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

• Interosseous membrane

• Muscles:– peroneals

– anterior tibialis

– posterior tibialis

– triceps surae

• Bursae

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

• 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.

• 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

• Other Tests:– Toe Raise

– Heel Raises

– Walking/Hopping/Jumping

On-field Functional Testing

• Willingness to:– Move joint

– Bear weight

• Contraindicated:– Obvious deformity

– Be cautious when full AROM present

Ligamentous Testing--p.157

• Anterior Drawer• Posterior Drawer• Talar tilt• Kleiger test

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

• Knee flexed/foot stabilized

• Assesses laxity in ATFL

• (+)= anterior movement of talus on mortise

Posterior Drawer

• Similar to Anterior Drawer

• Tests integrity of PTFL

• (+) = Posterior movement of talus on mortise

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

• 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

• Bump Test--p.170• Squeeze test--p.166• Thompson test--p.177• Homan’s sign--p.181

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

• 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

• 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

• 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

• 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

• 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

• 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

• 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)

• 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 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

• 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

Ankle Impingement Syndrome

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

• 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.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

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

• 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)

• Caused by Overuse: • Evaluate PROM in DF and PF

• Evaluate Achilles flexibility

• Treatment:– Improve circulation in

lower leg

– Reverse muscle strength imbalance

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.