-
the primary weight-bearing bone of the leg:
the tibia
provides attachment sites for muscles and tendons
-
what are the 4 fnxs of the fibia:
- serves as a site of muscular origin and attachments
- serves as a site of ligaments attachments
- provides lateral stability to the ankle mortise
- serves as a pully to increase the efficiency of the muscles that run posteriorly to it
-
the articulation formed by the distal articular surface of the tibia and its medial malleolus, and the fibula's lateral malleolus and the talus is called:
ankle mortise
-
the combination of dorsiflesion, abduction and eversion is called:
a closed chain of this causes:
pronation 
closed chain pronation causes: tibial rotation, knee flexion, and internal rotation of the femur at the hip
-
a combination of plantarflexion, adduction, and inversion is called:
a closed chain of this causes:
supination
closed chain supination causes: external tibial rotation, external rotation at the hip, and knee extension
-
which nerve passes posterior to the fibular head:
common peroneal nerve
-the site is protected only by skin, making it vulnerable to injury
-branches to the superficial and deep peroneal nerve, the peroneus longus and brevis nerve, and eventally to the lateral and medial cutaneous nerve
-trauma at this site causes weakness in plantarflexion, eversion, and dorsiflexion
-
list the 4 related bony structures of the ankle:
- calcaneal tubercle: insertion of teh achilles tendon
- navicular bone: insertion of the tibialis posterior
- cuboid:
- 5th MT: attachment for peroneus brevis
cuboid and 5th MT: provide passageway for the route of the peroneus longus
-
the close-fitting articulation between the talus, tibia, and fibula is called the :
list the 3 lateral ankle ligaments found at this joint:
talocrural joint
- 3 lateral ankle ligamentsanterior talofibular ligament (ATF)
- calcaneofibular ligament (CF) ~ 70% of ankle sprains
- posterior talofibular ligaments (PTF) ~ 50% ankle sprains
-
the close-fitting articulation between the talus, tibia, and fibula is called the:
list the 4 medial ankle ligments found at this joint:
talocrural joint
- 4 ligaments (the deltoid ligaments)
- anterior tibiotalar
- tibiocalcaneal
- posterior tibiotalar
- tibionavicular
-
the intergrity of the ankle mortise relies on the fnxal relationship between the tibia and fibula; name the joint that is the union of the ankle mortise:
list the 4 ligaments of this joint:
distal tibiofibular syndesmosis
- ligaments of the distal TF syndesmosisanterior and posterior tibiofibular
- crural interossesous
- interosseous membrane
-
list the structures within the anterior compartment:
muscles:
nerve:
blood vessel:
bone:
- muscles
tibialia anterior- extensor hallucis longus (EHL)
- extensor digitorum longus (EDL)
- peroneus tertius
- nerve: deep peroneal nerve
- blood vessel: anterior tibial artery, dorsalis pedis artery
- bone: tibia
-
list the structures within the lateral compartment:
muscles:
nerve:
bone:
- musclesperoneus longus
- peroneus brevis
- nerve: superficial peroneal nerve
- bone: fibula
-
list the structures of the superficical posterior compartment:
muscles:
nerve:
blood vessel:
- musclessoleus
- gastrocnemius
- plantaris
- nerve: tibial nerve
- blood vessel: posterior tibial artery
-
list the structures of the deep posterior compartment:
muscles:
blood vessles:
- musclestibialis posterior
- flexor digitorum longus
- flexor hallucis longus
blood vessels: peroneal vessels, posterior tibial
-
list and describe the 2 major bursae of the leg/ankle:
fxn:
- subtendinous bursa: b/w achilles tendon and calcaneus
