KIN 191A Advanced Assessment of  Lower Extremity Injuries ANKLE/LOWER LEG INJURIES
INTRODUCTION <ul><li>ANKLE SPRAINS </li></ul><ul><li>STRESS FRACTURES </li></ul><ul><li>OS TRIGONUM INJURY </li></ul><ul><...
ANKLE SPRAINS <ul><li>Lateral ankle sprains (inversion sprains) </li></ul><ul><li>Medial ankle sprains (eversion sprains) ...
Lateral Ankle Sprains <ul><li>Ankle complex is least stable when it is in the open packed position </li></ul><ul><ul><li>P...
<ul><li>Pain is localized along the lateral ligament complex and sinus tarsi </li></ul><ul><li>Produce rapid, diffuse swel...
<ul><li>Anatomic and physiologic factors </li></ul><ul><ul><li>Decreased proprioceptive ability </li></ul></ul><ul><ul><li...
Medial Ankle Sprains <ul><li>Strength of the deltoid ligament and the mechanical advantage of the longer lateral malleolus...
Syndesmosis Sprains <ul><li>Account 10% of all ankle sprains and as high as 18% of football players </li></ul><ul><li>Duri...
<ul><li>Pain with DF/ER due to wider anterior dome of talus spreading distal tib-fib joint </li></ul><ul><li>Must rule out...
Lateral Ankle Injuries <ul><li>Impingement of medial joint capsule/ligaments </li></ul><ul><li>Peroneal tendon strain/rupt...
Medial Ankle Injuries <ul><li>Avulsion fracture of medial malleolus </li></ul><ul><li>Bimalleolar (Pott’s) fracture </li><...
STRESS FRACTURES <ul><li>Accumulation of microtraumatic forces  </li></ul><ul><li>May affect the tibia, fibula, and talus ...
OS TRIGONUM INJURY <ul><li>Os trigonum is formed when Steida’s process separates from the talus </li></ul><ul><li>Impinges...
ACHILLES TENDON PATHOLOGY <ul><li>Achilles tendinitis </li></ul><ul><ul><li>Poorly vascularized structure that receives li...
<ul><li>Achilles tendon rupture </li></ul><ul><ul><li>Avascular zone of tendon just proximal to calcaneal insertion point ...
 
SUBLUXATING  PERONEAL TENDONS <ul><li>Forceful sudden DF/Eversion or PF/Inversion may stretch or rupture the superior pero...
NUEROVASCULAR DEFICIT <ul><li>Disruption of the blood or nerve supply to or from the lower leg can result from acute traum...
Anterior Compartment Syndrome <ul><li>Resulting from increased pressure within the anterior compartment – traumatic or exe...
<ul><li>Increased pressure in compartment compromises neurovascular supply to dorsal foot – ischemia to affected tissues <...
Deep Vein Thrombophlebitis <ul><li>The inflammation of veins with associated blood clots (thrombus), is most found in post...
