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The Ankle and Lower Leg
Overview
Ankle injuries, especially to the ligamentous tissue, are the most frequent injuries in sports. For the coach and
the athletic trainer, understanding the complex nature of ankle injuries should be a major goal.
Many sports place demands on the ankle and lower leg that far exceed the normal daily requirements. Many
ankle injuries could be prevented by Achilles tendon stretching, strengthening of key muscles, proprioceptive training,
proper footwear, and, in some cases, proper taping. The leg is prone to a number of acute conditions, of which
contusions and strains are most common. Although less common, fractures can occur because of direct trauma, such as
being struck by a blow or through torsioned forces with the foot fixed to the ground.
A number of problems of the leg can also be attributed to repetitive stress and overuse, such as medial shin
stress syndrome (shin splints), exercise-induced compartment compression syndromes (both acute and chronic), and
stress fractures.
Repetitive use and overuse of the lower extremity, particularly when there are biomechanical and subsequent
weight transmission discrepancies, can lead to problems in other regions of the body, particularly for the knee and hip.
This is especially true for long distance runners.
The athletic trainer should be capable of identifying, ameliorating, or preventing these problems whenever
possible.
I.
Anatomy of the Lower Leg and Ankle
1. Bones
a. Tibia
1. Tibia is the longest bone in the body with exception of the femur
2. Principle weight bearing bone of the leg
3. Anatomical weakness present in the lower third of the shaft
b. Fibula
1. Joins the tibia with an arthrodial articulation at the upper end, just below
the knee and as a syndesmotic joint at the lower end
2. Main function is to provide for attachment of muscles
c. Tibial and fibular malleoli
1. Lateral malleolus extends further distally which creates stability on the
lateral aspect of the ankle
d. Talus
1. 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
e. Calcaneous
1. Forms the heel, attachment site for ligaments and the achilles tendon
2. Articulations
a. Superior and Inferior Tibiofibular Joints
1. Inferior tibiofibular joint is a fibrous (Syndesmosis) articulation between
the lateral malleolus and the distal end of the tibia
2. Superior tibiofibular joint formed by the tibia’s lateral condyle and the
head of the fibula – allows for some gliding movements
b. Talocrual Joint
1. The ankle mortise formed by the distal portion of the tibia, lateral
malleolus and medial malleolus articulating with the trochlea of the talus
2. Movements include plantarflexion and dorsiflexion
3. The ankle joint is a hinge joint
c. Subtalar Joint
1. Discussed during the foot
2. Movements that occur include inversion, eversion
II.
III.
3. Stabilizing Ligaments
a. Tibiofibular Ligament
1. Oblique arrangement aids in diffusing the forces on the lower leg
2. Anterior and posterior tibiofibular ligaments, which hold the tibia and
fibula together, form the distal portion of the interosseous membrane
(syndesmotic ligaments)
b. Ankle Ligaments
1. Lateral Ligaments
A. Anterior Talofibular: restrains anterior displacement of talus
B. Calcaneofibular: restrains inversion of calcaneous
C. Posterior Talofibular: restrains posterior displacement of talus
2. Medial Ligaments
A. Deltoid (anterior tibiotalar, tibionavicular, tibiocalcaneal and
posterior tibiotalar):
B. Prevents abduction and eversion of the ankle and subtalar joint
C. Prevents eversion, pronation and anterior displacement of the talus
D. Joint Capsule
a. Encases the ankle joint, thick on the medial aspect and
becomes thin at the back
E. Muscle Compartments: divided into four distinct compartments
bounded by heavy fascia – (See Table 19-2)
a. Anterior Compartment: Contains the muscles that dorsiflex
the ankle and extend the toes (tibialis anterior, extensor
hallucis longus, extensor digitorum)
b. Lateral Compartment: Peroneus longus and brevis (evert
ankle), peroneus tertius (assists dorsiflexion), superficial
branch of the peroneal nerve
c. Superficial Posterior Compartment: Gastrocnemius, and
soleus (plantarflex ankle)
d. Deep Posterior Compartment: Tibialis Posterior, flexor
digitorum longus and flexor hallucis longus (invert ankle)
Posterior tibial artery
F. Nerve and Blood Supply
a. Major nerves of the lower leg are the tibial and common
peroneal
b. Major arteries include the posterior and anterior tibial
arteries
c. Primary veins consist of popliteal, peroneal and anterior
and posterior tibial veins.
Functional Anatomy
a. The ankle is a stable hinge joint, with dome of talus articulating with distal ends of
tibial and fibula
b. Medial or lateral displacement of talus prevented by malleoli
c. Talus is wider anteriorly than posteriorly – most stable position of the ankle is in
dorsiflexion
d. Ankle ROM ranges from 10º Dorsiflexion to 50º of plantarflexion
e. Normal gait requires at least 20 degrees of plantarflexion and 10 degrees of
dorsiflexion with the knee extended
Preventing Injury to the Lower Leg and Ankle
a. Achilles tendon stretching
b. Strength Training
IV.
V.
c. Neuromuscular Control Training
1. Involves adapting to uneven surfaces by controlling motion at the ankle joint
2. Neuromuscular control can be improved by working/balancing on uneven
surfaces daily
d. Footwear
1. Shoes should not be worn for activities for which they are not intended for
(running shoes should not be worn for tennis)
2. Cleats should be placed far enough on the border to avoid ankle sprains
3. High tops offer more stability than low tops for those with previous ankle
sprains
e. Preventative Ankle Taping and Orthoses
1. Controversy over taping ankles that have no history of sprains
2. If tape constricts soft tissue may disrupt normal biomechanical function and
create unnecessary injuries
3. Ankle braces superior to taping in preventing injuries
Assessing the Lower Leg and Ankle
a. History
b. Observation
c. Palpation (Bony and Soft-tissue)
d. Special Tests
1. Lower leg alignment tests: Determine malalignment
2. Percussion and compression Tests
3. Thompson Test: Achilles tendon integrity
e. Ankle Stability Tests
1. Anterior Drawer Test: Determines extent of injury to anterior talofibular
ligament
2. Talar Tilt Test: Determine extent of inversion or eversion injuries
f. Functional Tests
1. Walk on toes (tests PF)
2. Walk on heels (tests DF)
3. Walk on lateral borders of feet (tests inversion)
4. Walk on medial borders of feet (tests eversion)
5. Hop on injured ankle
Recognition of Specific Injuries
a. Ankle Injuries
1. Inversion Sprains (Grade I, Grade II, Grade III)
2. Eversion Sprains
3. Syndesmotic Sprains (High Ankle Sprain)
4. Ankle Fracture/Dislocation
5. Osteochondritis Dissecans
b. Lower Leg Injuries
1. Acute Achilles Tendon Strain
2. Achilles Tendinitis
3. Achilles Tendon Rupture
4. Peroneal Tendon Subluxation/Dislocation
5. Anterior Tibialis Tendinitis
6. Posterior Tibialis Tendinitis
7. Peroneal Tendinitis
8. Shin Contusion
9. Muscle Contusions
10. Leg Cramps and Spasms
11. Gastrocnemius Strain
12. Acute Leg Fractures
13. Medial Tibial Stress Syndrome
14. Compartment Syndrome
15. Stress Fracture of Tibial and Fibula