- subcutaneous calcaneal bursa: b/w achilles tendon and the skin
fxn: decrease friction
-
list the innervation area of the following nerves:
deep peroneal nerve:
superficial peroneal nerve:
sural nerve:
saphenous nerve:
- deep peroneal nerve: anterior compartment
- superficial peroneal nerve: lateral compartment
- sural nerve: posterior and lateral leg and lateral foot
- saphenous nerve: skin on medial ankle and foot
-
list the vasclar anantomy of the leg/ankle:
- great and small saphenous veins: empties into the femoral vein
- perforating veins: muscle contraction squeezes blood toward the heart
for any distal trauma.. check for pulse: dorsalis pedis artery or capillary refill
-
list and describe 2 things to consider in the past medical history in a clinical examination:
- history of injury to involved or uninvolved extermity: previous injury may demonstrate excess laxity, decreased proprioception
- review medical file for history
-
list the 8 possible soft tissue traumas that may occur on the lateral side of the ankle:
list the 7 bony traumas that may occur on the lateral side of the ankle:
- lateral soft tissue traumalateral ankle ligament sprain
- syndesmosis sprain
- capsular impingment
- subluxating peroneal tenonds
- peroneal muscle strain
- peroneal tendinopathy
- interosseous membrane trauma
- peroneal nerve trauma
- bony lateral ankle traumalateral ligament avulsion from malleolus, talus, and/or calcaneus
- lateral malleolus fx
- fibular stress fx
- frank fibular fx
- 5 MT fx
- peroneal tendon avulsion
- arthritis
-
list the 7 soft tissue traumas that may occur on the anterior ankle:
list the 6 bony traumas that may occur on the anterior ankle:
- soft tissue anterior ankleextensor retinaculum sprain
- syndesmosis sprain
- tibialis anterior or long toe extensor strain
- tibialis anterior/long toe extensor tendinopathy
- anterior compartment syndrome
- interosseous membrane trauma
- anterior tibiofibular ligament sprain
- bony anterior ankle trauma
- tibial stress fx
- frank tibial fx
- talar fx
- talar osteochondritis
- arthritis
- periostitis
-
list the 5 soft tissues traumas that may occur on the medial ankle:
list the 4 bony traumas that may occur on the medial ankle:
- soft tissue medial ankle traumadeltoid ligaments
- capsular impingment
- tibialis posterior strain
- tibialis posterior tendinopathy
- posterior tibal nerve compression (tarsal tunnel syndrome)
- bony medial ankle traumamedial ligament avulsion
- medial malleolus avulsion
- medial malleolus fx
- arthritis
-
list the 7 soft tissue traumas that may occur on the posterior ankle:
list the 3 bony traumas at may occur on the posterior ankle:
- posterior soft tissue traumatriceps surae strain
- achilles tendinopathy
- achilles tendon rupture
- subtendinous calcaneal bursitis
- subcutaneous calcaneal bursitis
- deep vein thrombophlebitis
- posterior tibiofibular ligament sprain
- bony posterior ankle traumacalcaneal fx
- arthritis
- os trigonum trauma
-
describe the history of the present condition:
location of pain:
onset:
injury mechanism:
type and severity of pain:
pain pattern:
changes in activity and conditioning regimen:
- location of pain: evaluation should emphasize the suspected structures involved
- onset: actue (sprain, strain, fx) or gradual (overuse)
- injury mechanism: acute (MOI), chronic requires more in-depth questioning
- type/severity of pain: burning-nerve involvemnt, sharp, localized pain involve bone structures
- pain pattern: how are symptoms are aggravated by certain activites, change thru the day, beginning of activity...
