Chapter 9: Ankle and Leg Pathologies Flashcards
Which bone provides lateral stability to the ankle mortise?
Fibula
The Achilles tendon attaches on the _______ tubercle.
Calcaneal
What is the closed-packed position of the ankle mortise?
Dorsiflexion
The most stable position of a joint occurs in which position?
Closed-packed position
The ATFL is tight in which talocrural joint motion?
Plantarflexion
Which ligament limits anterior translation of the talus?
Anterior talofibular ligament
Which ligament limits posterior translation of the talus?
Posterior talofibular ligament
Which ligament is strongest of the lateral ankle ligaments?
Posterior talofibular ligament
What does the distal tibiofibular syndesmosis responsible for?
Allows for rotation and slight spreading of the ankle mortise.
What ligaments make up the deltoid ligament?
Anterior tibiotalar
Posterior tibiotalar
Tibiocalcaneal
Tibionavicular
What ligaments make up the distal tibiofibular syndesmosis?
Anterior tibiofibular
Posterior tibiofibular
Crural interosseous membrane
TRUE or FALSE
The fibula glides inferiorly during dorsiflexion.
FALSE
What nerve innervates the lateral compartment of the leg?
Superficial fibular
What nerve innervates the posterior compartment of the leg?
Tibial
What nerve innervates the deep posterior compartment of the leg?
Tibial
Which muscles act as dorsiflexors of talocrural joint?
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Peroneus tertius
Which muscle act as plantarflexors of talocrural joint?
Gastrocnemius Soleus Plantaris Peroneus longus Peroneus brevis
List muscles of deep posterior compartment.
Flexor hallucis longus
Flexor digitorum longus
Popliteus
Posterior tibialis
Which two bursae are associated with the ankle and leg?
Subtendinous calcaneal bursae
Subcutaneus calcaneal bursae
Where is the subtendinous calcaneal bursae located?
Between the Achilles tendon and the posterior aspect of the calcaneus
Where is the subcutaneus calcaneal bursae located?
Between the posterior aspect of the Achilles and the skin
The deep fibular nerve and superficial fibular nerve arise from which nerve?
Common fibular nerve
What is the resting position of the talocrural joint?
Inversion
What is thrombophlebitis?
Inflammation of a vein and the subsequent formation of blood clots
Which ligament can be identified by locating sinus tarsi?
Anterior talofibular ligament
What does PQRST stand for?
Provocation - what cause it to hurt? Quality - how bad does it hurt? Region - where does it hurt? Severity - how bad does it hurt? Timing - when does it hurt?
How many degrees of dorsflexion must be provided by the talocrural joint during walking?
10 degrees
How many degrees of dorsflexion must be provided by the talocrural joint during running?
15 degrees
AROM plantarflexion degrees from a neutral position
50 degrees
AROM dorsiflexion degrees from a neutral position
20 degrees
AROM inversion degrees from a neutral position
20 degrees
AROM eversion degrees from a neutral position
5 degrees
Inversion and eversion occur at the _______ joint.
Subtalar
What are the end-feels of the talocrural and subtalar capsular patterns?
Firm - soft tissue stretch
A hard end-feel of the talocrural or subtalar joint may be a result of damage to which structures?
Capsular or ligamentous structures
Which special test would you use to test the integrity of the anterior talofibular ligament?
Anterior Drawer Test
This test is used to determine if the calcanefoibular ligament has been injured?
Inversion Talar Tilt test
Tests for deltoid ligament instability include…
Eversion Talar Tilt test
External Rotation Test
If posterior talar glide is restricted then this talocrural joint motion will be limited.
Dorsiflexion
If medial talar glide is restricted then this subtalar joint motion will be limited.
Eversion
If lateral talar glide is restricted then this subtalar joint motion will be limited.
Inversion
Special test used to evaluate lateral translation of the talus the
Cotton Test
Special test used to evaluate distal tibiofibular syndesmosis instability.
Klieger’s External Rotation Test
Why would overpressure at the end of dorsiflexion elicit pain?
If syndesmosis trauma is present forced dorsiflexion will wedge anterior border of talus between talocrural joint causing fibula to separate slightly from tibia thus causing pain
Describe Lower Quarter Screen myotomes
L2 - hip flexion L3 - knee extension L4 - dorsiflexion L5 - toe extension S1 - plantarflexion
Describe Lower Quarter Screen dermatomes.
L1 - Upper Anterior Thigh L2 - Greater Trochanter of femur L3 - Mid Anterior Thigh L4 - Medial Malleolus L5 - Dorsum 3rd MTP Joint S1 - Lateral Malleolus S2 - Popliteal Fossa S3 - Ischial Tuberosity S5 - Perianal Area
What is the open packed position of the ankle?
Plantarflexion + inversion
Pain and crepitus over the origin and insertion of the can indicate a possible…
Avulsion Fracture
How much more likely is a basketball player who has suffered an ankle sprain than a player who has not?
5x
This pulse must be established after any significant lower extremity bone fracture or joint dislocation.
Posterior Tibial artery
What does the Cotton test assess?
The amount of lateral translation of the ankle mortise
A positive Cotton test suggests a possible _______.
Tibiofibular syndesmosis sprain
How does a tight triceps surae muscle group predispose an individual to lateral ankle sprain?
