KNR 387

ANKLE AND LOWER

LEG
Clicker Questions
 A pt comes to you complaining of pain in
the arch and pain radiating to the toes and
plantar aspect of the foot. What condition
do you suspect?
1. Metatarsalgia
71%
2. Intermetatarsal
neuroma
3. Plantar fasciitis
4. Pump bumps
18%
5. MT fx
6% 6%
0%
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 What condition is depicted here?
47%
41%

1. Rearfoot varum
2. Rearfoot valgum
3. Forefoot varum 6% 6%
4. Forefoot valgum
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 Where would you palpate and find the dorsal
pedal pulse?
1. Posterior to the lateral
malleolus
2. Anterior to the medial 59%

malleolus
3. Between the 1st and 2nd
phalanges
4. Between the 1st and 2nd 18%

metatarsals 6%
12%
6%

5. None of the above

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 Introduction
 Ankle injuries among most common injury in
athletics
20-25% of all athletic time-lost

 High re-injury rate

Residual instability
Loss of joint position sense

 Trauma to lower leg can cause compression of

neurovascular structures
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 Clinical Anatomy
 Ankle mortise
Tibia/fibula/talus

 Weight Bearing
Tibia ≈ 83-100%
Fibula ≈ 0-17%
○ Muscle attachment
○ Ligamentous attachment
○ Lateral stability to mortise
○ Pulley for muscles posteriorly
to it
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 Talocrural Joint
 Dorsiflexion = closed-pack position

 Ligaments
ATF
CF
PTF
Deltoid

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 Interosseous Membrane & Syndesmosis
 Interosseous membrane
Strong, fibrous tissue fixating tibia to fibula

 Distal Tibiofibular Syndesmosis

Anterior/Posterior tib-fib ligaments
Extension of interosseous membrane

 Damaged through excessive eversion or

dorsiflexion
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 Muscles of Lower Leg
 Anterior Compartment
 Tibialis anterior
 Ext Hallucis Longus
 Ext Digitorum Longus
 Peroneus tertius

 Dorsiflexors

 Extensor retinaculum

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 Muscles of Lower Leg
 Lateral compartment
 Peroneus longus
 Preoneus brevis

 Superior & inferior

peroneal retinacula

 Superficial peroneal
nerve
 Peroneal artery
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 Muscles of the Lower Leg
 Superficial Posterior
Compartment
 Gastrocnemius
 Soleus
 Plantaris

 Triceps surae group

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 Muscles of the Lower Leg
 Deep Posterior
Compartment
 Tibialis posterior
 Flexor digitorum longus
 Flexor hallucis longus

 Tibial nerve
 Posterior tibial artery

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 Bursae
 Subtendinous
calcaneal
AKA:
retrocalcaneal

 Subcutaneous
calcaneal

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 This muscle is a dynamic restraint
against excessive inversion at the ankle.
56%
1. Tibialis posterior
2. Tibialis anterior
3. Peroneus tertius
4. Peroneus longus
19%
13% 13%

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 All of the following are muscles in the
superficial posterior compartment EXCEPT:

1. Plantaris 94%

2. Gastrocnemius
3. Soleus
4. Tibialis posterior
5. All of the above
are in the
superficial post.
6%
compartment 0% 0% 0%
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Clinical Evaluation
 History
 Location of pain
Referred pain
○ Anterior compartment syndrome, Tarsal tunnel
syndrome, or peroneal nerve, sciatic nerve root
impingement
Type of pain
Onset
Mechanism
Activity/conditioning changes
Previous history
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 Inspection
 Weight bearing status

 General bilateral comparison

Redness, pallor, obvious deformity

 Swelling
Girth or volumetric measurements

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 Inspection
 Peroneal muscle group
 Distal ⅓ of fibula
 Medial/Lateral malleolus
 Malleoli
 Talus
 Sinus tarsi
 Medial Longitudinal Arch
 Gastroc/soleus complex
 Achilles tendon
 Bursae
 Calcaneous
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Neurological Testing
 Dermatomes
Nerve Root Area
L4 Medial lower leg, medial
foot
L5 Lateral lower leg, dorsal
foot
S1 Lateral foot
Tibial Plantar calcaneus
Medial Medial plantar aspect of
Plantar foot
Lateral Lateral plantar aspect of
Plantar foot
Sural Lateral heel

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 Myotomes/Reflexes

Nerve Testing Reflex

Root
L4 Dorsiflexion Patellar tendon
L5 Toe extension
S1 Plantarflexion Achilles’
S2 Knee flexion
S3 Foot intrinsics

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Refer to Microsoft Word document

Palpation
 Range of Motion Testing
 AROM
Plantarflexion ≈ 50°
Dorsiflexion ≈ 20°
Inversion ≈ 20°
Eversion ≈ 5°

 PROM
Plantar/Dorsi w/ knee flexed & extended

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 Resisted ROM
 Plantarflexion
Single-leg heel raise
Straight & bent knee

 Dorsiflexion
 Inversion
 Eversion

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Ligamentous Stability
 Ligamentous Stress Tests
 ATFL
Anterior drawer test
 CFL
Inversion stress test (Talar Tilt)
 Deltoid ligament
Eversion stress test (Talar Tilt)
External Rotation Test (Kleiger’s Test)

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 Ligamentous Stress Tests
 Syndesmosis Instability
Overpressure w/ passive dorsi

External rotation of talus

○ Kleiger’s test

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Pathologies and Related
Special Tests
 Ankle Sprain Videos
 Video 1

 Video 2

 Video 3

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 Lateral Ankle Sprain
 Least stable in open-packed position
ATFL
CF
PTFL
 Predisposing factors
Decreased proprioception
Decreased muscular strength
Pes cavus
Tightness of the triceps surae
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 Lateral Ankle Sprain
 High re-incidence rate (70%)
60% experience residual effects