- changes in activity: to understand chronic, insidious conditions
-
list the possible tissue damage that could occur on the lateral ankle as a result from an inversion MOI:
list the possible tissue damage that could occur on the medial ankle as a result from and inversion MOI:
- lateral ankle damage from inversion anterior talofibular ligament
- calcaneofibular ligament
- posterior talofibular ligament
- lateral capsule
- peroneal tendons
- lateral malleolus fx
- medial ankle trauma from inversionmedial malleolus
- deltoid ligaments
- posterior tibial nerve
- tibial artery
- tibial vein
-
list the possible tissue damage that could occur on the lateral ankle as a result from an eversion MOI:
list the possible tissue damage that couuld occur on the medial ankle as a result from an eversion MOI:
- lateral ankle damage from eversionlateral malleolus
- lateral capsule
- medial ankle trauma from eversiondeltoid ligament
- tibials posterior
- long toe flexor
- posterior tibial nerve
- tibial artery
-
list the possible tissue damage to the anterior ankle that could occur as a result from plantarflexion:
list the possible tissue damage to the posterior ankle that could occur as a result from dorsiflexion:
- anterior ankle trauma from plantarflexionanterior capsule
- long toe extensors
- tibilas anterior
- extensor retinaculum
- lateral ankle trauma from plantarflexionanterior talofibular ligament
- posterior ankle trauma from plantarflexionposterior capsule
- subteninous calcaneal bursa
- subcutaneous calcaneal bursa
- os trigonum
- talus fx
-
list the possible posterior ankle trauma that could occur as a result from dorsiflexion:
list the possible lateral ankle trauma that coudl occur as a result from dorisflexion:
list the possible anterior ankle trauma that could occur from dorsiflexion:
- posterior ankle trauma from dorsiflexiontriceps surae
- achilles tendon
- tibialis posterior
- flexor hallucis longus
- flexor digitorum longus
- lateral ankle trauma from dorsiflexionposterior talofibular ligament
- peroneal tendons
- anterior ankle trauma from dorsiflexionanterior capusle
- syndesmosis
- extensor retinaculum
- anterior talu
-
dorsiflexion ROM:
plantarflexion ROM:
inversion ROM:
eversion ROM:
- dorsiflexion ROM: 20
- plantarflexion ROM: 50 degrees
- inversion ROM: 20 degrees
- eversion ROM: 5 degrees
-
goniometry for ankle plantarflexion/dorsiflexion:
patient postition:
fulcrum:
proximal arm:
distal arm:
- patien position: sitting knee flexed to 90, ankle in anatmoical position
- fulcrum: axis centered on lateral malleolus
- proximal arm: stationary arm is aligned with long axis of the fibula
- distal arm: movement arm is parallel with bottom of the foot
-
the anterior drawer test chekc the integrity of the:
anterior talofibular ligament
-
which test would you use to chekc the integrity fo teh calcaneofibular ligament:
what does a positive test "look" like:
what other ligaments does this test stress:
- inversion ( talar tilt) stress test
- posititve test: the talus tilts or gaps excessively
- other ligaments stressed: anterior and posterior talofibular ligaments
-
what test would you use to check for the integrity of the deltoid ligament, especially the tibiocalcaneal ligament:
what does a positive test "look" like:
- eversion (talar tilt) stress test
- postitive test: the talus tilts or gaps excessively
-
this test will test for 2 trauma's, rotatary damage to the deltoid ligaments, or distal tibiofibular syndesmosis:
what does a postive test look like for each:
- external rotation test (kleiger's test)
- positive deltoid ligament: medial joint pain, displacement of the talus away from the medial malleolus
- positive syndesmosis: pain is described in the anterolateral ankle at the site of syndesmosis
-
hypermobile medial glide is commonly assoicated with lateral ankle sprains, the amount of medial and lateral glide can be assesed with which joint play test:
- subtalar joint play
- positive test: increased or decreased medial or lateral translation of the talus relative to the opposite side
-
this joint play test will identify the amount of anterior-posterior play in the distal tibiofibular syndesmosis:
what does a positive test look like:
- distal tibiofibular joint play test
- positive test: pain arising from the syndesmosis or increased motion relative to the uninvolved side
-
which common nerve, either its superficial or deep branches are prone to trauma:
- peroneal nerve
-
the presences of this pulse after LE fx or dislocation and in those individuals suspected of having an anterior compartment syndrome must be established in this artery:
- dorsalis pedis artery
- posterior tibial artery: swelling may mask the presences of this pulse
-
what is the MOI for a lateral ankle sprain:
what is the most common sprained ankle ligament in a lateral sprain:
other symptoms in a lateral sprain:
what are the characteristics of pain in a lateral sprain:
- MOI: open-packed position - plantarflexion and calcaneal inversion ( supination) or talar rotation in any combination
- most common: anterior talofibular (ATF)
- other symptoms: associated "pop"
- characteristics of pain: lateral aspect of the malleolus and sinus tarsi
-
list the characteristics in examination findings or lateral ankle sprains:
inspection:
palpations:
AROM:
MMT:
PROM:
Joint stability:
Joint play:
Special tests:
Functional assessment:
- inspection: findings include swelling around lateral joint capsule, ecchymosis around lateral malleolus
- palpation: pain along involved ligaments, sinus tarsi sensitive to touch, crepitus
- AROM: pain lateral side during plantarflexion and inversion, pain medial indicates pinching of medial structurs
- MMT: peroneals are weak, painful, extensor digitorum is weak and painful
- PROM: inversion plantarflexion, inversion and neutral position, inversion and dorsiflexion are all painful
- joint stability: positive inversion stress test, and anterior drawer test
- Joint play: increased medial glide at subtalar joint
- special tests: squeeze test to rule out fx
- fxn assessment: shortened stance phase on involved side of gain, ankle maintained in resting position of slight plantarflexion
-
list the characteristics in examination findings of a lateral ankle sprain:
Joint stability:
Joint play:
Special tests:
Functional assessment:
- joint stability: positive inversion stress test, and anterior drawer test
- Joint play: increased medial glide at subtalar joint
- special tests: squeeze test to rule out fx
- fxn assessment: shortened stance phase on involved side of gain, ankle maintained in resting position of slight plantarflexion
-
list the characteristics in examination findings of a syndesmotic "high" ankle sprain:
pain characteristics:
other symptoms:
MOI:
- pain characteristics: anterior portion of the distal tibofibular syndesmosis
- other symptoms: "feel shifting in plantarflexion"
- MOIexternal rotation of the talus within the ankle mortise and/or dorsiflexion
- forced hyperdorsiflexion or hyperplantarflexion
- internal rotaion of the talus
-
list the characteristics in examination findings of a syndesmotic "high" ankle sprain:
- joint play: anterior/posterior tibiofibular joint play test
- special test: external rotation, dorsiflexion-compression test, squeeze test
- fxn assessment: shortened swing on contralateral side to avoid full dorsiflexion in gain, toe gain on the involved side
- differential diagnosis: lateral ankle sprain (mimics a lateral sprain, diagnosed when lateral ankle does not heal), fibular fx, deltoid sprain
-
list the characteristics in examination findings of a syndesmotic "high" ankle sprain:
inspection:
palpation:
AROM:
MMT:
PROM:
- inspection: swelling over distal tibiofibular syndesmosis (in time swelling may 'seep down')
- palpation: pain over tibiofibular syndesmosis, pain over anterior/posterior tibiofibular ligaments, palpate length of fibula to rule out fx
- AROM: restricted dorsiflexion, eversion, end range of plantarflexion and inversion
- MMT: anterior tibialis, posterior tibialis, are weak and painful
- PROM: pain in dorsiflexion, eversion
- stress test: not applicable
-
list the characteristics in an examination findings of a medial ankle sprain:
pain charcteristics:
MOI:
- Pain: medial border of the ankle, radiating from the medial malleolus
- MOI: eversion and or rotation
-
list the characteritics in an exmaination finding of a medial ankle sprain:
inspection:
palapation:
AROM:
MMT:
PROM:
- inspection: swelling around the medial joint capsule
- palpation: pain around the deltoid ligaments, creptius at the site of ligamentous origin or insertion may indicate an avulsion fx
- AROMpain on the medial side of the ankle during plantarflexion indicates stretching of the anterior tibiotalar and or/ tibionavicular ligaments
- pain durind dorsiflexion indicates trauma to the posteior tibiotalar ligament
- lateral pain pain may indicate a pinching of the lateral ligaments and/or trauma to the lateral malleolus
- MMT: posterior tibialis pain and weakness
- PROM: motion produces pain along the ligaments, as described in the legamentous and capsular testing
-
list the characteristics in examination findings of a medial ankle sprain