Tightness of the triceps surae muscle group place the ankle in a open-packed position (talocrural joint in a plantarflexed position and subtalar joint in an inverted position)
Pain and crepitus over the origin and insertion of the involved ligament indicates a possible _______ .
Avulsion fracture
This joint play test identifies the amount of anterior-posterior play in distal tibiofibular syndesmosis.
Distal tibiofibular joint play
The presence of this pulse must be established after lower extremity fracture or dislocation and in those individuals suspected to have anterior compartment syndrome.
Dorsal pedis artery
Describe the two theories of why individuals with a history of ankle sprains are more likely to suffer an ankle sprain by more than 70%.
(1) ankle sprains result in the loss of ligament ability to passively support the joint in conjunction with a reflex arc that is too slow to a evoke a contraction of the peroneal muscles
(2) decreased proprioceptive abilities of the capsule, ligament and peroneal muscles.
Define osteochondral defect (OCD).
Injury to cartilage or bony defect
Define osteochondritis dissecans.
Loose body of bone
What are some common mechanisms for syndesmosis sprains?
Forced dorsiflexion
Excessive external rotation of talus
Which other ligament will usually be affected by a syndesmotic sprain?
Deltoid ligament
Diagnosis based on these observations:
(+) external rotation test (Klieger’s)
(+) squeeze test
Pain primarily on the anterior aspect of ankle and along interosseous membrane most prominent during forced dorsiflexion
TTP over anterior and posterior tibiofibular ligaments
Pain is reduced witch dorsiflexion compression test
Syndesmotic sprain
Forces required to produce a syndesmotic sprain may lead to a spiral fracture to the distal 3rd of fibula called _______.
Maisonneuve fracture
How does a “knock-off” fracture occur?
Commonly occurs with forced eversion, caused by the calcaneous colliding with the lateral malleolus.
Describe an Os Trigonum injury.
The Stieda’s process seperates from the talus due to forced hyperplantarflexion or repetitive activity usually involving plantarflexion
Os Trigonum injuries commonly occur in which population?
Dancers, gymnasts and swimmers
Where is the Stieda’s process located?
Posterior aspect of talus
Athlete is assuming a stiff-legged gait pattern characterized by external rotation of lower extremity. Reports landing with his right leg while ascending from a jump. Reports a sensation of being “kicked” followed with severe pain around posterior aspect ankle. What do you suspect based on this information?
Possible Achilles tendon rupture
This test is used to confirm an Achilles tendon rupture.
Thompson Test
Where is the Os Peroneum located?
On the lateral aspect of the calcaneocuboid joint.
What are the “five P’s” used to describe the signs and symptoms of compartment syndrome?
Pain Pallor (redness) Pulselessness Paresthesia Paralysis
With a anterior compartment syndrome paresthesia may be present in the…
Web space between the 1st and 2nd rays and possibly on the dorsum of foot.
List two contraindications for treatment of anterior compartment syndrome.
Compression wrap
Elevation
Defien deep vein thrombosis (DVT).
Blood clot of a deep vein most commonly in leg
Palpation reveals warmth, tightness of the calf musculature and pain. Posterior aspect of leg is red and patient has been experiencing leg fatigue. What could you suspect based on this information?
Possible DVT
Lateral ankle sprains, fibularis brevis longus avulsion fracture, and medial malleolus fractures are associated with this mechanism.
Inversion ankle sprains
Syndesmotic ankle sprains and fractures of the lateral malleolus and proximal fibula are associated with this mechanism.
Eversion ankle sprains
Forced dorsiflexion can rupture (THIS TENDON) or cause sprain to this (THIS LIGAMENT).
Achilles tendon
Distal tibiofibular ligament
A “snap or “pop” may be associated with a…
Ligament rupture or bony fracture.
A description of being “kicked” in the calf may be associated with a…
Achilles tendon rupture
Radiating pain or numbness in the anterior ankle and leg can indicate…
anterior compartment syndrome or trauma to the deep fibular nerve.
Klieger’s Test assess injury to which ligament?
Deltoid ligament
Whats the difference between the External Rotation Test and Klieger’s test?
- External rotation test assesses tibiofibular ligament pathology
- Klieger’s assesses deltoid ligament
The External Rotation Test rotates the _______ into the _______ malleolus spreading the tibiofibular syndesmosis.
talus : lateral
Cotton test glides the ______ bone against the ______ to open the distal tibiofibular syndesmosis.
Calcaneus
What is possible pathology with this information.
Pain over distal syndesmosis is reduced with dorsiflexion compression test.
Localized pain with squeeze test
Distal syndesmosis sprain
Explain x-ray referral with Ottawa Ankle Rule.
- Pain with palpation over lateral borders of medial and lateral malleolus
- Pain with palpation over navicular or base of 5th MT
An ankle x-ray should be performed when pain is elicited over _______.
lateral and medial malleoli
A foot x-ray should be performed when pain is elicited over _______.
navicular and base of 5th MT
Define Homan’s Sign.
- Passive dorsiflexion of foot with knee extended & the squeeze calf for 30-60 seconds
- Pain in the calf; throbbing, Nx symptoms
What can give you a false positive Homan’s Sign?
Gastroc or soleus strain may give false positive
