KIN 191AKIN 191AAdvanced Assessment of Advanced Assessment of Lower Extremity InjuriesLower Extremity Injuries

ANKLE/LOWER LEG INJURIESANKLE/LOWER LEG INJURIES

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INTRODUCTIONINTRODUCTION

ANKLE SPRAINSANKLE SPRAINS STRESS FRACTURESSTRESS FRACTURES OS TRIGONUM INJURYOS TRIGONUM INJURY ACHILLES TENDON PATHOLOGYACHILLES TENDON PATHOLOGY SUBLUXATING PERONEAL TENDONSSUBLUXATING PERONEAL TENDONS NEUROVASCULAR DEFICITNEUROVASCULAR DEFICIT

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ANKLE SPRAINSANKLE SPRAINS

Lateral ankle sprains (inversion Lateral ankle sprains (inversion sprains)sprains)

Medial ankle sprains (eversion Medial ankle sprains (eversion sprains)sprains)

Syndesmosis sprains (high ankle Syndesmosis sprains (high ankle sprains)sprains)

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Lateral Ankle SprainsLateral Ankle Sprains

Ankle complex is least stable when it Ankle complex is least stable when it is in the open packed positionis in the open packed position Plantar flexion + InversionPlantar flexion + Inversion

ATFATFCFCFPTFPTF

Open packed position: the joint Open packed position: the joint position at which its bones are position at which its bones are maximally incongruentmaximally incongruent

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Pain is localized along the lateral ligament Pain is localized along the lateral ligament complex and sinus tarsicomplex and sinus tarsi

Produce rapid, diffuse swellingProduce rapid, diffuse swelling Tenderness along the involved ligament (s)Tenderness along the involved ligament (s) Possible fractures of the talus and calcaneusPossible fractures of the talus and calcaneus Possible fractures of the distal medial Possible fractures of the distal medial

malleolus, or base/styloid process of the 5malleolus, or base/styloid process of the 5thth metatarsalmetatarsal

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Anatomic and physiologic factorsAnatomic and physiologic factors Decreased proprioceptive abilityDecreased proprioceptive ability Decreased muscular strengthDecreased muscular strength Lack of muscular coordinationLack of muscular coordination Tightness of the Achilles tendon or the Tightness of the Achilles tendon or the

triceps surae musclestriceps surae muscles

Anterior drawer test (+): ATFAnterior drawer test (+): ATF Inversion stress test (+): CFInversion stress test (+): CF

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Medial Ankle SprainsMedial Ankle Sprains

Strength of the deltoid ligament and Strength of the deltoid ligament and the mechanical advantage of the the mechanical advantage of the longer lateral malleolus limit eversionlonger lateral malleolus limit eversion

External rotation of the talus in the External rotation of the talus in the ankle mortiseankle mortise

Eversion stress test (+)Eversion stress test (+) External rotation (Kleiger’s) test (+)External rotation (Kleiger’s) test (+)

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Syndesmosis SprainsSyndesmosis Sprains

Account 10% of all ankle sprains and Account 10% of all ankle sprains and as high as 18% of football playersas high as 18% of football players

During excessive external rotation of During excessive external rotation of the talus and/or forced dorsiflexion, the talus and/or forced dorsiflexion, the talus places pressure on the the talus places pressure on the fibula, causing the distal fibula, causing the distal syndesmosis to spreadsyndesmosis to spread

Damaged to anterior and/or posterior Damaged to anterior and/or posterior tibiofibular ligament as welltibiofibular ligament as well

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Pain with DF/ER due to wider Pain with DF/ER due to wider anterior dome of talus spreading anterior dome of talus spreading distal tib-fib jointdistal tib-fib joint

Must rule out involvement of fibular Must rule out involvement of fibular fracture due to common mechanismfracture due to common mechanism Proximal 1/3 of fibula fracture (Maisonneuve) Proximal 1/3 of fibula fracture (Maisonneuve)

from rotational stress that can cause from rotational stress that can cause syndesmosis injurysyndesmosis injury

Squeeze test (+)/Squeeze test (+)/ External rotation test (+)External rotation test (+)

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Lateral Ankle InjuriesLateral Ankle Injuries

Impingement of medial joint Impingement of medial joint capsule/ligamentscapsule/ligaments

Peroneal tendon strain/rupturePeroneal tendon strain/rupture Medial malleolar “push-off” fractureMedial malleolar “push-off” fracture Avulsion fracture of 5Avulsion fracture of 5thth metatarsal or lateral metatarsal or lateral

malleolusmalleolus Talus/ankle mortise chondral lesionsTalus/ankle mortise chondral lesions Superficial branch of peroneal nerve injuriesSuperficial branch of peroneal nerve injuries

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Medial Ankle InjuriesMedial Ankle Injuries

Avulsion fracture of medial malleolusAvulsion fracture of medial malleolus Bimalleolar (Pott’s) fractureBimalleolar (Pott’s) fracture Talus/ankle mortise chondral lesionsTalus/ankle mortise chondral lesions

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STRESS FRACTURESSTRESS FRACTURES Accumulation of microtraumatic forces Accumulation of microtraumatic forces May affect the tibia, fibula, and talusMay affect the tibia, fibula, and talus

