Anterior Leg, Lateral leg and Ankle Joint Flashcards
Tibialis Anterior
origin:
1. lateral tibia
2. interosseous membrane
Insertion:
1. medial cuneform
2. base 1st metatarsal
Action:
1. Ankle dorsiflexion
2. ankle inversion
Innervation:
1. deep peroneal (fibular) L4-L5
Extensor Hallucis Longus
Origin:
1. medial fibula
2. interosseous membrane
Insertion:
1. base distal phalanx of great toe
Action:
1. dorsiflexion
2. great toe extension
Innervation:
1. deep peroneal L5-S1
Extensor Digitorum Longus
Origin:
1. medial fibula
2. interosseous membrane
Insertion:
1. dorsal digital expansions of 4 lateral toes
Action:
1. ankle dorsiflexion
2. extension of lateral four toes
Innervation:
1. deep peroneal L5-S1
Peroneus Tertius
Origin:
1. medial fibula
Insertion:
1. base of 5th metatarsal
Action:
1. ankle dorsiflexion
2. ankle eversion
Innervation:
1. deep peroneal
L5-S1
Peroneus Longus
Origin:
1. upper lateral fibula
Insertion:
1. base of 1st metatarsal
2. medial cuneiform
Action:
1. ankle eversion
2. ankle plantarflexion
Innervation:
1. superficial peroneal L5-S2
Peroneus Brevis
Origin:
1. Lower lateral fibula
Insertion:
1. base of 5th metatarsal
Action:
1. ankle eversion
Innervation:
1. superficial peroneal L5-S2
Anterior Compartment - Vasculature and innervation
- Anterior tibial artery
- anteromedial malleolar, anterolateral malleolar, dorsalis pedis, lateral tarsal
- Deep peroneal nerve
- Saphenous nerve
Lateral compartment vasculature and innervation
- no major vessels pass through lateral compartment
- supplies branches of the peroneal/fibular artery
- common peroneal nerve
- superficial peroneal nerve
- lateral sural cutaneous nerve
Extensor retinacula
- superior extensor retinaculum: above ankle Fibular => tibia
- Inferior extensor retinculum: Y-shaped; calcaneus => medial malleolus and medial side of foot
Peroneal retinacula
- superiro peroneal retinaculum: distal fibula => calcaneus
- Inferior peroneal retinaculum: inferior extensor retinaculum => inferior calcaneous
Talocrural joint
- motions: ankle dorsiflexion/plantarflexion
- articulating surfaces: medial and lateral malleoli, superior talus
Subtalar joint
- motions: inversion and eversion
- articulating surfaces: inferior talus, superior calcaneous
Lateral ankle ligaments
- anterior talofibular ligament
- anterior and posterior tibiofibular ligament
- calcaneofibular ligament
- lateral talocalcaneal ligmament
Medial/deltoid ligament
- anterior and posterior tibiotalar
- tibiocalcaneal
- tibionavicular
Lateral ankle sprain
- most common type of ankle injury is an injury to the lateral ligaments
- MOI: forces plantar flexion/inversion movement
Clinial Presentation includes
Lateral ankle sprains
- ecchymosis
- tenderness and pain located over ATFL and calcaneofibular ligament
- limted ankle ROM
- antalgic gait
Lateral ankle sprain
diagnosis
- grade 1-3
- differential diagnosis includes ankle fracture
- damage to medial ligament
- dislocated ankle or other soft tissue damage
- use ottawa ankle rules to determine if there is presence of fracture
Lateral ankle sprain
PT diagnostic tests
- palpation
- anterior drawer test
- talar tilt test
- MSK ultrasound
- with varus test = ankle neutral will stress the calcaneofibular ligament
Lateral ankle sprain
interventions
- initially want to reduce pain and swelling with RICE
- as soon as pain allows begin pain free AROM
- restore eversion strength
- proprioceptive training
Anterior/medial tibial stress syndrome
- typically occurs in runners and other athletes that are exposed to intensive weight bearing over time
- presents as exercised induced pain over anterior/medial tibia
- pain persists for hours and days after exerise
- pain decreases with running in early stages
- early onset of pain with more frequent training in lateral stages
Anterior/medial tibial stress syndrome
clinical presentation
- tenderness over anterior medial border of tibia
- pes planus
- tight achilles tendon
Anterior/medial tibial stress syndrome
differential dx
- tibial and fibular stress fracture
- exertional compartment syndrome
- leg tendinopathy
- lumbar radiculopathy
- sural nerve or popliteal artery entrapment
Anterior/medial tibial stress syndrome
Diagnostic tools
- imaging is used mostly if there is a concern for a more significant tibial stress
- X-ray is used in an early stress fracture
- MRI is preferred imaging
Anterior/medial tibial stress syndrome
PT tests
- one leg hop test
- provocation test: pain with resisted plantarflexion
Anterior/medial tibial stress syndrome
interventions
- acute = rest with NSAIDs
- subacute: low impact and cross training exercise, stretching/strengthening of calf muscles, proprioceptive
- prefabricated orthotics can reduce tibial stress - shock absorption
Deep peroneal nerve entrapment
- entraped beneath the inferior extensor retinaculum
- caused by a tight inferior extensor retinaculum, repetitive microtrauma (running), acute trauma (ankle sprain)
- tight fitting shoes and abnormal biomechanics
- sharp shooting pain, numbness and or tingling alone the distribution
- symptoms exacerbated with physical activity and alleviated with rest
Deep peroneal nerve entrapment
Clinical presentation
- tinel sign - dorsum of foot
- edema of the ankle upon palpation
- end range PF may reproduce symptoms due to stretching of the nerve
- pes cavus can increase likelihood of nerve entrapment due to dorsal compressive forces against shoe
Deep peroneal nerve entrapment
treatment
- NSAIDs or topical anti-inflammatory creams
- rest from athletic activity
- footwear changes and shoe-lacing technique modification
tarsal tunnel syndrome
- compression of the posterior tibial nerve (L4-S3)
- in tarsal tunnel or one of its branches (lateral/medial plantar nerve)
- pain over tarsal tunnel
- sharp shooting pain and numbness in the foot
tarsal tunnel syndrome
- extrinsic causes
- intrinsic causes
- poorly fitted shoes, trauma, valgus or varus rearfoot
- tendinopathy, tenosynovitis, osteophytes, hypertrophic flexor retinaculum, ganglion cyst
tarsal tunnel syndrome
clinical findings
- tinel sign produces pain or tingling in the distribution area of nerve
- end-range DF and eversion produce symptoms
tarsal tunnel syndrome
treatment
- Ice, NSAIDs
- ultrasoud
- E-stim
- nerve mobilization/glides
High ankle sprain
- MOI: DF +ER
- anterior tibiofibular ligament
- shorter step length on opposite side
