Ankle & Lower Leg Flashcards
What two bones make up the Ankle Mortise?
Tibia (medial) & Fibula (lateral)
The Ankle Mortise is comprised of what joint?
- The Talocrural Joint
~ Articulation between Talus & Ankle
Mortise
~ Talus relative to Ankle Mortise
Tibia
- Primary weight bearing bone of lower leg
- Forms roof & medial portions of Ankle
Mortise - Distal portion known as Medial Malleolus
Fibula
- Forms lateral portion of Ankle Mortise
- Distal portion known as Lateral Malleolus
What are the classic movements for the Talocrural Joint?
Dorsiflexion & Plantarflexion
Which classic movement of the Talocrural Joint would offer the most stability & why?
Dorsiflexion is more stable because it causes the Talus to jam into the Ankle Mortise, leaving no space for movement. Movement at the Talocrural Joint causes injuries.
Functional Loading/Pronation: Planes of Motion at the TCJ
Sagittal: Dorsiflexion
Frontal: Eversion (very minimal due to lateral Malleolus)
Transverse: Adduction
Functional Unloading/Supination: Planes of Motion at the TCJ
Sagittal: Plantarflexion
Frontal: Inversion (very minimal)
Transverse: Abduction (very minimal)
Articulations: Proximal Tibiofibular
Articulation between Lateral Tibial Condyle & Head of Fibula
Movements: Proximal Tibiofibular
Anterior/Posterior & Superior/Inferior gliding
Articulations: Distal Tibiofibular
Articulation between Lateral Malleolus of the Fibula & Distal, Lateral portion of Tibia
Movements: Distal Tibiofibular
Anterior/Posterior & Superior/Inferior gliding
What muscles move the ankle?
- Tibialis Posterior
- Peroneus Longus
- Gastrocnemius
- Soleus
- Plantaris
Tibialis Posterior Function during Functional Loading at the MTJ, STJ, & TCJ
- MTJ
~ Decelerates Abduction & Dorsiflexion - STJ
~ Decelerates Eversion - TCJ
~ Decelerates Dorsiflexion
Peroneus Longus Function during Functional Loading at the MTJ and TCJ
- MTJ
~ Decelerates Inversion & Dorsiflexion - TCJ
~ Decelerates Dorsiflexion
Gastrocnemius Function during Functional Loading at the STJ & TCJ
- STJ
~ Decelerates Eversion - TCJ
~ Decelerates Dorsiflexion
Unhappy during Rearfoot Varus
Soleus Function during Functional Loading at the STJ & TCJ
- STJ
~ Decelerates Eversion - TCJ
~ Decelerates Dorsiflexion
Unhappy during Rearfoot Varus
Gastrocnemius
Origin: Posterior Femur Proximal to Femoral Condyles
Insertion: Calcaneus
Nerve: Tibial
Action: Plantarflexion & Knee Flexion
Plantaris
Origin: Lateral Epicondyle of Femur
Insertion: Calcaneus
Nerve: Tibial
Action: Plantarflexion & Knee Flexion
Soleus
Origin: Posterior & Medial Border of Middle 1/3 of Tibia, Proximal 1/3 of Posterior Fibula
Insertion: Calcaneus
Nerve: Tibial
Action: Plantarflexion
Tibialis Posterior
Origin: Proximal 2/3 of Posterior Tibia, Fibula, & Interosseous Membrane
Insertion: Navicular, Cuneiforms, Cuboid, & Bases of 2-4 Metatarsals
Nerve: Tibial
Action: Inversion & Plantar Flexion & Supports Arch
Peroneus Longus
Origin: Proximal 2/3 of Lateral Fibula
Insertion: Base of 1st metatarsal & Medial Cuneiform
Nerve: Superficial Fibular
Action: Eversion & Plantar Flexion & Supports Arch
Things to notice during Anterior Inspection
- Hip & Trunk Position
~ Fick’s Angle: 12-18 degrees of toe out - Foot Type
~ Pronated
~ Supinated - Swelling
~ Caveman Foot: foot looks obviously
enlarged
Things to notice during Posterior Inspection
- Gastrocnemius-Soleus Complex
- Achilles
- Calcaneus
- Swelling (Caveman Foot)
Things to notice during Lateral Inspection
- Peroneal Muscle Group
- Distal Fibula
- Swelling (Caveman Foot)
Things to notice during Medial Inspection
- Distal Tibia
- Medial Longitudinal Arch
- Swelling (Caveman Foot)
Where do most ankle sprains take place and why?
