BPK 241 Week 2

Tibia

Tibia

• Principal weight bearing bone of lower leg

• Medial malleolus

Fibula

• Long thin bone, lateral to tibia primarily for muscle attachment

• Lateral malleolus

Talus

• Rests on calcaneus

• Main weight bearing bone of ankle joint

• Talar dome (trochlea)

Calcaneus

• Heel bone

• Largest tarsal bone

Talocrural joint

• Formed between the distal tibia-fibula and the talus, and is commonly known as the ankle joint

• Synovial and Hinge joint (flexion & extension) aka plantar flexion and dorsiflexion

Eversion and Inversion

A result of subtalar joint movement between talus and calcaneus as well as intertarsal joints.

Distal Tibiofibular Joint

Ankle Mortise

Articulations

• Tibia & Fibula (ankle mortise)

• Syndemosis (1-2 mm of movement)

• Anterior and posterior inferior tibiofibular ligaments

• Interosseous membrane

AITFL

Anterior-Inferior Tibiofibular Ligament

IM

Interosseous membrane

PITFL

Posterior-Inferior Tibiofibular ligament

TrTFL

Transverse Tibiofibular ligament

Talus(tendon)

Wider anteriorly- joint more stable in dorsiflexion

ATFL

Anterior talofibular ligament

PTFL

Posterior Talofibular ligament

CFL

Calcaneofibular ligament

Ankle Muscles (Anteriorly)

• Tibialis Anterior

• EHL & EDL

• Dorsiflexion, inversion/flexion

Ankle Muscle (Posteriorly)

• Gastrocnemius & soleus

• Plantarflexion

Ankle Muscle (Posterior Medial)

• Tibialis Posterior

• FHL & FDL

• Inversion, plantarflexion

Ankle Muscle (Laterally)

• Peroneus longus, brevis & tertius

• Eversion

Tibialis Anterior

• Dorsiflexion of ankle

• Weak inversion of ankle

Extensor Digitorum Longus

• Extensor of toes 2 through 5

• Dorsiflexion of ankle

• Eversion of foot

Extensor Hallucis Longus

• Extension of 1st toe

• Dorsiflexion of ankle

• Weak inversion of ankle

Gastrocnemius

• Plantarflexion of ankle

• Flexion of ankle

• Contraction of calf muscle

• Crosses the knee joint

Soleus

• Plantarflexion of ankle

• Important for keeping us upright

• Shares with achilles tendon

• Doesn’t cross the knee joint

Flexion Digitorum Longus

• Flexion of toes 2 through 5

• Plantar flexion of ankle

• Weak inversion of foot

Flexor Hallucis Longus

• Flexion of 1st toe

• Plantar flexion of ankle

• Weak inversion of ankle

Tibialis Posterior

• Inversion of foot

• Plantar flexion of ankle

• Crosses over to the medial side pulling it into the inverted side (inversion)

Peroneus (fibularis) longus

• Eversion of foot

• Plantar flexion of ankle

• Tilt the sole of the foot away from the midline of the body and to extend the foot downward away from the body at the ankle.

Peroneus (fibularis) brevis

• Eversion of foot

• Plantar flexion of ankle

• Receives innervation from the superficial peroneal nerve, and its arterial supply is by muscular branches of the peroneal artery

Muscles grouped by Plantar Flexion

• Gastrocnemius

• Soleus

  • Flexor digitorum longus

  • Flexor hallucis longus

  • Peroneus longus

  • Peroneus brevis

  • Plantaris

  • Tibialis anterior

Muscles grouped by Dorsiflexion

• Tibialis anterior

  • Extensor digitorum longus

  • Extensor hallucis longus

Muscles grouped by Inversion

• Tibialis posterior

  • Tibialis anterior

  • Flexor digitorum longus

  • Flexor hallucis longus

Muscles grouped by Eversion

• Peroneus longus

• Peroneus brevis

  • Extensor digitorum longus

Proprioception

Sense of body position without the aid of vision

Kinaesthesia

Awareness of position and movement of body parts using proprioceptive sensory organs. Mediated by mechanosensory neurons in muscles, tendons and joints. Gives information on limb velocity, movement and loads on limbs. Feedback helps create overall picture of body position, movement, and acceleration

3 Basic types of proprioceptor neurons in vertebrates

• Muscle Spindles

• Golgi Tendons Organs

• Mechanoreceptors

Muscle Spindles

Found in skeletal muscle fibres

Golgi Tendon Organs

At interface of muscles and tendons

Mechanoreceptors

Found in joint capsule surrounding synovial joints

Why do we care about proprioceptors and injury?

