7. KNSS 220 Introduction to Athletic Therapy: The Ankle & Lower Leg

KNSS 220 Introduction to Athletic Therapy

The Ankle & Lower Leg

Anatomy

Bones

• Tibia

• Fibula

• Talus

• Calcaneus

The Ankle Joint of the Right Foot

• Anterior (front) view

• Lateral (outside) view

Anatomy: Ligaments

• Anterior and Posterior Inferior Tibiofibular Ligaments

• Lateral Ligaments:

  • Anterior Talofibular Ligament

  • Posterior Talofibular Ligament

  • Calcaneofibular Ligament

• Medial Ligament:

  • Deltoid Ligament

Anatomy: Articulations

• Tibiofibular Joint

• Talocrural Joint:

  • Components:

  • Trochlea of Talus

  • Articular facet on distal portion of the tibia

  • Medial Malleolus

  • Lateral Malleolus

  • Ankle Mortis

Lower Leg Injuries

Compartment Syndrome

• Definition: The pressure within a compartment increases, restricting blood flow to the area and potentially damaging the muscles and nearby nerves.

• CROSS-SECTION OF NORMAL CALF SHOWING MUSCLE COMPARTMENTS:

  • Deep Posterior Compartment

  • Anterior Compartment

  • Lateral Compartment

  • Superficial Posterior Compartment

• Etiology: Muscle swelling causing compression.

• Signs and Symptoms:

• Pain and tenderness on the outside of the ankle

• Swelling in the lateral aspect of the leg

• Decreased range of motion and strength in the ankle

• Difficulty weight-bearing or walking without support.

• Management:

• Apply R.I.C.E. (Rest, Ice, Compression, Elevation) principles to manage swelling and pain.

• Consider a progression of range of motion exercises to restore mobility.

• Implement strength training focused on the ankle and lower leg muscles to improve stability.

• Use assistive devices (crutches or braces) to support weight-bearing as tolerated.

Medial Tibial Stress Syndrome (Shin Splints)

• Etiology: Medial Tibial Stress Syndrome typically arises from repetitive stress on the tibia due to activities like running or jumping; it may also be exacerbated by improper footwear or biomechanical discrepancies such as flat feet.

• Signs and Symptoms: Common signs and symptoms of Medial Tibial Stress Syndrome include pain along the inner part of the lower leg, tenderness or soreness during physical activity, swelling in the affected area, and pain that typically decreases with rest but reoccurs with activity.

• Management:

  Management of Medial Tibial Stress Syndrome includes several strategies:

  • Rest: Reduce or modify activities that exacerbate the symptoms, allowing the tibia to heal.

  • Ice therapy: Apply ice packs to the affected area for 15-20 minutes several times a day to reduce swelling and alleviate pain.

  • Stretching and strengthening exercises: Perform specific stretches for the calf muscles and strengthening exercises for the lower legs to address underlying muscle imbalances.

  • Footwear evaluation: Ensure adequate support and cushioning in shoes, and consider orthotic devices if structural issues are present.

  • Gradual return to activity: Reintroduce physical activity slowly, monitoring for pain or discomfort.

Peroneal Tendinopathies

• Etiology: Sudden plantarflexion and dorsiflexion; acute ankle sprain.

• Signs and Symptoms:

• Pain along the lateral aspect of the ankle, especially during activities involving ankle movement.

• Swelling and tenderness over the peroneal tendons.

• Difficulty with activities requiring calf strength or balance, such as running or jumping.

• Management:

• Rest and ice application to reduce swelling and alleviate pain.

• Compression bandaging to support the injured area.

• Gradual rehabilitation exercises focusing on strengthening the calf muscles and improving balance.

• Functional mobility training to restore full range of motion and prepare for a return to activity.

Ankle Injuries

High Ankle Sprain

• Etiology:

  • Eversion

  • Dorsiflexion

  • Direct trauma

• Signs and Symptoms: Common signs and symptoms of injuries to the ankle and lower leg include swelling, bruising, pain during movement, limited range of motion, tenderness to touch, and instability in the joint.

• Management: Effective management strategies for ankle and lower leg injuries may include rest, ice application to reduce swelling, compression to limit edema, and elevation to minimize pain and promote healing.

• Involved Structures:

  • Interosseous membrane

  • Syndesmosis tear

  • Anteroinferior Tibiofibular Ligament (AITFL)

Inversion Ankle Sprain

• Etiology:

  • Caused by excessive inversion of the ankle, often during sports activities or sudden changes in direction.

  • Inversion

  • Plantarflexion

• Signs and Symptoms:

• Swelling around the ankle

• Pain along the outer edge of the foot or ankle

• Bruising that may spread to the foot

• Difficulty bearing weight on the affected foot

• Limited range of motion in the ankle joint

• Management:

• R.I.C.E. protocol (Rest, Ice, Compression, Elevation) to reduce swelling and pain

• Gradual return to activity with controlled weight-bearing exercises

• Strengthening exercises focusing on ankle stability and flexibility

• Consultation with a physiotherapist for tailored rehabilitation program.

• Involved Ligaments:

  • Torn calcaneofibular ligament

  • Torn anterior talofibular ligament

  • Anterior tibiofibular ligament

Eversion Ankle Sprain

• Etiology: The etiology of an ankle sprain often involves excessive inversion or eversion during physical activity, leading to strain on the ligaments that support the ankle joint.

• Signs and Symptoms: Common signs and symptoms of an ankle sprain include swelling, tenderness to touch, bruising, limited range of motion, and difficulty walking or bearing weight on the affected ankle.

