ANKLE
AND
LOWER LEG
Chapter 17
WARM - UP
http://www.youtube.com/watch?v=4hCS1O2LP_c
FACTS ON THE ANKLE, AND FOOT
15% of all sports injuries involve the ankle
Ankle absorbs three times the force of the
body during running and jumping
Estimated 20,000 ankle sprains every day
in the US
Foot is responsible for some of the most
minor yet potentially debilitating conditions
if not treated
ANKLE BONY ANATOMY
Talus (link between lower leg &
foot)
Tibia
 Medial malleolus
Fibula
 Lateral malleolus
Mortise
 The bony arch formed by the tibial
plafond and the two malleoli
Tibial tuberosity
Tibial condyles
BONY ANATOMY
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
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
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
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
LIGAMENTS
Lateral aspect
 Anterior talofibular (ATF)
 Anterior tibiofibular
 Calcaneofibular (CF)
 Posterior talofibular
Medial aspect
 Deltoid Ligament
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
Symptoms develop
gradually
ACHILLES TENDONITIS
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 +
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 fracture
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
Pain more
generalized
Pain worse in AM
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 Plantarflexion
 aka lateral ankle sprain
Anterior Talofibular Ligament (ATF)
 Calcaneofibular (CF)
 Posterior talofibular (PTF)
Eversion (medial) ankle sprain less common
 Deltoid ligament
Syndesmotic sprain
 High ankle sprain
 Syndesmosis and tibiofibular ligament
ANKLE SPRAINS
Injury to ligamentous
and capsular tissue
Traumatic joint twist
that results in stretching
or 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
ANKLE ASSESSMENT
HISTORY QUESTIONS – FOOT
Always start with the general history questions
first…. How, what, when, where, and who was
involved
Where is the pain (ankle, heel, arches, toes)
Any sound – snapping, popping, crepitus
What type of surface has athlete been training
on?
What type of footwear was worn during training?
 Is it appropriated for the type of training?
 Is discomfort increased when footwear is worn?
HISTORY QUESTIONS – ANKLE/LOWER
LEG
Is there any sense of muscle weakness or difficulty
walking?
How disabling is the injury? Could you walk right
away or was there a period of time when you
could not bear weight
Different questions will be asked if they have a
chronic condition of the ankle/foot
 Past injuries??
OBSERVATION - FOOT
Always check for swelling, discoloration,
bleeding, deformity
Walking with limp or unable to bear weight
Pes Planus and Pes Cavus
Everything aligned
2nd toe longer than big toe
OBSERVATION – ANKLE/ LOWER LEG
Postural deviations in foot and ankle
Difficulty walking
Are ankles symmetrical
Crepitus or abnormal sound
Normal range of motion
Able to walk with a normal walking pattern
SPECIAL TESTS
&
REHABILITATION
Anterior Drawer
Talar Tilt
Tests integrity of anterior
talofibular ligament
Tests integrity of calcaneofibular
ligament
Kleiger’s Test
Tests integrity of the deltoid
ligament and syndesmosis
Thompson Test
If the gastrocnemius is squeezed
and the foot should plantarflex. If
it does not then there is a possible
rupture of the Achilles tendon
Squeeze Test
Bump Test/Tap Test
Squeezing the tibia and
fibula together
Bump calcaneus
Can indicate fracture or
high ankle sprain
 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
ANKLE INJURY BROCHURE - TEST
General Anatomy of the Ankle
 Bones and ligaments
Injuries: Ankle sprains (x3), Achilles Tendonitis,
Achilles Tendon Rupture, Compartment Syndrome,
and Medial Tibial Stress Syndrome.
 Include the following for each injury
 General definition – include anatomy
 MOI
 S/SX
 TX
General Rehabilitation Exercises