 Why?
Loss of static restraints & too slow of a reflex arc
Decreased proprioceptive ability

 Prophylactic devices
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 Clinical Findings
 Mechanism of injury
 Sensation of “popping”
Localized pain along lateral ligament complex
Diffuse swelling
 Pt tenderness
 Painful inv, PF, and decreased ROM

 Medial ankle pain

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 Diagnostic Tests
 Bump & Squeeze/Compression Test
Must rule out fx FIRST

 Anterior drawer

 Talar tilt

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 Chronic Ankle Instability (CAI)
 Etiology
Repeated lateral ankle sprains
Laxity in ligamentous structures
Often found in pes cavus individuals
Decreased proprioception
 Objectives
Stabilize calcaneous at heel strike
Limit rearfoot inversion
External support
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 Syndesmosis Sprain
 10-18% of all ankle sprains

 Significant time lost

Painful weight bearing
Immobilization & non-weight bearing

 Must rule out fx

 Excessive ER of talus or forced DF

Causes mortise to spread
Can involve ATF, PTF, interosseous membrane
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 Syndesmosis Sprain
 AROM restricted
Pain w/ DF, eversion, end range of PF & Inv
 PROM pain in all directions
DF & eversion worst
 RROM weak
All directions

 Positive: Kleiger’s & squeeze tests

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 Medial Ankle Sprains
 Relatively stable deltoid ligament
Bony support from lateral malleolus
○ Small amount of eversion

 Mechanism typically external rotation

Syndesmotic sprain

 Pain along medial joint line

 Localized swelling
 Evaluate medial malleolus carefully for fx

 Special Tests: Talar tilt, Kleiger’s

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 Medial Tibial Stress Syndrome
 “Shin Splints”
 Etiology
Overuse or weakness of posterior tibial, flexor
hallicus/digitorum, or soleus muscles
Abnormal biomechanics
Improper shoes
Pes planus/hyperpronated foot
Frequency, intensity, & duration of activity
Practice/playing surface
Distance runners, jumpers
Can be caused by direct blow
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 MTSS
 Pain at posterior, medial aspect of tibia
Distal 2/3 most common
Increased pain w/ activity

 Objectives
Control pronation
Rest, ice, stretching
May require orthotics

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 Stress Fx
 Affects tibia, fibula, and talus
Persistent microtrauma

 Pain w/ activity  Better w/ rest

May report decreased muscle strength or
cramping
 May present w/ crepitus

 Squeeze & bump tests—likely negative

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 Achilles Tendon Pathology
 Achilles tendonitis
Inflammation of the tendon
Poorly vascularized

 Achilles tendon rupture

Forceful sudden contraction
Tends to occur in distal 2 to 6 cm (avascular)

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 Achilles tendonitis
 Poor vascular supply
Inflammatory process possible?
Paratenon: surrounds tendon—highly vascular
○ Inflammation: Peritendinitis
 Produces pain and forms adhesions with underlying
tendon

Tendinosis: Degeneration of tendon

Peritendinits  Tendinosis  Tendon rupture

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 Associated Factors
 Age & gender strongest predictor

 Running mechanics
 Duration/Intensity of training
 Type of shoe
 Running surface
 Biomechanics of foot/ankle

 Also can be caused by direct blow

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 Achilles Tendon Rupture
 Most prominent in men over 30

 Episodic strenuous activity

Deconditioning

 Feeling of being kicked—audible pop

 Positive Thompson test

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 Management
 Conservative
Casting for minimum of 8 weeks
○ Pros: absence of wound problems
○ Cons: increased risk of re-rupture, decreased
muscle function, pt dissatisfaction w/ outcome
 Surgically
Arthroscopic or open surgery
○ Pros: less than 5% re-rupture rate, greater return to
pre-injury level, good strength, power, endurance
○ Cons: surgical complications & wound healing
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 Subluxing Peroneal Tendon
 Cause
Tear of superior peroneal
retinaculum
○ Forceful, sudden dorsi &
eversion or plantar & inv
Tendons become
dorsiflexors

 Surgery required for

recurrent subluxations
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 Anterior Compartment Syndrome
 Cause
Increased pressure in ant
compartment
Obstructs neurovascular
network of lower leg
Compartment doesn’t
accommodate swelling well
○ Lack of oxygen leads to
ischemia and cell death

 Never apply compression

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 Type of Compartment Syndrome
 Traumautic Anterior Compartment Syndrome
Blow to ant or anteriolateral lower leg
○ Edema causes increase pressure
○ Pressure obstructs neurovascular network

 Chronic Exertional Compartment Syndrome

Occurs secondary to anatomic abnormalities
○ Increased thickness of fascia

 Acute Exertional Compartment Syndrome

No prior symptoms or history of traumatic injury
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 Signs & Symptoms
 “Five P’s”
Pain
○ Localized within affected area
○ Increased during active, passive, or resistive ROM
Pallor (redness)
Pulselessness
○ Dorsal pedal pulse (only very severe cases)
Paresthesia
○ Webspace between 1st & 2nd toes
Paralysis
○ Drop foot gait

 Pain w/ passive stretching of muscles within compartment

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 Deep Vein Thrombophlebitis (DVT)
 Thrombophlebitis: inflammation of veins with
associated blood clots

 Most common in post-surgical patients

 Symptoms:
Pain, tightness in calf
Possible swelling
Warmth, tightness of musculature

 Positive Homan’s sign

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On-Field Evaluations
 Equipment Removal
 Footwear

 Tape & Brace

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Questions?