unit 3 ankle - westada.org
TRANSCRIPT
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AnkleUnit 3
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Ankle LabelingSports Med 2
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Tibia Fibula
1 Structure per card
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Talus Calcaneus
1 Structure per card
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Navicular 1st Cuneiform
1 Structure per card
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1st Metatarsal 2nd Cuneiform
1 Structure per card
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Sesamoid 1st Proximal Phalanx
1 Structure per card
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1st distal phalanx
1 Structure per card
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Metatarsals (5) Cuboid
1 Structure per card
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1st cuneiformNavicular
2nd cuneiform
3rd cuneiform1 Structure per card
3 Structuresso 3 cards
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Talus Calcaneus
1 Structure per card
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FibulaTibia
1 Structure per card
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Posterior Tibiofibular LigamentDeltoid Ligament
Posterior TalofibularLigament
Calcaneofibular LigamentAnterior TalofibularLigament
Anterior Tibiofibular Ligament
5 Structuresso 5 cards
1 Structure per card
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GastrocnemiusSoleus
1 Structure per card
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Posterior TibialisTendon
Flexor DigitorumLongus
Flexor Hallicus Longus
1 Structure per card
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Gastrocnemius SoleusAnterior Tibialis
1 Structure per card2 Structures on 1 card
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Peroneus Longus Peroneus BrevisExtensor DigitorumLongus
1 Structure per card
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Peroneus Longus
Anterior Tibialis
Soleus
Gastrocnemius (muscle belly)
Extensor DigitorumLongus
Extensor HallicusLongus Achilles Tendon
4 Structuresso 4 cards 3 Structures
on 1 card
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1 Structure per card
Lateral longitudinal arch
Medial longitudinal arch
A-B: Transverse archA-C: Medial longitudinal archB-C: Lateral longitudinal arch
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Ankle/Foot Outline
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Facts:
• Ankle injuries occur most in sports.
• Plantar flexion/ Inversion ankle sprains account for about 90% of all ankle sprains
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Bones
• Distal end of tibia (medial malleolus) and fibula (lateral malleolus)
• Talus:• 2nd largest tarsal
• Main weight bearing bone in foot
• Almost square shape
• Calcaneus• largest
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MovementsThe most stable position of the ankle is when it is in dorsiflexion
Place the muscles from flashcards in the movement category:
Dorsiflexion
Plantarflexion
Inversion
Eversion
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MMT Scoring Chart: Start with the highest/hardest value. Change Right side of column first and fully; then work your way left. (fine in notes packet)
Score (5-0) ROM (Full, Some, None) Gravity? (Against, With) Resistance (Full, Some, None)
5
4
3
2
1
0
To test any joint, movement, or muscle:1. Start at a score of 32. If they can do 3, test a 4/5
• Remember to test bilaterally and the purpose of each of your two hands: stabilize and resistance.3. If they cannot do 3, test a 2-0
1. Eliminating gravity is the hardest part; doesn’t have to be fully with gravity either!
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Ankle ROM Rubric & MMT’s
• Review with your partner:• The steps, IN ORDER, of the ankle ROM rubric
• No notes
• Perform the ankle ROM on your “athlete.”• “Athlete:” initial what column you are putting the score into (make them better)
• SAT: give the “athlete” an actual score from the MMT chart for each movement
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Ankle MMTs:http://ahn.mnsu.edu/athletictraining/spata/footanklemodule/manualmuscle.html
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MMTs from video• Perform 25 single leg calf raises with the knee straight
and then with the knee bent
• Resist dorsiflexion (DF) and inversion• Start in PF and eversion
• Anterior tibialis
• Resist plantarflexion (PF) and eversion• Start in DF and inversion
• Peroneus longus and peroneus brevis
• Resist plantarflexion• Start in DF
• Gastrocnemius and soleus
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Foot/Ankle Read with main conceptson shiny desk (keep)
• Foot: pgs. 221-3• Bones (3)
• Ligaments (10)
• Muscles (6)
• Ankle: pgs. 235-7• Bones (6)
• Ligaments (6)
• Muscles (4)
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Ligament Support
Late
ral • Anterior
tibiofibular
• Posterior tibiofibular
• Anterior talofibular
• Posterior talofibular
• Calcaneofibular
med
ial • Deltoid
• Triangular
• Primary eversionresistor
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H.O.Palpations.S.
