1. Ankle Orthopedic Exams

2. Medial Aspect

3. Medial Tendons

4. Posterior Tibial Artery, Tibial Nerve

5. Lateral Malleolus & Attached Ligaments

6. Peroneus Longus and Peroneus Brevis Tendons

7. Anterior Aspect

8. Posterior Aspect

9. Ligamentous Instability Ligaments Anterior and posterior talofibular, anterior tibiofibular, and deltoid ligaments. If any of these ligaments are torn, the tibia can separate from the fibula and the talus may become unstable. Common mechanism of injury is a supination or inversion force.

10. Ligamentous Instability The foot turns under the ankle after walking or running on uneven surfaces or when landing on an inverted foot after a jump. The most common injured ligament is the anterior talofibular ligament. Ligament laxity can lead to chronic ankle sprains.

11. Ligamentous Instability Clinical Signs and Symptoms Ankle swelling Static ankle pain Pain on passive motion Tenderness over affected ligament

12. Proprioceptive Training

13. Ligaments

14. Drawer’s Foot Sign Procedure: Patient supine. Stabilize ankle with one hand. Press posterior on tibia with the other hand. Next, grasp anterior aspect of the foot with one hand and the posterior aspect of the tibia with the other. Pull anterior. Rationale: Gapping with posterior push – tear anterior talofibular Gapping with anterior pull – tear posterior talofibular

15. Drawer’s Foot Sign

17. Lateral Stability Procedure: Patient supine. Passively invert foot. Rationale: Gapping secondary to trauma. Suspect tear of anterior talofibular ligament or calcaneofibular ligament.

18. Lateral Stability

20. Medial Stability Procedure: Patient supine. Passively evert foot. Rationale: Gapping secondary to trauma. Suspect tear of deltoid ligament.

21. Medial Stability

23. Tarsal Tunnel Syndrome Tarsal tunnel syndrome occurs when the posterior tibial nerve becomes entrapped in its tunnel as it passes behind the medial malleolus to enter the foot. The tunnel can be compressed either intrinsically or extrinsically. Space-occupying lesions account for 50% of the cases.

24. Tarsal Tunnel Syndrome Direct trauma and repetitive dorsiflexion account for a significant portion of the remaining cases. A severe flat foot can unduly stretch the posterior tibial nerve. Other possible causes include: fracture callus, ganglion of the tendon sheath, lipoma, engorged venus plexus, and excessive pronation of the hind foot.

25. Tarsal Tunnel Syndrome Clinical Signs and Symptoms Intermittent paresthesia of plantar aspect of foot Pain on foot inversion and / or eversion of the foot Pain radiating to medial aspect of the leg Pain made worse by activity and improved by rest

26. Tarsal Tunnel

27. Tinel’s Foot Sign Procedure: Tap over the posterior tibial nerve with a neurological reflex hammer. Rationale: Paresthesias radiating to the foot indicate irritation of the posterior tibial nerve that may be caused by constriction at the tarsal tunnel.

28. Tinel’s Foot Sign

29. Achilles Tendon Rupture Achilles tendon rupture generally occurs in adults aged 30 to 50. It is usually spontaneous in athletes who account for most of these injuries. Decreased vascularity of the Achilles tendon as the patient ages may contribute.

30. Achilles Tendon Rupture Mechanism of injury - forced dorsiflexion of the foot as the soleus and gastrocnemius contract. Rupture occurs 2 to 6 cm from the insertion of the Achilles tendon into the calcaneus. As the proximal aspect of the tendon retracts, there is usually a palpable defect of the tendon.

31. Achilles Tendon Rupture Clinical Signs and Symptoms Severe posterior ankle pain Inability to stand on toes Posterior leg and heel swelling Posterior leg and heel ecchymosis

32. Thompson’s Test Procedure: Patient prone. Flex knee. Squeeze the calf muscles against the tibia and fibula. Rationale: The the gastrocnemius and soleus are squeezed, they mechanically contract. They are attached to the Achilles tendon, which plantar-flexes the foot. If the tendon is ruptured, contraction of the gastrocnemius and soleus muscles will NOT plantar- flex the foot.

33. Thompson’s Test