Download - Anatomy and evaluation of the ankle
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Anatomy and Anatomy and evaluation of the ankleevaluation of the ankle
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AnkleAnkle
Anatomical Structures◦Tibia◦Fibula◦Talus
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TibiaTibia
This is the strongest largest bone of the lower leg. It bears weight and the bone creates the medial malleoli (the bump on the inside of your ankle) which is the medial aspect of the mortise or the (hole) that the talus lies within.
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The Tibia is the medial bone and largest bone of the lower leg.
Tibia
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FibulaFibula
This is a smaller lateral bone of the lower leg. It is not vital for weight bearing yet it comprises the lateral (outside) aspect of the malleoli and makes up the lateral aspect of the mortise.
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Fibula--->
The fibula is longer and non weight bearing. It makes up the lateral aspect of the mortise. The lateral malleoli lies inferior (below) the medial malleoli
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Talus Talus
This bone transmits the forces from the calcaneus up into the tibia and also allows the articulations of Plantar Flexion (pointing the foot downward) Dorsiflexion or pulling the foot upward and Inversion (rolling the foot inward) and Eversion (rolling the foot outward)
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------ Talus
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Talocrural JointTalocrural Joint
The formation of the mortise (a hole) by the medial malleoli (Tibia) and lateral malleoli (fibula) with the talus lying in between them makes up the talocrural joint. This is a hinge joint and allows most of the motion with plantarflexion and dorsiflexion.
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________________
________________
Talocrural Jt.
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Subtalar JointSubtalar Joint
The articulation between the talus and the calcaneus is referred to as the subtalar joint. Motion allowed by this joint is inversion (roll inward)/eversion (roll outward) as well as rear foot pronation (inward tilt of the calcaneus) and supination (outward tilt of the calcaneus) .
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calcaneus
Talus
---Subtalar Joint
Medial aspect of foot
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Ankle LigamentsAnkle Ligaments
There are three lateral ligaments predominantly responsible for the support and maintenance of bone apposition (best possible fit). These ligaments prevent inversion of the foot.
These ligaments are:◦Anterior talofibular ligament◦Calcaneofibular ligament◦Posterior talofibular ligament
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Talus
Fibula
Tibia
Ant. Talofibular Ligament
Ant
.Tib
iofib
ular
Lig.
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Post. Tibiofibular Lig.
<- Fibula
<- Ant. Talofibular Lig
<- Talus
Peroneal Tendons
Calc
aneofi
bula
r Li
gam
ent
Calcaneus
Subtalar Joint Space
Cuboid
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calcaneus
<-Fibular head
Posterior tibiofibular Ligament
Ach
illes T
endon
Talus
Posterio
r
talo
fibular lig
.
Peroneal tendons
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The deltoid ligamentThe deltoid ligament
This is located on the medial aspect of the foot. It is the largest ligament but is actually comprised of several sections all fused together. This ligament prevents (eversion) of the ankle. The deltoid ligament is triangular in shape and has superficial and deep layers. It is the most difficult ligament in the foot to sprain.
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Tibia
X
X
X
Navicular ---
-- Talus
Tibia
lis P
oste
rior T
endon
Tibi
alis
Ant
.
Tend
on
Deltoid LigamentX
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Muscles of the lower leg/ankleMuscles of the lower leg/ankle
There are 4 compartments that make up the lower leg that operate the motions of the ankle.
Injury can cause swelling inside these compartments that can lead to tissue death or nerve damage.
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Anterior CompartmentAnterior CompartmentAnt. TibialisExt. Hallicus
LongusExtensor Digitorum
LongusContains Ant. Tibial
NerveContains Anterior
Tibial ArteryDorsiflexors of the
foot (lifts foot up)
<-Ant. Comp
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Lateral Compartment Lateral Compartment
Everters of the foot (turns foot outward)
Peroneus LongusPeroneus BrevisPeroneus TertiusContains the
superficial peroneal nerve
<-Lat. Comp.
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Posterior Superficial GroupPosterior Superficial Group
Plantar flexors (pushes foot downwards)
Gastrocnemius Soleus
Superficial
Posterior
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Posterior DeepPosterior Deep
Assists with Plantarflexion
Tibialis PosteriorFlexor Hallicus
LongusFlexor Digitorum
LongusPosterior tibial
artery
Post. Deep---
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Assessing the Lower Leg and Assessing the Lower Leg and AnkleAnkle
History Past history Mechanism of injury When does it hurt? Type of, quality of, duration of pain? Sounds or feelings? How long were you disabled? Swelling? Previous treatments?
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Observations◦Postural deviations?◦Is there difficulty with walking?◦Deformities, asymmetries or swelling?◦Color and texture of skin, heat, redness?◦Patient in obvious pain?◦Is range of motion normal?
