Chapter 5Chapter 5

The Ankle and Lower Leg The Ankle and Lower Leg ContinuedContinued

Stress FracturesStress Fractures

Evaluation FindingsEvaluation Findings Table 5-9, page 169Table 5-9, page 169

Predisposing factorsPredisposing factors Narrow tibial shaft, hip external rotation, pes Narrow tibial shaft, hip external rotation, pes

cavuscavus Diagnostic testingDiagnostic testing Bump Test (Box 5-9, page 170)Bump Test (Box 5-9, page 170) Treatment (Figure 5-26, page 169)Treatment (Figure 5-26, page 169) Table 5-10, page 171Table 5-10, page 171

Os Trigonum InjuryOs Trigonum Injury Evaluation FindingsEvaluation Findings

Table 5-11, page 173Table 5-11, page 173 Steida’s process (figure 5-27,page 172)Steida’s process (figure 5-27,page 172)

Formation of an os trigonum (Fig 5-28, p172)Formation of an os trigonum (Fig 5-28, p172) Os trigonum syndrome (talarcompression Os trigonum syndrome (talarcompression

syndrome)syndrome) Inflammation of posterior jointInflammation of posterior joint Inflammation of surrounding ligamentsInflammation of surrounding ligaments Fracture of the os trigonumFracture of the os trigonum Pathology involving Steida’s processPathology involving Steida’s process

Os Trigonum Injury cont.Os Trigonum Injury cont.

Inversion/plantarflexion Inversion/plantarflexion posterior talocalcaneal ligament tightens posterior talocalcaneal ligament tightens

against os trigonum or Steida’s processagainst os trigonum or Steida’s process Eversion of calcaneus Eversion of calcaneus

os trigonum or Steida’s process to become os trigonum or Steida’s process to become compressed between tibia and calcaneuscompressed between tibia and calcaneus

TreatmentTreatment

Achilles Tendon PathologyAchilles Tendon Pathology

Association with gastrocnemius and Association with gastrocnemius and soleussoleus

Decreased plantarflexion strengthDecreased plantarflexion strength Changes in gait; ability to walk, run, jumpChanges in gait; ability to walk, run, jump

Achilles TendinitisAchilles Tendinitis

Evaluation FindingsEvaluation Findings Table 5-12, page 174Table 5-12, page 174

Poorly vascularized structurePoorly vascularized structure Limited blood supply - posterior tibial arteryLimited blood supply - posterior tibial artery Distal avascularized zone – 2 to 6 cm Distal avascularized zone – 2 to 6 cm

proximal to insertion on calcaneusproximal to insertion on calcaneus Delayed healingDelayed healing

Achilles Tendinitis cont.Achilles Tendinitis cont.

ParatenonParatenon Highly vascularized structure, surrounds Highly vascularized structure, surrounds

tendontendon PeritendinitisPeritendinitis TendinosisTendinosis

Degeneration of tendon’s substanceDegeneration of tendon’s substance Peritendinitis Tendinosis Tendon Peritendinitis Tendinosis Tendon

RuptureRupture

Achilles Tendinitis cont.Achilles Tendinitis cont.

Factors leading to achilles tendon Factors leading to achilles tendon pathologypathology Tibial varumTibial varum CalcaneovalgusCalcaneovalgus HyperpronationHyperpronation Tightness of triceps surae, hamstring groupsTightness of triceps surae, hamstring groups Running mechanics, duration and intensity of Running mechanics, duration and intensity of

running, type of shoe, running surfacerunning, type of shoe, running surface Biomechanics of foot and ankleBiomechanics of foot and ankle

Acute OnsetAcute Onset

Achilles Tendinitis cont.Achilles Tendinitis cont.

Age and genderAge and gender Pain characteristicsPain characteristics Treatment/Return to activityTreatment/Return to activity

Achilles Tendon RuptureAchilles Tendon Rupture

Evaluation FindingsEvaluation Findings Table 5-13, page 176Table 5-13, page 176

Forceful, sudden contraction = large Forceful, sudden contraction = large amount of tension developing in tendonamount of tension developing in tendon

TheoriesTheories Chronic degeneration of tendonChronic degeneration of tendon Failure of inhibitory mechanism of Failure of inhibitory mechanism of

musculotendinous unitmusculotendinous unit Rupture tends to occur in distal 2-6 cmRupture tends to occur in distal 2-6 cm

Achilles Tendon Rupture cont.Achilles Tendon Rupture cont.

