Evaluation of the Evaluation of the AnkleAnkle

Sports PhysiologySports Physiology

Ankle Injuries- Hard Ankle Injuries- Hard TissueTissue

Fractured FibulaFractured Fibula

Ankle Fracture – Ankle Fracture – commonly caused by commonly caused by eversion. The fibula is eversion. The fibula is often broken.often broken.

Stress FractureWhat is a stress fracture?-An overuse injury. -A small crack or fracture in the bone

What causes it?-When muscles become fatigued or overloaded and can not absorb the stress and shock and repeated impact. -Fatigued muscles transfer that stress to the nearby bone and the result is a small crack or fracture, in the bone.

Ballerina Fracture

Where does it occur?-5th metatarsal.

What is it?-An avulsion of the proximal tip of the 5th metatarsal where the peroneus brevis muscle tendon attaches.

Cause-A severe inversion ankle sprain causes peroneus brevis tendon to pull away the base of the 5th metatarsal (Ballerina fracture)

Jones FractureThese X-Rays show a fracture of the proximal end of the 5th Metatarsal. This fracture is commonly called a "Jones Fracture".

Where does it occur?-5th metatarsal.

What is it?-A fracture to the 5th metatarsal caused by direct trauma to the styloid process.

Cause-Repetitive inversion ankle sprains-Poor shoe and tape support

Severe Jones Fracture fix

Ankle Injuries- Soft Ankle Injuries- Soft TissueTissue

Inversion Ankle Sprain

85% of sprains are 85% of sprains are caused by ankle caused by ankle inversion.inversion.

Inversion sprains Inversion sprains cause damage to the cause damage to the lateral ligamentslateral ligaments

Calcaneofibular and Calcaneofibular and anterior and posterior anterior and posterior talofibular ligamentstalofibular ligaments

Eversion Ankle SprainEversion Ankle Sprain

15% of sprains 15% of sprains result from eversion result from eversion mechanisms which mechanisms which are often the result are often the result of an outside force of an outside force such as being fallen such as being fallen on from the outside. on from the outside.

Damage to the Damage to the deltoid ligamentdeltoid ligament

Syndesmosis Sprain

What is it?-The tibia and fibula spread on the talus, the ankle mortise is disrupted and the ankle can become very unstable.-Syndesmosis damage-Anterior and Posterior tibiofibular ligament

Cause -injured with an eversion force.

Ruptured Achilles Tendon

Third degree strain of Third degree strain of the tendonthe tendon

Achilles Tendon Tear and Repair

Achilles TendonitisWhat is the Achilles tendon?-It is the largest and most vulnerable tendon in the body. -It joins the gastrocnemius and the soleus muscles of the lower leg to heel of the foot. -Tendons are strong, but not very flexible so they can only so far before they get inflamed and tear or rupture.

What is it?-Chronic injury caused from overuse.-Inflammation of the Achilles tendon.

What causes it?-Ignoring early warning signs and pushing through pain.-tight or weak calf muscles. -Tightness increases the stress on the Achilles tendon, and a tendonitis can develop.

Plantar FasciitisWhat does the plantar fascia do?-Provides support for the medial longitudinal arch of the foot. The plantar fascia is stretched and the arch flattens slightly to absorb the impact each time the heel impacts the ground. The fascia is not very flexible and such repetitive stretching from impact can result in small tears in the fascia.

What is plantar fasciitis?-Chronic injury-Common in runners-Common cause of pain on the bottom of the heel and usually defined by pain during the first steps of the morning. -Pain also occurs at the start of activity and go away with use. -It returns after a long rest and then restarting activity.

What causes it?-Repetitive flexion and extension of the toes-Sudden weight gain

Turf ToeWhat is turf toe?-A sprain or jammed toe-Typically the hallux

Possible Responsible Factors-artificial turf - no give, can be like playing on hard asphalt-shoes - too much forefoot flexion (no turf toe plate)-combination of turf & shoes

Mechanism of injury-hyperextension (most common)-hyperflexion-valgus injury - usually from sudden acceleration

What causes it?-When the toe is bent upwards this causes damage to the ligaments which can become stretched.

