ankle & lower leg heat 3685 athletic injury assessment i chapter 5, p. 136
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Ankle & Lower Leg
• HEAT 3685• Athletic Injury
Assessment I• Chapter 5, p. 136
Clinical Anatomy--p.136
• Bones:– tibia
– fibula
– talus
• Ligaments:– ATFL
– PTFL
– CFL
– Deltoid
• Interosseous membrane
• Muscles:– peroneals
– anterior tibialis
– posterior tibialis
– triceps surae
• Bursae
History--p. 145
• Onset of pain--– acute/gradual/chronic/ re-
injury
• PMH? (tx/rehab)• Mechanism:
– INV– EV– DF– PF– Combination
• Location of pain--– Table 5-2, p.147– medial/lateral:
• probable sprain• avulsion fx• stress fx• muscle strain
• Change in activity?– Position/requirements/
duration/frequency/ surface
Observation/Inspection--p.147
Fig. 5-15, p. 149
• WB status (antalgic?)
• Bilateral comparison– malleoli
– sinus tarsi (p.fig. 5-16, p149)
– triceps surae
– Achilles tendon
• Inflammation
• Swelling
• Deformity
Palpation-- p. 150-151
• Lateral ligaments (p.151)– ATFL
– PTFL
– CFL
• Medial Ligaments– Deltoid group
• Dorsalis pedis pulse– fig. 5-31, p. 180
– Between 1st & 2nd mets.
• Tibio-fibular Ligaments (p.152)
– Anterior
– Posterior
Functional Testing--p. 154
• AROM:– DF/PF:
• landmarks
• DF=20º
• PF=~50º
• fig. 4-24, p. 106
– INV/EV:• landmarks
• INV~20º
• EV~5º
• RROM: Box 5-3, p. 156
• Other Tests:– Toe Raise
– Heel Raises
– Walking/Hopping/Jumping
On-field Functional Testing
• Willingness to:– Move joint
– Bear weight
• Contraindicated:– Obvious deformity
– Be cautious when full AROM present
Ligamentous Testing--p.157
• Anterior Drawer• Posterior Drawer• Talar tilt• Kleiger test
Anterior Drawer--p.158
• Box 5-4, p. 158• 2 methods• knee flexed/foot
stabilized• Assesses laxity in
ATFL• (+)= anterior
movement of talus on mortise
Anterior Drawer Testing
• Knee flexed/foot stabilized
• Assesses laxity in ATFL
• (+)= anterior movement of talus on mortise
Posterior Drawer
• Similar to Anterior Drawer
• Tests integrity of PTFL
• (+) = Posterior movement of talus on mortise
Talar Tilt—p.159
• Inversion stress test• Box 5-5, p. 159• Stresses CFL• Always compare bilaterally• (+) = excessive PROM in INV• Also used in x-rays (WNL: <9º)• (EV talar tilt tests the deltoid ligament.—Box 5-6,
p.160)
Kleiger test—p. 161
• Box 5-7, p.161
• Syndesmosis test
• External Rotation (ER) with plantar flex. (PF)
• (+) Results: (2 possible)– Medial pain=deltoid sprain
– Anterior pain=ant. tibiofibular sprain
Lower Leg Special Tests
• Bump Test--p.170• Squeeze test--p.166• Thompson test--p.177• Homan’s sign--p.181
Bump Test--p.170
• Percussion test –Box 5-9
• Ankle DF to neutral and tap calcaneus
• (+) Results= – Pain proximally with distal
percussion
– Impression: lower leg fx. (tibia, fibula, or talus)
– false positives common
Squeeze test--p.166—Box 5-8
• Compression test
• Compress tibia & fibula together progressing distally
• (+) Results:– Distal pain with proximal
compression
– Impression: lower leg fx (tibia or fibula)
– Sometimes (+) with stress fx
Thompson test--p.177, Box 5-10
• Athlete is prone
• Squeeze the triceps surae belly and observe passive plantarflexion
• (+)=Reduced motion at ankle– Impression: torn Achilles tendon
Homan’s sign--p.181, Box 5-11
• Assesses presence of deep vein thrombosis (DVT)
• Findings must agree with other symptoms
• Passive DF with full knee EXT.
