KIN 191AKIN 191AAdvanced Assessment of Advanced Assessment of Lower Extremity InjuriesLower Extremity Injuries

ANKLE/LOWER LEG EVALUATIONANKLE/LOWER LEG EVALUATION

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INTRODUCTIONINTRODUCTION

HISTORY INSPECTION PALPATION ROM TESTING LIGAMENTOUS STABILITY TESTING NEUROLOGIC TESTING VASCULAR TESTING

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Location of painLocation of pain May be referred site for compartment May be referred site for compartment

syndrome, tarsal tunnel syndrome, syndrome, tarsal tunnel syndrome, peroneal/tibial nerve injury, sciatic nerve peroneal/tibial nerve injury, sciatic nerve or lumbar nerve root impingementor lumbar nerve root impingement

Nature/type of painNature/type of pain Aggravating/alleviating activitiesAggravating/alleviating activities Effect of pain on activitiesEffect of pain on activities

HISTORYHISTORY

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Onset of painOnset of pain Acute: trauma (sprain, strain, fracture, etc.)Acute: trauma (sprain, strain, fracture, etc.) Gradual/insidious - overuse syndromesGradual/insidious - overuse syndromes

Mechanism of injuryMechanism of injury Macrotrauma - typically easy to identify Macrotrauma - typically easy to identify

tissues involvedtissues involved Microtrauma - typically involves more in Microtrauma - typically involves more in

depth questioning to arrive at cause of depth questioning to arrive at cause of problemproblem

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Activity changesActivity changes Duration, frequency, intensity, surface, Duration, frequency, intensity, surface,

shoes, orthotics, etc.shoes, orthotics, etc.

Prior historyPrior history Those with prior history of ankle injury Those with prior history of ankle injury

may present with increased laxity and/or may present with increased laxity and/or decreased proprioception vs. normaldecreased proprioception vs. normal

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INSPECTIONINSPECTION

General inspectionGeneral inspection Weight bearing statusWeight bearing status Gait patternGait pattern SwellingSwelling Obvious deformityObvious deformity DiscolorationDiscoloration

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Inspection of the lateral structuresInspection of the lateral structures Peroneal muscle groupPeroneal muscle group Distal one third of the fibulaDistal one third of the fibula Lateral malleolusLateral malleolus

Inspection of the anterior structuresInspection of the anterior structures Appearance of the anterior lower legAppearance of the anterior lower leg Contour of the malleoliContour of the malleoli TalusTalus Sinus tarsiSinus tarsi

Lateral aspect of the talus (anterior from the Lateral aspect of the talus (anterior from the lateral malleolus)lateral malleolus)

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Inspection of the medial structuresInspection of the medial structures Medial malleolusMedial malleolus Medial longitudinal archMedial longitudinal arch

Inspection of the posterior structuresInspection of the posterior structures Gastrocnemius-soleus complexGastrocnemius-soleus complex Achilles tendonAchilles tendon BursaeBursae

Subtendinous (Retrocalcaneal) bursaSubtendinous (Retrocalcaneal) bursa Subcutaneous calcaneal bursaSubcutaneous calcaneal bursa

CalcaneusCalcaneus

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PALPATION (fibular PALPATION (fibular structure)structure)

1. Common peroneal nerve1. Common peroneal nerve2. Peroneus longus and brevis2. Peroneus longus and brevis3. Fibular shaft3. Fibular shaft4. Anterior and posterior4. Anterior and posterior tibiofibular ligamentstibiofibular ligaments5. Interosseous 5. Interosseous membranemembrane6. Superior peroneal 6. Superior peroneal retinaculumretinaculum

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PALPATION (lateral ankle)PALPATION (lateral ankle)1. Lateral malleolus1. Lateral malleolus2. Calcaneofibular ligament2. Calcaneofibular ligament3. Anterior talofibular ligament3. Anterior talofibular ligament4. Posterior talofibular ligament4. Posterior talofibular ligament5. Peroneal retinaculum5. Peroneal retinaculum6. Peroneal tubercle6. Peroneal tubercle7. Cuboid7. Cuboid8. Base of the fifth metatarsal8. Base of the fifth metatarsal9. Peroneus tertius9. Peroneus tertius

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PALPATION (anterior PALPATION (anterior structures)structures)1. Anterior tibial shaft1. Anterior tibial shaft

2. Tibialis anterior2. Tibialis anterior

3. Extensor hallucis longus3. Extensor hallucis longus

4. Extensor digitorum longus4. Extensor digitorum longus

5. Dome of the talus5. Dome of the talus

6. Extensor retinacula6. Extensor retinacula

7. Sinus tarsi7. Sinus tarsi

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PALPATION (medial PALPATION (medial structures)structures)

1. Medial malleolus1. Medial malleolus2. Deltoid ligament2. Deltoid ligament3. Sustentaculum tali3. Sustentaculum tali4. Spring ligament4. Spring ligament5. Navicular and 5. Navicular and navicular tuberositynavicular tuberosity6. Tibialis posterior6. Tibialis posterior77. Flexor . Flexor digitorumdigitorum longus longus88. Flexor . Flexor hallucishallucis longus longus

