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Ankle joint Talocrural joint (tibiotalar) Articulation of talus, tibia, and fibula Concave tibia-fibula complex meets with convex superior portion of the talus Lateral malleolus extends farther distally than medial malleolus; eversion is more limited than inversion Dorsi/plantar flexion Subtalar joint (talocalcaneal) Lies beneath the talus Articulates with the superior calcaneus Inversion/eversion Inferior tibiofibular joint
Ligaments Medial Deltoid Lateral Anterior talofibular (ATF) Posterior talofibular (PTF) Calcaneofibular (CF) Anterior Anterior inferior tibiofibular Posterior Posterior inferior tibiofibular
True
Plantar arches Support and distribute body weight from talus through foot
Transverse arch Runs across anterior tarsals and MT
Longitudinal arch — medial and lateral Runs from anterior inferior calcaneus to MT heads Plantar fascia Thick band that covers plantar surface of foot (medial tuberosity of calcaneus – metatarsal heads)
True
Strains of Foot and Lower Leg Tendinitis Common sites Achilles tendon just proximal to insertion on calcaneus Tibialis posterior just behind medial malleolus Peroneal tendons just behind lateral malleolus and at distal attachment on base of 5th metatarsal S&S History of morning stiffness Localized tenderness over tendon Swelling or thickness in tendon Pain with passive stretching and with active and resisted motion Management Cryotherapy; manual therapy; modalities; exercise; address mechanical issues
True
Myositis Ossificans MOI: Develops secondary to single significant blow or repetitive blows to same area S&S: Warm, firm, swollen thigh (2–4 cm larger) Palpable, painful mass may limit passive knee flexion to 20–30° Active quadriceps contractions and straight leg raises are difficult Management:
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Hip Sprains (not common because the hip is a secure area) MOI: Violent twisting actions With hip and knee flexed to 90°, force through shaft of femur
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Sprain to SI joint Single traumatic injury Heavy opponent lands on you while you are prone
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Hip Dislocation MOI Severe trauma to area Car accident - sitting and being hit
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Hip Muscle Strains MOI: Explosive movements Tensile stress from overstretching Predisposing factors: Beginning of season Fatigue
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Muscle Strains
Hamstrings Most frequently strained muscle in the body Most commonly seen in sprinters MOI:
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Quadriceps Typically rectus femoris Midsection of muscle belly
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Adductors Common with quick change of direction and explosive propulsion and acceleration
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Piriformis strain External rotation of hip In some individuals, sciatic nerve passes through or above piriformis, subjecting nerve to compression from trauma, hemorrhage, or spasm 6x more likely in females Symptoms mimic a herniated lumbar disc problem with nerve root impingement S&S
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Tibiofemoral Joint Condyles of femur with plateaus of tibia
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Meniscus Fibrocartilaginous discs attached to tibial plateaus Medial and lateral
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Medial meniscus Attaches to MCL and fibers of semimembranosus muscle Injured more frequently than lateral meniscus More attached than lateral Lateral meniscus Smaller and more freely moveable Attaches to posterior PCL and popliteus muscle
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ACL Goes from anterior-medial aspect of tibia posteriorly to posterior medial surface of lateral condyle of femur Resists: Anterior translation of tibia on femur Posterior translation of the femur on a fixed tibia Rotation of tibia on femur
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Thermotherapy (apply heat) Effects: increases collagen elasticity and BF; decreases muscle spasm, pain, inflammation (post-acute) Some time after swelling has gone down Contraindications: loss of sensation/decreased circulation; acute injury; sensitive area Heat pack Towels; 20-30 min Check every 5-10 min so you do not burn client Whirlpool bath Clean regularly Do alphabet motions in the water Paraffin bath Irregular/bony body parts; no open wounds
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Tennis elbow Repetitive strain Pain → burning and aching Weak grip Stiffness Decreased elbow ROM Cozen’s test Pain while gripping Mill’s Resisted middle finger extension
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Shoulder labral tear Fall or sudden pull when lifting objects Pain Clunk test O’brien’s test Passive ROM Active ROM
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Carpal tunnel syndrome
Pain Shocking sensations Paresthesia (abnormal sensation, tingling or prickling)
Tinel’s sign Phalen’s test Reverse phalen’s test Carpel compression test (durkan’s test) Hand elevation test
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Achilles tendon rupture Overuse Sudden movement/contractions High impact movements Pain Swelling Trouble/inability walking
Matles Test Simmonds-Thompson test
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Snapping hip syndrome (dancer’s hip) overuse Snapping sound Thomas test Ober test Hip flexion test Hip abduction test
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Meniscus Tear Twisting, hyperflexion of knee joint Sharp pain, swelling, difficulty fully extending the knee McMurray’s Test Thessaly Test
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Whiplash Hyperextension and compression of neck in a short period of time Neck pain and stiffness
