Ankle and Lower Leg Chapter 17

Ankle Bony Anatomy Talus (link between lower leg & foot) Tibia Fibula Medial malleolus Fibula Lateral malleolus Tibial tuberosity Tibial condyles

Bony Anatomy

Bones of the Ankle Tibia Fibula Tibia is the second longest bone in the body Principle weight bearing bone of the lower leg Anatomical weakness present in the lower third of the shaft Fibula Joins the tibia with an arthrodial articulation at the upper end, just below the knee and as a syndesmotic joint at the lower end Main function is to provide for attachment of muscles

Tibial and Fibular Malleoli Lateral malleolus extends further distally which creates stability on the lateral aspect of the ankle Medial malleolus is part of the tibia

Bones of the Ankle Talus Calcaneous Second largest tarsal, and main weight-bearing bone of the articulation, rests on the calcaneous and receives the articulating surfaces of the lateral and medial malleoli Calcaneous Forms the heel, attachment site for ligaments and the achilles tendon

Ankle Articulations Talar Joint (Talocrural joint) Tibia & fibula with talus Dome of talus articulates with mortise formed by tibia & fibula Motions: dorsiflexion & plantar flexion Subtalar Joint Articulation of talus with calcaneus Motions: inversion & eversion

Ligaments Lateral aspect Medial aspect Anterior talofibular (ATF) Anterior tibiofibular Calcaneofibular (CF) Posterior talofibular Medial aspect Deltoid Ligament

Superior and Inferior Tibiofibular Joints Inferior tibiofibular joint is a fibrous (Syndesmosis) articulation between the lateral malleolus and the distal end of the tibia Superior tibiofibular joint formed by the tibia’s lateral condyle and the head of the fibula – allows for some gliding movements

Stabilizing Ligaments Tibiofibular Ligaments Anterior and posterior tibiofibular hold the tibia and fibula together, form the distal portion of the interosseous membrane (syndesmotic ligaments) Oblique arrangement aids in diffusing the forces on the lower leg

Ankle Ligaments Lateral Ligaments Medial Ligaments Anterior Talofibular: restrains anterior displacement of talus Calcaneofibular: restrains inversion of calcaneous Posterior Talofibular: restrains posterior displacement of talus Deltoid (anterior tibiotalar, tibionavicular, tibiocalcaneal and posterior tibiotalar): Prevents abduction and eversion of the ankle and subtalar joint Prevents eversion, pronation and anterior displacement of the talus

Articular Capsule Encases the ankle joint, thick on the medial aspect and becomes thin at the back

Muscle Compartments Anterior Compartment Lateral Compartment Contains the muscles that dorsiflex the ankle and extend the toes (tibialis anterior, extensor hallucis longus, extensor digitorum) Contains muscles the evert the foot and ankle Peroneus longus and brevis (evert ankle), peroneus tertius (assists dorsiflexion), superficial branch of the peroneal nerve

Muscle Compartments Muscles that plantarflex the foot and ankle Superficial Posterior Compartment Deep Posterior Compartment Muscles that plantarflex the foot and ankle Gastrocnemius, and soleus Foot and ankle invertors Tibialis Posterior, flexor digitorum longus and flexor hallucis longus Posterior tibial artery

Compartments of the Lower Leg Anterior Tibialias anterior Extensor digitorum longus Peroneus tertius Extensor hallucis muscles Peroneal Peroneus longus Peroneus brevis Deep Posterior Popliteus Flexor digitorum longus Flexor hallucis longus Tibialis posterior Superficial Posterior Gastrocnemius Soleus Plantaris

Compartments of the Lower Leg

Compartments of the Lower Leg

Muscles of the Lower Leg Flexor hallucis longus Flexor digitorum longus Anterior tibialis

Muscles of the Lower Leg Peroneus tertius Peroneus longus Peroneus brevis

Muscles of the Lower Leg Gastrocnemius Soleus

Muscles of the Lower Leg

Muscles of the Lower Leg

Nerve and Blood Supply Major nerves of the lower leg are the tibial and common peroneal Major arteries include the posterior and anterior tibial arteries Primary veins consist of popliteal, peroneal and anterior and posterior tibial veins.

