Ankle and Lower Leg Notes Lower PDF

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Ankle and Lower Leg Osteology  Tibia o Primary weight bearing bone of the lower leg o On the medial side of the lower leg has the bony landmarks of  Tibial tuberosity  Medial and lateral condyles  Medial malleolus  Shaft Medial Posterior Border Intersorseous Tibia Medial Lateral Fibula

Anterior Border = Tibial cres

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Fibula o Nonweight bearing bone o Lateral side of the lower leg with the bony landmarks of  Fibula head  Lateral malleolus Talus + Calcaneus + Tibia + Fibula = Ankle

Joints  Distal Tibiofibular joint o Fibrous joint also known as the syndesmosis joint o Very strong joint with little movement o Spreads out during dorsiflexion o Composed of ligaments  Interosseous membrane  Anterior tibofibular ligament  Posterior tibofibular ligament  Talocural joint

“ True ankle” Articulation between tibia, fibula and talus This is a modified synovial hinge joint as it plantar/dorsiflexion Closed-packed position  Full dorsiflexion o Open-packed position  Slight plantarflexion (10 degree) o Ligaments  Anterior Talofibular  Posterior talofibular  Calcaneofibular  Deltiod  Subtalar joint o Articulation between talus and calcaneus o Synovial plane joint allowing motions of inversion and eversion o With the talocrural joint the ankle can preform supination: inversion and plantarflexion and pronation: Eversion and dorsiflexion  Retinacula o Extensor Retinaculum  Superior  Inferior o Flexor retinaculum o Peronal Retinaculum  Superior  Inferior Myology  Superficial posterior o Gastrocnemius: fast twitch  2-joint muscle, had 2 heads (med & lat)  O: Medial & lateral femoral condyles  I: Calcaneus via Achilles tendon  N: Tibial nerve  A: Pflex & assist in knee flex o Soleus: slow twitch  O: Fibular head, superior 1/3 posterior fibula, soleal line & middle 1/3 medial tibial border  I: Calcaneus via Achilles tendon  N: Tibial nerve  A: Pflex o Plantaris: Accessory  Could be used as graft  Deep Posterior o Tom, Dick and Harry o All innervated by tibial nerve o o o o

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o Tibialis Posterior  O: Interosseous membrane, posterior tibia & fibula  I: Navicular tuberosity, 3 cuneiforms, cuboid, bases of 2nd – 4th MTs  A: Pflex & Inversion o Flexor Digitorum Longus  O: Distal 2/3 posterior tibia  I: Bases of 2nd-5th distal phalanges  A: 2nd – 5th MTP, PIP, DIP flexion, assist in plantarflexion o Flexor Hallucis Longus  O: Distal 2/3 posterior fibula, interosseous membrane  I: Base of 1st Distal phalanx  A: 1st MTP and PIP flexion and assist in plantarflexion Lateral o Peronus Longus  O: Fibular head, upper 2/3 of lateral fibula  I: Base of the 1st MT, medial cuniform  N: Superficial peroneal nerve  A: Eversion, assist in plantarflexion o Peroneus Brevis  O: Distal 2/3 of lateral fibula  I: Base of the 5th MT  N: Superfical peroneal nerve  A: Eversion, assist in plantarflexion Anterior o Tibialis Anterior  O: Lateral Condyle and upper ½ of lateral tibia, interossesous membrane  I: Medial cuneiform and base of 1st MT  N: Deep peroneal nerve  A: Dorsiflexion and inversion o Peroneus Tertius  O: Distal 1/3 of anterior fibula, interosseous membrane  I: Base of 5th MT  N: Deep peroneal nerve  A: Dorsiflexion and Eversion o Extensor Digitorum Longus  O: Lateral condyle and proximal ¾ of anterior fibula, interossesous membrane  I: 2nd -5th distal phalanges  N: Deep peroneal nerve  A: 2nd – 5th MTP, PIP, DIP extension and assist in dorsiflexion o Extensor Hallucis Longus  O: Middle 2/3 of anterior fibula, interosseous membrane