Assessing InjuriesAssessing Injuries

HOPSHOPS– HistoryHistory– ObservationObservation– PalpationPalpation– Special TestsSpecial Tests

Assessing the Lower Assessing the Lower Leg and AnkleLeg and Ankle HistoryHistory

– Past historyPast history– Mechanism of injuryMechanism of injury– When does it hurt?When does it hurt?– Type of, quality of, duration of pain?Type of, quality of, duration of pain?– Sounds or feelings?Sounds or feelings?– How long were you disabled?How long were you disabled?– Swelling?Swelling?– Previous treatments?Previous treatments?

ObservationsObservations– Posture?Posture?– Is there difficulty with walking?Is there difficulty with walking?– Deformities, asymmetries or swelling?Deformities, asymmetries or swelling?– Color and texture of skin, heat, Color and texture of skin, heat,

redness?redness?– Patient in obvious pain?Patient in obvious pain?– Is range of motion normal?Is range of motion normal?

PalpationPalpation– Does anything feel out of place?Does anything feel out of place?– Is it hot?Is it hot?

Special TestsSpecial Tests– Depends on the injuryDepends on the injury

– Percussion and compression testsPercussion and compression tests Used when fracture is suspectedUsed when fracture is suspected Percussion test is a blow to the tibia, fibula or Percussion test is a blow to the tibia, fibula or

heel to create vibratory force that resonates heel to create vibratory force that resonates w/in fracture causing painw/in fracture causing pain

Compression test involves compression of tibia Compression test involves compression of tibia and fibula either above or below site of concernand fibula either above or below site of concern

– Thompson testThompson test Squeeze calf muscle, while foot is extended off Squeeze calf muscle, while foot is extended off

table to test the integrity of the Achilles tendontable to test the integrity of the Achilles tendon– Positive tests results in no movement in the footPositive tests results in no movement in the foot

Compression Test Percussion Test

Thompson Test

Ankle Stability TestsAnkle Stability Tests– Anterior drawer testAnterior drawer test

Used to determine damage to anterior talofibular Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarilyligament primarily and other lateral ligament secondarily

A positive test occurs when foot slides forward and/or A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end pointmakes a clunking sound as it reaches the end point

– Talar tilt testTalar tilt test Performed to determine extent of inversion or eversion Performed to determine extent of inversion or eversion

injuriesinjuries With foot at 90 degrees calcaneus is inverted and With foot at 90 degrees calcaneus is inverted and

excessive motion indicates injury to calcaneofibular excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior ligament and possibly the anterior and posterior talofibular ligamentstalofibular ligaments

If the calcaneus is everted, the deltoid ligament is testedIf the calcaneus is everted, the deltoid ligament is tested

Anterior Drawer Test Talar Tilt Test

– Kleiger’s testKleiger’s test Used primarily to determine extent of damage to the deltoid Used primarily to determine extent of damage to the deltoid

ligament and may be used to evaluate distal ankle ligament and may be used to evaluate distal ankle syndesmosis, anterior/posterior tibiofibular ligaments and syndesmosis, anterior/posterior tibiofibular ligaments and the interosseus membranethe interosseus membrane

With lower leg stabilized, foot is rotated laterally to stress With lower leg stabilized, foot is rotated laterally to stress the deltoidthe deltoid

– Medial Subtalar Glide TestMedial Subtalar Glide Test Performed to determine presence of excessive medial Performed to determine presence of excessive medial

translation of the calcaneus on the talustranslation of the calcaneus on the talus Talus is stabilized in subtalar neutral, while other hand Talus is stabilized in subtalar neutral, while other hand

glides the calcaneus, mediallyglides the calcaneus, medially A positive test presents with excessive movement, A positive test presents with excessive movement,

indicating injury to the lateral ligamentsindicating injury to the lateral ligaments

Kleiger’s Test Medial Subtalar Glide Test

Functional TestsFunctional Tests

– While weight bearing the following should be While weight bearing the following should be performedperformed

Walk on toes (plantar flexion)Walk on toes (plantar flexion) Walk on heels (dorsiflexion)Walk on heels (dorsiflexion) Walk on lateral borders of feet (inversion)Walk on lateral borders of feet (inversion) Walk on medial borders of feet (eversion)Walk on medial borders of feet (eversion) Hops on injured ankleHops on injured ankle Passive, active and resistive movements should be Passive, active and resistive movements should be

manually applied to determine joint integrity and muscle manually applied to determine joint integrity and muscle functionfunction

