Chapter 19: The Ankle and Lower Leg

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Chapter 19 The Ankle and Lower Leg
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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

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• 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

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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

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• 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

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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?

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• 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
• Homans 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

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Compression Test
Percussion Test
Homans Test
Thompson Test
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• 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

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Anterior Drawer Test
Talar Tilt Test
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• 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

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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

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• 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

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• Achilles Tendon Rupture
• Etiology
• Occurs w/ sudden stop and go forceful plantar
  flexion w/ knee moving into full extension
• Commonly seen in athletes gt 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

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• 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,
  NSAIDs, 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

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• 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

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• 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

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• 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

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• 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, NSAIDs and analgesics as needed
• Surgical release is generally used in recurrent
  conditions
• Return to activity after surgery - light
  activity- 10 days later

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• 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)

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• 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