Ankle and

Lower Leg

Chapter 17

Ankle Bony Anatomy

• Talus (link between lower leg & foot)

• Tibia– Medial malleolus

• Fibula– Lateral malleolus

• Tibial tuberosity• Tibial condyles

Bony Anatomy

Bones of the Ankle

– Tibia• Tibia is the second longest bone in the body • Principle weight bearing bone of the lower leg• Anatomical weakness present in the lower third of

the shaft

Fibula– Joins the tibia with an arthrodial articulation at the

upper end, just below the knee and as a syndesmotic joint at the lower end

– Main function is to provide for attachment of muscles

Tibial and Fibular Malleoli

• Lateral malleolus extends further distally which creates stability on the lateral aspect of the ankle

• Medial malleolus is part of the tibia

Bones of the Ankle

– Talus• Second largest tarsal, and main weight-bearing bone of

the articulation, rests on the calcaneous and receives the articulating surfaces of the lateral and medial malleoli

– Calcaneous• Forms the heel, attachment site for ligaments and the

achilles tendon

Ankle Articulations

Talar Joint (Talocrural joint)

• Tibia & fibula with talus

• Dome of talus articulates with mortise formed by tibia & fibula

• Motions: dorsiflexion & plantar flexion

Subtalar Joint• Articulation of talus

with calcaneus• Motions: inversion &

eversion

Ligaments

• Lateral aspect– Anterior talofibular

(ATF)– Anterior tibiofibular– Calcaneofibular (CF)– Posterior talofibular

• Medial aspect– Deltoid Ligament

Superior and Inferior Tibiofibular Joints

• Inferior tibiofibular joint is a fibrous (Syndesmosis) articulation between the lateral malleolus and the distal end of the tibia

• Superior tibiofibular joint formed by the tibia’s lateral condyle and the head of the fibula – allows for some gliding movements

Stabilizing Ligaments

• Tibiofibular Ligaments–Anterior and posterior

tibiofibular – hold the tibia and fibula together, form

the distal portion of the interosseous membrane (syndesmotic ligaments)

• Oblique arrangement aids in diffusing the forces on the lower leg

Ankle Ligaments

Lateral Ligaments• Anterior Talofibular:

restrains anterior displacement of talus

• Calcaneofibular: restrains inversion of calcaneous

• Posterior Talofibular: restrains posterior displacement of talus

Medial Ligaments

• Deltoid (anterior tibiotalar, tibionavicular, tibiocalcaneal and posterior tibiotalar):

• Prevents abduction and eversion of the ankle and subtalar joint

• Prevents eversion, pronation and anterior displacement of the talus

Articular Capsule

• Encases the ankle joint, thick on the medial aspect and becomes thin at the back

Muscle Compartments

Anterior Compartment

• Contains the muscles that dorsiflex the ankle and extend the toes (tibialis anterior, extensor hallucis longus, extensor digitorum)

Lateral Compartment

• Contains muscles the evert the foot and ankle

• Peroneus longus and brevis (evert ankle), peroneus tertius (assists dorsiflexion), superficial branch of the peroneal nerve

Muscle CompartmentsSuperficial Posterior Compartment

• Muscles that plantarflex the foot and ankle

• Gastrocnemius, and soleus

Deep Posterior Compartment

Foot and ankle invertors

• Tibialis Posterior, flexor digitorum longus and flexor hallucis longus Posterior tibial artery

Compartments of the Lower Leg

• Anterior– Tibialias anterior– Extensor digitorum

longus– Peroneus tertius– Extensor hallucis

muscles

• Peroneal– Peroneus longus– Peroneus brevis

• Deep Posterior– Popliteus– Flexor digitorum

longus– Flexor hallucis longus– Tibialis posterior

• Superficial Posterior– Gastrocnemius– Soleus– Plantaris

Compartments of the Lower Leg

Compartments of the Lower Leg

Muscles of the Lower Leg

• Flexor hallucis longus• Flexor digitorum

longus• Anterior tibialis

Muscles of the Lower Leg

• Peroneus tertius• Peroneus longus• Peroneus brevis

Muscles of the Lower Leg

• Gastrocnemius• Soleus

Muscles of the Lower Leg

Muscles of the Lower Leg

Nerve and Blood Supply

– Major nerves of the lower leg are the tibial and common peroneal

– Major arteries include the posterior and anterior tibial arteries

– Primary veins consist of popliteal, peroneal and anterior and posterior tibial veins.