• Management: Effective management of an ankle sprain includes the R.I.C.E. method: Rest, Ice, Compression, and Elevation. Additionally, rehabilitation exercises may be introduced to restore strength and flexibility.

• Involved Structures:

  • Deltoid ligaments

  • Medial malleoli

Achilles Tendinopathy

• Etiology:

• The underlying causes of Achilles Tendinopathy include repetitive strain and overuse, often exacerbated by factors such as improper footwear, excessive training intensity, or biomechanical abnormalities.

  • Activities such as jumping, running, and sprinting

  • can lead to increased strain on the Achilles tendon, resulting in microtraumas and eventual degeneration if not properly managed.

• Signs and Symptoms:

  • Pain, swelling, and stiffness of the Achilles tendon

• Management: 

• Management strategies include rest, ice application, anti-inflammatory medications, physical therapy exercises to strengthen surrounding muscles, and gradual return to activity to prevent recurrence.

• Types:

  • Mid-portion Achilles tendinopathy

  • Insertional Achilles tendinopathy

Achilles Rupture

• Etiology: Overuse injuries, degeneration of the tendon due to repetitive stress, and anatomical factors such as abnormal foot mechanics and tight calf muscles.

• Signs and Symptoms: Pain along the Achilles tendon, stiffness in the morning, swelling around the tendon, and difficulty with activities that involve pushing off the foot or raising the heel.

  • Characterized by a pop sound

• Management:

• Initial management includes the R.I.C.E protocol (Rest, Ice, Compression, Elevation) to reduce swelling and pain.

• Once acute symptoms subside, rehabilitation involving range of motion, strengthening exercises, and proprioception training should be implemented.

Deep Vein Thrombosis

• Etiology: Deep vein thrombosis (DVT) is primarily caused by prolonged inactivity, which can lead to blood pooling in the veins, increasing the risk of clot formation. Other contributing factors include trauma, certain medical conditions, surgery, and the use of medications that affect blood clotting.

• Signs and Symptoms:

• DVT may present with swelling, pain or tenderness in the affected leg, warmth, and discoloration. In some cases, patients may be asymptomatic despite having a clot.

• Swollen leg

• Management: 

• Elevation of the affected leg to reduce swelling

• Compression therapy using bandages or stockings to improve venous circulation

• Anticoagulant medications to prevent further clotting

• Gradual mobilization and physical therapy to restore function, if appropriate

• Monitoring for potential complications such as pulmonary embolism.

Ankle & Lower Leg Assessment

History

1. Who: Name, age, gender, job

2. Mechanism of injury:

   • What happened?

   • How did it happen?

   • When did it happen?

3. Pain:

   • Location

   • Onset: Gradual or acute

   • Type: Sharp, dull, ache, shooting

   • Severity: Scale of 1-10

   • What makes it feel worse and better?

4. Sounds/sensations: Did they feel or hear abnormal pop, snap, crack, etc.?

5. Signs and Symptoms

6. Previous health/injury history, medications/allergies

Observation

• Always compare bilaterally

• Look for:

  • Swelling, discoloration, deformity

  • Formations/abnormalities:

  • Pes planus/cavus

  • Hammer, claw, and mallet toe

  • Morton's toe

  • Inspection of medial, lateral, dorsal, and plantar views

  • Inspection of shoes and gait

Assessment

• Temperature

• Pulses:

  • Post tibialis

  • Dorsalis pedis

• Soft tissue assessment:

  • Muscle: Gastrocnemius, Soleus, Anterior compartment, Lateral compartment

  • Tendons:

  • Plantar fascia

  • Ligaments:

  • ATFL

  • PTFL

  • CFL

  • Deltoid

  • Bones/bony prominences:

  • Calcaneus

  • Talus

  • Cuboid

  • Navicular

  • Cuneiforms 1-3

  • Metatarsals 1-5

  • Styloid process of 5th MT

  • Phalanges

  • Sesamoids

  • Tibia

  • Fibula

  • Lateral/medial malleoli

Range of Motion (ROM)

• Ankle ROM:

  • Active Range of Motion (AROM)

  • Passive Range of Motion (PROM)

  • Resistive Range of Motion (RROM)

  • Movements:

  • Plantarflexion

  • Dorsiflexion

  • Eversion

  • Inversion

• Toe ROM:

  • Movements:

  • Extension

  • Flexion

Special Tests

1. Anterior Drawer Test

   • Purpose: Assess the stability of the anterior talofibular ligament

   • Method: Stabilize the tibia and fibula with one hand, pull heel with the other.

   • Positive Test: Laxity and pain

2. Talar Tilt Test

   • Purpose: Assess stability of the lateral and medial ligaments of the ankle

   • Method: Same hand position as anterior drawer test, but put the ankle through eversion and inversion motions.

   • Positive Test: Pain and laxity over the deltoid ligaments during eversion and over the lateral ligaments during inversion

3. Kleigers Test

   • Purpose: Assess syndesmosis (high ankle sprain)

   • Method: Place the foot into dorsiflexion and eversion.

   • Positive Test: Pain between the distal tibia and fibula

4. Bump Test

   • Purpose: Assess for fractures in the lower leg

   • Method: Bump heel with the palm.

   • Positive Test: Pain present

5. Thompson Test

   • Purpose: Assess for an Achilles rupture

   • Method: Patient lies prone; squeeze the gastrocnemius/soleus complex.

   • Positive Test: No plantarflexion of the ankle