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Kin191 A. Ch.5. Ankle. Lower Leg. Injuires. Fall 2007

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Kin191 A. Ch.5. Ankle. Lower Leg. Injuires. Fall 2007

  1. 1. KIN 191A Advanced Assessment of Lower Extremity Injuries ANKLE/LOWER LEG INJURIES
  2. 2. INTRODUCTION <ul><li>ANKLE SPRAINS </li></ul><ul><li>STRESS FRACTURES </li></ul><ul><li>OS TRIGONUM INJURY </li></ul><ul><li>ACHILLES TENDON PATHOLOGY </li></ul><ul><li>SUBLUXATING PERONEAL TENDONS </li></ul><ul><li>NEUROVASCULAR DEFICIT </li></ul>
  3. 3. ANKLE SPRAINS <ul><li>Lateral ankle sprains (inversion sprains) </li></ul><ul><li>Medial ankle sprains (eversion sprains) </li></ul><ul><li>Syndesmosis sprains (high ankle sprains) </li></ul>
  4. 4. Lateral Ankle Sprains <ul><li>Ankle complex is least stable when it is in the open packed position </li></ul><ul><ul><li>Plantar flexion + Inversion </li></ul></ul><ul><li>ATF  CF  PTF </li></ul><ul><li>Open packed position: the joint position at which its bones are maximally incongruent </li></ul>
  5. 5. <ul><li>Pain is localized along the lateral ligament complex and sinus tarsi </li></ul><ul><li>Produce rapid, diffuse swelling </li></ul><ul><li>Tenderness along the involved ligament (s) </li></ul><ul><li>Possible fractures of the talus and calcaneus </li></ul><ul><li>Possible fractures of the distal medial malleolus, or base/styloid process of the 5 th metatarsal </li></ul>
  6. 6. <ul><li>Anatomic and physiologic factors </li></ul><ul><ul><li>Decreased proprioceptive ability </li></ul></ul><ul><ul><li>Decreased muscular strength </li></ul></ul><ul><ul><li>Lack of muscular coordination </li></ul></ul><ul><ul><li>Tightness of the Achilles tendon or the triceps surae muscles </li></ul></ul><ul><li>Anterior drawer test (+): ATF </li></ul><ul><li>Inversion stress test (+): CF </li></ul>
  7. 7. Medial Ankle Sprains <ul><li>Strength of the deltoid ligament and the mechanical advantage of the longer lateral malleolus limit eversion </li></ul><ul><li>External rotation of the talus in the ankle mortise </li></ul><ul><li>Eversion stress test (+) </li></ul><ul><li>External rotation (Kleiger’s) test (+) </li></ul>
  8. 8. Syndesmosis Sprains <ul><li>Account 10% of all ankle sprains and as high as 18% of football players </li></ul><ul><li>During excessive external rotation of the talus and/or forced dorsiflexion, the talus places pressure on the fibula, causing the distal syndesmosis to spread </li></ul><ul><li>Damaged to anterior and/or posterior tibiofibular ligament as well </li></ul>
  9. 9. <ul><li>Pain with DF/ER due to wider anterior dome of talus spreading distal tib-fib joint </li></ul><ul><li>Must rule out involvement of fibular fracture due to common mechanism </li></ul><ul><ul><li>Proximal 1/3 of fibula fracture (Maisonneuve) from rotational stress that can cause syndesmosis injury </li></ul></ul><ul><li>Squeeze test (+)/ </li></ul><ul><li>External rotation test (+) </li></ul>
  10. 10. Lateral Ankle Injuries <ul><li>Impingement of medial joint capsule/ligaments </li></ul><ul><li>Peroneal tendon strain/rupture </li></ul><ul><li>Medial malleolar “push-off” fracture </li></ul><ul><li>Avulsion fracture of 5 th metatarsal or lateral malleolus </li></ul><ul><li>Talus/ankle mortise chondral lesions </li></ul><ul><li>Superficial branch of peroneal nerve injuries </li></ul>
  11. 11. Medial Ankle Injuries <ul><li>Avulsion fracture of medial malleolus </li></ul><ul><li>Bimalleolar (Pott’s) fracture </li></ul><ul><li>Talus/ankle mortise chondral lesions </li></ul>
  12. 12. STRESS FRACTURES <ul><li>Accumulation of microtraumatic forces </li></ul><ul><li>May affect the tibia, fibula, and talus </li></ul><ul><ul><li>Pain along the shaft of the bone </li></ul></ul><ul><li>Symptoms of gradual onset </li></ul><ul><li>May reveal crepitus and point tenderness </li></ul><ul><li>Not visible via x-ray until approximately 3 weeks post-onset </li></ul><ul><li>Bump test (+) </li></ul><ul><li>Squeeze test (+) </li></ul>