Proprioception and kinaesthesia can be interrupted/impaired following injury. What are the implications of this?

Ankle Assessment

• History of current injury

• Past history

• Compare with uninjured extremity

• Inspection/Observation

• Range of Motion (ROM)

• Ligament Test

• Functional/Special tests

• Palpation

• Be systematic

Contusion

• History: Traumatic bruise: direct blow

• Symptoms: Pain, tenderness, Discolouration, Limp?

• Differential Diagnosis: Fracture, Body tenderness? Then X-Ray

• Treatment: POLICE, Padding, Rehabilitation

Strain

• Injury to tendon or muscle

• History: Sudden Stretch (run, jump)

• Symptoms: Pain, tenderness, may feel or hear a “snap”

• Limp?(2nd or 3rd degree)

• Treatment: POLICE, Tape or cast, ROM exercises, Physiotherapy

Tendinopathy

• Tendonitis, Tendinosis or Tenosynvotis

• History: acute strain or overuse

• Symptoms: Those of acute strain?, Tenderness, Crepitus. Swelling/bogginess

• Treatment: Complete tendon test(brace?), NSAID, Physio & ROM exercises, Tape, Slow return to exercise - graded

Sprain

• Acute injury to ligament(s), very common, usually under-treated

• Symptoms & disability for months

• Most common in inversion(85%): usually in plantarflexion, ATFL

• Less common in eversion(10%): usually forced eversion in dorsiflexed position, deltoid ligament

• Dorsiflexion (Syndesmosis/”High ankle sprain”) sprains are rare

• May destabilize mortise. AITFL damaged

Lateral (Inversion) Ankle Sprain

Has three degrees of tears in LCL

1st degree sprain

• Partial tear of ligament(s)

• Symptoms: Mild tenderness, pain, swelling

• NO snap, no limp, no increased laxity

• Treatment: POLICE, reduce predisposing factors

2nd degree sprain

• Tear of ligament(s) - incomplete

• Symptoms: Snap/pop, Pain, Tenderness, Swelling, Bruises, Limp, Resists inversion, increased laxity(has end-ponts)

• Treatment: POLICE- 2 days rest, X-Ray?, Air cast, tape or plastar cast and NSAID

3rd degree sprain

• Complete rupture of ligament(s)

• Symptoms: Same as 2nd but more severe, Positive Anterior drawer test for inversion sprain, increased laxity, nor firm end point on talar tilt test, higher risk of fracture or dislocation

• Treatment: Stabilize(NPO), get medical help, X-Ray, may need surgery, cast, Physio and rehab

Anterior Sprain Assessment Anterior Drawer Test

A quick way for your healthcare provider to diagnose a torn ACL. They'll move your lower leg to see if your ACL is holding your knee in place like it should. If your leg moves further than usual, you might have an ACL tear.

Ankle Sprain Assessment Talar Tilt Test

Assesses the lateral ankle ligaments for laxity, specifically calcaneofibular ligamentous laxity. The test is performed by stabilizing the distal leg in a neutral position while the examiner inverts the ankle. The degree of inversion is compared with the uninjured ankle.

