Chapter 19 - Ankle and Lower Leg Lecture Notes PDF

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Prevention and Care of athletic injuries course with professor Jonathan Davis...

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The ankle and lower leg ● The ankle joint ○ True ankle joint ■ Tibia, fibula and talus ○ Subtalar joint ■ Talus, calcaneus ● Lateral Ankle ligaments ○ Anterior Talofibular (ATF) ■ Most commonly sprained in lateral ankle sprain ■ On top of everything ○ Calcaneofibular is also common ● Functional Anatomy ○ Ankle is a stable hinge joint ○ Medial and lateral displacement is prevented by the malleoli ○ Ligament arrangement limits inversion and eversion at the subtalar joint ○ Square shape of talus adds to stability of the ankle ○ Most stable during dorsiflexion, least stable in plantar flexion ○ Normal range is 10 degrees dorsiflexion and 50 degrees plantar flexion ■ Normal gait requires 10 dorsiflexion and 20 plantarflexion ● Preventing injury in the lower leg and ankle ○ Achilles Tendon Stretching ■ A tight heel cord may limit dorsiflexion and may predispose individual to ankle injury ■ Should routinely stretch before and after practice ■ Stretching should be performed with knee extended and flexed 15-30 degrees ○ Strength training ■ Static and dynamic joint stability is critical in preventing injury ■ While maintaining normal ROM, muscles and tendons surrounding joint must be kept strong ○ Neuromuscular control training ■ Can be enhanced by training in controlled activities

■ Uneven surfaces BAPS boards, rocker boards, or dynadiscs can also be utilized to challenge athlete ■ 3 month program=decreased risk ● Specific ankle injuries ○ Ankle sprains ■ Single most common injury in the active ■ Caused by sudden inversion or eversion moments ○ Inversion Sprains ■ Most common and result in injury to the lateral ligaments (90%) ■ Anterior talofibular ligament is injured with inversion, plantar flexion and internal rotation ■ Rupture of the ATF ligament (weakest ligament) ■ Posterior talofibular and calcaneofibular ligaments can be injured with increased force ■ Occasionally the force is great enough for an avulsion fracture to occur w/ the lateral malleolus (Pott’s) ● Avulsion fracture- pulls off bone ■ Severity of ligament sprains is classified according to grades ■ With inversion sprains the foot is forcefully inverted or occurs when the foot comes into contact with uneven surfaces ● Inversion ankle sprains ○ Mechanism of injury ■ Inversion, plantar flexion ■ ATF, lateral ligaments ○ Signs/symptoms ■ Swelling, pain, ecchymosis ■ Non weight bearing (grade 2 and 3) ○ Treatment ■ Dependent on severity ○ Prognosis ■ Grade 1 ● 1-2 days RICE

● Early ROM ● 1 week RTP ■ Grade 2 ● 3 days RICE ● x-ray/MRI ● 5-10 days no weight bearing ● Early ROM, 48 hours post ■ Grade 3 ● 3 days RICE ● Casting/bracing 6 weeks ● Isometrics while non weight bearing ● Possible surgery ● Eversion ankle sprains ○ Represent 5-10% of all ankle sprains ○ Etiology ■ Eversion force results in damage to deltoid ligament and possibly fracture of the fibula ● Deltoid ligament- gives strength and stability to outside of foot ○ Assist with m-l arch and this can lead to flat foot ● Caused by compression ■ Foot that is pronated, hypermobile or has a depressed medial longitudinal arch is more predisposed to eversion sprains ■ Less common, more severe and takes more time ■ Listen to patients history. Inversion sprains can affect medial side as well with compression ○ Mechanism of injury ■ Eversion ■ Avulsion of the tibia ■ Deltoid ligaments ○ Signs/symptoms ■ Pain

● Abduction and adduction ● Pressing on bottom of foot causes nothing ■ Non weight bearing ○ Treatment ■ X-ray ■ RICE/NSAIDs ○ Prognosis ■ Similar to inversion ■ Treat by grade ○ Management ■ Rice; X-ray to rule out fracture; no weight bearing initially; posterior splint tape; NSAIDs ■ Follows the same course of treatment as inversion sprains ● Posteromedial ankle muscles ● Inner heel wedge ■ Grade 2 or higher will present with considerable instability and may cause weakness in medial longitudinal arch resulting in excessive pronation or fallen arch ● High ankle sprains ○ Syndesmotic sprain ○ Mechanism of injury ■ Distal tibiofibular joint ■ Increased external rotation or forced dorsiflexion ■ Interosseous tearing ○ Signs/symptoms ■ Severe pain ● Passive externally rotated or dorsiflexed ■ Loss of function ○ Treatment/prognosis ■ Months ■ Extended period of immobilization ● Ankle fractures/dislocations ○ Etiology

■ Number of mechanisms ● Distal tibia and fibula, distal posterior tibia, avulsion (sprains), bimalleolar fractures ■ Signs/symptoms ● Swelling and pain may be extreme with possible deformity ● Splint! ■ Management ● RICE to control hemorrhaging and swelling ● Once swelling is reduced, a walking cast or brace may be applied with immobilization lasting 6-8 weeks ● Chronic Ankle instability ○ Develops in 74% of patients who sustain an ankle sprain ○ Mechanical vs. functional instability ■ Mechanical instability is laxity that physically allows for movement beyond the physiologic limit of the ankle range of motion ■ Functiona; instability is a subjective feeling that the ankle is unstable ● Attributed to proprioceptive and/or neuromuscular deficits that negatively impact postural control and thus stability and balance ○ Rehab should focus on a combination of ankle strengthening and improving proprioception ● Acute Achilles Strain ○ Etiology ■ Common in sports and often occurs with sprains or excessive dorsiflexion ○ Signs/symptoms ■ Pain may be mild to severe ■ Most severe injury is partial/complete avulsion or rupturing of the achilles ○ Management ■ Pressure and RICE should be applied

