Chapter 15: The Ankle and Lower Leg PDF

Access Provided by: Essentials of Athletic Injury Management, 11e Chapter 15: The Ankle and Lower Leg ©William E. Prentice OBJECTIVES When you finish this chapter you will be able to: Describe the bony, ligamentous, and muscular anatomy of the ankle and lower leg. List considerations for preventing injuries to the ankle and lower leg. Explain how to assess common ankle and lowerleg injuries. Identify the possible causes and signs of various injuries that can occur in the ankle and lower leg. Examine the procedures that can be used in caring for ankle and lower leg injuries. ANKLE AND LOWERLEG ANATOMY Bones The portion of the anatomy below the knee and above the ankle is the lower leg. It is composed of the thicker tibia, which is more medial, and the thinner fibula, which is more lateral. The ankle joint or talocrural joint is formed by the thickened distal portion of the fibula, called the lateral malleolus; the thickened distal portion of the tibia, called the medial malleolus; and the moreorless cubeshaped tarsal bone, called the talus, that fits between the two malleoli. The ankle joint allows two motions: plantarflexion and dorsiflexion. The joint between the talus and the calcaneus is called the subtalar joint. Inversion and eversion take place at the subtalar joint (Figure 15–1). FIGURE 15–1 The ankle joint is formed by the tibia, fibula, and talus. The subtalar joint is formed by the talus and calcaneus. ©William E. Prentice Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 1 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility the subtalar joint. Inversion and eversion take place at the subtalar joint (Figure 15–1). FIGURE 15–1 Access Provided by: The ankle joint is formed by the tibia, fibula, and talus. The subtalar joint is formed by the talus and calcaneus. ©William E. Prentice The ankle joint is composed of the Tibia Fibula Talus Ligaments The tibia and fibula are held together by the interosseous membrane, which extends the entire length of the two bones (Figure 15–1). The anterior and posterior tibiofibular ligaments bridge the tibia and fibula and form the distal portion of the interosseous membrane (Figure 15–2A). The medial aspect of the ankle is relatively stable because of the thick deltoid ligament. The presence of this strong deltoid ligament, combined with the fact that the lateral malleolus of the fibula extends further distally than the medial malleolus, limits the ability of the ankle to evert (Figure 15–2B). Thus, eversion ankle sprains are considerably less common than inversion sprains. The three lateral ligaments include the anterior talofibular, the posterior talofibular, and the calcaneofibular. The lateral ligaments collectively limit inversion and are much more susceptible to injury. FIGURE 15–2 Ligaments of the ankle joint: ( A ) Lateral view. (B) Medial view. (From Van De Graaff, K., Human anatomy, 6th ed. Dubuque, IA: McGrawHill Higher Education, 2009.) Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 2 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility FIGURE 15–2 Ligaments of the ankle joint: ( A ) Lateral view. (B) Medial view. (From Van De Graaff, K., Human anatomy, 6th ed. Dubuque, IA: McGrawHill Higher Access Provided by: Education, 2009.) The talocrural joint allows two motions: Plantarflexion Dorsiflexion The subtalar joint allows two motions: Inversion Eversion Muscles Contraction of the muscles in the lower leg produces movement at the ankle joint. The muscles of the lower leg are divided into four distinct groups (Figure 15–3). Each of the four muscle groups is contained separately within a compartment by thick sheets of fascia (connective tissue) that surround them. Essentially, the muscles that dorsiflex the ankle are contained within the anterior compartment; the muscles that plantarflex the ankle are in the superficial posterior compartment; the muscles that evert the ankles are in the lateral compartment; and the muscles that invert the ankle are found in the deep posterior compartment (Table 15–1). Visual examples of the movements of the lower leg and ankle appear in Appendix C. FIGURE 15–3 The muscles of the lower leg are divided into four distinct groups contained separately within individual compartments. Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 3 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility the deep posterior compartment (Table 15–1). Visual examples of the movements of the lower leg and ankle appear in Appendix C. FIGURE 15–3 Access Provided by: The muscles of the lower leg are divided into four distinct groups contained separately within individual compartments. TABLE 15–1 Muscles of the Ankle Joint Ankle dorsiflexion (Anterior compartment) Extensor digitorum longus Extensor hallucis longus Tibialis anterior (primary dorsiflexor) Ankle plantarflexion (Superficial posterior compartment) Soleus Gastrocnemius Ankle inversion (Deep posterior compartment) Tibialis posterior Flexor digitorum longus Flexor hallucis longus Ankle eversion (Lateral compartment) Fibularis longus Fibularis brevis Tibialis anterior Medial ligament includes the deltoid. Lateral ligaments include the Anterior talofibular Posterior talofibular Calcaneofibular PREVENTION OF LOWERLEG AND ANKLE INJURIES Many lowerleg and ankle injuries, especially sprains, can be reduced by Achilles tendon stretching, strengthening of key muscles, improving neuromuscular control, choosing appropriate footwear, and, when necessary, proper bracing and taping.9,10,11 Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 4 / 26 Preventing ©2024 McGraw lowerleg and ankle Hill. All Rights injuries: Reserved. Terms of Use Privacy Policy Notice Accessibility Stretching of the gastrocnemius and soleus muscles and the Achilles tendon PREVENTION OF LOWERLEG AND ANKLE INJURIES Many lowerleg and ankle injuries, especially sprains, can be reduced by Achilles tendon stretching, strengthening of key muscles, improving Access Provided by: neuromuscular control, choosing appropriate footwear, and, when necessary, proper bracing and taping.9,10,11 Preventing lowerleg and ankle injuries: Stretching of the gastrocnemius and soleus muscles and the Achilles tendon Strength training Neuromuscular control Appropriate footwear Ankle taping and bracing Achilles Tendon Complex Stretching The athlete with a tight Achilles tendon complex should routinely stretch before and after practice.2 To properly stretch the Achilles tendon complex, the ankle should be dorsiflexed and the knee fully extended to stretch the gastrocnemius muscle, and then the knee should be flexed to about 30 degrees to stretch the soleus muscle (Figure 15–4). There needs to be at least 10 degrees of dorsiflexion for normal ankle motion to occur.2 FIGURE 15–4 Stretching techniques for the right Achilles tendon complex: ( A ) Stretching position for the gastrocnemius muscle. (B) Stretching position for the soleus muscle. ©William E. Prentice Strength Training Achieving both static and dynamic joint stability through strength training is critical in preventing ankle injury (Figure 15–5). A balance in strength throughout the full range of motion must be developed and maintained in each of the four muscle groups that surround the ankle joint.20 Strengthening exercises should be done in eversion and inversion, which can be done by rocking the ankle back and forth on a wobble board, and also by using surgical tubing. FIGURE 15–5 Strengthening exercises are important in prevention of ankle sprains and may be done using ( A ) surgical tubing resistance or (B) a Bosu Balance Trainer. ©William E. Prentice Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 5 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility FIGURE 15–5 Strengthening exercises are important in prevention of ankle sprains and may be done using ( A ) surgical tubing resistance or (B) aAccess BosuProvided Balanceby: Trainer. ©William E. Prentice Neuromuscular Control As is the case with strength training, maintaining neuromuscular control is critical to prevention of injury to the ankle joint. Neuromuscular control relies on the central nervous system to interpret and integrate proprioceptive and kinesthetic information and then to control individual muscles and joints to produce coordinated movements that collectively protect the joint from injury.18 Thus, the foot and ankle must respond quickly