Syndesmosis Sprain “High Ankle Sprain”

• Forced dorsiflexion with external rotation

• Tenderness between distal tibia & fibulae

• Anterior ankle swelling

• Patient walks on toes to avoid painful dorsiflexion

• Positive side to side talar tilt test (widened mortise)

Sydesmosis Sprain “High Ankle Sprain” X-Ray Findings

• Increased tibiofibular (syndesmosis) clear space

• Decreased tibiofibular overlap

• Increased medial clear space

Ankle Sprain Complications

• Recurrence (degrees)

• Chronic instability (2nd/3rd)

• Fracture: Malleolus(tibia or fibula), Fibular shaft(spiral), Talus - osteochondral fracture

• Dislocation

• Subtalar joint injury

Temporary Loss of Proprioception

• Periods of growth - adolescence

• Significant changes in bodyweight/size

• Increased flexibility - stretching

• Fatigue

• Vitamin B6 overdose

• Alcohol consumption

• Musculoskeletal injury

• Concussion

• CNS injury

Permanent Loss of Proprioception

• Joint hyper-mobility

• Viral Infection

• Brain injuries, Parkinson, ALS

Assessing Proprioception

• Joint Position Matching

• Field Sobriety Test

• Romberg Test

• Y test or Star Excursion Balance Test

Star Excursion Balance Test (SEBT)

Dynamic balance test, requires strength, flexibility and proprioception. Using injured & uninjured leg to see balance & imperfections

Fractures

• Evidence: History of severe trauma Deformity, Bony tenderness, Crepitus, difficultly weight bearing

• Treatment: Recognize likelihood, Stabilize & Transport if suspicious, X-Ray, Reduction(may need surgery), Cast, Physio and Rehab

Ottawa Ankle Rules

• Helps determine if x-ray needed

• Ankle X-Rays needed if pain in malleolar area AND 1 of:

  • Pain over distal 6 cm inferior or posterior pile of med or lat malleolus

  • Inability to weight bear at all at time of injury

  • Inability to weight bear 4 steps at time of examination (ie. in hospital)

• Foot X-Rays needed if pain in midfoot area AND 1 of:

  • Inability to bear weight at all at time of injury

  • Inability to weight bear 4 steps at time of examination (ie. in hospital)

  • Tenderness along base of 5th metatarsal or navicular bone

Ankle Rehab

• Activity Modification/ Controlled Weight Bearing

• Range of Motion

• Strengthening

• Balance/ Proprioception

• Running Progression

• Return to Sport

Activity Modification/ Controlled Weight bearing

• Partial or non weight bearing during initial healing period, may promote faster or stronger healing

• If possible maintain partial weight bearing to help combat muscle atrophy, proprioceptive loss, decreased circulation, tendinitis

Range of Motion

• ROM activities should be kept pain free

• Minimize inversion and eversion initially

  • Towel assisted stretching into plantar and dorsiflexion

• As pain decreases include inversion/eversion

  • Spelling alphabet with foot, towel pulls into inversion/eversion

Strengthening

• Isometric exercises in all four ankle movement directions

• Isotonic exercises into plantar and dorsiflexion

• As pain free ROM increases, can add resistance to inversion and eversion exercises

• Lighter resistance and higher reps (2 sets of 10 reps, progressing to 4 sets of 10 reps)

Balance/Proprioception

• Initially seated rocker board plantar flexion/ dorsiflexion

• Once pain free add seated rocker board inversion/eversion

• Double leg stand eyes open, progress to single leg stand eyes open

• Double leg stand eyes close, progress to single leg stand eyes close

• Double and single leg exercises on Rocker, BOSU, mini trampoline, eyes open, eyes closed , perturbations

Running Progression

• Pool Running

• Walking

• Running on mini ramp

• Side to side hopping

• Karaoke

• Ladder work

• Running on inside turf of track

• Running on harder surface

• Running figure eights (gradually making circles smaller)

• Running and cutting

• Sprinting

• Sprinting with cutting

Return to Sport

• Walking drills

• Jogging drills

• Running drills

• Drills without contact

• Drills with contact

• Return to play

Criteria for return to sport

• Full pain-free ROM?

  • May take 10 weeks to restore

• Normal strength?

  • Strength loss may be avoided by early functional training

• Normal proprioceptive function function?

  • How measure this?

• Injured ligament healed?

  • May take at least 6 months

Use of tape or brace

• Brace or tape should be used to prevent re-injury until rehabilitation program has been completed

• Provided effective injury prevention in athletes with previous ankle injury, but not in uninjured players

• Benefit most through proprioceptive stimulated

• No effect on sprint and jump performance