Ankle
and
Lower Leg
Chapter 17
Ankle Bony Anatomy
• Talus (link between
lower leg & foot)
• Tibia
– Medial malleolus
• Fibula
– Lateral malleolus
• Tibial tuberosity
• Tibial condyles
Bony Anatomy
Bones of the Ankle
– Tibia
• Tibia is the second longest bone in the body
• Principle weight bearing bone of the lower leg
• Anatomical weakness present in the lower third of
the shaft
Fibula
– Joins the tibia with an arthrodial articulation at the
upper end, just below the knee and as a syndesmotic
joint at the lower end
– Main function is to provide for attachment of muscles
Tibial and Fibular Malleoli
• Lateral malleolus extends further distally which creates
stability on the lateral aspect of the ankle
• Medial malleolus is part of the tibia
Bones of the Ankle
– Talus
• Second largest tarsal, and main weight-bearing bone of
the articulation, rests on the calcaneous and receives the
articulating surfaces of the lateral and medial malleoli
– Calcaneous
• Forms the heel, attachment site for ligaments and the
achilles tendon
Ankle Articulations
Talar Joint (Talocrural
joint)
• Tibia & fibula with
talus
• Dome of talus
articulates with
mortise formed by
tibia & fibula
• Motions: dorsiflexion
& plantar flexion
Subtalar Joint
• Articulation of talus
with calcaneus
• Motions: inversion &
eversion
Ligaments
• Lateral aspect
– Anterior talofibular
(ATF)
– Anterior tibiofibular
– Calcaneofibular (CF)
– Posterior talofibular
• Medial aspect
– Deltoid Ligament
Superior and Inferior Tibiofibular
Joints
• Inferior tibiofibular joint is a fibrous
(Syndesmosis) articulation between the lateral
malleolus and the distal end of the tibia
• Superior tibiofibular joint formed by the tibia’s
lateral condyle and the head of the fibula –
allows for some gliding movements
Stabilizing Ligaments
• Tibiofibular Ligaments
–Anterior and posterior
tibiofibular
– hold the tibia and fibula together, form
the distal portion of the interosseous
membrane (syndesmotic ligaments)
• Oblique arrangement aids in diffusing the forces on the
lower leg
Ankle Ligaments
Lateral Ligaments
• Anterior Talofibular:
restrains anterior
displacement of talus
• Calcaneofibular:
restrains inversion of
calcaneous
• Posterior Talofibular:
restrains posterior
displacement of talus
Medial Ligaments
• Deltoid (anterior
tibiotalar, tibionavicular,
tibiocalcaneal and
posterior tibiotalar):
• Prevents abduction and
eversion of the ankle and
subtalar joint
• Prevents eversion,
pronation and anterior
displacement of the talus
Articular Capsule
• Encases the ankle joint, thick on
the medial aspect and becomes
thin at the back
Muscle Compartments
Anterior Compartment
Lateral Compartment
• Contains the
muscles that
dorsiflex the ankle
and extend the
toes (tibialis anterior,
• Contains muscles
the evert the foot
and ankle
extensor hallucis
longus, extensor
digitorum)
• Peroneus longus and
brevis (evert ankle),
peroneus tertius
(assists dorsiflexion),
superficial branch of
the peroneal nerve
Muscle Compartments
Superficial Posterior
Compartment
• Muscles that
plantarflex the
foot and ankle
• Gastrocnemius,
and soleus
Deep Posterior
Compartment
Foot and ankle
invertors
• Tibialis Posterior,
flexor digitorum
longus and flexor
hallucis longus
Posterior tibial artery
Compartments of the
Lower Leg
• Anterior
– Tibialias anterior
– Extensor digitorum
longus
– Peroneus tertius
– Extensor hallucis
muscles
• Peroneal
– Peroneus longus
– Peroneus brevis
• Deep Posterior
– Popliteus
– Flexor digitorum
longus
– Flexor hallucis longus
– Tibialis posterior
• Superficial Posterior
– Gastrocnemius
– Soleus
– Plantaris
Compartments of the
Lower Leg
Compartments of the
Lower Leg
Muscles of the Lower Leg
• Flexor hallucis longus
• Flexor digitorum
longus
• Anterior tibialis
Muscles of the Lower Leg
• Peroneus tertius
• Peroneus longus
• Peroneus brevis
Muscles of the Lower Leg
• Gastrocnemius
• Soleus
Muscles of the Lower Leg
Muscles of the Lower Leg
Nerve and Blood Supply
– Major nerves of the lower leg are the tibial
and common peroneal
– Major arteries include the posterior and
anterior tibial arteries
– Primary veins consist of popliteal, peroneal
and anterior and posterior tibial veins.