to any uneven surface condition. Ankle joint position sense can be enhanced by training on uneven surfaces or by spending time each day on a balance board (Figure 15–6). FIGURE 15–6 Ankle exercises on a BAPS Board. ©William E. Prentice Footwear As discussed in Chapters 6 and 14, proper footwear can be an important factor in reducing injuries to both the foot and the ankle. Shoes should not be used in activities for which they were not intended—for example, running shoes, which are designed for straightahead activity, should not be worn to play basketball, a sport demanding a great deal of lateral movement. Preventive Ankle Taping and Bracing There is some doubt about whether it is beneficial to routinely tape ankles that have no history of sprain. Tape, properly applied, can provide some prophylactic protection. Poorly applied tape does more harm than good. Tape that constricts soft tissue and blood circulation or disrupts normal biomechanical function can, in time, create unnecessary problems.18 Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 6 / 26 24 Braces may prevent lateral and inversion movement of the foot without Ankle ©2024bracing McGraw canHill. alsoAlloffer protection Rights to theTerms Reserved. ankleof joint Use(Figure 15–7). Privacy Policy Notice Accessibility inhibiting plantarflexion (see Chapter 6).11 Laceup supports and semirigid ankle braces are increasingly being used instead of tape to prevent recurrent ankle sprains. Preventive Ankle Taping and Bracing Access Provided by: There is some doubt about whether it is beneficial to routinely tape ankles that have no history of sprain. Tape, properly applied, can provide some prophylactic protection. Poorly applied tape does more harm than good. Tape that constricts soft tissue and blood circulation or disrupts normal biomechanical function can, in time, create unnecessary problems.18 Ankle bracing can also offer protection to the ankle joint (Figure 15–7).24 Braces may prevent lateral and inversion movement of the foot without inhibiting plantarflexion (see Chapter 6).11 Laceup supports and semirigid ankle braces are increasingly being used instead of tape to prevent recurrent ankle sprains. FIGURE 15–7 Ankle braces may be used to support weak ankles. Courtesy of Active Ankle ASSESSING THE ANKLE JOINT Generally fitness professionals, coaches, and others working in areas related to exercise and sports science are not adequately trained to evaluate injuries. It is strongly recommended that injured athletes be referred to qualified medical personnel (i.e., physicians, athletic trainers, physical therapists) for injury evaluation. Information has been included simply to give some idea about the different basic tests that nonmedical personnel may do to determine the nature and severity of the athlete's injury. The primary responsibility of those who are not health care personnel is to be able to recognize any potential "red flags" associated with the injury, provide appropriate first aid for the injury, and make correct decisions about how the injury should be managed initially, including immediate return to play or activity decisions (refer to Chapter 8). History The athlete's history may vary, depending on whether the problem is the result of sudden trauma or is chronic. The athlete with an acute sudden trauma to the ankle should be asked the following questions: What trauma or mechanism occurred? What was2024828 Downloaded heard when thePinjury 1:19 Youroccurred—a crack, snap, or pop? IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 7 / 26 ©2024 McGraw What Hill.duration were the All Rights andReserved. intensity ofTerms pain? of Use Privacy Policy Notice Accessibility How disabling was the occurrence? Could the athlete walk right away, or was he or she unable to bear weight for a time? The athlete's history may vary, depending on whether the problem is the result of sudden trauma or is chronic. The athlete with an acute sudden trauma to the ankle should be asked the following questions: Access Provided by: What trauma or mechanism occurred? What was heard when the injury occurred—a crack, snap, or pop? What were the duration and intensity of pain? How disabling was the occurrence? Could the athlete walk right away, or was he or she unable to bear weight for a time? Has a similar injury occurred before? Was there immediate swelling, or did the swelling occur later (or at all)? Where did the swelling occur? What past ankle injuries have occurred? Observation Immediately following injury, the athlete should be observed to determine the following: Is there an obvious deformity? Are the bony contours of the ankle normal and symmetrical, or is there a deviation such as a bony deformity? Is there any discoloration? Is there crepitus or abnormal sound in the ankle joint? Is heat, swelling, or redness present? Is the athlete in obvious pain? Does the athlete have a normal ankle range of motion? If the athlete is able to walk, is there a normal walking pattern, or does the athlete walk with a limp? Palpation Palpation in the ankle region should start with key bony landmarks and ligaments and progress to the musculature, especially the major ligaments that surround the ankle. The purpose of palpation in this region is to detect obvious structural deformities, swelling, and localized tenderness. 15–1 Critical Thinking Exercise A basketball player sustains a grade 1 inversion sprain of her left ankle during a game. There is immediate pain and swelling, and she is unable to bear weight. ? What is the most important firstaid goal immediately following injury, and how may that firstaid goal best be accomplished? Special Tests for Ankle Injuries Bump Test When fracture is suspected, a gentle percussive blow can be applied upward on the bottom of the heel. Such blows set up a vibratory force that resonates at the fracture, causing pain (Figure 15–8A). FIGURE 15–8 Special tests for ankle injuries: ( A ) Bump test. (B) Anterior drawer test. (C) Talar tilt test. ©William E. Prentice Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 8 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility that resonates at the fracture, causing pain (Figure 15–8A). FIGURE 15–8 Access Provided by: Special tests for ankle injuries: ( A ) Bump test. (B) Anterior drawer test. (C) Talar tilt test. ©William E. Prentice Anterior Drawer Test The anterior drawer test is used to determine the extent of injury to the anterior talofibular ligament primarily and to the other lateral ligaments secondarily (Figure 15–8B). The examiner grasps the lower tibia in one hand and the calcaneus in the palm of the other hand. The tibia is then pushed backward as the calcaneus is pulled forward. A positive anterior drawer sign occurs when the foot slides forward. Talar Tilt Test Talar tilt tests are used to determine the extent of inversion or eversion injuries. With the foot positioned at 90 degrees to the lower leg and stabilized, the calcaneus is inverted. Excessive motion of the talus at 90 degrees indicates injury to the calcaneofibular and possibly the anterior and posterior talofibular ligaments as well (Figure 15–8C). Excessive motion in inversion with the ankle plantarflexed indicates a sprain of the anterior talofibular ligament. Functional Examination Muscle function is important in evaluating the ankle injury. If the athlete cannot execute or has difficulty performing the following functional activities, the athlete is not ready to return to activity: Walk on toes. Walk on heels. Hop on affected foot without heel touching surface. Start or stop the running motion. Change direction rapidly. Run figure eights. RECOGNITION AND MANAGEMENT OF INJURIES TO THE ANKLE Ankle Sprains Cause of Injury Ankle sprains are among the more common injuries seen in athletics (Figure 15–9).16 Injuries to the ligaments of the ankle may be classified by the mechanism of injury.30 FIGURE 15–9 Downloaded 2024828 1:19 P Your IP is 149.150.236.147 The ankle15: Chapter and usually The Anklethe foot and may Leg, Lower be swollen and discolored following an ankle sprain. ©William E. Prentice Page 9 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Cause of Injury Ankle sprains are among the more common injuries seen in athletics (Figure 15–9).16 Injuries to the ligaments of the ankle may be classified by the mechanism of injury.30 Access Provided by: FIGURE 15–9 The ankle and usually the