 I: Base of 1st distal phalanx  N: Deep peroneal nerve  A: 1st MTP and IP extension, assist in dorsiflexion  4 compartments in lower leg o Superficial posterior  Gastrocnemius, soleus, plantaris o Deep posterior  Flexor digitorum/hallucis longus, tibialis posterior  Posterior tibial artery and nerve o Lateral  Peronus longus/bervis  Peroneal artery, superficial peroneal nerve o Anterior  Extensor digitorum/hallucis longus, tibalials anterior, peronus tertius  Anterior tiabial artery, deep personal nerve  Greatest risk for compartments syndrome Neurologic anatomy  Common peroneal nerve o Goes around fibula head and becomes very superficial  Branches into o Superficial peroneal nerve o Deep peroneal nerve Evaluation  Similar to foot  Remember everything is connected o A foot problem causes ankle/lower leg problem  History o Shoes and training surfaces o Weight change  Observation o Foot (arch, toes, alignment, abnormalities) o Gait and posture  Palpation o Tibial tuberosity o Medial and lateral condyles and malleoli o Tibial crest o Fibula head o Anterior/posterior tibiofibula ligament o ATF o PTF o CF o Deltoid

o Retinaculum  Special tests o ROM  Dorsiflexion: 20 degree  Plantarflexion: 50 degree  Inversion: 45 degree  Eversion: 15 degree o MMT  Gastrocnemius/soleus  Stabilizing lower leg while applying resistance against plantarflexion  Soleus: knee flexed  Gastrocnemius: knee extended  IF the pt is strong enough preform while weight bearing  Tibial posterior  Stabilize lower leg  Pressure against lower leg on medial plantar aspect  Inversion and plantarflexion  Tibial anterior  Pressure against lower leg on medial dorsal aspect  Dorsiflexion and inversion  Peronus longus/brevis  Lateral border and sole of foot  Plantarflexion and eversion  Peronus tertius  Dorsiflexion and eversion o Joint play  Distal tibofibial joint play  Grasp fibula base and stabilize tibia  Move posterior and anterior  Positive: increased pain or laxity  Implication: syndesmosis sprain Stress fracture/reaction  Onset: Chronic o Tibia is most common  Pain characteristics o Pain with bone and increase with activities, achy  Other findings o Crepitus o Night pain o Negative x-ray o Positive tuning fork  Percussion test

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Squeeze test

Fracture  Onset: acute  Pain characteristics o Sharp  Other possibilities o Immediate swelling o Deformity o Crepitus o Positive tuning fork  Percussion  Squeeze  Potts’ fracture: medial and lateral malleoli fracture  Hagier fracture: Fibula shaft fracture Lateral ankle sprain – most common  Inversion  Onset: acute  Pain characteristics o Lateral pain o Swelling, ecchymosis over lateral side o Peroneus weakness  Other o Popping o Antalgic gait – limb o Medial pain o PROM  Inversion and plantarflexion: ATF and CF  Inversion and dorsiflexion: PTF o Positive anterior drawer and talar tilt –inversion Medial ankle sprain  Eversion  Onset: acute  Pain characteristics o Medial ankle pain (tender to palpate over deltoid o Swelling, ecchymosis over medial  Other o Popping o Antalgic gait – limb o Lateral pain o Positive talar tilt – eversion and positive kilegers test Syndesmosis sprain  High ankle sprain – most sever

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Onset: acute Pain characteristics o Anterior distal tibiofibula pain o Swelling o All movements Other o Positive squeeze, distal tibiofibula joint play and kilegers

Bifurcated ligament  Lateral aspect “Y” shaped  Calcaneus to cuboid and navicular  Distal to sinus tarsi Achilles tendonpathy/rupture  Tendonitis/ tendonosis -> tendon rupture  Onset: acute or insidious  Pain characteristics o Tendonopathy: pain with active plantarflexion o Rupture: Feels as if being kicked or hit followed by inability to plantarflexion  Other o Tendonpathy: exostosis thinking of tendon, squeaky sensation with foot problems and calf tightness o Rupture: Obvious deformity and positive Thompson test