– If any of these are painful they should be avoidedIf any of these are painful they should be avoided

Prevention of Injury to Prevention of Injury to the Anklethe Ankle

Stretching of the Achilles tendonStretching of the Achilles tendon Strengthening of the surrounding Strengthening of the surrounding

musclesmuscles Proprioceptive training: balance Proprioceptive training: balance

exercises and agilityexercises and agility Wearing proper footwear and or Wearing proper footwear and or

tape when appropriatetape when appropriate

Injury PreventionInjury Prevention

Strength training allows the Strength training allows the supporting musculature to supporting musculature to stabilize where ligaments may no stabilize where ligaments may no longer be capable of holding the longer be capable of holding the original tension between bones of original tension between bones of the joint. This will also help the joint. This will also help prevent reinjury.prevent reinjury.

Chronic Ankle Injury Chronic Ankle Injury “the vicious cycle”“the vicious cycle”

Why are some people prone to ankle Why are some people prone to ankle re-injury over and over?re-injury over and over?

Most commonly due to lack of Most commonly due to lack of rehabilitation, but more importantly rehabilitation, but more importantly lack of neuromuscular training.lack of neuromuscular training.

This means the person has not This means the person has not retrained the body to recognize where retrained the body to recognize where the ankle and foot are during motion.the ankle and foot are during motion.

This sets up the body part to be re-This sets up the body part to be re-injured due to improper feedback to injured due to improper feedback to the brain about body position.the brain about body position.

Injury PreventionInjury Prevention

Neuromuscular Control is the ability Neuromuscular Control is the ability to compensate for uneven surfaces to compensate for uneven surfaces or sudden change in surfaces. It is or sudden change in surfaces. It is retrained by using balance and retrained by using balance and agility exercises such as a BAPS agility exercises such as a BAPS board or standing on one leg with board or standing on one leg with eyes closed as well as using a eyes closed as well as using a single leg on a mini trampoline.single leg on a mini trampoline.

Neuromuscular Neuromuscular Control TrainingControl Training– Can be enhanced Can be enhanced

by training in by training in controlled activitiescontrolled activities

– Uneven surfaces, Uneven surfaces, BAPS boards, BAPS boards, rocker boards, or rocker boards, or Dynadiscs can also Dynadiscs can also be utilized to be utilized to challenge athletechallenge athlete

Injury preventionInjury prevention

Tight Achilles tendons can Tight Achilles tendons can predispose someone to injuring predispose someone to injuring the ankle. Tendonitis, plantar the ankle. Tendonitis, plantar fasciitis, and other disorders may fasciitis, and other disorders may occur due to a tight Achilles occur due to a tight Achilles tendon.tendon.

Injury PreventionInjury Prevention

Footwear is something often Footwear is something often overlooked but improper footwear overlooked but improper footwear can predispose someone with a can predispose someone with a foot condition such as pes planus foot condition such as pes planus (flat feet) to be more prone to (flat feet) to be more prone to having problems with their feet having problems with their feet and ankles.and ankles.

Preventative Taping and Preventative Taping and OrthosisOrthosis

Taping is often post injury treatment. Taping is often post injury treatment. Some will argue that taping will Some will argue that taping will weaken the ankle. This has not been weaken the ankle. This has not been proven without a doubt but exercise proven without a doubt but exercise and strengthening of the ankle is and strengthening of the ankle is always advised.always advised.

Othotics will help rectify conditions Othotics will help rectify conditions that are permanent and will not be that are permanent and will not be fixed by any other means.fixed by any other means.

Tape vs. BraceTape vs. Brace

Why choose one over anotherWhy choose one over another Taping may be more time consuming over Taping may be more time consuming over

bracebrace Braces may or may not allow more support Braces may or may not allow more support

over tapeover tape Tape allows more functional movement and Tape allows more functional movement and

often feels more stableoften feels more stable Tape will loosen with timeTape will loosen with time Braces will often loosen with timeBraces will often loosen with time It really is based on the quality of the brace It really is based on the quality of the brace

vs. the ability of the person to tape. Both vs. the ability of the person to tape. Both have advantages and disadvantages.have advantages and disadvantages.