Chapter 5
The Ankle and Lower Leg
Clinical Anatomy
 VERY
IMPORTANT! Pages 136-145
 Bones and bony landmarks
 Articulations and ligamentous support
 Muscles
 Compartments
 Bursae
Clinical Evaluation of the Ankle and
Lower Leg
 Bi-lateral
comparison
 Patient Positioning
 Interrelated to foot and knee
 Evaluation Map, page 146
History
 Location
of pain (Table 5-2, page 147)
 Nature or type of pain
 Onset
 Injury Mechanism (Table 5-3, page 148)
 Changes in activity and conditioning
 Prior history of injury
Inspection
 General



Weight-bearing status
Bilateral comparison
Swelling
 Lateral



Inspection
Structures
Peroneal muscle group
Distal one third of fibula
Lateral Malleolus (Figure 5-15, page 149)
Inspection
 Anterior




Appearance of anterior lower leg
Contour of the malleoli
Talus
Sinus tarsi (Figure 5-16, page 149)
 Medial


Structures
Structures
Medial malleoli
Medial longitudinal arch
Inspection
 Posterior




Structures
Gastrocnemius-soleus complex
Achilles tendon
Bursae
Calcaneus
Palpation
 Utilize
textbook pages 150-154
 Refer to list of Clinical Proficiencies
 Palpation of Pulses


Posterior tibial artery
Dorsalis pedis artery
Range of Motion Testing
 Talocrural




Joint
Affected by muscular tightness, bony
abnormalities, or soft tissue constraints
100 of dorsiflexion during walking
150 of dorsiflexion during running
If DF is limited, the foot compensates by
increasing pronation
 Table
5-4, page 154
 Goniometry (Box 5-2, page 155)
Active Range of Motion
 Plantarflexion


700 of motion
Figure 5-17, page 155
 Inversion


and dorsiflexion
and eversion
250 of motion
Figure 5-18, page 155
Passive Range of Motion
 Plantarflexion


and dorsiflexion
Measured with knee flexed and extended
Firm end-feel
• Anterior capsule, deltoid lig, ATF lig (PF)
• Achilles tendon (DF)
 Inversion


and Eversion
Stabilize lower leg
End-feel
• Inversion – firm (lateral ankle ligs, peroneals)
• Eversion – hard (fibula striking calcaneus) or firm
(medial jt capsule and musculature)
Resistive Range of Motion
 Box
5-3, page 156
 DF, PF, INV, EV
 Toe-raise test (figure 5-19, page 157)
Tests for Ligamentous Stability
 Specific
testing for joint play and specific
ligament tenderness and pain
Test for Anterior Talofibular
Ligament Instability
 ATF
prevents anterior translation of the
talus relative to ankle mortis
 Combination of PF, INV, and SUP place
strain on ATF
 Anterior Drawer Test

Box 5-4, page 158
Test for Calcaneofibular Ligament
Instability
 Talar


Tilt test (inversion stress test)
Box 5-5, page 159
Also stresses anterior and posterior talofibular
ligaments
Test for Deltoid Ligament Instability
 Talar

Tilt test (eversion stress test)
Box 5-6, page 160
 Kleiger’s

test (external rotational test)
Box 5-7, page 161
Test for Ankle Syndesmosis
Instability
 Overpressure


at end of DF
Ankle syndesmosis, anterior tibiofibular
ligament, interosseous membrane, posterior
tibiofibular ligament
Talus is wedged into talocrural joint, causing
separation between tibia and fibula
 Kleiger’s
Test (external rotational test)
Neurologic Testing
 Dysfunction
can occur secondary to
compartment syndrome or direct trauma
 Common peroneal nerve


Table 5-5, page 162
Figure 5-20, page 162
 Lower
16)
quarter screening (Chapter 1, page
Pathologies and Related Special
Tests
 Ankle



Sprains
Most occur secondary to supination and
cause trauma to the lateral ligament complex,
due to calcaneal inversion
Less commonly, the medial ankle ligaments
and distal tibiofibular syndesmosis are
sprained
Trauma to capsule
Lateral Ankle Sprains
 Open-packed
vs closed-packed position
 Sudden forceful inversion; specific
structures injured depends on talocrural
joint position
 ATF ligament – most commonly sprained
 Calcaneofibular and posterior talofibular
ligaments may also be injured
Lateral Ankle Sprains
 Anatomic
and physiologic predisposing
conditions
 Prophylactic devices
 Re-incidence rates


Loss of ligament’s ability to protect and
support joint
Decreased proprioceptive ability
Lateral Ankle Sprains
 Evaluation

Table 5-6, page 163
 Additional


trauma may be overlooked
Medial structures, peroneals, achilles tendon,
etc.
Figure 5-21, page 164
 Secondary


Findings
conditions
Thickened connective tissue, bone bruises,
blood accumulations, etc.
Figure 5-22, page 164
Lateral Ankle Sprains
 Traction
injuries to peroneal nerve
 Evaluating ankle sprains in adolescents
 Treatment
Syndesmosis Sprains
 Only
represent between 10% and 18% of
all ankle sprains
 Associated with significantly increased
amounts of time loss
 Excessive external rotation or forced
dorsiflexion = talus placing pressure on
fibula = spreading of syndesmosis
 Figure 5-23,page 165
Syndesmosis Sprains
 Factors
contributing to occurrence
 Evaluation Findings

Table 5-7, page 167
 Squeeze

Test
Box 5-8, page 166
 Maisonneuve

Fracture
Figure 5-24, page 167
 Treatment
Medial Ankle Sprains
 Eversion


is limited by:
Strength of deltoid ligament
Mechanical advantage - longer lateral
malleolus
 External
rotation of talus in ankle mortis
 Medial longitudinal arch and syndesmosis
may also be involved
Medial Ankle Sprains
 Evaluation

Table 5-8, page 168
 Injuries



Findings
to surrounding structures
“knock-off” fracture (Figure 5-25, page 168)
Pott’s fracture
Interarticluar trauma to talus and tibia