Peroneal Tendon Subluxation  Peroneal retinaculum rupture or stretch  Tendon slips out of the groove anterior with dorsiflexion and eversion  Onset: Acute or insidious  Pain Characteristics o Over area of superior retinaculum  Other possible findings o Visible and palpable tendon subluxation o Snapping sensation MTSS – Medial Tibial Stress Syndrome  “Shin Splint”  A very general term for “ pain in the shin”  Possible causes o Periostitis  Inflammation of the bone membrane  Repetitive muscle contraction pulling force on the periosteum leading to inflammation  Pain Characteristics  Tender to palpate over the tibia – medial border  Increase with ankle movement  Other possible findings  Crepitus  Abnormal foot arch/alignment  Negative percussion  Negative bump  Negative tuning fork  Compressive force around the shin and decrease pain  Evidence: Probably not as common as we thought  Very few have identified inflammation markers o Myofascial element o Muscular overuse and fatigue  Usually combination of overuse and imbalance  Foot alignment probably can add stress  Pain Characteristics  Tender to palpate over tibia and lower medial side  Increase with activity o Tibialis anterior: Inversion and dorsiflexion o Tibialis posterior: Inversion and Plantarflexion o Soleus: Plantarflexion o Flexor Halluces Longus: Flexion of the 1st toe o Flexor Digitorum Longus: Flexion of the 2-5th toe  Other possible findings  Muscular imbalance

 Foot/arch problem  Tight calf o Stress reaction  Tibia is most commonly affected  Pain Characteristic  Pain along with the bone and increase with activity  Other possible findings  Crepitus  Night pain  Negative x-ray  Negative or inconclusive tuning fork, percussion, squeeze  The research agrees  May lead to stress fracture  Patient almost always has a foot alignment/biomechanical issues  Literature review by Bennett -2007 o X-ray won’t help o MRI inconclusive  Significant relationship between chronic MTSS and average MRI o Triple Phase Bone Scintography is the gold standard (bone scan)  Especially in differentiating between a stress fracture and MTSS DVT-Deep Vein Thromobosis  A blood clot in a deep vein that can potentially life-threating  Secondary to a lower extremity trauma  Pain characteristics o Dull achy pain in one leg with sudden intense throbbing  Other possible findings o Fatigue o Warm skin o Swelling o Redness o Tightness of calf muscle o Positive homans’ sign o Positive calf swelling o Positive wells score  Homans’ Sign o Forced dorsiflexion o Knee extended or flexed o Positive  Pain in calf or knee  Also palpating the calf causes pain o Implication: DVT o Crappy test  Calf Swelling test

o Measure the circumference of the calf and compare to the opposite side o Positive test: > 15mm for men and > 12 mm for women o Indication: DVT o Very good  Well score o Original vs. Modified – both very good to rule in DVT o Score system, if 3 day of bed rest or surgery - +1  Tenderness - +1  Swollen - +1  Calf swelling by > 3 cm - +1  Pitting edema - +1  Collateral superficial veins - +1  Alternative diagnosis likely and greater then DVT – (-2) o Modified added  Previous case of DVT - +1 Compartment Syndrome  Acute – traumatic  Chronic – exertional  Excessive swelling in compartment o Fluid pressure increase within a compartment o Compressing muscles, nerve, and blood vessels o If untreated then necrosis will distally occur o 911 emergency  Anterior compartment most common  Deep compartment second most common  Onset: acute o Kicked or hit from external force  Pain characteristics o Severe pain and numbness o Leg swollen and shiny  Other possible findings o Tightness, cramp o Weakness/inability to contact affect muscles  Distal pulse and call 9-1-1  Onset: Insidious o Often seen in distance runners, 50-60% of cases bilateral  Chronic inflammation and metabolic waste build up

Fluid pressure increase with exercise Pain characteristics o Ischemic pain that increase with activity o Subside or completely go away with rest  Other possible findings o Tightness and cramps o Weakness of inability to contract  Drop foot o Neurological involvement is rare  Treatment o Chronic  Compartment pressure is measured commonly right after or during exercise o Acute  Fasicaectomy  Cute and releases of fascia Other conditions  Shin, muscle contusion  Muscle strain  Fibula head dislocation  Osteochondritis dissicans  Ankle dislocation  ...