Chapter 5 The Ankle and Lower Leg Continued

Stress Fractures  Evaluation Findings Table 5-9, page 169 Table 5-9, page 169  Predisposing factors Narrow tibial shaft, hip external rotation, pes cavus 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 Findings Table 5-11, page 173 Table 5-11, page 173  Steida’s process (figure 5-27,page 172) Formation of an os trigonum (Fig 5-28, p172) Formation of an os trigonum (Fig 5-28, p172)  Os trigonum syndrome (talarcompression syndrome) Inflammation of posterior joint Inflammation of posterior joint Inflammation of surrounding ligaments Inflammation of surrounding ligaments Fracture of the os trigonum Fracture of the os trigonum Pathology involving Steida’s process Pathology involving Steida’s process

Os Trigonum Injury cont.  Inversion/plantarflexion posterior talocalcaneal ligament tightens against os trigonum or Steida’s process 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 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 Changes in gait; ability to walk, run, jump

Achilles Tendinitis  Evaluation Findings Table 5-12, page 174 Table 5-12, page 174  Poorly vascularized structure Limited blood supply - posterior tibial artery Limited blood supply - posterior tibial artery Distal avascularized zone – 2 to 6 cm proximal to insertion on calcaneus Distal avascularized zone – 2 to 6 cm proximal to insertion on calcaneus Delayed healing Delayed healing

Achilles Tendinitis cont.  Paratenon Highly vascularized structure, surrounds tendon Highly vascularized structure, surrounds tendon  Peritendinitis  Tendinosis Degeneration of tendon’s substance Degeneration of tendon’s substance  Peritendinitis Tendinosis Tendon Rupture

Achilles Tendinitis cont.  Factors leading to achilles tendon pathology Tibial varum Tibial varum Calcaneovalgus Calcaneovalgus Hyperpronation Hyperpronation Tightness of triceps surae, hamstring groups Tightness of triceps surae, hamstring groups Running mechanics, duration and intensity of running, type of shoe, running surface Running mechanics, duration and intensity of running, type of shoe, running surface Biomechanics of foot and ankle 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 Table 5-13, page 176  Forceful, sudden contraction = large amount of tension developing in tendon  Theories Chronic degeneration of tendon Chronic degeneration of tendon Failure of inhibitory mechanism of musculotendinous unit 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 Previous or current tendinosis, age-related changes in tendon, deconditioning  Corticosteroid injections  Characteristics of rupture Figure 5-29, page 175 Figure 5-29, page 175  Thompson Test Box 5-10, page 177 Box 5-10, page 177  Treatment

Subluxating Peroneal Tendons  Evaluation Findings Table 5-14, page 178 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 Figure 5-30, page 176

Subluxating Peroneal Tendons cont.  Predisposing factors Flattened fibular groove Flattened fibular groove Pes planus Pes planus Hindfoot valgus Hindfoot valgus Recurrent ankle sprains Recurrent ankle sprains Laxity of peroneal retinaculum Laxity of peroneal retinaculum  Characteristics  Treatment

Neurovascular Deficit  Disruption of blood or nerve supply to or from lower leg Acute trauma Acute trauma Overuse conditions Overuse conditions Congenital defects Congenital defects Surgery Surgery  Dermatomes, reflexes, pulses

Anterior Compartment Syndrome  Evaluation Findings Table 5-15, page 179 Table 5-15, page 179  Increased pressure in compartment threatens integrity of lower leg, foot, and toes Obstructs neurovascular network Obstructs neurovascular network Deep peroneal nerveDeep peroneal nerve Anterior tibial arteryAnterior tibial artery

Anterior Compartment Syndrome cont.  Bony posterolateral border and dense fibrous fascial lining = poor elastic properties Cannot accommodate for expansion of intracompartmental tissues Cannot accommodate for expansion of intracompartmental tissues Increased pressure = lack of oxygen to local tissues Increased pressure = lack of oxygen to local tissues Leads to ischemia and possibly cell deathLeads to ischemia and possibly cell death

