Transcript document
Lecture 4 Ankle Anatomy Review Joints of the lower leg - ankle and foot are separate but function together - work together to distribute and dissipate the different forces acting on the body through contact with the ground Talocural Joint ( ankle) - uniaxial modified hinge synovial joint - between the talus and the tibia and fibula - dorsiflexion – talus wedges between the tib&fib (most stable position) - plantarflexion – talus moves out from between tib&fib (much more mobile position) - fibula bears approx 17% of load - resting position – 10 degrees PF Ligaments of the Ankle Medial - Deltoid ligament tibionavicular tibiocalcaneal post tibiotalar ant tibiotalar Lateral Anterior Talofibular Calcaneal Fibular Posterior talofibular Lateral side Anterior Talofibular – resists inversion of talus (especially in PF position ) **most commonly injured Calcaneal Fibular – resists ankle DF – adduction and medical rotation Posterior Talofibular – resists inversion relative weakness compared to Deltoid lig and less bony stability - leads to higher frequency of injury for lateral ligs. Muscles Superficial posterior compartment Gastroc/ Soleus/ plantaris Anterior Compartment - Tib anterior/ Extensors of foot and toes – ext digitorum longus - ext hallicus Longus Deep posterior compartment - Tib Posterior/ Flexors of foot and toes flexor digitorum longus – Flexor hallicus longus Lateral compartment - Peroneus longus and brevis Nerves of the Lower Leg and Ankle Sciatic Nerve - provides primary innervation for leg- travels down posterior aspect of leg just proximal to the popliteal fossa it branches Branches Tibial Nerve -innervates posterior aspect of lower leg Common Peroneal - passes laterally around head of fibula then splits to the deep peroneal (innervates anterior compartment ) and superficial peroneal (innervates lateral compartment ) Given the extensive innervation route of the Sciatic nerve .There is often pain, numbness and or impaired function in the lower leg , ankle or foot when the sciatic nerve is impinged ROM of Ankle / End Feels PF/DF, Inv/Eversion Muscles? Special Tests Anterior Drawer Test of the ankle - ATF ( sprain or tear) - Athlete supine ( or high sitting) - Examiner stabilizes the tib and fib above the ankle - Cup the heel in the other hand with the foot in slight dorsiflexion , draw the talus forward in the mortise - Positive signs - Dimple or suction sign – a dimple appears over the ATF on anterior translation - If pain and muscle spasm are minimal - Pain and instability - Anterior translation is greater if both CF and ATF are torn - http://www.youtube.com/watch?v=sIWuEt bHEQ4&feature=related - http://www.youtube.com/watch?v=4UzoP0 PZfZg&feature=related Varus Stress test of ankle - ATF , CF , PTF - Athlete in supine or high sitting Foot slightly PF Stabilize the tib & fib above the ankle Invert and plantar flex the foot Positive test - Lateral gapping or rocking of talus beneath the mortise indicates instability of all 3 lateral ligaments, and pain on lateral side - All 3 must be torn or lax for gross instabilities - http://www.youtube.com/watch?v=cQanwBh0Q G8 Valgus stress test of ankle ( Kleiger’s Test) - Deltoid - Stabilize the lower leg - Grip and evert (externally rotate) the calcaneus - Positive sign - medial gapping is a result of gross instability of the entire deltoid ligament - http://www.youtube.com/watch?v=UgxOJZ -_AmQ&feature=related Squeeze Test of Leg - Bones - Athlete is supine or sitting - Examiner grasps the lower leg at mid calf and squeezes tib and fib firmly together - Positive test - Pain in lower leg may indicate a fracture Thompson Test - Achilles tendon - Athlete is prone or kneeling with foot hanging over edge of the table - Examiner squeezes the gastroc muscle - Positive test is the absence of any movement of the foot into PF - This indicates a complete tear of the Achilles tendon - http://www.youtube.com/watch?v=AmDi08 rlR3I&feature=fvw One must be careful not to assume the Achilles is not rupture if the athlete is able to PF while weight bearing . The long flexors of the foot and plantaris can perform this function even without the Achilles tendon. Morton’s Test - Stress fracture or neuroma - Athlete is supine - Examiner grasps the foot around the metatarsal heads and squeezes them together - Positive sign - pain Reflexes Babinski – fanning of the 2nd and 5th toes – positive sign extension of the big toe – upper motor neuron lesion Achilles (S1)– kneeling or prone ( PF) Positive sign no movement of foot Dermatomes - L3, L4, L5, S1 Myotomes - L3 (knee extension), L4( ankle dorsiflexion), L5 (toe extension) , S1(ankle planterflexion) Muscle Testing Gastrocnemius and Plantaris – PF of foot knee extended – Preferred method is WB (against gravity) – Athlete stands with knee extended , opposite foot off the floor – Body weight provides resistance – Positive test – pain and weakness Soleus – PF of foot regardless of position of the knee – To determine strength of soleus knee is flexed to eliminate gastroc – Against gravity – PF with knee flexed body weight is resistance – Positive test – pain and weakness Tibialis Anterior – DF of ankle with inversion – Subject high sitting with knee slightly flexed (takes stress of hamstrings) – Athlete resists examiner – Examiner applies resistance to the medial and dorsal aspect of the foot and pushes into eversion and PF – Positive test – pain and weakness Tibialis Posterior – PF and inversion of ankle – Subject high sitting with knee slightly flexed (takes stress of hamstrings) – Athlete resists examiner – Examiner applies resistance to medial border of foot and tries to push into eversion and DF – Positive test – pain and weakness Peroneals – Eversion of foot – Examiner applies resistance to lateral border of foot and tries to push into inversion – Athlete resists examiner – Positive test – pain and weakness Flexors of toes – Athlete tries to curl toes against resistance Extensors of toes – Athlete tries to extend toes against resistance Positive test – pain and weakness Sport specific Functional Tests Tests should be performed pain free before return to play Squatting with both heels on floor Up and down on toes for 20 times without pain Walking on toes 20 to 30 feet Running straight ahead , stopping , running backwards Balancing on one foot at al time Running figure 8’s, circles (various sizes) Running at angles , making cuts Jump rope for at least one minute Jump straight up and go to 90 degree squat