Functional Anatomy Ankle is a stable hinge joint Medial/lateral dislocation is prevented by malleoli Square shape of talus adds stability of ankle Most stable during dorsiflexion, least stable in plantar flexion

Ankle Motions Plantar Flexion Dorsiflexion Inversion Eversion Pronation Supination

Common Injuries to the Ankle & Lower Leg

Contusions Occur most often on tibia Can be painful and disabling Complication compartment syndrome

Muscle Strains Most common in calf Result from: violent contraction Overstretching Continued overuse Usually occur in area of MTJ or insertion of Achilles tendon Result from: Repetitive overuse Single violent contraction Acute strain to Achilles have tendency to become chronic

Cramps A sudden, involuntary contraction of a muscle Contributing factors include: Fatigue Fractures Dehydration Lack of nutrients in diet Poor flexibility Improperly fitted equipment

Cramps—Treatment Passive stretching Fluid replacement Water Sports drink Massage Rest Ice

Achilles Tendonitis Inflammation of Achilles tendon Tearing of tendon tissues caused by excessive stress Occurs at point where tendon attaches to heel

Achilles Tendonitis Symptoms develop gradually Repeated or continued overstress increases inflammation Pain, crepitus, redness Treatment Prevention Stretching Biomechanical problems? Ice/Rest NSAIDs Heel lift/Achilles taping

Achilles Tendon Rupture Rupture occurs w/in tendon, approx 1-2” proximal to insertion Eccentric force applied to dorsiflexed foot Poor conditioning Overexertion Direct trauma Surgically repaired Rehab = 1yr + Thompson test

Medial Tibial Stress Syndrome aka shin splints Catchall term for pain that occurs below knee Anterior shin Medial shin Result of doing too much too soon Associated with: repetitive activity on hard surface forcible excessive use of leg muscles (running, jumping) tightness of gastroc and/or soleus muscles improper footwear running biomechanics

MTSS Treatment Ice Reduce activity level Gentle stretching Biomechanical assessment Orthotics NSAIDs Strengthening and flexibility program

Stress Fractures Incomplete crack in bone Microscopic fractures in bone that will eventually lead to full fracture if left untreated Repeated stress placed on bone greater than body’s ability to heal it

Stress Fractures—S/Sxs “hot spot” of sharp, intense pain upon palpation Shin-splint Pain more generalized Pain worse in am Stress Fx Pain worse in pm

Compartment Syndrome Swelling within one or more of the compartments of the lower leg Caused by: Contusion Fracture Crush injury Localized infection Excessive exercise Overstretching

Ankle Sprains MOI: combo of excessive inversion and PF aka lateral ankle sprain Anterior Talofibular Ligament (ATF) Calcaneofibular (CF) Posterior talofibular (PTF) Eversion (medial) ankle sprain less common Deltoid ligament

Ankle Sprains Injury to ligamentous and capsular tissue Traumatic joint twist that results in stretching of total tearing of the stabilizing connective tissue One of most common & disabling sports injuries General Symptoms: Joint swelling Local temperature increase Pain Point tenderness Skin discoloration

Ankle Sprains

Inversion Eversion Syndesmotic Anterior Talofibular Calcaneofibular Posterior Talofibular Eversion Deltoid Ligament Syndesmotic High ankle sprain

Ankle Sprain—S/SXS Grade 1 Grade 2 Grade 3 Some pain Severe sprain Minimum LOF Mild point tenderness Little or no swelling No abnormal motion Grade 2 Pain Moderate LOF Swelling Slight to moderate instability Grade 3 Severe sprain Extremely painful initially LOF Severe instability Tenderness Swelling May represent subluxation that reduced spontaneously

Ankle Sprain—Treatment R.I.C.E. Crutches Boot Splint, tape, brace Compressive wrap Horseshoe

Special Tests & Rehabilitation

Anterior Drawer Talar Tilt Tests integrity of anterior talofibular ligament Tests integrity of calcaneofibular ligament

Squeeze Test Bump Test/Tap Test Squeezing the tibia and fibula together Can indicate fracture or high ankle sprain Bump calcaneus Indicate fracture to tibia/fibula Indicate high ankle sprain Tap mallelous Indicate fracture of particular bone

Ankle Rehab 4-way TheraBand® Heel walks/Toe walks 3-way heel raises Unilateral Balance 3-way Tramp throw