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Spinal Stenosis Repetitive twisting movements Direct trauma Poor form in lifting Numbness, pain, tingling, weakness
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ACL tear Sudden pivoting or cutting Sharp deceleration
Lachman’s test Anterior draw test Level sign test
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Thermotherapy (apply heat) Effects: increases collagen elasticity and BF; decreases muscle spasm, pain, inflammation (post-acute) Some time after swelling has gone down Contraindications: loss of sensation/decreased circulation; acute injury; sensitive area Heat pack Towels; 20-30 min Check every 5-10 min so you do not burn client Whirlpool bath Clean regularly Do alphabet motions in the water Paraffin bath Irregular/bony body parts; no open wou
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Effleurage Light and deep methods; in direction of muscle fibers; encouraging fluid return to heart (hand-over-hand method) Hands going up and coming back down Towards the trunk Increase ROM
Petrissage (kneading) Pick up muscle/skin between thumb and forefinger, roll/twist with one hand as other hand picks up adjacent tissue Between thumb and fingers
Friction Loosen adhesions in area (increase BF); effleurage before and after
Percussion/tapotement Cupping/hacking/pinching; invigorating area before activity
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Electrical energy → sound waves (ultrasound) → tissue molecules vibrate (micromassage effect) → heat Depth of ~5 cm Effects: increases BF; decreases swelling; repairs tissue; relieves pain; heating Contraindications: pregnant; eyes/ears/spine/face/reproductive organ/lungs (open cavity) pacemaker circulatory problems metal in area new scar/open wound
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Interferential Current (IFC) Two separate electrical generators that cross over injured area Low-frequency (0-10 Hz) – muscle pump action to help decrease swelling High-frequency (80-150 Hz) – decreases pain
Contraindications: pregnant; cardiac problems; electrical implants; skin diseases; MS
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Laser Light Amplification by Stimulated Emission of Radiation Effects: breaks down scar tissue, improves appearance of scar; increases metabolism/circulation/ATP production in mito/phagocytosis; decreases swelling/pain perception
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Transcutaneous Electrical Nerve Stimulation (TENS) Very weak electrical impulses to contract and relax muscles Effects: chronic pain relief; help decrease muscle atrophy; re-educate muscle action; decrease edema (muscle pump); decrease adhesions, muscle spasm Contraindications: pacemaker; pregnant; cardiac disease; degenerative disease; over fractures; transthoracically Trying to stimulate muscles in the area
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Anatomy: Scalp: 3 layers, skin, subcutaneous connective tissue, pericranium. Important for protection, and blood supply Cranium: flat bones connected by suture joints (immovable) Bones: Temporal, forntal, occipital, parietal, mandible, maxilla, etc. Three meninges which help protect the brain. Dura mater (outside layer) Arachnoid mater (middle layer) (contains blood vessels) Pia mater (inside layer) Subarachnoid space houses many blood vessels. Has cerebrospinal fluid Major regions: Cerebrum, diencephalon, brainstem, and cerebellum Five regions of spinal column: Cervical, thoracic, lumbar, sacrum, coccyx There is curvature to the spine: cervical and lumbar concave and the rest convex
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Lordosis = lumbar and cervical (arch back, butt out) Kyphosis = the other regions (hunch back)
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Movement of the spine allows for nourishment of the intervertebral discs Not much movement between each vertebrae but lots of movement with all of them Cervical is the most prone to injury
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Scalp injuries: Highly vascularized, bleeds easily Lacerations: control bleeding, prevent contamination, assess for skull fracture Management: If no fracture, cleanse, cover, and refer. Wear gloves Abrasions and contusions: Cleanse, ice, if 24hrs no improvement - refer Type of injury to occur: Thickness of skull, magnitude of force, size of impact area Because of the shape of the skull can get injury at thinner portion even if object hits thicker region Fracture S&S: Visible deformity, bleeding, CSF from nose/ears, loss of smell/sight, unequal pupils
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Cranial injuries: Can be shear, tensile, and compression strains within brain Contrecoup injury: Injury away from actual impact site Focal injury: Localized damage, skull fracture, epidural, subdural, or intracerebral hematomas Diffuse injury: Widespread disruption, concussion Accurate and quick assessment is important for head injuries Hematoma S&S: severe headache, nausea/vomiting, pupil irregularity, rising BP, drastic emotional change, etc. Diffuse is a lot less fatal but more long lasting effects Ischemia: lack of oxygen
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Cranial Injury Mechanisms Injury dependent on: Material properties of skull Thickness of skull Varies at different parts of skull Thin/Thick Magnitude and direction of force Size of impact area Fracture S/S: Visible deformity; bleeding; CSF from nose/ears; loss of smell/sight; depression/crepitus; unequal pupils; unconscious 2+ min; Battle sign(bruise behind ears)/raccoon eyes(black eyes) On impact shock waves pass through the skull to the brain and cause acceleration Brain acceleration Shear, tensile, and compression strains within brain Contrecoup injury Injury away from actual impact site Due to axial rotation coupled with Acceleration Focal injury