foot may be swollen and discolored following an ankle sprain. ©William E. Prentice Ankle sprain classifications: Inversion sprain Eversion sprain High ankle sprain Inversion sprains An inversion ankle sprain is most common and often results in injury to the lateral ligaments. The anterior talofibular ligament is the weakest of the three lateral ligaments. It is injured in an inverted and plantarflexed position (Figure 15–10). The calcaneofibular and posterior talofibular ligaments are also likely to be injured in inversion sprains as the force of inversion is increased. Increased inversion force is needed to tear the calcaneofibular ligament (Figure 15–11).30 FIGURE 15–10 A mechanism of injury that involves ( A ) plantarflexion and inversion can (B) cause a sprain of the anterior talofibular ligament. (A) ©William E. Prentice Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 10 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility FIGURE 15–11 the calcaneofibular ligament (Figure 15–11).30 FIGURE 15–10 Access Provided by: A mechanism of injury that involves ( A ) plantarflexion and inversion can (B) cause a sprain of the anterior talofibular ligament. (A) ©William E. Prentice FIGURE 15–11 A mechanism of injury that involves ( A ) inversion can (B) cause a sprain of the calcaneofibular ligament. (A) ©William E. Prentice Eversion sprains Eversion ankle sprains are less common than inversion ankle sprains, largely because of the bony and ligamentous anatomy. Eversion injuries may involve an avulsion fracture of the tibia before the deltoid ligament tears. The deltoid ligament may also be contused in inversion sprains because of impingement between the medial malleolus and the calcaneus. Although eversion sprains are less common, these sprains may take longer to heal than do inversion sprains (Figure 15–12).20 FIGURE 15–12 A mechanism of injury that involves ( A ) eversion can (B) cause a sprain of the deltoid ligament. (A) ©William E. Prentice Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 11 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility longer to heal than do inversion sprains (Figure 15–12).20 FIGURE 15–12 Access Provided by: A mechanism of injury that involves ( A ) eversion can (B) cause a sprain of the deltoid ligament. (A) ©William E. Prentice High ankle sprains The anterior and posterior tibiofibular ligaments and the distal portion of the interosseous membrane holding the tibia and fibula together are torn with forced hyperdorsiflexion and external rotation of the foot as when twisting on a planted foot.23 These structures are often injured in conjunction with a severe sprain of the medial and lateral ligament complexes. Sprains of these ligaments are extremely hard to treat and often take months to heal. Return to sports may be delayed for a longer time than for inversion or eversion sprains (Figure 15–13).28 FIGURE 15–13 A mechanism of injury that involves ( A ) hyperdorsiflexion and external rotation of the foot can (B) cause a sprain of the anterior tibiofibular ligament. (A) ©William E. Prentice Signs of Injury In a grade 1 sprain, there is some stretching or perhaps tearing of the ligamentous fibers, with little or no joint instability. Mild pain, little swelling, and joint stiffness may be apparent. With a grade 2 sprain, there is some tearing and separation of the ligamentous fibers and moderate instability of the joint. Moderatetosevere pain, swelling, and joint stiffness should be expected. Grade 3 sprains involve total rupture of the ligament, manifested primarily by gross instability of the joint. Severe pain may be present initially, followed by little or no pain because of total disruption of nerve fibers. Swelling may be profuse, and thus the joint tends to become very stiff some hours after the injury. A grade 3 sprain with marked instability usually requires some form of immobilization lasting several weeks.21 Surgical repair or reconstruction may be necessary to correct a chronic instability.8 Care For ankle sprains, as for all acute musculoskeletal injuries, initial treatment efforts should be directed toward limiting the amount of swelling. This treatment is more essential for ankle sprains than for many other injuries. Controlling initial swelling is the single most important Downloaded 2024828 treatment measure 1:19bePtaken that can Yourduring the entire rehabilitation process.18 Limiting the amount of acute swelling can significantly reduce the time IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, required for rehabilitation. Initial management includes POLICE: protection, optimal loading, ice, compression, and elevation. Page 12 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility reconstruction may be necessary to correct a chronic instability.8 Access Provided by: Care For ankle sprains, as for all acute musculoskeletal injuries, initial treatment efforts should be directed toward limiting the amount of swelling. This treatment is more essential for ankle sprains than for many other injuries. Controlling initial swelling is the single most important treatment measure that can be taken during the entire rehabilitation process.18 Limiting the amount of acute swelling can significantly reduce the time required for rehabilitation. Initial management includes POLICE: protection, optimal loading, ice, compression, and elevation. The most important factor in rehabilitation of an ankle sprain is controlling initial swelling with PRICE. The technique described in Focus Box 15–1 should be followed exactly to be maximally effective in limiting swelling following ankle sprain. FOCUS BOX 15–1 Technique for controlling swelling immediately following injury As soon as possible following the injury, cut out a horseshoeshaped pad made of felt or foam and fit it around the malleolus on the side of injury. The horseshoe will provide focal compression in the injured area (Figure 15–14A).19 Apply a wet compression wrap over this pad. Wetting the elastic wrap helps facilitate the passage of cold from ice packs. Wrapping should begin distally and progress proximally, completely compressing the ankle joint and ending just below the level of the gastrocnemius muscle (Figure 15–14A).18 Surround the ankle joint entirely with ice bags, and secure them in place with a second, dry, elastic wrap. Ice bags should be left on for 20 minutes initially and then 1 hour off and 20 minutes on as much as possible over the next 24 hours. During the following 72hour period, ice should be applied as often as possible (Figure 15–14B). The foot and ankle should be elevated to a minimum of 45 degrees while icing. The ankle should be elevated as much as possible during the 72 hour period after injury. Keeping the injured part elevated while sleeping is particularly important (Figure 15–14C). The athlete should be placed on crutches to avoid weight bearing for a minimum of 24 hours following injury, to allow the healing process to accomplish what it needs to (see Chapter 8). After 24 hours, the athlete should be encouraged to begin weight bearing as soon as tolerated. ©juliardi/Getty Images FIGURE 15–14 POLICE technique: ( A ) Apply a wet compression wrap over the horseshoe pad; (B) secure ice bags in place by a dry compression wrap; and (C) elevate the leg during the initial treatment period. ©William E. Prentice In the past, athletes were simply returned to sports once the pain was low enough to tolerate the activity. Returning to full activity should include a gradual progression of functional activities (i.e., walking, jogging, running, cutting, etc.) that slowly increase the stress on the ligament.7 The specific demands of each individual sport dictate the individual drills of this progression.8,15,21 Ideally, the athlete Downloaded should1:19 2024828 return to sport P Your IP without the aid of ankle support. However, it is common practice to wear some type of ankle support is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 13 may initially. Ankle bracing or taping has a stabilizing effect on unstable ankles without interfering with motor performance.11 Hightopped footwear 24 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility further stabilize the ankle. If cleated shoes are worn, cleats should preferably be placed on the lateral and medial borders of the shoe's sole to provide stability. A protective ankle brace can also be worn for support as a