Pain along the shaft of the bonePain along the shaft of the bone Symptoms of gradual onsetSymptoms of gradual onset May reveal crepitus and point May reveal crepitus and point

tendernesstenderness Not visible via x-ray until approximately Not visible via x-ray until approximately

3 weeks post-onset3 weeks post-onset

Bump test (+)Bump test (+) Squeeze test (+)Squeeze test (+)

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OS TRIGONUM INJURYOS TRIGONUM INJURY Os trigonum is formed when Os trigonum is formed when

Steida’s process separates from Steida’s process separates from the talusthe talus

Impinges on surrounding soft Impinges on surrounding soft tissues causing symptoms – tissues causing symptoms – typically gradual onsetstypically gradual onsets Os trigonum syndrome (talar Os trigonum syndrome (talar

compression syndrome)compression syndrome) Inflammation of the posterior joint and Inflammation of the posterior joint and

ligaments surrounding the os trigonumligaments surrounding the os trigonum Fracture of the os trigonumFracture of the os trigonum

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ACHILLES TENDON ACHILLES TENDON PATHOLOGYPATHOLOGY

Achilles tendinitisAchilles tendinitis Poorly vascularized structure that receives Poorly vascularized structure that receives

limited blood supply from the posterior limited blood supply from the posterior tibial arterytibial artery

May present with crepitus to palpation or May present with crepitus to palpation or ROM testingROM testing

ParatenonParatenon Tendon surrounded by a highly vascular Tendon surrounded by a highly vascular

structurestructure Inflammation of paratenon causes peritendinitisInflammation of paratenon causes peritendinitis TendinosisTendinosis

Lesions caused by decreased local blood flow Lesions caused by decreased local blood flow (ischemia) secondary to peritendinitis(ischemia) secondary to peritendinitis

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Achilles tendon ruptureAchilles tendon rupture Avascular zone of tendon just proximal to Avascular zone of tendon just proximal to

calcaneal insertion pointcalcaneal insertion point Forceful, sudden contractions is most Forceful, sudden contractions is most

common MOIcommon MOI Chronic degeneration of the tendon due Chronic degeneration of the tendon due

to inflammatory conditionto inflammatory condition Most treated surgicallyMost treated surgically

Thompson test (+)Thompson test (+)

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SUBLUXATING SUBLUXATING PERONEAL TENDONSPERONEAL TENDONS

Forceful sudden DF/Eversion or Forceful sudden DF/Eversion or PF/Inversion may stretch or rupture PF/Inversion may stretch or rupture the superior peroneal retinaculumthe superior peroneal retinaculum

May visibly/palpably move from May visibly/palpably move from behind lateral malleolus – become DF behind lateral malleolus – become DF instead of normal PF function and can instead of normal PF function and can also contribute to development of also contribute to development of biomechanical complicationsbiomechanical complications

Local inflammatory symptoms at site Local inflammatory symptoms at site of injuryof injury

May require surgical interventionMay require surgical intervention

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NUEROVASCULAR DEFICITNUEROVASCULAR DEFICIT Disruption of the blood or nerve supply Disruption of the blood or nerve supply

to or from the lower leg can result from to or from the lower leg can result from acute trauma, overuse conditions, acute trauma, overuse conditions, congenial defects, or surgerycongenial defects, or surgery

A complete examination of the A complete examination of the dermatomes, reflexes, and pulses of dermatomes, reflexes, and pulses of the lower and foot should be conductedthe lower and foot should be conducted

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Anterior Compartment Anterior Compartment SyndromeSyndrome

Resulting from increased pressure Resulting from increased pressure within the anterior compartment – within the anterior compartment – traumatic or exertionaltraumatic or exertional Traumatic – bleeding from direct blow to Traumatic – bleeding from direct blow to

compartment musclescompartment muscles Exertional – can be acute or chronic due Exertional – can be acute or chronic due

to volumetric changes in muscle tissue to volumetric changes in muscle tissue and/or poor vascular function/venous and/or poor vascular function/venous outflow secondary to arterial inflowoutflow secondary to arterial inflow

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Increased pressure in compartment Increased pressure in compartment compromises neurovascular supply to dorsal compromises neurovascular supply to dorsal foot – ischemia to affected tissuesfoot – ischemia to affected tissues

5 P’s5 P’s PainPain Pallor (redness)Pallor (redness) Pulselessness (dorsal pedal artery)Pulselessness (dorsal pedal artery) Paresthesia (deep peroneal nerve)Paresthesia (deep peroneal nerve) Paralysis (deep peroneal nerve)Paralysis (deep peroneal nerve)

Require immediate referral for treatment, Require immediate referral for treatment, may be limb threatening if not treatedmay be limb threatening if not treated

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Deep Vein ThrombophlebitisDeep Vein Thrombophlebitis The inflammation of veins with The inflammation of veins with

associated blood clots associated blood clots (thrombus), is most found in (thrombus), is most found in postsurgical patientspostsurgical patients

Homan’s signHoman’s sign The calf is squeezed while the The calf is squeezed while the

ankle is passively dorsiflexedankle is passively dorsiflexed Pain in the calfPain in the calf