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Concussion: Brain injury, and is a complex pathophysiological process affecting the brain, induced by mechanical force Almost always rapid onset Neurons are firing uncontrollably leading to excessive energy expenditure Recovery usually follows a sequential course Early Symptoms: headache, dizziness/vertigo, lack of awareness, nausea Late: Persistent low-grade headaches, light-headed, poor attention, intolerant to loud noises, anxiety, etc Frequent observe features: Vacant stares, disorientation, emotional, memory deficit, etc. Can categorize concussions: Cognitive, physical, emotional, and sleep No two concussions are alike Majority resolve in 7-10 days (80-90%) Three grades: Grade 3 is loss of consciousness Can return to play two weeks after asymptomatic Other two grades are based on how long they had symptoms
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Diffuse Cerebral Conditions Concussion “A brain injury, and is a complex pathophysiological process affecting the brain, induced by biomechanical forces” Caused by direct or indirect blow to head, face, neck, or elsewhere with an impulsive force transmitted to head; typically result in rapid onset of short-lived impairment of neurologic function that resolves spontaneously Neuropathologic changes may occur, but acute clinical symptoms typically reflect a functional disturbance rather than a structural injury May or may not involve an LOC …may lead to a gradient of clinical symptoms associated with grossly normal structural neuroimaging studies Resolution of the clinical and cognitive symptoms usually follows a sequential course Should be suspected in the presence of any one of the following: Early (minutes – hours): headache; dizziness/vertigo; lack of awareness; nausea/vomiting Late (days – weeks): persistent low-grade headache; light-headed; poor attention/concentration; memory dysfunction; easy fatiguability; irritable; intolerant of bright lights/vision difficulty; intolerant loud noises/ringing in ears; anxiety/depression; sleep disturbance Frequently observed features: Vacant stares Delayed verbal/motor responses; slurred/incoherent speech; uncoordination Confusion and inability to focus Disorientation Emotional Memory deficit LOC Classification of concussion Numerous!!! …potentially problematic! Zurich panel 2008
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Cranial injuries: Can be shear, tensile, and compression strains within brain Contrecoup injury: Injury away from actual impact site Focal injury: Localized damage, skull fracture, epidural, subdural, or intracerebral hematomas Diffuse injury: Widespread disruption, concussion Accurate and quick assessment is important for head injuries Hematoma S&S: severe headache, nausea/vomiting, pupil irregularity, rising BP, drastic emotional change, etc. Diffuse is a lot less fatal but more long lasting effects Ischemia: lack of oxygen
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Study Notes
Ankle Joint
- Articulation of talus, tibia, and fibula
- Concave tibia-fibula complex meets with convex superior portion of the talus
- Lateral malleolus extends farther distally than medial malleolus; eversion is more limited than inversion
- Dorsi/plantar flexion possible
Subtalar Joint (Talocalcaneal)
- Lies beneath the talus
- Articulates with the superior calcaneus
- Inversion/eversion possible
Ligaments
- Medial: deltoid
- Lateral: anterior talofibular (ATF), posterior talofibular (PTF), calcaneofibular (CF)
- Anterior: anterior inferior tibiofibular
- Posterior: posterior inferior tibiofibular
Plantar Arches
- Support and distribute body weight from talus through foot
- Transverse arch: runs across anterior tarsals and MT
- Longitudinal arch: runs from anterior inferior calcaneus to MT heads
- Plantar fascia: thick band that covers plantar surface of foot (medial tuberosity of calcaneus – metatarsal heads)
Strains of Foot and Lower Leg
- Tendinitis: common sites include Achilles tendon, tibialis posterior, and peroneal tendons
- Symptoms: morning stiffness, localized tenderness, swelling or thickness in tendon, pain with passive stretching and active/resisted motion
- Management: cryotherapy, manual therapy, modalities, exercise, address mechanical issues
Myositis Ossificans
- MOI: develops secondary to single significant blow or repetitive blows to same area
- Symptoms: warm, firm, swollen thigh (2–4 cm larger), palpable, painful mass may limit passive knee flexion to 20–30°
- Management: varied
Hip Sprains
- MOI: violent twisting actions
- Symptoms: pain, swelling, limited ROM
- Management: varied
Hip Dislocation
- MOI: severe trauma to area
- Symptoms: pain, deformity, limited ROM
- Management: varied
Hip Muscle Strains
- MOI: explosive movements
- Symptoms: pain, swelling, limited ROM
- Management: varied
Knee Joint
- Tibiofemoral joint: condyles of femur with plateaus of tibia
- Meniscus: fibrocartilaginous discs attached to tibial plateaus
- Medial meniscus: injured more frequently than lateral meniscus
- Lateral meniscus: smaller and more freely moveable
- ACL: goes from anterior-medial aspect of tibia posteriorly to posterior medial surface of lateral condyle of femur
- Resists: anterior translation of tibia on femur, posterior translation of the femur on a fixed tibia, rotation of tibia on femur
Thermotherapy
- Effects: increases collagen elasticity and BF; decreases muscle spasm, pain, inflammation (post-acute)
- Contraindications: loss of sensation/decreased circulation; acute injury; sensitive area
- Heat pack: towels; 20-30 min; check every 5-10 min
- Whirlpool bath: clean regularly; do alphabet motions in the water
- Paraffin bath: irregular/bony body parts; no open wounds
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Description
Test your knowledge of the anatomy and ligaments of the ankle joint, including the talocrural joint, subtalar joint, and the various ligaments involved in ankle stability.
