Ankle & Lower Leg

Question 1

What type of joint is the ankle?

Answer 1

Stable hinge joint

Question 2

Where does inversion and eversion occur?

Answer 2

subtalar joint

Question 3

Range of motion of the ankle?

Answer 3

10 degrees dorsiflexion, 50 degrees plantar flexion. Walking requires 10 degrees dorsiflexion, 20 degrees plantar flexion

Question 4

What are some injury prevention strategies for this region?

Answer 4

Achilles Tendon Stretching(adding mobility to tight heel cord), Strength training(keep muscles and tendons surrounding joint strong), Neuromuscular control training (uneven surfaces, rocker boards, etc.) proper footware, preventative taping (lace up braces more effective for prevention. Can effect ankle and knee biomechanics)

Question 5

Percussion test

Answer 5

Blow to tibia, fibular, or heal, creates vibratory force in factor. Tests for: fracture Positive sign: Reproduction of patient’s worst pain

Question 6

Compression test

Answer 6

Compression test involves compression of tibia and fibula either above or below site of concern. Testing for: fracture
Positive sign: pain

Question 7

Thompson test

Answer 7

Squeeze calf muscle, while foot is extended off table

testing for: the integrity of the Achilles tendon. Positive sign: no movement in the foot

Question 8

Homan’s test

Answer 8

With knee extended and foot off table, ankle is moved into dorsiflexion. Testing for: deep vein thrombosis. Positive sign: pain in calf

Question 9

Anterior drawer test

Answer 9

Put hand under heel, pull like a drawer. Testing for: Damage to anterior talofibular ligament primarily, other lateral ligaments secondarily. Positive sign: Foot slides forward and/or makes clunking sound

Question 10

Talar tilt test

Answer 10

With foot at 90 degrees calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments
Tests for: extent of inversion or eversion injuries
Positive sign: Excessive motion

Question 11

What is the most common type of ankle sprain?

Answer 11

Inversion sprains

Question 12

Inversion sprains

Answer 12

Foot is forcefully inverted. Injured: Lateral ligaments. Anerior talofibular ligament. W/ increased force posterior talogibular and calcaneofibular ligaments can be injured

Question 13

Ottawa Ankle Rules

Answer 13

Determines need for xray
X-ray required if pain in malleolar or midfoot area
Inability to bear weight for 4 steps (2 on each foot) at time of injury and examination
Tenderness over inferior or posterior pole of either malleoli
Inability to bear weight (4 steps taken independently, even if limping) at time of injury and/or evaluation
Tenderness along base of 5th metatarsal or navicular bone

Question 14

Grade 1 Ligament Sprain

Answer 14

–Occurs with inversion plantar flexion and adduction
–Causes stretching of the anterior talofibular ligament
Signs and Symptoms
–Mild pain and disability; weight bearing is minimally impaired; point tenderness over ligaments and no laxity
–Management
RICE for 1-2 days; limited weight bearing initially and then aggressive rehab
Tape may provide some additional support
Return to activity in 7-10 days

Question 15

Grade 2 Ligament Sprain

Answer 15

Etiology
–Moderate inversion force causing great deal of disability with many days of lost time
Signs and Symptoms
–Feel or hear pop or snap; moderate pain w/ difficulty bearing weight; tenderness and edema
Positive talar tilt and anterior drawer tests
Management
–RICE for at least first 72 hours; X-ray exam to rule out fx; crutches 5-10 days, progressing to weight bearing
–Will require protective immobilization but begin ROM exercises early to aid in maintenance of motion and proprioception
–Taping will provide support during early stages of walking and running
–Long term disability will include chronic instability with injury recurrence potentially leading to joint degeneration
–Must continue to engage in rehab to prevent against re-injury

Question 16

Grade 3 Ligament sprain

Answer 16

Etiology
–Relatively uncommon but is extremely disabling
–Caused by significant force (inversion) resulting in spontaneous subluxation and reduction
–Causes damage to the anterior/posterior talofibular and calcaneofibular ligaments as well as the capsule
Signs and Symptoms
–Severe pain, swelling, hemarthrosis, discoloration
–Unable to bear weight
–Positive talar tilt and anterior drawer
Management
–RICE, X-ray (physician may apply dorsiflexion splint for 3-6 weeks)
–Crutches are provided after cast removal
Isometrics in cast; ROM, PRE and balance exercise once out
–Surgery may be warranted to stabilize ankle due to increased laxity and instability

Question 17

Eversion Ankle Sprains

Answer 17

Represent 5-10% of all
ankle sprains
–Eversion force results in damage to deltoid ligament and possibly fx of the fibula
–Deltoid can be impinged and contused with inversion sprainsSigns and Symptoms
–Pain may be severe; unable to bear weight; and pain with abduction and adduction but not direct pressure on bottom of foot

Management

• -RICE; X-ray to rule out fx; no weight bearing initially; posterior splint tape; NSAID’s
• -Follows the same course of treatment as inversion sprains
• -Grade 2 or higher will present with considerable instability and may cause weakness in medial longitudinal arch resulting in excessive pronation or

