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