• H =• Can you list the 10 questions?
• Can you list a specific ankle question?
• O =• What 6 things do we observe?
• Palpation should start with bony sites. Why?• Purpose of palpation is to detect obvious defects, swellings, localized
tenderness
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H.O.Palpations.S.
Bony
• Medial:
• Medial malleolus
• Navicular
• Talus
• Cuneiforms
• Lateral
• Lateral malleolus
• Proximal base of the 5th metatarsal
• cuboid
Soft
• Medial:
• Deltoid ligament
• Lateral
• Anterior talofibular ligament
• Calcaneofibular ligament
• Posterior talofibular
• Anterior tibiofibular
• Peroneal tendon
• Posterior
• Achilles tendon
• Gastrocnemius
• Anterior
• Anterior tibialis
• Flexor tendons
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10 sites of Palpation(memorize in order)
1. Squeeze the midshaft of calf2. Medial malleolus 3. Lateral malleolus4. Base of the 5th metatarsal5. Calcaneus6. Achilles tendon7. Deltoid Ligament8. Syndesmosis (interosseous membrane)9. Anterior talofibular10. Posterior talofibular
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Functions of Ankle LigamentsLigament Primary Function
*Put on back of corresponding flashcard also*
Anterior Talofibular Restrains (directional term) displacement of talus
Calcaneofibular Restrains (movement term) of calcaneus
Posterior Talorfibular Restrains (directional term) displacement of talus
Deltoid Ligaments Prevents (movement term) of ankle
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Types and Grades of Ankle Sprain• Read pg. 240-242
MOIMechanism of Injury
Grade 1 Grade 2 Grade 3
Inversion Calcaneofibular (CF) CF + CF + ATF +
Inversion + Plantarflexion
(most common)
Anteriotalofibular (ATF) ATF + ATF + CF +
Forced ER and hyper dorsiflextion
“SyndesmosisOr high ankle sprain”
Anteriotibiofibular (ATiF) + Posteriotibiofibular (PTiF)
ATiF + PTiF+ ATiF + PTiF+ Interosseous membrane +
Eversion Deltoid ligaments + possible avulsion fx or medial maleolus
Deltoid + joint instability+
Deltoid + joint instability+ interosseous membrane +
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Foot/Ankle Injuries and Special Tests
Sports Med 2
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Foot Functions• The foot is critical in walking, running, jumping and
changing direction
1) Shock absorber
2) Lever that propels the body forward, backward or to the side
Foot management is key for the athletic population
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• Label review
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Arches of the Foot
• Arches support the body weight, shock absorb during weight bearing.
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Lateral Longitudinal Arch
• Write the bones that it supports
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Medial longitudinal Arch
• Write the bones that it supports
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Transverse Arch
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Foot Injuries
Please look these up in your own books.
• Mortons Toe 2nd meta fx p 227
• Plantar fasciitis p 226
• Jones fracture p 226-228
• Bunion p 229-230
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Ankle Injuries Etiology
A. Generally caused by sudden lateral or medial twist
B. Most common – Inversion (w/Plantar flexion)1. More bony stability on the lateral side
2. Tight heel cord
3. Graded by the ligaments involved
C. Eversion etiology:A. Pronated, hypermobile or depressed arched
B. Represents about 10% of ankle sprains
C. More serious than lateral ankle sprains
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Grade I Inversion ankle sprain
MOI: Foot inversion, PF, with mild stretching of the ATF
S/S:
- Mild pain and disability
- Weight bearing is not impaired
- Mild point tenderness
- Mild/slight swelling over ligament
- No joint laxity (looseness)
TX:
- PRICE
- Progressive Resistance Exercises (PRE’s)
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Grade II Inversion Ankle Sprain
MOI:
- Moderate force in inversion, PF
- Complete tear of the ATF and stretch of the CF
S/S:
- c/o pop or snap
- Moderate pain and disability
- Weight bearing is difficult
- Tenderness and edema w/blood in the joint
- Ecchymosis
- + talar tilt, + anterior drawer tests
TX:
- PRICE
- x-ray, crutches
- PF and DF exercises
- ROM, PRE’s
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Grade III Inversion Ankle Sprain(relatively uncommon in sports)
MOI:
- Severe force in inversion, PF
- Involving ATF, CF and PTF
S/S:
- c/o pain in region of lateral malleolus
- Swelling is diffused along w/ discoloration
- No possible weight bearing
- Major loss of function (LOF)
- Severe swelling
- + talar tilt, + anterior drawer tests
TX:
- PRICE
- Crutches, refer for x-ray
- ROM, PRE’s
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10 Palpations practice
• Need a washable marker from teacher
• Label each palpation site by placing the number over the site• Should go in order
• Just label one leg and then switch partners
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REVIEW: Special test-a procedure to tests for certain injury.
