Ankle, Lower Leg and Foot Patterns

Question 1

List some extra questions that can be asked when doing a subjective examination of the lower leg and foot.

Answer 1

• Clicking / clunking
• Grating(common with OA)
• Snapping
• Giving way (ligaments aren’t suppoting structure very well or muscles are weak)
• Changes to circulation
• Footwear/ orthotics (wear and tear in shoes)

Question 2

List some extra activities that can be assessed in a physical examination of the lower leg and foot

Answer 2

• Specific activities e.g.
• Gait (can ask them to modify their gate to exacerbate certain things in walking pattern eg. DF)
• Squatting / DF activities
• Stairs / hills
• Sporting activities

Question 3

Which ligaments make up the lateral collateral ligament complex? Which is the most commonly sprained?

Answer 3

• Anterior talofibular ligament
• Posterior talofibular ligament
• Calcaneofibular ligament

-The ATFL is the most commonly sprained of these ligaments

Question 4

Describe the onset and mechanism of a lateral ankle sprain

Answer 4

Onset: sudden
Mechanism: Rapid direction change or awkward landing
•PF and INV of ankle
•ATFL – ↑ risk with PF + INV
•CFL – ↑ risk with DF (loose in PF, 2x stronger cf ATFL)
•PTFL-least sprained

•Peroneal tendons, mm, lateral retinaculum, N can also be injured – not as common but still possible

Question 5

List common findings in a subjective examination of a lateral ankle sprain

Answer 5

• PF/ INV injury
• Painful/ swollen – lateral or whole ankle
• Pain with WB
• +/- instability (instability and feeling like it will give way hints at ligament problems)

Question 6

List common findings in a physical examination of a lateral ankle sprain

Answer 6

• Obs: swollen & bruised
• AROM: ↓ (*PF & INV)
• PROM: ↓ (*PF & INV)
• Anterior drawer: +ve (depends on grade) (testing ATFL) (if not a grade 3, there will be some end feel)
• Palpation – local TOP
• (Peroneal structures-resisted PF/EV)

Question 7

How would you manage a grade 1 or 2 lateral ankle sprain in the acute phase (1-3 days)?

Answer 7

• RICER
• Taping and bracing (can be used to protect the joint)
• Early mobilisation – to P1 pf, df, inv, ev (this helps to decrease pain)
• Protect joint and decrease WB (i.e. crutches)
• EPA

Question 8

How would you manage a grade 1 or 2 lateral ankle sprain in the subacute and chronic stages?

Answer 8

• Stretching -maintain mm. length
• Strengthening exercise-maintain strength, perception
• Taping, bracing -maintain joint protection
• Gait re-education – biofeedback with mirror (used if someone has developed an antalgic gait when had sprain; don’t want to cause secondary problems)
• EPA’s - pain
• Massage, DTF, US, EPA’s-promote healing
• Passive mobs- prevent stiffness of non-affected jts
• Balance exercises -restore and ↑proprioception (can lose proprioception when damage ligament; if not fixed the person is more prone to injury)
• Goal to return to full function - full strength and ROM, no Sx, may need strapping/ brace for RTS

Question 9

How would you manage a grade 3 lateral ankle sprain?

Answer 9

• Immobilise - POP for 6/52
• Surgery - reconstruct lateral ligament or repair with peroneal tendon - POP 6/52
• Rehab post POP or surgery > Goal to restore full pain free ROM, strength/control and proprioception

Question 10

Describe common signs of functional ankle instability (chronic ankle injury)

Answer 10

• Poor control of surrounding muscles > poor dynamic stabilising restraints
• Reduced proprioception of ankle joint

Question 11

How can functional ankle instability be managed?

Answer 11

• Multifactorial management is important
• Improve strength and control of supporting mms
• Proprioception training – wobble board
• Injury prevention – taping / bracing

Question 12

List some other sources of lateral ankle pain (other than lateral ankle sprain)

Answer 12

• Osteochondral lesion or # of the talar dome
• Inferior tibio-fibular ligament (interosseus lgt)
• Post traumatic synovitis of TCJ or STJ
• Peroneal nerve entrapment

Question 13

List some common sources of medial ankle pain

Answer 13

• Deltoid ligament sprain
• Tib post tendinopathy
• FHL tendinopathy
• Tarsal tunnel syndrome (compression of tibial nerve)

Question 14

Describe the mechanism of a deltoid ligament sprain

Answer 14

• EV & ABD injury
• Lots of force needed (much less common than LLC)
• Often occurs with fractures (due to high force)
• Medial joint may get compressed with LLC sprain

Question 15

How can a deltoid ligament sprain be managed? How long does recovery take?

Answer 15

•Treated the same as LLC sprain (recovery takes twice as long) (strengthening muscles, improving proprioception etc)

Question 16

What are typical subjective findings with a medial tendinopathy?

Answer 16

• Area: local to tendon (need to know the path of the tendons)
• Causes: Usually overuse
• History: gradual onset

Question 17

What are typical physical findings with a medial tendinopathy?

Answer 17

• Some biomechanical Contributing factors (eg. Pronation of foot, type of shoes needing clawing of feet)
• Tender On Palpation over affected tendon
• Swelling over tendon
• RSC → Pain (no movement of joint and ligament involved with joint so only using tendon)
• Stretch→ pain

Question 18

How can medial tendinopathies be managed?

Answer 18

•Local Rx: EPA’s, Soft Tissue Massage (STM)
•Stretching
•Strengthening-concentric/eccentric
•Consider contributing factors:
Altered biomechanics-control ?orthotic (eg. So takes off pronation which can put medial structures on stretch), tape
Training regime: rate of increase, training too much
Shoes (amount of support etc)