Question 18

syndesmotic sprain (high sprain)

Answer 18

Etiology
–Injury to the distal tibiofemoral joint (anterior/posterior tibiofibular ligament)
–Torn w/ increased external rotation or dorsiflexion
–Injured in conjunction w/ medial and lateral ligaments
Signs and Symptoms
–Severe pain, loss of function; passive external rotation and dorsiflexion cause pain
–Pain is usually anterolaterally located
Management
–Difficult to treat and may requires months of treatment
–Same course of treatment as other sprains, however, immobilization and total rehab may be longer
–Surgery may be required

Question 19

mechanical instability

Answer 19

laxity that physically allows for movement beyond the physiologic limit of the ankle/s range of motion

Question 20

functional instability

Answer 20

a subjective feeling that the ankle is unstable

Question 21

Acute achilles Strain

Answer 21

–often occurs with strains or excessive dorsiflexion
Sign and Symptoms
–Pain may be mild to severe
–Most severe injury is partial/complete avulsion or rupturing of the Achilles
Management
–Pressure and RICE should be applied
–After hemorrhaging has subsided an elastic wrap should continue to be applied
–Conservative treatment should be used as Achilles problems generally become chronic
–A heel lift should be used and stretching and strengthening should begin soon

Question 22

Achilles Tendinosis

Answer 22

–Achilles tendinitis is an inflammatory condition involving tendon, sheath or paratenon
Signs and Symptoms
–Generalized pain and stiffness, localized proximal to calcaneal insertion
–Warm and painful with palpation, also presents with thickening
–May limit strength
–May progress to morning stiffness
Crepitus with active plantar flexion and passive dorsiflexion
–Chronic inflammation may lead to thickening

Question 23

Achilles Tendon Rupture

Answer 23

Etiology
–Occurs w/ sudden stop and go; forceful plantar flexion w/ knee moving into full extension
–Commonly seen in athletes > 30 years old
–Can be observed at any age
–Generally has history of chronic inflammation
Signs and Symptoms
–Sudden snap (kick in the leg) w/ immediate pain which rapidly subsides
–Point tenderness, swelling, discoloration; decreased ROM
–Obvious indentation and positive Thompson test
–Usual management involves surgical repair for serious injuries (return of 75-80% of function)
–Non-operative treatment consists of RICE, NSAID’s, analgesics, and a non-weight bearing cast for 6 weeks, followed up by a walking cast for 2 weeks (75-90% return to normal function)
–Rehabilitation lasts about 6 months and consists of ROM, PRE and wearing a 2cm heel lift in both shoes

Occurs 2-6 cm proximal the calcaneal insertion

Question 24

Gastrocnemius Strain

Answer 24

Etiology
–Susceptible to strain near musculotendinous attachment
–Caused by quick start or stop, jumping
Signs and Symptoms
–Depending on grade, variable amount of swelling, pain, muscle disability
–May feel like being “hit in leg with a stick”
Edema, point tenderness and functional loss of strength
Management
–RICE, NSAID’s and analgesics as needed
–Grade 1 should apply gentle stretch after cooling
Weight bearing as tolerated; use heel wedge to reduce calf stretching while walking
Gradual rehab program should be instituted

Question 25

Medial Tibial Stress Syndrome (Shin Splints)

Answer 25

Etiology

• -Pain in anterior portion of shin
• -Catch all for stress fractures, muscle strains, chronic anterior compartment syndrome
• -Accounts for 10-15% of all running injuries, 60% of leg pain in athletes
• -Caused by repetitive microtrauma
• -Weak muscles, improper footwear, training errors, varus foot, tight heel cord, hypermobile or pronated feet and even forefoot supination can contribute to MTSS
• -May also involve, stress fractures or exertional compartment syndrome

Signs and Symptoms
–Four grades of pain
—-Pain after activity
—–Pain before and after activity and not affecting performance
—–Pain before, during and after activity, affecting performance
—–Pain so severe, performance is impossible
Management
–Physician referral for X-rays and bone scan
–Activity modification
–Correction of abnormal biomechanics
–Ice massage to reduce pain and inflammation
–Flexibility program for gastroc-soleus complex
Arch taping and or orthotics
–

Question 26

Compartment syndrome

Answer 26

• -Complain of deep aching pain & tightness due to pressure and swelling
• -Reduced circulation and sensation of foot occurs
• -Intracompartmental measures further define severity
• -Must be recognized and treated early
• -If severe acute or chronic case, may present as medical emergency that requires surgery to reduce pressure or release fascia
• -RICE, NSAID’s and analgesics as needed
• -Under acute and exertional cases pressures will be monitored and surgical needs will be dependent on findings
• -Following surgical release patient may not return to activity for 2-4 months
• -In chronic conditions management is initially conservative
• -Fasciotomy may be necessary if conservative measures fail