Functional Anatomy

• Ankle is a stable hinge joint

• Medial/lateral dislocation is prevented by malleoli

• Square shape of talus adds stability of ankle

• Most stable during dorsiflexion, least stable in plantar flexion

Ankle Motions

• Plantar Flexion• Dorsiflexion• Inversion• Eversion• Pronation• Supination

Common Injuries to the

Ankle & Lower Leg

Contusions

• Occur most often on tibia

• Can be painful and disabling

• Complicationcompartment syndrome

Muscle Strains

• Most common in calf• Result from:

– violent contraction– Overstretching– Continued overuse

• Usually occur in area of MTJ or insertion of Achilles tendon

• Result from:– Repetitive overuse– Single violent

contraction

• Acute strain to Achilles have tendency to become chronic

Cramps

• A sudden, involuntary contraction of a muscle

• Contributing factors include:– Fatigue– Fractures– Dehydration– Lack of nutrients in diet– Poor flexibility– Improperly fitted equipment

Cramps—Treatment

• Passive stretching

• Fluid replacement

– Water

– Sports drink

• Massage

• Rest

• Ice

Achilles Tendonitis

• Inflammation of Achilles tendon

• Tearing of tendon tissues caused by excessive stress

• Occurs at point where tendon attaches to heel

Achilles Tendonitis• Symptoms develop gradually

• Repeated or continued overstress increases inflammation

• Pain, crepitus, redness

• Treatment– Prevention

– Stretching

– Biomechanical problems?

– Ice/Rest

– NSAIDs

– Heel lift/Achilles taping

Achilles Tendon Rupture

• Rupture occurs w/in tendon, approx 1-2” proximal to insertion

• Eccentric force applied to dorsiflexed foot– Poor conditioning

– Overexertion

• Direct trauma

• Surgically repaired

• Rehab = 1yr +

• Thompson test

Medial Tibial Stress Syndrome

• aka shin splints

• Catchall term for pain that occurs below knee– Anterior shin– Medial shin

• Result of doing too much too soon

• Associated with:– repetitive activity on

hard surface– forcible excessive

use of leg muscles (running, jumping)

– tightness of gastroc and/or soleus muscles

– improper footwear– running

biomechanics

MTSS Treatment

• Ice

• Reduce activity level

• Gentle stretching

• Biomechanical assessment

• Orthotics

• NSAIDs

• Strengthening and flexibility program

Stress Fractures

• Incomplete crack in bone

• Microscopic fractures in bone that will eventually lead to full fracture if left untreated

• Repeated stress placed on bone greater than body’s ability to heal it

Stress Fractures—S/Sxs• “hot spot” of sharp,

intense pain upon palpation

Shin-splint• Pain more

generalized• Pain worse in

am

Stress Fx• Pain worse

in pm

Compartment Syndrome

• Swelling within one or more of the compartments of the lower leg

• Caused by:– Contusion– Fracture– Crush injury– Localized infection– Excessive exercise– Overstretching

Ankle Sprains• MOI: combo of excessive inversion and

PF– aka lateral ankle sprain

• Anterior Talofibular Ligament (ATF)– Calcaneofibular (CF)– Posterior talofibular (PTF)

• Eversion (medial) ankle sprain less common– Deltoid ligament

Ankle Sprains

• Injury to ligamentous and capsular tissue

• Traumatic joint twist that results in stretching of total tearing of the stabilizing connective tissue

• One of most common & disabling sports injuries

• General Symptoms:Joint swellingLocal temperature

increasePain Point tendernessSkin discoloration

Ankle Sprains

• Inversion – Anterior Talofibular– Calcaneofibular– Posterior Talofibular

• Eversion– Deltoid Ligament

• Syndesmotic– High ankle sprain

Ankle Sprain—S/SXS

Grade 1 Some pain Minimum LOF Mild point tenderness Little or no swelling No abnormal motion

Grade 2 Pain Moderate LOF Swelling Slight to moderate

instability

Grade 3 Severe sprain Extremely painful initially LOF Severe instability Tenderness Swelling

May represent subluxation that reduced spontaneously

Ankle Sprain—Treatment

• R.I.C.E.

• Crutches

• Boot

• Splint, tape, brace

• Compressive wrap

• Horseshoe

Special Tests&

Rehabilitation

Anterior Drawer

• Tests integrity of anterior talofibular ligament

Talar Tilt

• Tests integrity of calcaneofibular ligament

Squeeze Test

• Squeezing the tibia and fibula together

• Can indicate fracture or high ankle sprain

Bump Test/Tap Test

• Bump calcaneus– Indicate fracture to

tibia/fibula– Indicate high ankle sprain

• Tap mallelous– Indicate fracture of

particular bone

Ankle Rehab

• 4-way TheraBand®

• Heel walks/Toe walks• 3-way heel raises• Unilateral Balance• 3-way Tramp throw