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Ankle and Lower Leg Chapter 17 Ankle Bony Anatomy • Talus (link between lower leg & foot) • Tibia – Medial malleolus • Fibula – Lateral malleolus • Tibial tuberosity • Tibial condyles Bony Anatomy Bones of the Ankle – Tibia • 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 • 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 – 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 • Anterior Talofibular: restrains anterior displacement of talus • Calcaneofibular: restrains inversion of calcaneous • Posterior Talofibular: restrains posterior displacement of talus Medial Ligaments • 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, • Contains muscles the evert the foot and ankle extensor hallucis longus, extensor digitorum) • Peroneus longus and brevis (evert ankle), peroneus tertius (assists dorsiflexion), superficial branch of the peroneal nerve Muscle Compartments Superficial Posterior Compartment • Muscles that plantarflex the foot and ankle • Gastrocnemius, and soleus Deep Posterior Compartment 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 Stress Fx • Pain more generalized • Pain worse in am • 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 – Anterior Talofibular – Calcaneofibular – Posterior Talofibular • Eversion – Deltoid Ligament • Syndesmotic – High ankle sprain Ankle Sprain—S/SXS Grade 1 Some pain 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 • Squeezing the tibia and fibula together • Can indicate fracture or high ankle sprain Bump Test/Tap Test • 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