substitute for taping.11,24 In the past, athletes were simply returned to sports once the pain was low enough to tolerate the activity. Returning to full activity should include a gradual progression of functional activities (i.e., walking, jogging, running, cutting, etc.) that slowly increase the stress on the ligament.7 The specific Access Provided by: demands of each individual sport dictate the individual drills of this progression.8,15,21 Ideally, the athlete should return to sport without the aid of ankle support. However, it is common practice to wear some type of ankle support initially.24 Ankle bracing or taping has a stabilizing effect on unstable ankles without interfering with motor performance.11 Hightopped footwear may further stabilize the ankle. If cleated shoes are worn, cleats should preferably be placed on the lateral and medial borders of the shoe's sole to provide stability. A protective ankle brace can also be worn for support as a substitute for taping.11,24 Ankle Fractures Cause of Injury When assessing an ankle injury, always be cautious about suspecting an ankle sprain when a fracture actually exists. Ankle fractures can occur from several mechanisms that are similar to those that cause ankle sprains.6 In an inversion injury, medial malleolus fractures often occur along with a sprain of the lateral ligaments of the ankle. A fracture of the lateral malleolus is often more likely to occur than a sprain if an eversion force is applied to the ankle. With a fracture of the lateral malleolus, however, there may also be a sprain of the deltoid ligament. With avulsion injuries, it is often the injured ligaments rather than the fracture that prolong the rehabilitation period (Figure 15–15). FIGURE 15–15 The mechanism that produces an inversion ankle sprain can also cause an avulsion fracture of the fibula. Signs of Injury A fracture of the malleoli generally results in immediate swelling. There is point tenderness over the bone and the athlete is apprehensive when asked to bear weight. Care If the possibility of a fracture exists, splint the ankle and refer the athlete to the physician for Xray examination and immobilization. Usually a physician treats fractures by casting the leg in a short walking cast for 6 weeks with early weight bearing. The course of rehabilitation following this period of immobilization is generally the same as for ankle sprains. Once nearnormal levels of strength, flexibility, and neuromuscular control have been regained and the injured athlete can perform functional activities, full activity may be resumed.6 Tendinitis/Tendinosis Cause of Injury Tendinitis (inflammation), which can potentially lead to tendinosis (degeneration) of the tendons surrounding the ankle joint, is a common problem in athletes.2,3 The tendons most often involved are the posterior tibialis tendon behind the medial malleolus, the anterior tibialis on the dorsal surface Downloaded of the ankle, 2024828 1:19 Pand theIP Your fibularis tendons behind the lateral malleolus (Figure 15–16). Tendinitis in these tendons may result from one is 149.150.236.147 specific cause Chapter or from 15: The Anklea and collection LowerofLeg, mechanisms including faulty foot mechanics, inappropriate or poor footwear that can create faulty foot Page 14 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility mechanics, acute trauma to the tendon, tightness in the heel cord complex, or training errors. 13 FIGURE 15–16 Tendinitis/Tendinosis Cause of Injury Tendinitis (inflammation), which can potentially lead to tendinosis (degeneration) of the tendons surrounding the ankle Access joint, Provided by:is a common problem in athletes.2,3 The tendons most often involved are the posterior tibialis tendon behind the medial malleolus, the anterior tibialis on the dorsal surface of the ankle, and the fibularis tendons behind the lateral malleolus (Figure 15–16). Tendinitis in these tendons may result from one specific cause or from a collection of mechanisms including faulty foot mechanics, inappropriate or poor footwear that can create faulty foot mechanics, acute trauma to the tendon, tightness in the heel cord complex, or training errors.13 FIGURE 15–16 Common sites of tendinosis around the ankle. ©William E. Prentice Common sites for tendinitis: Anterior tibialis Posterior tibialis Fibularis Signs of Injury Athletes who develop tendinitis are likely to complain of pain with both active movement and passive stretching; swelling around the area of the tendon possibly caused by inflammation of the tendon; crepitus on movement; and stiffness and pain following periods of inactivity but particularly in the morning.18 15–2 Critical Thinking Exercise A jogger, after running downhill for an extended period, experiences pain in the anterior medial aspect of the left foot. The condition is diagnosed as anterior tibialis tendinosis. ? How should this condition be managed? Care Techniques that help tendon healing, including rest, therapeutic modalities (ice), and possibly antiinflammatory medications, should be used.18 The use of an orthotic device to correct the biomechanics or taping the foot may also be helpful in reducing stress on the tendons. In many instances, Downloaded if the mechanism 2024828 1:19 P Your that IP is is causing the irritation of the tendon is removed and the healing process is allowed to run its normal course, 149.150.236.147 Chapter 15: The the tendinitis will Ankle and Lower often resolve Leg, within Page 10 days to 2 weeks. It is best to allow the athlete to rest for a sufficient time for tendon healing to take 1518/ 26 place. ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Longterm inflammation of the tendon may eventually cause degeneration (tendinosis) of the tendon. Care Techniques that help tendon healing, including rest, therapeutic modalities (ice), and possibly antiinflammatory medications, should be used.18 Access Provided by: The use of an orthotic device to correct the biomechanics or taping the foot may also be helpful in reducing stress on the tendons. In many instances, if the mechanism that is causing the irritation of the tendon is removed and the healing process is allowed to run its normal course, the tendinitis will often resolve within 10 days to 2 weeks. It is best to allow the athlete to rest for a sufficient time for tendon healing to take place.18 Longterm inflammation of the tendon may eventually cause degeneration (tendinosis) of the tendon. ASSESSING THE LOWER LEG Generally fitness professionals, coaches, and others working in areas related to exercise and sports science are not adequately trained to evaluate injuries. It is strongly recommended that injured athletes be referred to qualified medical personnel (i.e., physicians, athletic trainers, physical therapists) for injury evaluation. History An athlete who complains of discomfort in the lowerleg region should be asked the following questions: How long has it been hurting? Where is the pain or discomfort? Has the feeling changed or is there numbness? Is there a feeling of warmth? Is there any sense of muscle weakness or difficulty in walking? How did the problem occur? Observation The athlete is generally observed for the following: Any postural deviations, such as toeing in, should be noted. Any walking difficulty should be noted, along with leg deformities or swelling. Palpation Palpation should be done over the musculature in each of the four compartments. When fracture is suspected, a percussive blow can be applied upward on the bottom of the heel. Such blows set up a vibratory force that resonates at the fracture, causing pain (see Figure 15–8A). The tibia and the fibula can be gently squeezed to determine a specific point of tenderness. Special Tests Thompson Test The Thompson test is used to determine if there is a rupture of the Achilles tendon. The Thompson test (Figure 15–17) is performed by squeezing the calf muscle while the leg is extended and the foot is hanging over the edge of the table. A positive Thompson sign is one in which squeezing the calf muscle does not cause the heel to move or pull upward or causes the heel to move less when compared with the uninjured leg. FIGURE 15–17 The Thompson test is looking for a complete rupture of the Achilles tendon. ©William E. Prentice Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 16 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility squeezing the calf muscle does not cause the heel to move or pull upward or causes the heel to move less when compared with the uninjured leg. FIGURE 15–17 Access Provided by: The Thompson test is looking for a complete rupture of the Achilles tendon. ©William E. Prentice RECOGNITION AND MANAGEMENT OF INJURIES TO THE LOWER LEG Tibial and Fibular Fractures Cause of Injury The tibia and fibula constitute the bony components of the lower leg and are primarily responsible for weight bearing and muscle attachment. The tibia is the most commonly fractured long bone in the body; this injury is usually the result either of direct trauma to the area or of indirect trauma, such as a combination rotatory/compressive force. Fractures of the fibula are usually seen in combination with a tibial fracture or as a result of direct trauma to the area (Figure 15–18).6 FIGURE 15–18 Fractures of the ankle and lower leg can be serious injuries. Courtesy of Jordan B. Renner, MD, Departments of Radiology and Allied Health Sciences, University of North Carolina The tibia is more commonly fractured than the fibula. Signs of Injury Tibial fractures present with immediate pain, swelling, and possible deformity and may be open or closed. Fibular fractures alone are usually closed and present with pain and point tenderness on palpation and with ambulation. Care Immediate treatment should include applying a splint to immobilize the fracture along with ice, followed by immediate medical referral. Most likely a period of immobilization and restricted weight bearing is necessary for weeks to possibly months, depending on the severity and involvement of 17 the injury.1:19 Downloaded 2024828 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 17 / 26 Tibial and Fibular ©2024 McGraw StressReserved. Hill. All Rights Fractures Terms of Use Privacy Policy Notice Accessibility Cause of Injury Stress fractures of the tibia and fibula are common in sports. Studies indicate that tibial stress fractures occur at a higher rate than usually closed and present with pain and point tenderness on palpation and with ambulation. Care Immediate treatment should include applying a splint to immobilize the fracture along with ice, followed by immediateAccess Provided by: medical referral. Most likely a period of immobilization and restricted weight bearing is necessary for weeks to possibly months, depending on the severity and involvement of the injury.17 Tibial and Fibular Stress Fractures Cause of Injury Stress fractures of the tibia and fibula are common in sports. Studies indicate that tibial stress fractures occur at a higher rate than those of the fibula. Stress fractures in the lower leg are usually the result of repetitive loading during training and conditioning (Figure 15–19). Potential causes of stress fractures may be attributed to shoes, or faulty foot and ankle biomechanics, both of which can be easily dealt with.27 Tibial stress fractures are prevalent in athletes involved with jumping. (The progression of a stress fracture was discussed in Chapter 13.) FIGURE 15–19 Xray film of a stress fracture in the tibia. Courtesy of Jordan B. Renner, MD, Departments of Radiology and Allied Health Sciences, University of North Carolina Signs of Injury The athlete complains of pain with activity that sometimes becomes worse when activity is stopped. Focal point tenderness on the bone helps differentiate a stress fracture from medial tibial stress syndrome, which is located in the same area but is more diffuse. Tibial stress fractures usually occur in the middle of the shaft, whereas fibular stress fractures are more likely to occur in the distal part of the bone.27 Care An athlete with a suspected stress fracture should be referred to a physician for diagnosis. The physician will most likely do a bone scan, looking for signs of inflammation. Immediate elimination of the offending activity is most important. Generally recuperation requires about a 2week period during which the athlete can continue to be weight bearing but must not engage in the activity that caused the problem in the first place. The athlete must be educated on the importance of adhering to this advice to prevent further damage to the bone. Progressively increasing stresses and strains can be placed on the bone so the athlete can gradually return to normal training.19 Shin Splints (Medial Tibial Stress Syndrome) Cause of Injury The term shin splints is a catchall that has traditionally referred to any type of pain in the anterior aspect of the lower leg.1 Medial tibial stress syndrome, as it is more correctly called, is a condition that involves increasing pain specifically at the distal twothirds of the posterior medial aspect of the tibia (Figure 15–20).26,31 A strain of the posterior tibialis muscle and its fascial sheath at its attachment to the periosteum of the distal tibia during running activities is the most likely mechanism for this injury.12 Pain in the anterior shin could also be caused by other injuries or Downloaded 2024828 conditions, including 1:19 stress P Your compartment fractures, syndromes, or tendinitis.1 Pain can arise secondary to a combination of faulty foot mechanics, IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 18 / 26 tightness of the Achilles ©2024 McGraw Hill. All complex, muscle weakness, Rights Reserved. Terms ofimproper footwear, Use Privacy and Policy training Notice errors usually involving a change in running surfaces.26 Accessibility FIGURE 15–20 Shin Splints (Medial Tibial Stress Syndrome) Cause of Injury The term shin splints is a catchall that has traditionally referred to any type of pain in the anterior aspect of the lower leg.1 Medial tibial stress syndrome, as it is more correctly called, is a condition that involves increasing pain specifically at the distal twothirds of theProvided Access posterior by: medial aspect of the tibia (Figure 15–20).26,31 A strain of the posterior tibialis muscle and its fascial sheath at its attachment to the periosteum of the distal tibia during running activities is the most likely mechanism for this injury.12 Pain in the anterior shin could also be caused by other injuries or conditions, including stress fractures, compartment syndromes, or tendinitis.1 Pain can arise secondary to a combination of faulty foot mechanics, tightness of the Achilles complex, muscle weakness, improper footwear, and training errors usually involving a change in running surfaces.26 FIGURE 15–20 In medial tibial stress syndrome, the pain is usually located on the medial aspect of the lower leg just posterior to the tibia (shaded area). Pain is most often associated with the posterior tibialis muscle. ©William E. Prentice shin splints Medial tibial stress syndrome; anterior lowerleg pain. Signs of Injury Pain is usually diffuse about the distal medial tibia and the surrounding soft tissues. Initially, the area may hurt only after an intense workout. As the condition worsens, daily ambulation may be painful, and morning pain and stiffness may be present. Medial tibial stress syndrome can progress to a stress fracture if not treated appropriately.26 Care Management of this condition should include physician referral to rule out the possibility of stress fracture via the use of bone scan and plain films. Activity modification along with measures to maintain cardiovascular fitness are set in place immediately. Correction of abnormal foot mechanics during walking and running must also be addressed with shoes and, if needed, custom foot orthotics.31 Ice massage to the area may be helpful in the reduction of localized pain and inflammation. A stretching program for the Achilles complex should be initiated (refer to Figure 15–4). Occasionally, supportive taping to the longitudinal arch might be helpful (refer to Figure 10–13).17 Shin Contusions Cause of Injury The shin (tibia), lying just under the skin, is exceedingly vulnerable and sensitive to blows or bumps. Because of the absence of muscular or adipose padding, force is not dissipated and the periosteum receives the impact delivered to the shin. Shin contusions occur frequently in soccer, and the incidence can be minimized by wearing appropriate shin guards (refer to Figure 6–26).1 Downloaded 2024828 Signs of Injury 1:19complains The athlete P Your IPofisintense 149.150.236.147 pain, swelling, and increased warmth. A bulging hematoma with a jellylike consistency develops Chapter 15: The Ankle and Lower Leg, Page 19 / 26 rapidly. In some instances, the hematoma may increase to the size of a golf ball (Figure 15–21). ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility FIGURE 15–21 Shin Contusions Cause of Injury The shin (tibia), lying just under the skin, is exceedingly vulnerable and sensitive to blows or bumps. Because of the absence of muscular or adipose padding, force is not dissipated and the periosteum receives the impact delivered to the shin. Shin contusionsAccess occur frequently Provided by: in soccer, and the incidence can be minimized by wearing appropriate shin guards (refer to Figure 6–26).1 Signs of Injury The athlete complains of intense pain, swelling, and increased warmth. A bulging hematoma with a jellylike consistency develops rapidly. In some instances, the hematoma may increase to the size of a golf ball (Figure 15–21). FIGURE 15–21 A serious shin contusion can cause a compartment syndrome. ©William E. Prentice Severe blows to an unprotected shin can lead to a chronic inflammation. Care A compressive wrap along with ice and elevation should be applied immediately to minimize swelling. Occasionally, a physician may decide to aspirate the hematoma. A protective doughnut pad constructed to disperse pressure away from the contusion should be worn to protect the area from additional injury. Compartment Syndromes Cause of Injury Compartment syndromes are conditions in which increased pressure within one of the four compartments of the lower leg causes compression of muscular and neurovascular structures within that compartment (refer to Figure 15–3).29 The anterior and deep posterior compartments are usually involved.14 Compartment syndrome classifications: Acute compartment syndrome Acute exertional compartment syndrome Chronic compartment syndrome Compartment syndromes are divided into three categories: acute compartment syndrome, acute exertional compartment syndrome, and chronic compartment syndrome.5 Acute compartment syndrome occurs secondary to direct trauma to the area, such as being kicked in the anterior aspect of Downloaded 2024828 1:19 P Your IP is 149.150.236.147 the lower15: Chapter 22 Acute leg.The Ankle compartment syndrome is considered to be a medical emergency because of the possibility of compression of arterial and Lower Leg, and20nerve Page / 26 ©2024 supply, McGraw Hill.result which could All Rights Reserved. in additional Terms injury of Use distal to structures Privacy Policy to the Notice Accessibility compartment. Acute exertional compartment syndrome occurs without any precipitating trauma and can evolve with minimal to moderate activity.22 Chronic compartment syndrome is activity related in that the symptoms arise Chronic compartment syndrome Access Provided by: Compartment syndromes are divided into three categories: acute compartment syndrome, acute exertional compartment syndrome, and chronic compartment syndrome.5 Acute compartment syndrome occurs secondary to direct trauma to the area, such as being kicked in the anterior aspect of the lower leg.22 Acute compartment syndrome is considered to be a medical emergency because of the possibility of compression of arterial and nerve supply, which could result in additional injury to structures distal to the compartment. Acute exertional compartment syndrome occurs without any precipitating trauma and can evolve with minimal to moderate activity.22 Chronic compartment syndrome is activity related in that the symptoms arise rather consistently at a certain point in the activity. Chronic compartment syndrome usually occurs during running and jumping activities, and symptoms cease when activity stops.14,29 15–3 Critical Thinking Exercise A soccer player who is not wearing shin guards is kicked on the outside shin of his right leg. After several minutes the pain begins to increase and he feels some tingling and numbness in his foot. ? What is the primary concern with this injury, and what steps should be taken to manage this situation? Signs of Injury Because of increased intracompartmental pressure associated with compartment syndromes, the athlete complains of a deep aching pain, tightness and swelling of the involved compartment, and pain with passive stretching of the involved muscles.14 Reduced circulation and sensory changes can be detected in the foot. Intracompartmental pressure measurements further define the severity of the condition. A compartment syndrome that is not recognized, diagnosed, and treated properly can lead to a poor functional outcome for the athlete.22 Care Immediate first aid for acute compartment syndrome should include the application of ice and elevation. However, in this situation a compression wrap should not be used to control swelling because there is already a problem with increased pressure in the compartment. Using a compression wrap only acts to increase the pressure. In the case of both acute compartment syndrome and acute exertional compartment syndrome, measurement of intracompartmental pressures by a physician confirms the diagnosis, with emergency surgical procedure to release the pressure within that compartment being the definitive treatment.22 Athletes undergoing anterior or deep posterior compartment surgical procedure may not return to full activity for 2 to 4 months postsurgery.17 Management of chronic compartment syndrome is initially conservative, with activity modification, icing, and stretching of the anterior compartment musculature and Achilles complex. If conservative measures fail, fasciotomy of the affected compartments has shown favorable results in an athlete's return to higher levels of activity. Achilles Tendinitis/Tendinosis Cause of Injury The Achilles tendon is the largest tendon in the human body. It serves as a common tendon for the gastrocnemius and soleus muscles and inserts on the calcaneus. This Achilles tendon complex produces plantarflexion of the ankle. Achilles tendinitis is an inflammatory condition that occurs because of repetitive stresses and strains placed on the tendon such as with running or jumping activities.2 Repetitive weight bearing activities such as running or early season conditioning in which the duration and intensity are increased too quickly with insufficient recovery time worsen the condition. Uphill running or hill workouts usually aggravate the condition. The athlete may experience reduced gastrocnemius and soleus muscle flexibility in general that may worsen as the condition progresses and adaptive shortening occurs. When there is ongoing chronic pain, inflammation may subside but the tendon may begin to degenerate with thickening and scar formation, which is more correctly referred to as Achilles tendinosis. Chronic Achilles tendinosis may eventually lead to rupture of the Achilles tendon.3 Signs of Injury The athlete often complains of generalized pain and stiffness about the Achilles tendon just proximal to the calcaneal insertion. Achilles tendinitis often begins with a gradual onset over time. Symptoms may progress to morning stiffness and discomfort with walking after periods of prolonged sitting. The tendon may be warm and painful to palpation, and if the inflammation persists, the tendon may thicken (see Figure 13–9).3 Care Achilles tendinitis generally takes a long time to resolve. It is important to create a proper healing environment by limiting or restricting the activity that caused the initial inflammation. Aggressive stretching of the Achilles tendon complex (refer to Figure 15–4), inserting a heel lift under the calcaneus, using Downloaded taping techniques 2024828 1:19 P Your to provide support to the Achilles tendon (refer to Figure 10–17), and using antiinflammatory medication have all IP is 149.150.236.147 Chapter 15: The Ankle and been recommended as treatments.Lower 2Leg, Page 21 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Achilles tendinitis often begins with a gradual onset over time. Symptoms may progress to morning stiffness and discomfort with walking after periods of prolonged sitting. The tendon may be warm and painful to palpation, and if the inflammation persists, the tendon may thicken (see Figure 13–9).3 Access Provided by: Care Achilles tendinitis generally takes a long time to resolve. It is important to create a proper healing environment by limiting or restricting the activity that caused the initial inflammation. Aggressive stretching of the Achilles tendon complex (refer to Figure 15–4), inserting a heel lift under the calcaneus, using taping techniques to provide support to the Achilles tendon (refer to Figure 10–17), and using antiinflammatory medication have all been recommended as treatments.2 Achilles tendinitis generally takes a long time to resolve. Achilles Tendon Rupture Cause of Injury Injury may range from a grade 1 strain of the muscle to complete rupture of the tendon. A tight Achilles tendon is prone to strain, particularly of the gastrocnemius muscle. Achilles tendon rupture is usually caused by a sudden, forceful plantarflexion of the ankle.25 A rupture of the Achilles tendon is more common in athletes above the age of 30 years and occurs in activities requiring dynamic movement, such as tennis and basketball (Figure 15–22).4 FIGURE 15–22 Achilles tendon rupture involves tearing and separation of fibers. 