Anterior Compartment Syndrome cont.  3 classifications Traumatic Traumatic blow to anterior or anterolateral portion of lower legblow to anterior or anterolateral portion of lower leg Exertional Exertional acute or chronic; during or after exercise (or both)acute or chronic; during or after exercise (or both) Chronic (recurrent or intermittent claudication) Chronic (recurrent or intermittent claudication) Occurs secondary to anatomic abnormalities obstructing blood flow to exercising musclesOccurs secondary to anatomic abnormalities obstructing blood flow to exercising muscles Increased thickness of fascia inhibits venous outflowIncreased thickness of fascia inhibits venous outflow Other anatomic factors – page 178Other anatomic factors – page 178

Anterior Compartment Syndrome cont.  Associated with Tibial fractures Tibial fractures Anticoagulant therapy Anticoagulant therapy Diabetes Diabetes Knee braces Knee braces High-heeled shoes High-heeled shoes  Signs and Symptoms 5 P’s 5 P’s Pain, pallor, pulselessness, paresthesia, paralysisPain, 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 Severe pain with passive muscle stretching  Medical emergency Decreased pulse, paresthesia, paralysis Decreased pulse, paresthesia, paralysis  Compartmental pressure  Treatment

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 Inspection – swelling in calf Palpation – warmth, tightness, pain Palpation – warmth, tightness, pain  Homan’s sign Box 5-11, page 181 Box 5-11, page 181

On-Field Evaluation of Lower Leg and Ankle Injuries  Goals Rule out fractures and dislocations Rule out fractures and dislocations Determine weight-bearing status Determine weight-bearing status Removal methods Removal methods

Equipment Considerations  Footwear Removal Rule out fracture/dislocation and then remove shoe Rule out fracture/dislocation and then remove shoe Figure 5-32, page 181 Figure 5-32, page 181 Apprehensive athletes – remove themselves Apprehensive athletes – remove themselves If fracture is suspected – check pulses If fracture is suspected – check pulses  Tape and Brace Removal Similar to shoe removal Similar to shoe removal Tape is cut on opposite side of injury Tape is cut on opposite side of injury

 On-Field History Mechanism of injury Mechanism of injury InversionInversion EversionEversion RotationRotation DorsiflexionDorsiflexion PlantarflexionPlantarflexion Associated sounds and sensations Associated sounds and sensations

 On-Field Inspection  On-Field Palpation Bony palpation Bony palpation Soft tissue palpation Soft tissue palpation  On-Field Range of Motion Tests Willingness to move involved limb Willingness to move involved limb Willingness to bear weight Willingness to bear weight

Initial Management of On-Field Injuries  Ankle Dislocations (talocrural joint) Excessive rotation combined with INV or EV Excessive rotation combined with INV or EV Disruption of capsule/ligaments, fractures of malleoli, long bones, talus Disruption of capsule/ligaments, fractures of malleoli, long bones, talus Pain, loss of function, audible sounds Pain, loss of function, audible sounds Figure 5-33, page 183 Figure 5-33, page 183 Confirm presence of pulses Confirm presence of pulses  Lower Leg Fractures Signs/symptoms (Figure 5-34, page 183) Signs/symptoms (Figure 5-34, page 183) Fibula – may be able to walk Fibula – may be able to walk Bump/squeeze tests Bump/squeeze tests

Management of Lower Leg Fractures and Dislocations  Immediately immobilized Moldable or vacuum splints Moldable or vacuum splints  Leave shoe on until emergency room  Figure 5-35, page 183  Compound fracture Control bleeding Control bleeding  Treatment Figure 5-36, page 184 Figure 5-36, page 184

Anterior Compartment Syndrome  Avoid compression  Acute gross hemorrhage or absent dorsalis pedis pulse – immediate refer to physician  Educate athletes