• Ligament tests:• Look for laxity (L for laxity & ligament)
• Muscle tests:• Test for strength, decreased ROM, or pain
• Fracture tests:• Test for pain, discontinuity of bone,
crepitus
• Misc. Tests:• Impingement?
• Squeeze/pinch area
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Ankle Anterior Drawer Special Test(notes packet & flashcards)
Picture Positive/Purpose Diagnosis
Look for laxity ATF and/or CF sprain
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Inversion Talar Tilt Special Test
Picture Positive/Purpose Diagnosis
Look for laxity CF sprain
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Eversion Ankle Sprain
MOI:
- Eversion, DF
- Avulsion fx of the medial malleolus in 15% of cases
S/S:
- c/o pain over the foot and lower leg
- Unable to bear weight on the foot
- Ab/adduction causes pain
TX:
- x-ray to rule out fx.
- PRICE
- NSAIDS
- PRE’s for posteromedial ankle muscle and for arch, could lead to pronation of the foot.
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Eversion Talar Tilt Special Test
Picture Positive/Purpose Diagnosis
Look for laxity Deltoid ligament sprain
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External Rotation (Kleiger’s) Special Test
Picture Positive/Purpose Diagnosis
Look for laxity Deltoid ligament sprain
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Bump Special Test
Picture Positive/Purpose Diagnosis
Look for pain or crepitus
Fracture
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Syndesmotic Ankle Sprain(high ankle sprain)Relatively common in football
MOI:
- Forceful external rotation of the ankle- While lying on the field w/ ankle externally rotated, someone falls on the back
of the leg and foot, forcing ER
- Lateral blow to knee/leg with foot planted, forcing ER
- External force can rupture ant. Tibiofibular lig., posterior tibiofibular lig., or fracture the posterior tibial tubercle.
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Syndesmotic Ankle Sprain(high ankle sprain)S/S:
- c/o severe pain, loss of function
- When ankle is passively externally rotated, major pain in lower leg
- Pain along the antero-lateral leg
TX:
- Out of competition
- PRICE
- NSAIDS
- X-ray can reveal fracture or widening of the ankle mortise
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Squeeze Special Test
Picture Positive/Purpose Diagnosis
Look for pain, crepitus, movement of fibula
Fracture or high ankle sprain
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Achilles Tendon Rupture (Weekend Warrior)• quick acceleration/jumping-type sports
• MOI• forceful PF of foot while the knee is extended• Unexpected rapid DF of the foot, stepping in a hole, stepping on a
curb• violent dorsiflexion when jumping from a height and landing on a
plantar flexed foot
• S/S• report feeling a kick in the calf and severe sharp pn• loud pop or snap sound and swelling.• Limping, cant plantarflex
• TX• Immobilize• PRICE, crutches• Refer
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Achilles Rupture and Fixture
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Thompson’s Special Test
Picture Positive/Purpose Diagnosis
Look for no movement of plantarflexion
Achilles tendon rupture
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Deep vein thrombosis (DVT) Special Test
Picture Positive/Purpose Diagnosis
Look for pain in gastrocnemius
Deep vein thrombosis
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Other Injuries
• Please look up these injuries of foot and ankle on your own:• Severs Disease (apophysitis) p. 225
• Achilles Tendinitis/Tendinosis p. 248
• Medial tibial Stress Syndrome p. 246
• Compartment Syndrome p. 248
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SOAP Note Practice
• Pick an ankle injury MOI and grade of sprain
• Your partner will fill in a SOAP note • Ask history questions
• Palpate ligaments
• Determine injury and grade of sprain
• Then switch with your partner
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Ankle RehabSports med 2
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REVIEW: Purpose of rehab
• What are the 5 goals of rehab:• Decreasing swelling
• Increasing ROM
• Increasing strength
• PNF
• Functional activities
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Rehab progress
• Phase 1 (think the injury just happened; could last 5 days)• What would we see?