Age and genderAge and gender Previous or current tendinosis, age-related Previous or current tendinosis, age-related

changes in tendon, deconditioningchanges in tendon, deconditioning Corticosteroid injectionsCorticosteroid injections Characteristics of ruptureCharacteristics of rupture

Figure 5-29, page 175Figure 5-29, page 175 Thompson TestThompson Test

Box 5-10, page 177Box 5-10, page 177 TreatmentTreatment

Subluxating Peroneal TendonsSubluxating Peroneal Tendons

Evaluation FindingsEvaluation Findings Table 5-14, page 178Table 5-14, page 178

Forceful, sudden DF/EV or PF/INV = Forceful, sudden DF/EV or PF/INV = stretch or rupture of superior peroneal stretch or rupture of superior peroneal retinaculumretinaculum

Tendon alignment Tendon alignment Figure 5-30, page 176Figure 5-30, page 176

Subluxating Peroneal Tendons Subluxating Peroneal Tendons cont.cont.

Predisposing factorsPredisposing factors Flattened fibular grooveFlattened fibular groove Pes planusPes planus Hindfoot valgusHindfoot valgus Recurrent ankle sprainsRecurrent ankle sprains Laxity of peroneal retinaculumLaxity of peroneal retinaculum

CharacteristicsCharacteristics TreatmentTreatment

Neurovascular DeficitNeurovascular Deficit

Disruption of blood or nerve supply to or Disruption of blood or nerve supply to or from lower legfrom lower leg Acute traumaAcute trauma Overuse conditionsOveruse conditions Congenital defectsCongenital defects SurgerySurgery

Dermatomes, reflexes, pulsesDermatomes, reflexes, pulses

Anterior Compartment SyndromeAnterior Compartment Syndrome

Evaluation FindingsEvaluation Findings Table 5-15, page 179Table 5-15, page 179

Increased pressure in compartment Increased pressure in compartment threatens integrity of lower leg, foot, and threatens integrity of lower leg, foot, and toestoes Obstructs neurovascular network Obstructs neurovascular network

• Deep peroneal nerveDeep peroneal nerve• Anterior tibial arteryAnterior tibial artery

Anterior Compartment Syndrome Anterior Compartment Syndrome cont.cont.

Bony posterolateral border and dense Bony posterolateral border and dense fibrous fascial lining = poor elastic fibrous fascial lining = poor elastic propertiesproperties Cannot accommodate for expansion of Cannot accommodate for expansion of

intracompartmental tissuesintracompartmental tissues Increased pressure = lack of oxygen to local Increased pressure = lack of oxygen to local

tissuestissues• Leads to ischemia and possibly cell deathLeads to ischemia and possibly cell death

Anterior Compartment Syndrome Anterior Compartment Syndrome cont.cont.

3 classifications3 classifications Traumatic Traumatic

• blow to anterior or anterolateral portion of lower legblow to anterior or anterolateral portion of lower leg Exertional Exertional

• acute or chronic; during or after exercise (or both)acute or chronic; during or after exercise (or both) Chronic (recurrent or intermittent claudication)Chronic (recurrent or intermittent claudication)

• Occurs secondary to anatomic abnormalities Occurs secondary to anatomic abnormalities obstructing blood flow to exercising musclesobstructing blood flow to exercising muscles

• Increased thickness of fascia inhibits venous Increased thickness of fascia inhibits venous outflow outflow

• Other anatomic factors – page 178Other anatomic factors – page 178

Anterior Compartment Syndrome Anterior Compartment Syndrome cont.cont.

Associated withAssociated with Tibial fracturesTibial fractures Anticoagulant therapyAnticoagulant therapy DiabetesDiabetes Knee bracesKnee braces High-heeled shoesHigh-heeled shoes

Signs and SymptomsSigns and Symptoms 5 P’s5 P’s

• Pain, pallor, pulselessness, paresthesia, paralysisPain, pallor, pulselessness, paresthesia, paralysis

Anterior Compartment Syndrome Anterior Compartment Syndrome cont.cont.

