)
• Soft Tissue
• Muscles
• Ligaments
• Interosseous Membrane
• Retinaculum
• Peroneal, Extensor (superior, inferior)
• Circulation
• Posterior Tibial Artery, Anterior Tibial Artery,
  Peroneal Artery, Veins

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Joints Ligaments

• Medial Ligaments
• Deltoid ligament 2 layers (deep superficial)
• Superficial 3 parts, Deep 1 part

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Joints Lateral Ligaments

• Anterior Talofibular Lig. (ATF)
• Anterior Tibiofibular Lig.
• Posterior Talofibular Lig.
• Posterior Tibiofibular Lig.
• Calcaneofibular Lig.

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Joints

• Talocrural Joint dorsi plantarflexion
• Subtalar Joint - inversion eversion
• Classified as gliding or arthrodial
• Intertarsal tarsometatarsal joints
• Arthrodial
• Minimal movement

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Muscles of the Ankle Low Leg

• Anterior Compartment
• Tibialis Anterior
• EHL
• EDL
• Peroneus Tertius
• Lateral Compartment
• Peroneus Longus
• Peroneus Brevis
• Superficial Posterior Compartment
• Gastrocnemius
• Soleus
• Plantaris
• Deep Posterior Compartment
• Tibialis Posterior
• FHL
• FDL

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Anterior Leg Muscles
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Lateral Medial Leg Muscles
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Posterior Leg Muscles - Deep
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Posterior Leg Muscles - Superficial
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Thanks Katie!

• MAP(L) OF SCIATIC(L)
• Medial Obturator Nerve
• Anterior Femoral Nerve
• Posterior Sciatic Nerve
• (L)ateral (L)ateral Cutaneous Nerve

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Neurological Anatomy - Posterior
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Nerves

• Sciatic nerve
• Tibial division
• gastrocnemius (medial head)
• soleus
• tibialis posterior
• flexor digitorum longus
• flexor hallucis longus
• Medial plantar nerve
• Lateral plantar nerve

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Nerves

• Sciatic nerve
• Common peroneal (fibular) division
• Superficial peroneal nerve
• peroneus longus
• peroneus brevis
• Deep peroneal nerve
• tibialis anterior
• extensor digitorum longus
• extensor hallucis longus
• peroneus tertius
• extensor digitorum brevis

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Neurological Anatomy - Anterior
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Nerves

• Femoral nerve
• Iliopsoas
• Rectus femoris
• Vastus medialis
• Vastus intermedius
• Vastus lateralis
• Pectineus
• Sartorius
• Saphenous nerve
• Medial leg foot

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Nerves

• Obturator Nerve
• Adductor brevis
• Adductor longus
• Adductor magnus
• Gracilis
• Obturator externus
• Sensation to medial thigh

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Neurovascular Anatomy of Leg
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Dermatomes (L4 green, L5 purple, S1 flesh)
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Movements

• Eversion
• Turning ankle foot outward abduction, away
  from midline weight is on medial edge of foot
• 5-15º of eversion
• Inversion
• Turning ankle foot inward adduction, toward
  midline weight is on lateral edge of foot
• 20-30º of inversion
• Dorsiflexion (flexion)
• Movement of top of ankle foot toward anterior
  tibia
• 15-20º of dorsiflexion
• Plantar flexion (extension)
• Movement of ankle foot away from tibia
• 50º of plantar flexion

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Evaluation of the Ankle Low Leg

• History
• What happened? (MOI)
• Where is the pain?
• What causes the pain?
• When did it happen? (onset)
• Has it happened before?
• What does it feel like?
• Pain scale (1-10)
• What type of surface?
• How old are the shoes?
• Type of pain
• Unusual noises/sensations

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What is the History? What do you See?
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Observation

• Appearance
• How is their ankle hanging?
• Bilateral comparison
• Color
• Deformity
• Edema/Swelling
• Is there a lot of swelling immediately?
• Gait
• Infection
• Weight bearing vs. non-weight bearing

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What Do You See?
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Evaluation of the Ankle Low Leg

• Palpation
• Start away from the point of pain
• Medial structures
• Lateral structures
• Dorsal structures
• Plantar structures
• Crepitus
• Heat
• Swelling
• Rigidity
• Deformities

• Stress/ Special Tests
• ROM tests (AROM, PROM, RROM-strength)
• Special Tests
• Fracture tests
• Ligament/Capsular tests
• Neurologic tests
• Other

Which stress/special test do you perform first?
How do you make the correct decision?
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Stress/ Special Tests
When do you perform all of these tests?

• Lower Leg Fractures
• Compression (Squeeze) test (fracture)
• Bump (Tap or Percussion) test (stress fracture)
• ROM AROM, PROM, RROM
• Talar Tilt (Inversion Eversion Stress) tests
  (calcaneofibular ligament or deltoid ligament
  instability)
• Anterior Drawer test (ATF ligament instability)
• Kleigers Test (syndesmosis instability)
• Homans Sign (deep vein thrombophlebitis
  neurovascular pathology)
• Thompson test (achilles tendon pathology)

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Whats your Diagnosis?

• What is the MOI?
• Where is the pain elicited?
• Which tests elicit positive findings?
• What are your observations?
• How is the ROM strength?
• Are there any neurovascular symptoms?
• What do you think the injury is?

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What Do You Do Next?

• Is referral needed?
• RICES
• Are any home instructions
• needed?

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Conclusion

• Questions?????
• Case Study
• Trivia
• What is the os calcis?
• What is an os trigonum injury?