The Ankle and Lower Leg

1
The Ankle and Lower Leg

• Chapter 5

2
Ankle

• What bones make up the ankle joint?

3
Lower leg

• Periosteum
• What is inflammation of the periosteum called?
• What would cause this injury?

4
Fibula

• Non-weight bearing
• 12 of weight
• Serves 4 functions (?)
• Site of muscular attachment and origin
• Site of ligamentous attachment
• Provides lateral stability
• Serves as a pulley to increase muscular
  efficiency of muscles which lie posterior (?)

5
Fibula Cont.

• Superiorly
• Common peroneal N splits into the Superficial
  peroneal nerve and Deep peroneal nerve (Fig 5-3)

6
Lateral Malleolus

• Why is the lateral malleolus better at preventing
  ankle sprains than medial?
• Mechanically superior

7
Talus

• What structural feature allows the closed pack
  position to be dorsiflexion?

8
Talocrural Joint

• Name the bones that make up this joint?
• Closed-pack position??
• Ligamentous support
• Medially?
• Laterally?

9
Injury

• Most common injury?
• Most common mechanism?
• Must have ability to rationalize why mechanism
  cause certain injury
• Anterior talotibial and Tibionavicular PF
• Posterior talotibial and Tibiocalcaneal - DF

10
Tib-Fib Joint

• Integrity is maintained by what ligaments?
• Add crural interosseous lig
• Extension of interosseous membrane
• Common mechanism of injury for TibFib joint?

11
Muscles

• Anterior Compartment
• Posterior Compartment
• Deep Posterior Compartment
• Lateral Compartment

12
Retinaculum

• A structure that retains and organ or tissue in
  place
• Superior and Inferior Extensor Retinaculum
• Superior and Inferior Peroneal Retinaculum

13
Nerves and Vessels

• Anterior compartment
• Deep Peroneal N and Anterior Tibial Artery and
  Vein
• Posterior Compartment
• Tibial N and Posterior Tibial Artery and Vein
• Lateral Compartment
• Peroneal Artery and Vein
• Superficial Peroneal Artery
• Which is nerve is most prone to injury?
• What are examples of injury?

14
Bursae

• Retrocalcaneal bursae (subtendinous)
• Subcutaneous Calcaneal bursae

15
History

• Prior history
• May lead to decreased proprioception
• Why is this important?
• Injury Mechanism (Table 5-3)
• Dont forget opposite side due to compressive
  forces that will exist

16
Inspection

• Sinus Tarsi (Fig 5-16)

17
Palpation

• ???????????????????????????

18
Pulses

• What are the two pulses in the LE?

19
Active and Passive ROM

• What is neutral?
• 20 0 50 degrees (Dorsi/Plantarflexion)
• Evaluation of Dorsi/Plantarflexion should occur
  with knee flexed and extended
• Why?
• Firm endfeel in both directions
• 20 0 5 degrees (Inversion/Eversion)
• Pt. should lie supine for most reliable
  measurement
• Firm endfeel in inversion
• Hard endfeel in eversion
• Why?

20
Resistive ROM

• Due to large posterior muscle group, MMT may be
  inadequate for testing
• Use 10 rep unilateral heel raise

21
Ligamentous Testing

• Anterior Drawer?
• Posterior Drawer?
• Talar tilt for inversion?
• Talar tilt for eversion?
• Kleiger Test?
• Box 5-7, pg 161
• Maximal dorsiflexion test
• Squeeze test
• What other purposes are there for this test?

22
Neurologic Testing

• Figure 5-20
• Table 5-5
• Lower quarter screening
• L4, L5, S1, S2

23
Ankle Sprains

• Most common ligament injured?
• Mechanism??
• Capsular structures so result in more effusion
  than CF, which is extracapsular
• If moderate to severe, gt70 reincidence rate
• Why?
• Pg 163
• Possible pain over fibula indicates?

24
Syndesmosis

• Mechanism (s) ??
• Typically associated with deltoid lig sprain
• Heterotopic ossification?
• Synostosis?

25
Injuries
26
Injuries
27
Injuries

• Fig 5-21
• Fig 5-22

28
Medial Ankle Sprains

• Asses Spring Lig when dealing with medial ankle
  sprain
• Why?

29
Stress Fx

• Where is the most common site of stress fx in the
  leg?
• Test used to assess?
• Table 5-10

30
Os Trigonum

• Fracture of Steidas Process
• Ossification occurs around 13 y.o.
• Can occur due to non-union or stress fx
• Also can occur through trauma known as a
  traumatic os trigonum

31
Achilles Tendon

• An avascular zone is present 2 6 cm proximal to
  the insertion on the calcaneus
• This is the most common site of tendon pathology
• Succumbs to a continuous breakdown.
• Pg 173
• Age and gender most common predictors

32
Achilles Tendon Rupture

• Two theories exist as to why it occurs
• Chronic degeneration
• Failure of the inhibitory mechanism
• Increased risk with corticosteroids (Cortisone)

33
Subluxing peroneal tendons

• Sudden dorsiflexion may rupture superior peroneal
  retinaculum
• Changes line of pull
• Technique used for treatment

34
On-field management

• Fig 5-32