Chapter 5
The Ankle and Lower Leg
Continued
Stress Fractures
 Evaluation

Findings
Table 5-9, page 169
 Predisposing

factors
Narrow tibial shaft, hip external rotation, pes
cavus
 Diagnostic
testing
 Bump Test (Box 5-9, page 170)
 Treatment (Figure 5-26, page 169)
 Table 5-10, page 171
Os Trigonum Injury
 Evaluation

Table 5-11, page 173
 Steida’s

Findings
process (figure 5-27,page 172)
Formation of an os trigonum (Fig 5-28, p172)
 Os
trigonum syndrome (talarcompression
syndrome)




Inflammation of posterior joint
Inflammation of surrounding ligaments
Fracture of the os trigonum
Pathology involving Steida’s process
Os Trigonum Injury cont.
 Inversion/plantarflexion

posterior talocalcaneal ligament tightens
against os trigonum or Steida’s process
 Eversion

of calcaneus
os trigonum or Steida’s process to become
compressed between tibia and calcaneus
 Treatment
Achilles Tendon Pathology
 Association
with gastrocnemius and
soleus
 Decreased plantarflexion strength

Changes in gait; ability to walk, run, jump
Achilles Tendinitis
 Evaluation

Table 5-12, page 174
 Poorly



Findings
vascularized structure
Limited blood supply - posterior tibial artery
Distal avascularized zone – 2 to 6 cm
proximal to insertion on calcaneus
Delayed healing
Achilles Tendinitis cont.
 Paratenon

Highly vascularized structure, surrounds
tendon
 Peritendinitis
 Tendinosis

Degeneration of tendon’s substance
 Peritendinitis
Rupture
Tendinosis
Tendon
Achilles Tendinitis cont.
 Factors
leading to achilles tendon
pathology






Tibial varum
Calcaneovalgus
Hyperpronation
Tightness of triceps surae, hamstring groups
Running mechanics, duration and intensity of
running, type of shoe, running surface
Biomechanics of foot and ankle
 Acute
Onset
Achilles Tendinitis cont.
 Age
and gender
 Pain characteristics
 Treatment/Return to activity
Achilles Tendon Rupture
 Evaluation

Findings
Table 5-13, page 176
 Forceful,
sudden contraction = large
amount of tension developing in tendon
 Theories


Chronic degeneration of tendon
Failure of inhibitory mechanism of
musculotendinous unit
 Rupture
tends to occur in distal 2-6 cm
Achilles Tendon Rupture cont.
 Age

and gender
Previous or current tendinosis, age-related
changes in tendon, deconditioning
 Corticosteroid
injections
 Characteristics of rupture

Figure 5-29, page 175
 Thompson

Test
Box 5-10, page 177
 Treatment
Subluxating Peroneal Tendons
 Evaluation

Findings
Table 5-14, page 178
 Forceful,
sudden DF/EV or PF/INV =
stretch or rupture of superior peroneal
retinaculum
 Tendon alignment

Figure 5-30, page 176
Subluxating Peroneal Tendons
cont.
 Predisposing





factors
Flattened fibular groove
Pes planus
Hindfoot valgus
Recurrent ankle sprains
Laxity of peroneal retinaculum
 Characteristics
 Treatment
Neurovascular Deficit
 Disruption
of blood or nerve supply to or
from lower leg




Acute trauma
Overuse conditions
Congenital defects
Surgery
 Dermatomes,
reflexes, pulses
Anterior Compartment Syndrome
 Evaluation

Findings
Table 5-15, page 179
 Increased
pressure in compartment
threatens integrity of lower leg, foot, and
toes

Obstructs neurovascular network
• Deep peroneal nerve
• Anterior tibial artery
Anterior Compartment Syndrome
cont.
 Bony
posterolateral border and dense
fibrous fascial lining = poor elastic
properties


Cannot accommodate for expansion of
intracompartmental tissues
Increased pressure = lack of oxygen to local
tissues
• Leads to ischemia and possibly cell death
Anterior Compartment Syndrome
cont.
3

classifications
Traumatic
• blow to anterior or anterolateral portion of lower leg

Exertional
• acute or chronic; during or after exercise (or both)

Chronic (recurrent or intermittent claudication)
• Occurs secondary to anatomic abnormalities
obstructing blood flow to exercising muscles
• Increased thickness of fascia inhibits venous
outflow
• Other anatomic factors – page 178
Anterior Compartment Syndrome
cont.
 Associated





Tibial fractures
Anticoagulant therapy
Diabetes
Knee braces
High-heeled shoes
 Signs

with
and Symptoms
5 P’s
• Pain, pallor, pulselessness, paresthesia, paralysis
Anterior Compartment Syndrome
cont.
 Drop
foot gait
 Dorsalis pedis pulse (Figure 5-31, pg 180)
 Most important clinical finding

Severe pain with passive muscle stretching
 Medical

emergency
Decreased pulse, paresthesia, paralysis
 Compartmental
 Treatment
pressure
Deep Vein Thrombophlebitis
 Inflammation
of veins with associated
blood clots
 Common in postsurgical patients
 May be secondary to trauma to lower
extremity
 Pain and tightness in calf during walking


Inspection – swelling in calf
Palpation – warmth, tightness, pain
 Homan’s

sign
Box 5-11, page 181
On-Field Evaluation of Lower Leg
and Ankle Injuries
 Goals



Rule out fractures and dislocations
Determine weight-bearing status
Removal methods
Equipment Considerations
 Footwear




Rule out fracture/dislocation and then remove
shoe
Figure 5-32, page 181
Apprehensive athletes – remove themselves
If fracture is suspected – check pulses
 Tape


Removal
and Brace Removal
Similar to shoe removal
Tape is cut on opposite side of injury
 On-Field

Mechanism of injury
•
•
•
•
•

History
Inversion
Eversion
Rotation
Dorsiflexion
Plantarflexion
Associated sounds and sensations
 On-Field
Inspection
 On-Field Palpation


Bony palpation
Soft tissue palpation
 On-Field


Range of Motion Tests
Willingness to move involved limb
Willingness to bear weight
Initial Management of On-Field
Injuries

Ankle Dislocations (talocrural joint)






Excessive rotation combined with INV or EV
Disruption of capsule/ligaments, fractures of malleoli,
long bones, talus
Pain, loss of function, audible sounds
Figure 5-33, page 183
Confirm presence of pulses
Lower Leg Fractures



Signs/symptoms (Figure 5-34, page 183)
Fibula – may be able to walk
Bump/squeeze tests
Management of Lower Leg
Fractures and Dislocations
 Immediately

immobilized
Moldable or vacuum splints
 Leave
shoe on until emergency room
 Figure 5-35, page 183
 Compound fracture

Control bleeding
 Treatment

Figure 5-36, page 184
Anterior Compartment Syndrome
 Avoid
compression
 Acute gross hemorrhage or absent
dorsalis pedis pulse – immediate refer to
physician
 Educate athletes