AT 359
Chapter 19 - The Ankle and Lower Leg

Bones of the Ankle:

Tibia- main weight bearing bone
Fibula- non-weight bearing bone; does not articulate with femur or true knee joint
Talus - main weight bearing tarsal bone; articulates with tibia and fibula
Calcaneus - supporting ankle ligaments attach to this bone as well; along with talus, forms subtalar joint

Joints:
Superior & Inferior Tibiofibular - between the tibia and fibula proximally and distally; associate with
        high ankle sprains
Talocrural - the ankle joint; hinge joint; movements that occur are plantar flexion and dorsiflexion;
        sometimes referred to as the "mortise" joint
Subtalar - talus and calcaneus form this joint; movements that occur are: inversion, supination, eversion, pronation

Primary Ligaments:
Tibiofibular - anterior and posterior; distal and proximal; hold tibia and fibula together; referred to as "syndesmotic"
        ligaments
Lateral Complex-
        -Anterior Talofibular
        -Posterior Talofibular
        -Calcaneofibular
Medial Complex-
        -Deltoid -superficial and deep parts
        -Spring

Main Musculature:

Nerve Supply: (both of the following divisions originate from sciatic nerve)
Tibial nerve - supplies muscles on the back of the leg and on the plantar aspect of foot
Common Peroneal nerve - splits into deep and superficial peroneal nerve; supplies front of leg and foot

Blood Supply:
Anterior Tibial artery - comes down on top of foot just lateral to Tibialis Anterior; supplies dorsum of foot
Posterior Tibial artery - comes down behind medial malleolous; supplies plantar aspect of foot

Prevention of Ankle Injury
    *achilles tendon stretching
    *strength training
    *neuromuscular control training
    *appropriate footwear
    *prophylactic taping/bracing

Ankle Assessment
Special Tests -
    -Percussion/Tap - checking for fx's
    -Compression - checking for fx's
    -Thompson - checking for achilles tendon rupture
    -Homan's Sign - checking for deep vein thromobophlebitis
    -Anterior Drawer - checking for anterior talofibular integrity
    -Talar Tilt - checking for medial and lateral ligamentous integrity
    -Kleiger's - checking for deltoid/tibiofibular ligament integrity
   
Inversion Ankle Sprains
    -most common ankle sprain mechanism; accounts for about 85% of all ankle sprains
    -injury to the lateral ligamentous complex, especially the anterior talofibular ligament
    -classified as Grades 1, 2 & 3
    -With grade 2 & 3 there will be some laxity/instability
    -must rule out Jone's fx
   
Eversion Ankle Sprains
    -not as common
    -usually more painful and takes longer to heal
    -can be associated with high ankle sprains as well as fibular fx's
    -also classified as Grades 1, 2 & 3

Syndesmotic Sprains (High Ankle Sprains)
    -injury to the distal tibiofibular ligaments
    -talus acts as a wedge that "splits" the tibia and fibula apart
    -takes months to heal (6 weeks) at the least
    -will require a boot at first

Fx's/Dislocations
    -more common with eversion grade 2 & 3 sprains
    -avulsion fx's most common                                                                      
            -Jone's fx
            -fibular fx
    -immobilization for at least 6-8 weeks

Osteochondritis Dissecans
    -occurs frequently on the talar dome
            -os trigonum fx
    -occurs from high trauma, overuse/degenerative conditions or repetitive trauma
    -surgical excision may be required

Acute Achilles Strain
    -MOI is usually a quick stretch of tendon, i.e. - stepping in a hole
    -can be a full rupture of tendon - (Thompson's Test)
    -ice and stretch along with a heel lift to take some pressure off of tendon

Achilles Tendonitis
    -involves either the tendon or the sheath surrounding it
    -s/s include: swelling, pain, crepitus on AROM of plantar flexion/dorsiflexion
    -usually an overuse condition
    -apply heel lift
   
Peroneal Tendon Subluxation/Dislocation
    -peroneal tendons held in place by peroneal retinaculum
    -retinaculum ruptures thereby allowing tendon to "pop" out of place upon eversion
    -ankle sprains are most common cause of rupture
    -"popping/snapping" occurs upon jumping, running, cutting, eversion
    -a compression horseshoe pad over area for 5-6 weeks in boot is recommended
            -if injury is not better after that period, then surgery is indicated

Anterior Tibialis Tendonitis
    -overuse condition common in runners especially running downhill
    -tenderness over muscle belly/tendon and pain upon active dorsiflexion
    -rest, stretching, NSAID's

Posterior Tibial Tendonitis
    -common amoung runners with hypermobility or pronated feet
    -stress is place upon posterior tibialis
    -orthotics, NSAID's, stretching, and sometimes casting may be helpful

Peroneal Tendonitis
    -can be more common in pes cavus type feet - from supinating
    -tenderness over peroneal muscles/tendons
    -overuse injury with pain on eversion
    -lateral heel wedge, NSAID's, stretching, strengthening are helpful

Shin Contusion
    -very painful - injury to periosteum
    -usually has a lot of swelling (hemtoma)
    -can be an emergency situation (Acute compartment syndrome)
    -can develop into osteomyelitis if not properly protected/treated

Muscle Contusions
    -common in contact sports
    -protection is required
                -watch for myositis ossificans
    -ice in a stretched position

Leg Cramps/Spasms
    -fatigue, fluid loss are factors
    -stretch with ice massage best treatment

Shin Splints (medial tibial stress syndrome)
    -overuse injury that is caused by various factors
    -can lead to stress fx
    -area of pain is usually generalized, not focal
    -focal pain is indicative of stress fx (Pencil Test)

Compartment Syndromes
    -can be acute or chronic
    -acute is more serious - usually related to contusion
    -"drop foot" is an indicator of emergency situation
    -chronic usually involves both legs, acute usually one leg

Functional Tests
    -walking on toes, heels
    -hopping
    -straight ahead running
    -figure "8"
    -side-to-side (zig-zags, carioca, shuffling)
    -sprinting
    -sports-specific skills

Web Sites for further study/learning:
www.medsite.com  -  Medical Search Engine

www.clarknet/pub/pribut/spsport.html - Dr. Pribut's Running Injuries Page

www.medmedia.com/med.htm - Wheeless' Textbook of Orthopedics

www.bunionbusters.com - North Shore Podiatry Foot Care Center

www.acfas.org - American College of Foot and Ankle Surgeons