- Lateral ankle
- The lateral ligaments are small and weak
because they don’t have to deal with
much stress
AROM Talocrural Joint Test
- Dorsiflexion & Plantarflexion measured with goniometer
- Normal Dorsiflexion: 20 degrees
- Normal Plantarflexion: 50 degrees
AROM Subtalar Joint Test
- Inversion & Eversion measured with goniometer
- Normal Inversion: 20 degrees
- Normal Eversion: 5 degrees
ROM Testing
- Passive
- Resistive
Neurological Assessment
Lower Quarter Screen
What ligaments support the TCJ?
- Laterally:
~ Anterior Talofibular Ligament (ATF)
~ Calcaneofibular Ligament (CF)
~ Posterior Talofibular Ligament (PTF) - Medially:
~ Deltoid Ligaments
> Anterior Tibiotalar
> Tibiocalcaneal
> Posterior Tibiotalar
> Tibionavicular
Anterior Talofibular Ligament (ATF)
Origin: Anterolateral Surface of Lateral Malleolus
Inserts: Talus near Sinus Tarsi
Resists: Plantarflexion & Inversion
Calcaneofibular Ligament (CF)
Origin: Posterolateral portion of Lateral Malleolus
Inserts: Calcaneus
Resists: Inversion
Posterior Talofibular Ligament (PTF)
Origin: Posterior portion of Lateral Malleolus
Inserts: Talus & Calcaneus
Resists: Posterior translation of talus on Tibia or Ankle Mortise
ATF Ligament Test
- Anterior Drawer
~ Positive test indicated by Talus sliding
anteriorly with excess laxity
CF Ligament Test
- Inversion Talar Tilt
~ Lengthens lateral ligaments
~ Positive test indicated by excessive
Talar Tilt
Deltoid Ligaments
- Anterior Tibiotalar
- Tibiocalcaneal
- Posterior Tibiotalar
- Tibionavicular
- Used more and therefore, harder to
rehab due their importance to daily life - Thicker and more supportive
Ankle sprain vs Deltoid ligaments?
- Listen to where pain is
- Pt. will point to exactly where pain is
What ligaments & structure support the Distal Tibiofibular Joint?
- Anterior & Posterior Tibiofibular
Ligaments - Interosseous Membrane
~ Keeps Tibia & Fibula from separating
~ Crural Interosseous Ligament
> Extension of Interosseous
Membrane
Distal Tibiofibular Joint Tests
- Kleiger’s Test (External Rotation):
Ligaments
~ Positive test indicated by pain in
anterolateral ankle at the site of the
Distal Tibiofibular Joint - Squeeze Test: Fractures
~ Positive test indicated by pain at the
site of the Distal Tibiofibular Joint
Ankle Sprains
- Usually caused by forceful inversion
(lateral ankle sprain) or eversion (medial
ankle sprain) - Signs & Symptoms:
~ Tenderness over ligament site
~ Swelling on side of sprain
> High Ankle Sprain: all over
~ Discoloration
~ Increased laxity: grade 2 & 3
~ Instability
Ankle/Lower Leg Fracture Test
- Stress or Gross
- Squeeze Test
~ Positive test indicated by pain away
from point of compression
~ Not needed if displaying typical signs
for fracture - Bump/Thump Test
~ Positive test indicated by pain away
from area being bumped
Other than fractures, what else could the Bump/Thump Test be used for?
High Ankle Sprains
~ Causes Fibula & Tibia to separate
Achilles Tendinitis
- Chronic inflammation due to limited
blood supply especially in the Distal
Portion 2-6 cm from insertion
Achilles Tendon Rupture
- Long term breakdown (inflammation or disuse) of tendon or one forceful event
- Also occurs at 2-6 cm from insertion, therefore it’s common to have a Rupture & Tendonitis simultaneously
- Very loud
- Feels like you’ve been kicked
- No obvious deformity, but obvious
swelling: looks like ankle sprain
Achilles Tendon Rupture Test
- Thompson Test
~ Artificially making the Achilles contract
~ Positive test indicated by a lack of
Plantarflexion when calf is squeezed
> May still Plantarflex due to muscles
Compartment Syndrome
- VERY IMPORTANT TO NOT MISS!