Functional Anatomy
• Ankle is a stable hinge joint
• Medial/lateral dislocation is prevented by
malleoli
• Square shape of talus adds stability of
ankle
• Most stable during dorsiflexion, least
stable in plantar flexion
Ankle Motions
•
•
•
•
•
•
Plantar Flexion
Dorsiflexion
Inversion
Eversion
Pronation
Supination
Common Injuries
to the
Ankle & Lower Leg
Contusions
• Occur most often on
tibia
• Can be painful and
disabling
• Complication
compartment syndrome
Muscle Strains
• Most common in calf
• Result from:
– violent contraction
– Overstretching
– Continued overuse
• Usually occur in area
of MTJ or insertion of
Achilles tendon
• Result from:
– Repetitive overuse
– Single violent
contraction
• Acute strain to
Achilles have
tendency to become
chronic
Cramps
• A sudden, involuntary contraction of a
muscle
• Contributing factors include:
– Fatigue
– Fractures
– Dehydration
– Lack of nutrients in diet
– Poor flexibility
– Improperly fitted equipment
Cramps—Treatment
• Passive stretching
• Fluid replacement
– Water
– Sports drink
• Massage
• Rest
• Ice
Achilles Tendonitis
• Inflammation of
Achilles tendon
• Tearing of tendon
tissues caused by
excessive stress
• Occurs at point where
tendon attaches to
heel
Achilles Tendonitis
• Symptoms develop gradually
• Repeated or continued
overstress increases
inflammation
• Pain, crepitus, redness
• Treatment
–
–
–
–
–
–
Prevention
Stretching
Biomechanical problems?
Ice/Rest
NSAIDs
Heel lift/Achilles taping
Achilles Tendon Rupture
• Rupture occurs w/in
tendon, approx 1-2”
proximal to insertion
• Eccentric force applied
to dorsiflexed foot
– Poor conditioning
– Overexertion
•
•
•
•
Direct trauma
Surgically repaired
Rehab = 1yr +
Thompson test
Medial Tibial Stress
Syndrome
• aka shin splints
• Catchall term for
pain that occurs
below knee
– Anterior shin
– Medial shin
• Result of doing too
much too soon
• Associated with:
– repetitive activity on
hard surface
– forcible excessive
use of leg muscles
(running, jumping)
– tightness of gastroc
and/or soleus
muscles
– improper footwear
– running
biomechanics
MTSS Treatment
•
•
•
•
Ice
Reduce activity level
Gentle stretching
Biomechanical
assessment
• Orthotics
• NSAIDs
• Strengthening and
flexibility program
Stress Fractures
• Incomplete crack in
bone
• Microscopic fractures
in bone that will
eventually lead to full
fracture if left
untreated
• Repeated stress
placed on bone
greater than body’s
ability to heal it
Stress Fractures—S/Sxs
• “hot spot” of sharp,
intense pain upon
palpation
Shin-splint
Stress Fx
• Pain more
generalized
• Pain worse in
am
• Pain worse
in pm
Compartment Syndrome
• Swelling within one or more of the
compartments of the lower leg
• Caused by:
– Contusion
– Fracture
– Crush injury
– Localized infection
– Excessive exercise
– Overstretching
Ankle Sprains
• MOI: combo of excessive inversion and
PF
– aka lateral ankle sprain
• Anterior Talofibular Ligament (ATF)
– Calcaneofibular (CF)
– Posterior talofibular (PTF)
• Eversion (medial) ankle
sprain less common
– Deltoid ligament
Ankle Sprains
• Injury to ligamentous
and capsular tissue
• Traumatic joint twist
that results in
stretching of total
tearing of the
stabilizing connective
tissue
• One of most common
& disabling sports
injuries
• General Symptoms:
 Joint swelling
 Local temperature
increase
 Pain
 Point tenderness
 Skin discoloration
Ankle Sprains
• Inversion
– Anterior Talofibular
– Calcaneofibular
– Posterior Talofibular
• Eversion
– Deltoid Ligament
• Syndesmotic
– High ankle sprain
Ankle Sprain—S/SXS
 Grade 1





Some pain
Minimum LOF
Mild point tenderness
Little or no swelling
No abnormal motion
 Grade 2




Pain
Moderate LOF
Swelling
Slight to moderate
instability
 Grade 3
 Severe sprain
 Extremely painful initially
 LOF
 Severe instability
 Tenderness
 Swelling
 May represent
subluxation that
reduced
spontaneously
Ankle Sprain—Treatment
•
•
•
•
•
•
R.I.C.E.
Crutches
Boot
Splint, tape, brace
Compressive wrap
Horseshoe
Special Tests
&
Rehabilitation
Anterior Drawer
Talar Tilt
• Tests integrity of anterior
talofibular ligament
• Tests integrity of
calcaneofibular ligament
Squeeze Test
• Squeezing the tibia and
fibula together
• Can indicate fracture or
high ankle sprain
Bump Test/Tap Test
• Bump calcaneus
– Indicate fracture to
tibia/fibula
– Indicate high ankle sprain
• Tap mallelous
– Indicate fracture of
particular bone
Ankle Rehab
•
•
•
•
•
4-way TheraBand®
Heel walks/Toe walks
3-way heel raises
Unilateral Balance
3-way Tramp throw