15–4 Critical Thinking Exercise A 35yearold racquetball player feels a pop and severe immediate pain in the back of his left lower leg. He actually felt like someone kicked him, but when he turned around, no one was there. Then he realized he could not push off on his foot. ? What injury does he most likely have, and how should it be managed? A ruptured Achilles tendon can occur following chronic inflammation. Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 22 / 26 Signs ©2024of Injury Hill. McGraw Athletes may feel All Rights or hear a pop Reserved. andofoften Terms Use report Privacythat they have Policy been Notice kicked in the back of the leg. Plantarflexing the ankle will be Accessibility painful and limited but still possible with the assistance of the tibialis posterior and the peroneals. A palpable defect will be noted along the length of the tendon. The athlete will require the use of crutches to continue ambulation without an obvious limp.17 when he turned around, no one was there. Then he realized he could not push off on his foot. ? What injury does he most likely have, and how should it be managed? Access Provided by: A ruptured Achilles tendon can occur following chronic inflammation. Signs of Injury Athletes may feel or hear a pop and often report that they have been kicked in the back of the leg. Plantarflexing the ankle will be painful and limited but still possible with the assistance of the tibialis posterior and the peroneals. A palpable defect will be noted along the length of the tendon. The athlete will require the use of crutches to continue ambulation without an obvious limp.17 Care After an Achilles tendon rupture, the question of surgical repair versus cast immobilization arises.17 Surgical repair of the tendon is recommended to allow the athlete to return to previous levels of activity. Surgical repair of the Achilles tendon may require a period of immobilization for 6 to 8 weeks to allow for proper tendon healing. It is important that the athlete not only regain full range of motion without harming the repair, but also regain normal muscle function through controlled progressive strengthening exercises.17 SUMMARY The movements that take place at the talocrural joint are ankle plantarflexion and dorsiflexion. Inversion and eversion occur at the subtalar joint. Many lowerleg and ankle injuries, especially sprains, can be reduced by Achilles tendon stretching, strengthening of key muscles, improving neuromuscular control, choosing appropriate footwear, and, when necessary, proper taping or bracing. Ankle sprains are very common. Inversion sprains usually involve the lateral ligaments of the ankle, and eversion sprains frequently involve the medial ligaments of the ankle. Dorsiflexion injuries often involve the tibiofibular ligaments and may be more severe. The early phase of treatment following an ankle sprain uses protection, optimal loading, ice, compression, and elevation, all of which are critical components in preventing swelling. Tendinitis or tendinosis in the posterior tibialis, anterior tibialis, and the fibularis tendons may result from one specific cause or from a collection of mechanisms. Techniques that act to reduce or eliminate inflammation, including rest, ice, and antiinflammatory medications, should be incorporated into rehabilitation. Although some injuries that occur in the region of the lower leg are acute, the majority of injuries seen in an athletic population result from overuse, most often from running. Tibial fractures can create longterm problems for the athlete if inappropriately managed, whereas fibular fractures generally require much shorter periods for immobilization. Treatment of these fractures is immediate medical referral and most likely a period of immobilization and restricted weight bearing. Stress fractures in the lower leg are usually the result of the bone's inability to adapt to the repetitive loading response during training and conditioning of the athlete and are more likely to occur in the tibia. Care for medial tibial stress syndrome must be comprehensive and must address several factors, including musculoskeletal training and conditioning as well as proper footwear and orthotics intervention. Compartment syndromes can occur from acute trauma or from repetitive trauma or overuse. They can occur in any of the four compartments but are most likely to occur in the anterior compartment or deep posterior compartment. Achilles tendinitis often presents with a gradual onset over time and may be resistant to a quick resolution. Perhaps the greatest question after an Achilles tendon rupture is whether surgical repair or cast immobilization is the best method of treatment. Regardless, the time required for rehabilitation is significant. SOLUTIONS TO CRITICAL THINKING EXERCISES Downloaded 151 The 2024828 1:19 P care most important Your IP can that is 149.150.236.147 be given immediately following ankle sprain is to control or minimize the swelling. This goal is Chapter 15: The Ankle and Lower Leg, Page 23 / 26 accomplished by using a combination of ice, compression, elevation, and rest, beginning immediately and continuing for at least the next 72 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility hours. 152 The athlete is instructed to rest or reduce the stress of running. Application of ice packs followed by stretching is carried out before and Perhaps the greatest question after an Achilles tendon rupture is whether surgical repair or cast immobilization is the best method of treatment. Regardless, the time required for rehabilitation is significant. Access Provided by: SOLUTIONS TO CRITICAL THINKING EXERCISES 151 The most important care that can be given immediately following ankle sprain is to control or minimize the swelling. This goal is accomplished by using a combination of ice, compression, elevation, and rest, beginning immediately and continuing for at least the next 72 hours. 152 The athlete is instructed to rest or reduce the stress of running. Application of ice packs followed by stretching is carried out before and after activity. A strengthening program is implemented along with treatment by oral antiinflammatory medications as needed. 153 This athlete may be developing an acute compartment syndrome in the anterior compartment. If so, this condition should be handled as an emergency. The coach should immediately elevate the leg and apply ice, but no compression wrap, and the athlete should be given medical attention as soon as possible. 154 This scenario is a classic description of a ruptured Achilles tendon. In cases of a complete rupture, surgery is necessary to repair the tendon, followed by a reasonably long period of rehabilitation. REVIEW QUESTIONS AND CLASS ACTIVITIES 1. Describe the anatomy of the ankle and lower leg. 2. How can ankle and lowerleg injuries be prevented? 3. What questions should be asked when assessing injuries to the lower leg or ankle? 4. Describe the common mechanisms of injury for acute ankle sprains. What structures are damaged? 5. How can fractures in the lower leg and ankle be ruled out? 6. What is the appropriate care for stress fractures of the tibia and fibula? 7. Which of the tendons surrounding the ankle joint can potentially develop tendinitis? 8. What are some indications of an Achilles tendon rupture? How is an Achilles tendon rupture cared for? 9. How does Achilles tendinitis develop? How should it be cared for? 10. Contrast acute compartment syndrome with chronic compartment syndrome. 