• Swelling (brainstorm)• Discoloration• Painful• Limited ROM• Limited strength
• Cryokinetics: making the part numb first and then exercises until they can feel again.• 5-7 mins in ice (need to be numb)• ABC’s, circles, P=D or I=E• Repeat 3-5 times• End in ice
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Phase 1 (immediate protocol(?))• ABC’s (what do you think this does for the athlete?)
• Upper and lower case
• Towel scrunches (what do you think this does for the athlete?)
• Foam pick ups (what do you think this does for the athlete?)• Uses intrinsic muscles/tendons of foot
• Balancing (floor) (what do you think this does for the athlete?) • 3 x 30 sec
• Calf stretch (what do you think this does for the athlete?) • On incline board, 3 x 1 min
• Passive ROM (what do you think this does for the athlete?)• BAPS board
• ICE • 20 min. on 40 min off• 72 hours minimum
• Compression wrap w/horseshoe• Crutches if limping
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Phase 2 (harder than phase 1; simple way to increase?)
• ABC’s (what do you think this does for the athlete?)
• Towel scrunches (what do you think this does for the athlete?)
• Balancing (tramp or foam pad) (what do you think this does for the athlete?) • Eyes open and closed
• Calf stretch (what do you think this does for the athlete?)
• Resisted ROM/bands (what do you think this does for the athlete?)
• Calf raises (what do you think this does for the athlete?)• Increase sets and reps, single leg?
• ICE 20 min.
• Compression wrap w/horseshoe
• Bike
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Rehab equipment progression
• Bands:• Yellow
• Red
• Green
• Blue
• Black
• Weights:• See number on them
• Size also matters
• Balance• Always no shoes
• Start with eyes open, progress to eyes closed on each surface• Ground
• Pink foam
• Squishy (dyna disc)
• Bosu ball (half ball)
• Theraball
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Phase 3 (increase sets/intensity/time)
• ABC’s (what do you think this does for the athlete?)
• Balancing (tramp) 1 leg, catch ball (what do you think this does for the athlete?)
• Calf stretch (what do you think this does for the athlete?)
• Resisted ROM/bands (what do you think this does for the athlete?)
• Calf raises single leg (what do you think this does for the athlete?)
• Functional activities (what do you think this does for the athlete?)
• ICE 20 min.
• Compression wrap w/horseshoe if swelling
• Tape for limited practice
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Release
• Full Strength
• Sport specific Testing• Pass Functional testing
• Full ROM
• Support usually required• tape
• brace
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Functional Testing examples
• Walks on toes, test plantar flexion
• Walk on heels, test dorsiflexion
• Walks on lateral border of feet, test inversion
• Walks on medial border of feet, tests eversion
• Hop on both feet 10 times
• Run forward 70 -100%
• Run backwards 70-100%
• Zig zags down and back
• Figure 8’s
• Sports specific
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Rehab and Skills Stations
• Stations 1-8 around the room/hallway.• 5 minutes per slide
• USE TIME WISELY• This will be on the test and you will use it in the clinic
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Unit 3: Ankle Test ReviewShiny Desk PRACTICE quizzes
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Unit 2 Review
• Major questions missed in Unit 2
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Ankle Outline
1. What MOI of ankle sprains account for about 90% of all ankle sprains?• Plantarflexion & inversion
2. List a muscle that does dorsiflexion?• Anterior tibialis, extensor hallicus longus, extensor digitorum
longus, & peroneus tertius
3.
4.
5.
Medial longitudinal arch
Gastrocnemius
Peroneus longus