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Sports Medicine II Mrs. Marr THE 4 BONES OF THE ANKLE JOINT TIBIA FIBULA TALUS CALCANEUS ANKLE LIGAMENTS – MEDIAL • Deltoid Ligament Complex A B D C – – – – – 4 ligaments Broad Flat Overlapping = STRONG! ANKLE LIGAMENTS - LATERAL • Lateral Collateral Ligaments – ATF • Anterior • From Talus to Fibula • Weakest of 3 ligaments – PTF • Posterior • From Talus to Fibula • Strongest/Deepest of 3 ligaments – CF • Anterior • From Calcaneus to Fibula • Largest; Strong and Cord-like ANKLE MUSCLES: ANTERIOR SIDE • TIBIALIS ANTERIOR – – – – Muscle starts @ top of Tibia Tendon crosses over Ankle Joint @ Talus Attaches at the base of the 1st foot bone Cross over at joint allows for multiple motions • Major Motion: – – – Dorsiflexion of the ankle joint Inversion of the foot Prevents the forefoot slapping AND scrapping the ground ANKLE MUSCLES: LATERAL SIDE • PERONEAL GROUP – – – – 3 muscles (peroneus brevis/longus/tertius) Muscle group starts @ top of Fibula Peroneal tendon hooks around the back of Lateral Malleolus Insertion of Peroneal Tendon is at the base of the 5th foot bone • Major Motion: Eversion of the Foot @ the Ankle ANKLE MUSCLES: POSTERIOR • GASTROCNEMIUS – – – – Muscle starts on distal femur 1 muscle with two points of origin Achilles Tendon is other attachment Crosses two joints Major Motion: Plantarflexion @ the Ankle •ACHILLES TENDON -Large Tendon/Cord from Gastroc. -Inserts firmly at Calcaneus -Largest, Strongest Tendon in Body -Combination of Gastroc and Soleus Tendons Compartments of the Leg 1. Anterior 2. Lateral (peroneal) 3. Deep posterior 4. Superficial posterior Anterior Compartment Musculature • • • • Tibialis anterior Extensor digitorum longus Extensor hallucis longus Peroneus tertius Tibialis Anterior • DF and inversion • O: lateral tibial condyle and shaft • I: medial/plantar 1st cuneiform and metatarsal • N: deep peroneal Extensor Digitorum Longus • Extension of 2nd-5th MP joints, assists with eversion and DF • O: lateral tibial condyle, proximal ¾ of anterior fibula • I: via 4 tendons into distal phalanges of 2nd-5th toes • N: deep peroneal Extensor Hallucis Longus • Extension of 1st MP and IP joints • O: middle 2/3 of anterior fibula • I: base of distal 1st phalanx • N: deep peroneal Peroneus Tertius • • • • Eversion of foot, assists in PF O: distal 1/3 of anterior fibula I: dorsal base of 5th metatarsal N: deep peroneal Lateral Compartment Musculature • Peroneus longus • Peroneus brevis Peroneus Longus • Eversion of the foot, assists with PF • O: lateral tibial condyle, fibular head, upper 2/3 of lateral fibula • I: lateral base of 1st metatarsal, lateral and dorsal aspect of 1st cuneiform • N: superficial peroneal Peroneus Brevis • Eversion of the foot, assists with PF • O: distal 2/3 of lateral fibula • I: styloid process at base of 5th metatarsal • N: superficial peroneal Superficial Posterior Compartment Muscles • Gastrocnemius • Soleus • Plantaris Gastrocnemius • Ankle PF, assists knee flexion • O: medial head – posterior medial femoral condyle, lateral head – posterior lateral femoral condyle • I: calcaneus via Achilles tendon • N: tibial Soleus • Ankle PF • O: posterior fibular head, upper 1/3 of posterior fibular, soleal line on posterior tibial shaft, middle 1/3 of medial tibial border • I: calcaneus via Achilles tendon • N: tibial Plantaris • Ankle PF, assists knee flexion • O: distal supracondylar line of lateral femoral condyle, femoral popliteal surface • I: calcaneus via Achilles tendon • N: tibial Deep Posterior Compartment Musculature • “Tom, Dick, AND Harry” • Tibialis posterior •Flexor Hallucis Longus •Flexor Digitorum Longus Tibialis Posterior • Inversion of the foot, assists with PF • O: posterior/lateral tibia, upper 2/3 of medial fibula • I: navicular tuberosity, via slips into sustentaculum tali, cuneiforms, cuboid and bases of 2nd-4th metatarsals • N: tibial Flexor Digitorum Longus • Flexion of 2nd-5th PIP/DIP/MP joints, assists with foot inversion and PF • O: posterior medial 2/3 of distal tibia • I: plantar surface of base of 2nd-5th distal phalanges • N: tibial Flexor Hallucis Longus • Flexion of 1st IP joint, assists with flexion of 1st MP joint, foot inversion and PF • O: posterior/distal 2/3 of fibula • I: plantar surface of 1st proximal phalanx • N: tibial Syndesmosis Interosseous membrane (Syndesmosis) isn't a compartment but ligamentous sheathe that holds the tibia and the fibula together. Nerves and Blood Vessels • Nerves: – Peroneal N. – Tibialis Anterior/ Posterior N. – Saphenous N. • Blood Vessels – Dorsal Pedal A. – Posterior Tibial A. – Greater/ Lesser Saphenous V. Neuroanatomy • Anterior compartment – Deep branch of Peroneal nerve • Lateral compartment – Superficial branch of Peroneal nerve • Deep posterior compartment – Tibial nerve • Superficial posterior compartment – Tibial nerve Deep Branch of Peroneal Nerve • Branches from common Peroneal nerve near fibular head • “Dives” into anterior compartment Superficial Branch of Peroneal Nerve • Branches from common Peroneal nerve near fibular head • Stays superficial and lateral in lateral compartment Tibial Nerve • Runs in fascial sheath between deep and superficial posterior compartments • Provides innervation to both, but not “in” either Vascular Anatomy • Anterior compartment – Anterior tibial artery • Lateral compartment – Peroneal artery • Deep posterior compartment – Posterior tibial artery • Superficial posterior compartment – Posterior tibial artery Anterior Tibial Artery • Traverses similar path to deep Peroneal nerve • Terminating as dorsal pedal artery Peroneal Artery • Branches off of posterior tibial artery Posterior Tibial Artery • Runs in fascial sheath between deep and superficial posterior compartments • Provides vascular supply to both, but not “in” either Special Tests The Squeeze Test • Squeeze test – check malleolus – Check tibia and fibula – May indicate FX • Feel for any abnormalities • Feeling for grinding or movement Special Tests Anterior Drawer/Tilt Anterior drawer tests should always be performed with the knee bent to eliminate the Achilles and Gastrocnemius muscles from providing any stability to the ankle. A lateral talar tilt test can be conducted at the same time. Anterior Drawer Test Tilt Test Special Tests Functional Tests • Functional tests (Return to play) a) walking - check gait b) toe raises 1) both feet 2) one foot c) jump and land on both feet and then on one foot