■ After hemorrhaging has subsided an elastic wrap should continue to be applied (pressure) ■ Conservative treatment should be used as achilles problems generally become chronic ■ A heel lift should be used and stretching and strengthening should begin soon ● Achilles tendon rupture ○ Mechanism of injury ■ Sudden push off ■ Falling in hole ○ Signs/symptoms ■ “Feels like being kicked in the leg” ■ Sudden pain that vanishes ■ Swelling, ecchymosis, point tenderness ■ Minimal motion ○ Treatment ■ Refer ■ Surgical ■ RICE/NSAIDs ○ Prognosis ■ 6 weeks non weight bearing ■ 2 weeks short leg walking cast ■ 6 months rehab ■ 75-90% full recovery ■ Always chronic swelling ○ Management ■ Usual management involves surgical repair for serious injuries (return of 75-80% of function) ■ Non operative treatment consists of RICE, NSAIDs, analgesics, and a non weight bearing cast for 6 weeks, followed up by a walking cast for 2 weeks (75-90% return to normal function) ■ Rehabilitation lasts about 6 months and consists of ROM, PRE and wearing a 2cm heel lift in both shoes ● Medial Tibial Stress Syndrome (shin splints)

○ Etiology ■ Pain in anterior portion of shin ■ Accounts for 10-15% of all running injuries, 60% of leg pain in athletes ■ Caused by repetitive microtrauma ■ Weak muscles, improper footwear, training errors (hard surfaces), varus foot, tight heel cord, hypermobile or pronated feel and even forefoot supination can contribute to MTSS ■ May also involve stress fracture or exertional compartment syndrome ○ Signs/symptoms ■ Four grades of pain ● Pain after activity ● Pain before and after activity and not affecting performance ● Pain before, during and after activity, affecting performance ● Pain so severe, performance is impossible ○ Management ■ Physician referral for x-rays and bone scan ■ Activity modification ■ Correction of abnormal biomechanics ■ Ice massage to reduce pain and inflammation (do not use compression) ■ Flexibility program for gastroc-soleus complex ■ Arch taping and or orthotics ● Stress fracture of tibia or fibula ○ Etiology ■ Common overuse condition, particularly in those with structural and biomechanical insufficiencies ■ Runners tends to develop in lower third of lower leg (dancers middle third) ■ Often occur in unconditioned, non experienced individual ■ Often training errors are involved

■ Component of female triad ● Loss of bone density in female athletes because of too much activity and malnourishment leading to loss of menstrual cycle and estrogen ■ Signs and symptoms ● Pain more intense after exercise than before ● Point tenderness; difficult to discern bone and soft tissue pain ● Bone scan results (stress fracture vs. periostitis ■ Management ● Discontinue stress inducing activity 14 days ● Use crutches ● Weight bearing may return when pain subsides ● Cycling before running ● After pain free for 2 weeks patient can gradually return to running ● Biomechanics must be addressed ● Rehabilitation techniques ○ General body conditioning ■ Must be maintained with non weight bearing activities ○ Weight bearing ■ Non weight bearing vs. partial weight bearing ■ Protection and faster healing ■ Partial weight bearing helps to limit muscle atrophy, proprioceptive loss, circulatory stasis and teinitis ■ Protected motion facilitates collagen alignments and stronger healing ○ Joint mobilizations ■ Movement of an injured joint can be improved with manual mobilization techniques ○ Flexibility ■ During early stages inversion and eversion should be limited ■ Plantar flexion and dorsiflexion should be encouraged ■ With decreased discomfort inversion and eversion

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exercises should be initiated Neuromuscular control ■ Deficits can predispose individuals to injury ■ Patient should engage in proprioception progression including double and single leg stances, eyes open and closed, and alternating apparatuses and surfaces ■ Use of a variety of closed kinetic chain exercises may be beneficial ● Enhances overall proprioceptive return Strengthening ■ Isometrics (4 directions) early during rehab phase ■ With increased healing, aggressive nature of stretching should increase (isotonic) exercises ■ Pain should serve as the guideline for progression ■ Tubing exercises allows for concentric and eccentric exercises ■ PNF allows for isolation of specific motions Taping and bracing ■ Ideal to have have patient return without taping and bracing ■ Cmon practice to use tape and brace initially to enhance stabilization ■ Must be sure it does not interfere with overall motor performance ■ Utilize braces and taping to provide support to ligamentous structures ■ May help athlete detect movement in the ankle and reduce injury ■ Ankle braces improve ● Functional stability ● Proprioception ● Postural stability ● Balance and neuromuscular control ● Functional performance Functional progressions

■ Severe injuries require more detailed plan ■ Introduction of weight bearing activities (partial vs. full) is critical to progress ■ Progression must occur based on pain and level of function ■ Running can begin when ambulation is pain free (transition from pool to even surface then changes of speed and direction) ○ Return to activity ■ Must have complete ROM an at least 80-90% of pre injury strength before return to sport ■ If full practice is tolerated without insult, patient can return to competition ■ Return to activity must involve regular progression of functional activities, slowly increasing stress on injured structure ■ Specific sport dictate specific drills...