• (+) = intense pain in calf along with other signs of inflammation
• Triceps surae strain may give false (+)
Neurological Testing--p.162
• Most common neuro. Trauma:– common peroneal
nerve injury• Dec. in PF, EV, DF
strength
– secondary to other injuries (fx, contusions, LBP)
• Signs/symptoms:– Decreased strength
– Paresthesia/Anesthesia
– Decreased reflexes
Pathologies
• Inversion ankle sprain• Eversion ankle sprain• Lower leg fractures• Stress fx• Ankle impingement• Achilles tendonitis• Subluxating Peroneal
Tendons• Anterior compartment
syndrome• Medial Tibial Stress
Syndrome (Shin Splints)
Inversion ankle sprain--Box 5-6, p. 163
• More common than EV sprains
• Mechanism: INV +/- rotation
• Injured structures: ATFL/PTFL/ CFL
• Symptoms:– lateral swelling/pain
– hx of tight heel cord (HC)
• Testing:– (+) Anterior Drawer– (+) Talar tilt– (-) Bump/Squeeze test– (-) Kleiger test– R/O fx’s in kids
Eversion ankle sprain--Box 5-8, p. 168
• Mechanism: EV +/- rotation or compression mechanism
• Injured structures: Deltoid Ligament complex
• Symptoms:– Medial swelling/pain
– hx of tight heel cord (HC)
• Testing:– (+)Kleiger test– (+) Talar tilt– (-) Bump/Squeeze test– R/O “knock-off” fx’s (p. 168)
Syndesmosis Sprains(High Ankle sprains)
• 10 – 18% of cases• Involves the Ant/Post. Tib/fib. Ligaments,
interosseous membrane, crural interosseous ligament, possibly deltoid lig.
• MOI – excessive ER of talus with associated DF
• S/S – pain at anterior/dist aspect of lower leg. Inc with DF, ER and squeeze test
Syndesmosis Sprains(High Ankle sprains)
• Eval – palpate entire shaft of fib for crepitus
• FX – usually in distal 1/3 but can be in proximal 1/3 (Maisonneuve FX)
• TX – splint & crutch
• Recovery: usually 3 – 4 weeks
Ankle Impingement Syndrome
• Hx--recurrent ankle sprains
• Symptoms:– Tenderness between Ant.
Tib. Tendon and Med. Malleolus
– chronic inflammation
– Pain worsens with DF and decreases with PF
– Ankle weakness in INV/EV
– Anterior pain without laxity
Ankle Impingement Syndrome
Stress Fractures
• History:– gradual onset– Usually accompanies a change
in activity – c/o “burning” after activity in
lower leg
• Palpation:– point tenderness at site of fx
– often confused with other injuries
• Observation:– Swelling is minimal/absent– Altered gait/activities due to
pain– Usually no
discoloration/deformity
• Special Tests:– (-) Bump test?
– (-) Squeeze test?
– (+) Tuning Fork sign
• Tx: Minimum 2 wks rest
Achilles Tendinitis--p.173
• History:– Poorly vascularized area– Usual mechanism= overuse– Sometimes acute (strain/trauma)– Check shoes, gait, and technique
for risk factors
• Palpation:– Usually point tender at
musculotendonous junction
– Crepitus possible with AROM
• Observation:– Localized inflammation
which worsens with activity
– Over pronation/supination
• Special Tests:– Thompson test painful
– Limited AROM in DF/PF
• If untreated, may lead to HC rupture
Achilles Tendinitis--p.173
• Treatment: • Eliminate cause(s)
• Temporary heel lift
• Gentle stretches (2)
• Arch supports
• Taping
• Modalities & Medications
Subluxating Peroneal Tendon—p. 178
• Box 5-14• May be primary or secondary injury• Subluxation may be seen, felt, or heard• Easily palpated with AROM and RROM• Fig. 5-30: Biomechanical changes possible• May require surgical correction to prevent
further injuries
Anterior compartment syndromep. 179
• History:– Acute or chronic onset
– Traumatic or overuse onset
– C/O numbness/tingling in foot with decreased DF
• Palpation:– Decreased dorsalis pedis
pulse
– Dec. RROM in DF
• Observation:
– Possible generalized swelling
– Altered gait due to pain and weakness
• Treatment:– Find/eliminate cause
– Avoid ext. compression
– Decrease int. compression
– fasciotomy may be indicated
Shin Splints
• Medial tibial stress syndrome
• Pain with activity in distal 1/3 of tibia
• Initially pain only after activity
• Two primary causes:– Overuse (Muscle imbalance)– Biomechanical (Overpronation)
Medial Tibial Stress Syndrome(Shin Splints)
• Caused by Overuse: • Evaluate PROM in DF and PF
• Evaluate Achilles flexibility
• Treatment:– Improve circulation in
lower leg
– Reverse muscle strength imbalance
MTSS cont.
• Caused by Poor Biomechanics:
• Evaluate RROM in EV and INV
• Evaluate Achilles flexibility
• Assess arch integrity• Treatment:
– Improve circulation in lower leg
– Support arch– Strengthen post. tib.
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