The document provides an overview of procedures for evaluating lower extremity injuries of the ankle and lower leg. It details assessing history, inspecting for signs of injury, performing palpation of anatomical structures, range of motion and ligament stability testing, and evaluating neurologic and vascular function. The evaluation covers the anterior, lateral, medial, and posterior structures of the ankle and lower leg.

1. KIN 191A Advanced Assessment of Lower Extremity Injuries ANKLE/LOWER LEG EVALUATION

2. INTRODUCTION HISTORY INSPECTION PALPATION ROM TESTING LIGAMENTOUS STABILITY TESTING NEUROLOGIC TESTING VASCULAR TESTING

3. Location of pain May be referred site for compartment syndrome, tarsal tunnel syndrome, peroneal/tibial nerve injury, sciatic nerve or lumbar nerve root impingement Nature/type of pain Aggravating/alleviating activities Effect of pain on activities HISTORY

4. Onset of pain Acute: trauma (sprain, strain, fracture, etc.) Gradual/insidious - overuse syndromes Mechanism of injury Macrotrauma - typically easy to identify tissues involved Microtrauma - typically involves more in depth questioning to arrive at cause of problem

5. Activity changes Duration, frequency, intensity, surface, shoes, orthotics, etc. Prior history Those with prior history of ankle injury may present with increased laxity and/or decreased proprioception vs. normal

6. INSPECTION General inspection Weight bearing status Gait pattern Swelling Obvious deformity Discoloration

7. Inspection of the lateral structures Peroneal muscle group Distal one third of the fibula Lateral malleolus Inspection of the anterior structures Appearance of the anterior lower leg Contour of the malleoli Talus Sinus tarsi Lateral aspect of the talus (anterior from the lateral malleolus)

8. Inspection of the medial structures Medial malleolus Medial longitudinal arch Inspection of the posterior structures Gastrocnemius-soleus complex Achilles tendon Bursae Subtendinous (Retrocalcaneal) bursa Subcutaneous calcaneal bursa Calcaneus

9. PALPATION (fibular structure) 1. Common peroneal nerve 2. Peroneus longus and brevis 3. Fibular shaft 4. Anterior and posterior tibiofibular ligaments 5. Interosseous membrane 6. Superior peroneal retinaculum

10. PALPATION (lateral ankle) 1. Lateral malleolus 2. Calcaneofibular ligament 3. Anterior talofibular ligament 4. Posterior talofibular ligament 5. Peroneal retinaculum 6. Peroneal tubercle 7. Cuboid 8. Base of the fifth metatarsal 9. Peroneus tertius

11. PALPATION (anterior structures) 1. Anterior tibial shaft 2. Tibialis anterior 3. Extensor hallucis longus 4. Extensor digitorum longus 5. Dome of the talus 6. Extensor retinacula 7. Sinus tarsi

12. PALPATION (medial structures) 1. Medial malleolus 2. Deltoid ligament 3. Sustentaculum tali 4. Spring ligament 5. Navicular and navicular tuberosity 6. Tibialis posterior 7 . Flexor digitorum longus 8 . Flexor hallucis longus

13. PALPATION (posterior structures) 1. Gastroncnemius-soleus complex 2. Achilles tendon 3. Subcutaneous calcanel bursa 4. Calcaneus 5. Subtendinous calcaneal bursa

14. Palpation of Pulses Posterior tibial artery Between the flexor digitorum longus and flexor hallucis longus tendons as they pass behind the medial malleolus Dosalis pedis artery Between the extensor digitorum longus and extensor hallucis longus tendons as they pass over the cuneiforms

15. RANGE OF MOTION TESTING The ROM can be affected by Muscular tightness Bony abnormalities Soft tissue constraints Active ROM Passive ROM Resistive ROM

16. Active ROM Plantar flexion/dorsiflexion at talocrural joint Inversion/eversion at subtalar joint PF – 50 degrees, DF – 15~20 degrees Must have 10 degrees DF to walk with normal gait (15 degrees to run) – if absent, predisposes to biomechanical problems and overuse injuries INV – 20 degrees, EV – 5~10 degrees

18. Passive ROM Dorsiflexion Measured with the knee extended to determine the overall influence of the triceps surae group Measured with knee flexed to determine the influence of the soleus Normal firm end-feel Plantar flexion Normal firm end-feel Anterior joint capsule, deltoid ligament, and ATF ligament are stretched

19. Inversion Should lie supine position Normal firm end-feel (especially the CF ligament stretch) and peroneal muscles stretch The tibia and fibular are stabilized to prevent hip or lower leg rotation Eversion A hard end-feel (because of the fibular’s striking the calcaneus)

20. Goniometry Plantar flexion/Dorsiflexion Sitting or lying with the knee flexed to at least 30 degrees Fulcrum Centered over the lateral malleolus Stationary arm Aligned with the long axis of the fibula Movement arm Parallel with the long axis of the 5 th metatarsal

22. Goniometry Inversion/Eversion Sitting or lying with the knee flexed to at least 30 degrees Fulcrum Over the talocrural joint line, centered between the malleoli Stationary arm Centered over the long axis of the tibia Movement arm Over the 2 nd metatarsal

23. Resistive ROM

24. Anterior talofibular ligament Anterior drawer test Calcaneofibular ligament (Talar Tilt) Inversion stress test Deltoid ligament (Talar Tilt) Eversion stress test Kleiger’s (External rotation) test Place the ankle in neutral or slightly plantar flexed LIGAMENTOUS STABILITY TESTS

25. Anterior Drawer Test Talar Tilt Inversion Stress Test

26. Distal tibiofibular ligaments/syndesmosis Kleiger’s (External rotation) test Place the ankle in dorsiflexion Squeeze (Compression) test Stress fractures of lower leg: tibia, fibular, talus, and/or calcaneus Bump (Percussion) test

27. Kleiger’s (External rotation) Test Squeeze (Compression) Test Bump (Percussion) Test

28. Homan’s Test Thompson Test For Achilles tendon rupture For Deep Vein Thrombosis

29. NEUROGIC TESTING L4 – S2 dermatomes/myotomes/reflex Tibial nerve Deep peroneal nerve Superficial peroneal nerve

30. VASCULAR TESTING Anterior compartment Lateral compartment Deep posterior compartment Superficial posterior compartment