Drop foot gaitDrop foot gait Dorsalis pedis pulse (Figure 5-31, pg 180)Dorsalis pedis pulse (Figure 5-31, pg 180) Most important clinical findingMost important clinical finding

Severe pain with passive muscle stretchingSevere pain with passive muscle stretching Medical emergencyMedical emergency

Decreased pulse, paresthesia, paralysisDecreased pulse, paresthesia, paralysis Compartmental pressureCompartmental pressure TreatmentTreatment

Deep Vein ThrombophlebitisDeep Vein Thrombophlebitis

Inflammation of veins with associated Inflammation of veins with associated blood clotsblood clots

Common in postsurgical patientsCommon in postsurgical patients May be secondary to trauma to lower May be secondary to trauma to lower

extremityextremity Pain and tightness in calf during walkingPain and tightness in calf during walking

Inspection – swelling in calfInspection – swelling in calf Palpation – warmth, tightness, painPalpation – warmth, tightness, pain

Homan’s sign Homan’s sign Box 5-11, page 181Box 5-11, page 181

On-Field Evaluation of Lower Leg On-Field Evaluation of Lower Leg and Ankle Injuriesand Ankle Injuries

GoalsGoals Rule out fractures and dislocationsRule out fractures and dislocations Determine weight-bearing statusDetermine weight-bearing status Removal methodsRemoval methods

Equipment ConsiderationsEquipment Considerations

Footwear RemovalFootwear Removal Rule out fracture/dislocation and then remove Rule out fracture/dislocation and then remove

shoeshoe Figure 5-32, page 181Figure 5-32, page 181 Apprehensive athletes – remove themselvesApprehensive athletes – remove themselves If fracture is suspected – check pulsesIf fracture is suspected – check pulses

Tape and Brace RemovalTape and Brace Removal Similar to shoe removalSimilar to shoe removal Tape is cut on opposite side of injuryTape is cut on opposite side of injury

On-Field HistoryOn-Field History Mechanism of injuryMechanism of injury

• InversionInversion• EversionEversion• RotationRotation• DorsiflexionDorsiflexion• PlantarflexionPlantarflexion

Associated sounds and sensationsAssociated sounds and sensations

On-Field InspectionOn-Field Inspection On-Field PalpationOn-Field Palpation

Bony palpationBony palpation Soft tissue palpationSoft tissue palpation

On-Field Range of Motion TestsOn-Field Range of Motion Tests Willingness to move involved limbWillingness to move involved limb Willingness to bear weightWillingness to bear weight

Initial Management of On-Field Initial Management of On-Field InjuriesInjuries

Ankle Dislocations (talocrural joint)Ankle Dislocations (talocrural joint) Excessive rotation combined with INV or EVExcessive rotation combined with INV or EV Disruption of capsule/ligaments, fractures of malleoli, Disruption of capsule/ligaments, fractures of malleoli,

long bones, taluslong bones, talus Pain, loss of function, audible soundsPain, loss of function, audible sounds Figure 5-33, page 183Figure 5-33, page 183 Confirm presence of pulsesConfirm presence of pulses

Lower Leg FracturesLower Leg Fractures Signs/symptoms (Figure 5-34, page 183)Signs/symptoms (Figure 5-34, page 183) Fibula – may be able to walkFibula – may be able to walk Bump/squeeze testsBump/squeeze tests

Management of Lower Leg Management of Lower Leg Fractures and DislocationsFractures and Dislocations

Immediately immobilizedImmediately immobilized Moldable or vacuum splintsMoldable or vacuum splints

Leave shoe on until emergency roomLeave shoe on until emergency room Figure 5-35, page 183Figure 5-35, page 183 Compound fracture Compound fracture

Control bleedingControl bleeding TreatmentTreatment

Figure 5-36, page 184Figure 5-36, page 184

Anterior Compartment SyndromeAnterior Compartment Syndrome

Avoid compressionAvoid compression Acute gross hemorrhage or absent Acute gross hemorrhage or absent

dorsalis pedis pulse – immediate refer to dorsalis pedis pulse – immediate refer to physicianphysician

Educate athletesEducate athletes