stress test:
joint play:
special tests:
fxn assessment:
differential diagnosis:
- stress test: eversion stress test
- joint play: cotton test, talonavicular glide
- special test: external rotation test, squeeze test to rule out a fx of distal fibula
- fxn assesementdecreased strength or medial pain during most motions secondary to stretching the medial ligmaments
- gait evaluation reveals shortened midstance phase and/or supinated gait as the pt avoids pronation
- increased pain during midstance phase of gait
- differential diagnosisposterior tibialis strain
- fibular fx
- distal syndemosis sprain
- medial malleolus fx
- posterior tibialis neuropathy
-
describe the patholgoies related to the ankle and leg. tibial shaft
- may exhibit obvious gross deformity
- significant force is required
- inability to bear weight
-
describe the patholgoies related to the ankle and leg. Fibula:
types of forces that can cause fx:
other structures that may be involved:
Maisonneuve fx:
Hugier fx:
fxn assesment:
- forces: inversion, eversion, rotational forces
- structures involved: malleoli, interosseous membrane
- maisonneuve fx: disruption of the interosseous membrane
- Hugier fx: only the shaft of the fibula is fx'd
- fxn assesment: capable of walking
-
what is the fxn of the modified ottawa ankle rule:
list the criteria for radiographic referal:
what two zones should be considered for an ankle radiograph referal:
what two zones should be considered for a foot radiograph referal:
- fxn: ottawa ankle rule provides evaluative criteria to indentify when the patient should be referred for radiographs
- criteria for referal:
- the patients inability to walk 4 steps both immediately following the injury and at the time of examination
- ankle radiograph referal:
- posterior edge or tip of the lateral malleolus
- posterior edge or tip of the medial malleolus
- foot radiograph referal:base of the 5th MT
- Navicular
-
describe the examinaition findings for achilles tendinopathy:
onset:
pain charactistics:
other symptoms:
MOI:
predisposing conditions:
- onset: insidious or the result of trauma of the achilles tendon
- pain characteristics: along the length of the achilles tendon, any where along the posterior side
- other symptoms: may describe squeaking sensation
- MOIacute onset relating to a sudden, large increase in load or a blow to the achilles tendon
- tendinosis results from reptitive stressors and subsequent local tissue degeneration
- impoperly fitting shoe rubbing against the tendon may also activate the inflammatory repsonse
- predisposing conditions:tibial varum
- calcaneal valgum
- hyperpronation or other forms of foot rigidity
- tightness of the triceps surae muscle group
- risk increases with age, especially males
- decreased strenght of the plantarflexion, increased dorsiflexion ROM
- sudden chage in duration and/or intensity of training
- ankle sprains or other foot/ankle pathologies resulting in toe-only gait and subsequent shortening of the achilles tendon
-
describe the examination findings for achilles tendinopathy:
inspection:
palpation:
AROM:
MMT:
PROM:
- inspection:
- possible visible edema along the lenght of the tendon
- the tendon on the involved leg may appear thicker than on the opposite leg
- pitted edema
- palpation:
- pain elicited during palpation of the tendon, especially 2 to 6 cm proximal to the tendon's insertion on the calcaneus;
- creptius may be evident with active motion
- AROM: pain and crepitus during plantarflexion and dorsiflexion
- MMT: pain and decreased strength present during plantarflexion (gastrocnemius and soleus)
- PROM: pain at end range of DF, resulting from stretching the tendon, DF may be decreased
-
describe the examination finding for achilles tendinopathy:
joint play:
fxn assement:
differential diagnosis:
- joint play: hypomobile lateral glide of the talus
- fxn assessment: decreased push off during gait
- differential diagnosis: subcutaneous calcaneal bursitis; subtendinous calcaneal bursitis
-
describe the examination finding for an achilles tendon rupture:
onset:
pain characteristics:
other sypmtoms:
mechanism:
predisposing conditions:
- onset: acute
- pain characteristics: achilles tendon and/or lower portion of teh gastrocnemius
- other symptoms: reports sensation of being kicked; audible "pop" may be described
- MOI: forceful plantarflexion with eccentric loading, usually the result of eccentric loading or plyometric contraction of teh calf musculature
- predisposing conditionsa possible relationship b/w a history achilles tendinits and rupture of the tendon