- Injury to a structure within a
compartment in the leg that causes a
build up of fluids (swelling) & compresses
nerves, arteries, & veins
~ No blood flow = tissue death - Most common in the Anterior & Deep
Posterior compartments
Anterior Compartment Contents
- Muscles
~ Tibialis Anterior
~ Extensor Hallucis Longus
~ Extensor Digitorum Longus
~ Peroneus Tertius - Nerve
~ Deep Peroneal (1st web space of foot) - If limited/dysfunction with Dorsiflexors &
nerves along with calf pain: refer
immediately
Deep Posterior Compartment Contents
- Muscles
~ Popliteus
~ Flexor Hallicus Longus
~ Flexor Digitorum Longus
~ Tibialis Posterior - Nerve
~ Tibial (bottom of foot & toes) - If limited/dysfunction with Plantarflexors
along with calf pain: refer immediately
Signs, Symptoms, & Management for Compartment Syndrome
- Signs & Symptoms:
~ Complaints of pain and PRESSURE in
affected compartment
~ Paresthesia/Anesthesia
~ Loss of function
~ Will be able to see and feel difference
between unaffected leg - Management
~ Early diagnosis
~ Surgery
> Cuts connective tissue, but causes
scar tissue, ultimately bringing pt.
back to square one
~ Not sure? Refer!
Exertional Compartment Syndrome
- Compartment syndrome only with activity
~ Causes blood to enter muscles & cause
pressure
~ Goes away after some time
Deep Vein Thrombosis (DVT)
- VERY IMPORTANT TO NOT MISS!
- Blood clot, usually post surgery or
following trauma to lower leg - Causes:
~ Abnormalities in vessel wall
~ Abnormal Blood: increased
coagulation factors
~ Decreased Plasma Volume:
dehydration
~ Major Surgery or Trauma: cutting
vessels
~ Slowing down blood flow: causes
clotting
DVT Signs, Symptoms, & Management
- Signs & Symptoms
~ Calf tenderness
~ Swelling of leg
~ Increased warmth in leg
~ Discoloration of leg
~ Pain with Dorsiflexion - Management
~ Booties/compression sleeve: squeezes
blood vessels & allows for blood to
flow
DVT Test
- Homan’s Signs
~ Forced Dorsiflexion with calf squeeze
~ Positive test indicated by pain in calf
Subluxating Peroneal (Longus & Brevis) Tendons
- Tendons don’t stay behind Lateral
Malleolus
~ Peroneals can’t Evert or Plantarflex - Cause
~ Forceful Dorsiflexion & Inversion
causing tearing of Peroneal
Retinaculum
Subluxating Peroneal (Longus & Brevis) Signs, Symptoms, & Management
- Signs & symptoms
~ Pain in lower leg/foot
~ Pain on site & popping of tendons
~ Dysfunction due to altered
biomechanics - Management
~ Surgery
~ Deal with pain
~ Retire
Medial Tibial Stress Syndrome (“Shin Splints”)
- Soft tissue pain around medial aspect of
Tibia
~ Tibialis Posterior or Soleus - Cause
~ New activity/changes in activity
> Muscles need to build up edurance
Medial Tibial Stress Syndrome (“Shin Splints”) Signs, Symptoms, & Management
- Signs & symptoms
~ Stress fracture
~ Pain - Management
~ Compression sleeve can bring muscles
closer to bone & relieve pain/tension
Talar/Tibial Osteochondral Lesions
- Bone & Cartilage defects
~ Piece gets knocked off - Cause
~ Excess inversion/eversion/rotation
Talar/Tibial Osteochondral Lesions Signs, Symptoms, & Management
- Signs & symptoms
~ Listen to complaints
~ Self limiting
~ Difficult to see on X-Ray - Management
~ May need surgery if serious
Deltoid Ligament Tests
- Eversion Talar Tilt
~ Lengthens the medial ligaments
~ Positive test indicated by excessive
Talar tilt - Kleiger’s Test (External Rotation)
~ Positive test indicated by medial joint
pain