  13. 13. OS TRIGONUM INJURY <ul><li>Os trigonum is formed when Steida’s process separates from the talus </li></ul><ul><li>Impinges on surrounding soft tissues causing symptoms – typically gradual onsets </li></ul><ul><ul><li>Os trigonum syndrome (talar compression syndrome) </li></ul></ul><ul><ul><ul><li>Inflammation of the posterior joint and ligaments surrounding the os trigonum </li></ul></ul></ul><ul><ul><ul><li>Fracture of the os trigonum </li></ul></ul></ul>
  14. 14. ACHILLES TENDON PATHOLOGY <ul><li>Achilles tendinitis </li></ul><ul><ul><li>Poorly vascularized structure that receives limited blood supply from the posterior tibial artery </li></ul></ul><ul><ul><li>May present with crepitus to palpation or ROM testing </li></ul></ul><ul><ul><li>Paratenon </li></ul></ul><ul><ul><ul><li>Tendon surrounded by a highly vascular structure </li></ul></ul></ul><ul><ul><ul><li>Inflammation of paratenon causes peritendinitis </li></ul></ul></ul><ul><ul><ul><li>Tendinosis </li></ul></ul></ul><ul><ul><ul><ul><li>Lesions caused by decreased local blood flow (ischemia) secondary to peritendinitis </li></ul></ul></ul></ul>
  15. 15. <ul><li>Achilles tendon rupture </li></ul><ul><ul><li>Avascular zone of tendon just proximal to calcaneal insertion point </li></ul></ul><ul><ul><li>Forceful, sudden contractions is most common MOI </li></ul></ul><ul><ul><li>Chronic degeneration of the tendon due to inflammatory condition </li></ul></ul><ul><ul><li>Most treated surgically </li></ul></ul><ul><ul><li>Thompson test (+) </li></ul></ul>
  16. 17. SUBLUXATING PERONEAL TENDONS <ul><li>Forceful sudden DF/Eversion or PF/Inversion may stretch or rupture the superior peroneal retinaculum </li></ul><ul><li>May visibly/palpably move from behind lateral malleolus – become DF instead of normal PF function and can also contribute to development of biomechanical complications </li></ul><ul><li>Local inflammatory symptoms at site of injury </li></ul><ul><li>May require surgical intervention </li></ul>
  17. 18. NUEROVASCULAR DEFICIT <ul><li>Disruption of the blood or nerve supply to or from the lower leg can result from acute trauma, overuse conditions, congenial defects, or surgery </li></ul><ul><li>A complete examination of the dermatomes, reflexes, and pulses of the lower and foot should be conducted </li></ul>
  18. 19. Anterior Compartment Syndrome <ul><li>Resulting from increased pressure within the anterior compartment – traumatic or exertional </li></ul><ul><ul><li>Traumatic – bleeding from direct blow to compartment muscles </li></ul></ul><ul><ul><li>Exertional – can be acute or chronic due to volumetric changes in muscle tissue and/or poor vascular function/venous outflow secondary to arterial inflow </li></ul></ul>
  19. 20. <ul><li>Increased pressure in compartment compromises neurovascular supply to dorsal foot – ischemia to affected tissues </li></ul><ul><li>5 P’s </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Pallor (redness) </li></ul></ul><ul><ul><li>Pulselessness (dorsal pedal artery) </li></ul></ul><ul><ul><li>Paresthesia (deep peroneal nerve) </li></ul></ul><ul><ul><li>Paralysis (deep peroneal nerve) </li></ul></ul><ul><li>Require immediate referral for treatment, may be limb threatening if not treated </li></ul>
  20. 21. Deep Vein Thrombophlebitis <ul><li>The inflammation of veins with associated blood clots (thrombus), is most found in postsurgical patients </li></ul><ul><li>Homan’s sign </li></ul><ul><ul><li>The calf is squeezed while the ankle is passively dorsiflexed </li></ul></ul><ul><ul><li>Pain in the calf </li></ul></ul>

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