- history of corticosteroid injections to the tendon
- advancing age
- male generd
-
describe the examination findings for an achilles tendon rupture:
inspection:
palpation:
AROM:
MMT:
PROM:
- inspection:a defect may be visible in the achilles tendon or at the musculotendinous junction, but rapid swelling may obsure this
- discoloration may be present around the tendon
- the patient is unable to bear weight on the involved extremity b/c of pain
palpation: a palpable defect in the achilles tendon, although it may be quickly become obsucred by swelling; pain elicited along the tendon and lower gastrocnemius-soleus muscle group
- AROMplantarflexion may possibly still be present owing to the tibials posterior, plantaris, peroneals, and long toe flexors, although pt may complain of pain during this motion and during DF
- MMT: weak or absent PF (gastrocnemius and/or soleus)
- PROM: pain during DF; an empty end feel may be obtained secondary to pt apprehension
-
describe the examinatin findings for an achilles tendon rupture:
Special tests:
fxn assesment:
differential diagnosis:
- special tests: thompson tests
- fxn assesment: unable to perform a heel raise or push off during gait
- differential diagnosis:
- posterior tibial tendon rupture
- plantaris tendon rupture
- triceps surae strain
- achilles tendinopathy
- deep vein thrombosis
-
what is the fxn of the thomposon test:
describe the evaluative procedure:
what does a positive test look like:
- fxn: achilles tendon rupture, when the achilles tendon is intact, squeezing the calf muscle results in slight plantarflexion
- evaluative procedure: the examiner squeezes the calf musclature while observing for plantarflexion of the foot
- postivie test: when the calf is squeezed, the foot does not plantarflex
-
what are the 4 classifications that the peroneal dislocations can fall into:
- I. superior peroneal retinaculum is torn from its fibular insertion
- II. superior retinaculum and fibrocartilaginous ridge are avulsed from the lateral fibula
- III. superior retinaculum is torn from the lateral fibula, the fibrocartilaginous ridge is avulsed, and flake fxs occur on the lateral malleolus
- IV. superior retinaculum is torn from its calcaneal insertion
-
describe the examination findings for a subluxating peroneal tendon:
onset:
pain characteristics:
other symptoms:
MOI:
onset: actue or insidious
- pain characteristics:
- behind the lateral malleolus in the area of the superior peroneal retinaculum
- across the lateral malleolus
- length of the peroneal tendons
- rare case: site of the inferior peroneal retinaculum
other symptoms: ankle instability accompained by snapping of the tendon is often reported
- MOIforceful dorsiflexion and eversion
- plantarflexion and inversion
-
describe the examination findings for a subluxating peroneal tendon:
inspection:
palpation:
AROM:
MMT:
- inspectionswelling and ecchymosis may be isolated behind the lateral malleolus
- tendons may be seen to sublux during eversion
- palpationtenderness behind the lateral malleolus, over the peroneal tendons, and perhaps the site of the inferior peroneal retinaculum
- involvement of the peroneus longus may result in pain following the tendons course through the foot
- palpate the area behind the lateral malleolus during peroneal MMT to idenitfy abnormal movement of the peroneal tendons
AROM: the peroneal tendon may be seen, felt, or heard as it subluxates while the foot and ankle move from plantarflexion and inversion to dorsiflexion and eversion and back
MMT: peroneals
-
a periostitis at the posterior medial border of the tibial is called:
what are are the causes 5 causes of this condition:
a periostitis at the posterior medial border of the tibial is called: medial tibial stress syndrome
- causesrepetitive overuse (running)
- training errors (training on a hard surface, increasing load too quickly)
- incorrect shoe wear
- muscle fatigue (ankle is not conditioned; coach doesnt plan for rest properly)
- biomechanical abnormalitites ( high/low arches, going thru growth spurts, a learned activity they dont know is wrong)
-
describe the examination findings of a leg and ankle stress fx
onset:
pain characteristics:
MOI:
- onset: insidious or chronic, secondary to repetitive running and/or jumping
- pain characteristics:
- along the shaft of the tibia or fibula, localized during or after exericse,
- may be described as a localize "ache" while at rest
- MOIsudden increase in the duratin, frequency, or intensity of exercise
- change in a playing surface
- change in shoe ware
|
|