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Palpation Percussion and compression tests
Used when fracture is suspected Percussion test is a blow to the tibia, fibula or heel
to create vibratory force that resonates w/in fracture causing pain
Compression test involves compression of tibia and fibula either above or below site of concern
Thompson test Squeeze calf muscle, while foot is extended off
table to test the integrity of the Achilles tendon Positive tests results in no movement in the foot
Homan’s test Test for deep vein thrombophlebitis With knee extended and foot off table, ankle is
moved into dorsiflexion Pain in calf is a positive sign and should be referred
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Compression Test Percussion Test
Homan’s Test Thompson Test
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Stress Test Ankle Stability Tests
Anterior drawer test Used to determine damage to anterior talofibular
ligament primarily and other lateral ligament secondarily
A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point
Talar tilt test Performed to determine extent of inversion or
eversion injuries With foot at 90 degrees calcaneus is inverted and
excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments
If the calcaneus is everted, the deltoid ligament is tested
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Anterior Drawer Test Talar Tilt Test
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Kleiger’s test Used primarily to determine extent of damage to
the deltoid ligament and may be used to evaluate distal ankle syndesmosis, anterior/posterior tibiofibular ligaments and the interosseus membrane
With lower leg stabilized, foot is rotated laterally to stress the deltoid
Medial Subtalar Glide Test Performed to determine presence of excessive
medial translation of the calcaneus on the talus Talus is stabilized in subtalar neutral, while other
hand glides the calcaneus, medially A positive test presents with excessive movement,
indicating injury to the lateral ligaments
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Kleiger’s Test Medial Subtalar Glide Test
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Functional Tests While weight bearing the following should be
performed Walk on toes (plantar flexion) Walk on heels (dorsiflexion) Walk on lateral borders of feet (inversion) Walk on medial borders of feet (eversion) Hops on injured ankle Passive, active and resistive movements should be
manually applied to determine joint integrity and muscle function
If any of these are painful they should be avoided
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Prevention of Injury to the Prevention of Injury to the AnkleAnkle
Stretching of the Achilles tendonStrengthening of the surrounding musclesProprioceptive training: balance exercises
and agilityWearing proper footwear and or tape
when appropriate
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Specific InjuriesSpecific Injuries
Ankle Injuries: Sprains Single most common injury in athletics caused
by sudden inversion or eversion moments Inversion Sprains
Most common and result in injury to the lateral ligaments
Anterior talofibular ligament is injured with inversion, plantar flexion and internal rotation
Occasionally the force is great enough for an avulsion fracture to occur w/ the lateral malleolus
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Severity of sprains is graded (1-3)
With inversion sprains the foot is forcefully inverted or occurs when the foot comes into contact w/ uneven surfaces
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Grade 1 Inversion Ankle Sprain Etiology
Occurs with inversion plantar flexion and adduction Causes stretching of the anterior talofibular
ligament Signs and Symptoms
Mild pain and disability; weight bearing is minimally impaired; point tenderness over ligaments and no laxity
Management RICE for 1-2 days; limited weight bearing initially
and then aggressive rehab Tape may provide some additional support Return to activity in 7-10 days
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Grade 2 Inversion Ankle Sprain Etiology
Moderate inversion force causing great deal of disability with many days of lost time
Signs and Symptoms Feel or hear pop or snap; moderate pain w/
difficulty bearing weight; tenderness and edema Positive talar tilt and anterior drawer tests Possible tearing of the anterior talofibular and
calcaneofibular ligaments Management
RICE for at least first 72 hours; X-ray exam to rule out fx; crutches 5-10 days, progressing to weight bearing
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Management (continued) Will require protective immobilization but
begin ROM exercises early to aid in maintenance of motion and proprioception
Taping will provide support during early stages of walking and running
Long term disability will include chronic instability with injury recurrence potentially leading to joint degeneration
Must continue to engage in rehab to prevent against re-injury
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Grade 3 Inversion Ankle Sprain Etiology
Relatively uncommon but is extremely disabling Caused by significant force (inversion) resulting
in spontaneous subluxation and reduction Causes damage to the anterior/posterior
talofibular and calcaneofibular ligaments as well as the capsule
Signs and Symptoms Severe pain, swelling, hemarthrosis,
discoloration Unable to bear weight Positive talar tilt and anterior drawer
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◦Management RICE, X-ray (physician may apply dorsiflexion
splint for 3-6 weeks) Crutches are provided after cast removal Isometrics in cast; ROM, PRE and balance
exercise once out Surgery may be warranted to stabilize ankle
due to increased laxity and instability
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•Eversion Ankle SprainsEversion Ankle Sprains--(Represent 5-10% of all ankle (Represent 5-10% of all ankle
sprains)sprains)
Etiology Bony protection and
ligament strength decreases likelihood of injury
Eversion force results in damage to deltoid ligament and possibly fx of the fibula
Deltoid can also be impinged and contused with inversion sprains
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Injury PreventionInjury Prevention
Strength training allows the supporting musculature to stabilize where ligaments may no longer be capable of holding the original tension between bones of the joint. This will also help prevent reinjury.
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Chronic Ankle Injury “the Chronic Ankle Injury “the vicious cycle”vicious cycle”
Why are some people prone to ankle re-injury over and over?
Most commonly due to lack of rehabilitation, but more importantly lack of neuromuscular training.
This means the person has not retrained the body to recognize where the ankle and foot are during motion.
This sets up the body part to be re-injured due to improper feedback to the brain about body position.
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Injury PreventionInjury Prevention
Neuromuscular Control is the ability to compensate for uneven surfaces or sudden change in surfaces. It is retrained by using balance and agility exercises such as a BAPS board or standing on one leg with eyes closed as well as using a single leg on a mini trampoline.
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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
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Injury PreventionInjury Prevention
Tight Achilles tendons can predispose someone to injuring the ankle. Tendonitis, plantar fasciitis, and other disorders may occur due to a tight Achilles tendon.
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Injury PreventionInjury Prevention
Footwear is something often overlooked but improper footwear can predispose someone with a foot condition such as pes planus (flat feet) to be more prone to having problems with their feet and ankles.
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Preventative Taping and Preventative Taping and OrthosisOrthosis
Taping is often post injury treatment. Some will argue that taping will weaken the ankle. This has not been proven without a doubt but exercise and strengthening of the ankle is always advised.
Othotics will help rectify conditions that are permanent and will not be fixed by any other means.
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Tape vs. BraceTape vs. Brace
Why choose one over anotherTaping may be more time consuming over
braceBraces may or may not allow more
support over tapeTape allows more functional movement
and often feels more stableTape will loosen with timeBraces will often loosen with timeIt really is based on the quality of the
brace vs. the ability of the person to tape. Both have advantages and disadvantages.