11. What exactly are shin splints, and what measures can be taken to eliminate this problem? 12. What is the most important thing that can be done in caring for a shin contusion? RECOMMENDED REFERENCES 1. Blackman, P. 2010. Shin pain in athletes—Assessment and management. Australian Family Physician 39(12):24–29. [PubMed: 20369130] 2. Carcia, C. 2010. Clinical guidelines. Achilles pain, stiffness and muscle power deficits: Achilles tendinitis. Journal of Orthopedic and Sports Physical Therapy 40(9):1–26. 3. Carey, D. 2010. The management of Achilles tendinosis—A review of the literature. Podiatry Now 13(11):13–17. 4. Claessen, F. 2014. Predictors of Achilles tendon rupture. Sports Medicine 44(9):1241–1259. [PubMed: 24929701] 5. Davis, D. 2013. Characteristics of patients with chronic exertional compartment syndrome. Foot & Ankle International 34(10):1349–1354. [PubMed: 23669162] 6. Dodson, N.2024828 Downloaded 2013. Factors1:19affecting P Yourhealing of ankle fractures. Journal of Foot and Ankle Surgery 52(1):2–5. IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 24 / 26 7. Doherty ©2024 C., & Bleakley McGraw C. 2017. Hill. All Rights TreatmentTerms Reserved. and prevention of acutePolicy of Use Privacy and recurrent Notice ankle sprain: An overview of systematic reviews with metaanalysis Accessibility British Journal of Sports Medicine 51(2):113–125. [PubMed: 28053200] 4. Claessen, F. 2014. Predictors of Achilles tendon rupture. Sports Medicine 44(9):1241–1259. [PubMed: 24929701] 5. Davis, D. 2013. Characteristics of patients with chronic exertional compartment syndrome. Foot & Ankle International 34(10):1349–1354. [PubMed: Access Provided by: 23669162] 6. Dodson, N. 2013. Factors affecting healing of ankle fractures. Journal of Foot and Ankle Surgery 52(1):2–5. 7. Doherty C., & Bleakley C. 2017. Treatment and prevention of acute and recurrent ankle sprain: An overview of systematic reviews with metaanalysis British Journal of Sports Medicine 51(2):113–125. [PubMed: 28053200] 8. Donovan, L. 2012. A new paradigm for rehabilitation of patients with chronic ankle instability. Physician and Sports Medicine 40(4):41–51. 9. Enke, R. 2012. Diagnosis, treatment and prevention of common running injuries. Journal of Clinical Outcomes Management 19(2):86–94. 10. Evans, L. 2012. Prevention of ankle sprain: A systematic review. International Musculoskeletal Medicine 34(4):146–158. 11. Farwell, K. 2013. The effectiveness of prophylactic ankle braces in reducing the incidence of acute ankle injuries in adolescent athletes: A critically appraised topic. Journal of Sport Rehabilitation 22(2):137–142. [PubMed: 23117177] 12. Franklyn, M., & Oakes, B. 2015. Aetiology and mechanisms of injury in medial tibial stress syndrome: Current and future developments. World Journal of Orthopedics , 6(8):577–589. [PubMed: 26396934] 13. Galloway, H. 2013. Overuse injuries of the lower extremity. Radiologic Clinics of North America 51(3):511–528. [PubMed: 23622096] 14. George, C. 2012. Chronic exertional compartment syndrome. Clinics in Sports Medicine 31(2):307–319. [PubMed: 22341019] 15. Gottschalk, A. 2010. Current concepts in the prevention of ankle sprains. EvidenceBased Practice 13(1):1–2. 16. Hiller, C. 2011. Chronic ankle instability: Evolution of a model. Journal of Athletic Training 46(2):133–141. [PubMed: 21391798] 17. Hirth, C. 2015. Rehabilitation of lower leg injuries. In W. Prentice (ed.), Rehabilitation techniques in sports medicine and athletic training , 6th ed. Thorofare, NJ: Slack. 18. Hunter, S., Prentice, W., & Zinder, S. 2015. Rehabilitation of foot and ankle injuries. In W. Prentice (ed.), Rehabilitation techniques in sports medicine and athletic training , 6th ed. Thorofare, NJ: Slack. 19. Kahanov, L., & Eberman, L. 2015. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access Journal of Sports Medicine 6:87–95. [PubMed: 25848327] 20. Kaminski, T., et al. 2013. NATA position statement: Conservative management and prevention of ankle sprains in athletes. Journal of Athletic Training 48(4):528–545. [PubMed: 23855363] 21. Kemler, E. 2011. A systematic review of the treatment of acute ankle sprain. Sports Medicine 41(3):185–197. [PubMed: 21395362] 22. Mauser, N., & Gissel, H. 2013. Acute lowerleg compartment syndrome. Orthopedics 36(8):619–624. [PubMed: 23937740] 23. Miller, T., & Skalak, T. 2014. Evaluation and treatment recommendations for acute injuries to the ankle syndesmosis without associated fracture. Sports Medicine 44(2):179–188. [PubMed: 24127279] 24. Parsley, A. 2013. Effect of 3 different ankle braces on functional performance and ankle range of motion. Athletic Training and Sports Health Care 5(2):69–75. 25. Pedowitz, D., & Kirwan, G. 2013. Achilles tendon ruptures. Current Reviews in Musculoskeletal Medicine 6(4):285–293. [PubMed: 24151122] 26. Reshef, N. 2012. Medial tibial stress syndrome. Clinics in Sports Medicine 31(2):273–290. [PubMed: 22341017] 27. Shindle, M., & Endo, Y. 2012. Stress fractures about the tibia, foot, and ankle. Journal of the American Academy of Orthopaedic Surgeons 20(3):167–176. Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 25 / 26 28. Valkering, ©2024 McGraw K. Hill. 2012.AllIsolated Rights syndemosis Reserved. ankle Termsinjury. of UseOrthopedics 35(12):1705–1710. Privacy Policy Notice Accessibility 29. West R., & Ferguson J. 2016. Chronic exertional compartment syndrome. In T. Miller (ed.), Endurance sports medicine. New York, NY: Springer. 25. Pedowitz, D., & Kirwan, G. 2013. Achilles tendon ruptures. Current Reviews in Musculoskeletal Medicine 6(4):285–293. [PubMed: 24151122] 26. Reshef, N. 2012. Medial tibial stress syndrome. Clinics in Sports Medicine 31(2):273–290. [PubMed: 22341017] Access Provided by: 27. Shindle, M., & Endo, Y. 2012. Stress fractures about the tibia, foot, and ankle. Journal of the American Academy of Orthopaedic Surgeons 20(3):167–176. 28. Valkering, K. 2012. Isolated syndemosis ankle injury. Orthopedics 35(12):1705–1710. 29. West R., & Ferguson J. 2016. Chronic exertional compartment syndrome. In T. Miller (ed.), Endurance sports medicine. New York, NY: Springer. 30. Wikstrom, E. 2013. Understanding and treating lateral ankle sprains and their consequences. Sports Medicine 43(6):385–393. [PubMed: 23580392] 31. Winters, K. 2014. Treatment of medial tibial stress syndrome: A critical review. International Journal of Athletic Therapy and Training 19(4):27–31. ANNOTATED BIBLIOGRAPHY Altchek, D. 2012. Foot and ankle in sports medicine. Baltimore, MD: Lippincott, Williams & Wilkins. A comprehensive and practical resource for the treatment of foot and ankle sports injuries. Over 40 specialists in orthopedic surgery, podiatry, physiatry, physical therapy, and athletic training contributed to this book's contents. Marder, R., & Lian, G. 2012. Sports injuries of the ankle and foot. New York, NY: Springer. This book reaches beyond the orthopedic surgery market to provide a onesource reference for the treatment of both simple and complex sportsrelated injuries of the foot and ankle. McKeon, P., Wikstrom, E. 2015. Quick questions in ankle sprains: Expert advice in sports medicine. Thorofare, NJ: Slack. Presents 39 common clinical questions regarding the prevention, assessment, treatment, management, and rehabilitation of ankle sprains. Porter, D., & Schon, L. 2008. Baxter's The foot and ankle in sport. St. Louis, MO: Mosby. Discusses all aspects of dealing with foot and ankle injuries as they occur in an athletic population Rome, K., & McNair, P. 2014. Management of chronic conditions in the foot and lower leg. Edinburgh: Churchill Livingstone. This resource uses an interdisciplinary approach to help manage chronic conditions in the lower limb and foot. WEBSITES AAOS Online Service: Foot and Ankle https://.orthoinfo.aaos.org/menus/foot.cfm Provides answers to a wide range of questions on foot and ankle injuries, from the American Academy of Orthopaedic Surgeons. American Orthopaedic Foot and Ankle Society: www.aofas.org American Podiatric Medical Association: www.apma.org Provides a variety of information on foot and ankle injuries, from the APMA. Gray's Anatomy of the Human Body: www.bartleby.com/107 Downloaded 2024828 1:19 P Your IP is 149.150.236.147 Chapter 15: The Ankle and Lower Leg, Page 26 / 26 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility

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