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PALPATION (posterior PALPATION (posterior structures)structures)

1. Gastroncnemius-soleus complex1. Gastroncnemius-soleus complex

2. Achilles tendon2. Achilles tendon

3. Subcutaneous calcanel bursa3. Subcutaneous calcanel bursa

4. Calcaneus4. Calcaneus

5. Subtendinous calcaneal bursa5. Subtendinous calcaneal bursa

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Palpation of PulsesPalpation of Pulses Posterior tibial arteryPosterior tibial artery

Between the flexor digitorum longus and Between the flexor digitorum longus and flexor hallucis longus tendons as they flexor hallucis longus tendons as they pass behind the medial malleoluspass behind the medial malleolus

Dosalis pedis arteryDosalis pedis artery Between the extensor digitorum longus Between the extensor digitorum longus

and extensor hallucis longus tendons as and extensor hallucis longus tendons as they pass over the cuneiformsthey pass over the cuneiforms

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RANGE OF MOTION TESTINGRANGE OF MOTION TESTING The ROM can be affected byThe ROM can be affected by

Muscular tightnessMuscular tightness Bony abnormalitiesBony abnormalities Soft tissue constraintsSoft tissue constraints

Active ROMActive ROM Passive ROMPassive ROM Resistive ROMResistive ROM

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Active ROMActive ROM Plantar flexion/dorsiflexion at Plantar flexion/dorsiflexion at

talocrural joint talocrural joint Inversion/eversion at subtalar jointInversion/eversion at subtalar joint

PF – 50 degrees, DF – 15~20 degreesPF – 50 degrees, DF – 15~20 degrees Must have 10 degrees DF to walk with Must have 10 degrees DF to walk with

normal gait (15 degrees to run) – if normal gait (15 degrees to run) – if absent, predisposes to biomechanical absent, predisposes to biomechanical problems and overuse injuriesproblems and overuse injuries

INV – 20 degrees, EV – 5~10 degreesINV – 20 degrees, EV – 5~10 degrees

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Passive ROMPassive ROM DorsiflexionDorsiflexion

Measured with the knee extended to determine Measured with the knee extended to determine the overall influence of the triceps surae groupthe overall influence of the triceps surae group

Measured with knee flexed to determine the Measured with knee flexed to determine the influence of the soleusinfluence of the soleus

Normal firm end-feelNormal firm end-feel Plantar flexionPlantar flexion

Normal firm end-feelNormal firm end-feel Anterior joint capsule, deltoid ligament, and Anterior joint capsule, deltoid ligament, and

ATF ligament are stretchedATF ligament are stretched

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InversionInversion Should lie supine positionShould lie supine position Normal firm end-feel (especially the CF Normal firm end-feel (especially the CF

ligament stretch) and peroneal muscles ligament stretch) and peroneal muscles stretchstretch

The tibia and fibular are stabilized to The tibia and fibular are stabilized to prevent hip or lower leg rotationprevent hip or lower leg rotation

EversionEversion A hard end-feel (because of the fibular’s A hard end-feel (because of the fibular’s

striking the calcaneus)striking the calcaneus)

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GoniometryGoniometry Plantar flexion/DorsiflexionPlantar flexion/Dorsiflexion

Sitting or lying with the knee flexed to at Sitting or lying with the knee flexed to at least 30 degreesleast 30 degrees

FulcrumFulcrum Centered over the lateral malleolusCentered over the lateral malleolus

Stationary armStationary arm Aligned with the long axis of the fibulaAligned with the long axis of the fibula

Movement armMovement arm Parallel with the long axis of the 5Parallel with the long axis of the 5thth metatarsal metatarsal

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GoniometryGoniometry Inversion/EversionInversion/Eversion

Sitting or lying with the knee Sitting or lying with the knee flexed to at least 30 degreesflexed to at least 30 degrees

FulcrumFulcrum Over the talocrural joint line, Over the talocrural joint line,

centered between the malleolicentered between the malleoli Stationary armStationary arm

Centered over the long axis of Centered over the long axis of the tibiathe tibia

Movement armMovement arm Over the 2Over the 2ndnd metatarsal metatarsal

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Resistive ROMResistive ROM

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Anterior talofibular ligamentAnterior talofibular ligament Anterior drawer testAnterior drawer test

Calcaneofibular ligamentCalcaneofibular ligament (Talar Tilt) Inversion stress test(Talar Tilt) Inversion stress test

Deltoid ligamentDeltoid ligament (Talar Tilt) Eversion stress test(Talar Tilt) Eversion stress test Kleiger’s (External rotation) testKleiger’s (External rotation) test

Place the ankle in neutral or slightly plantar flexedPlace the ankle in neutral or slightly plantar flexed

LIGAMENTOUS STABILITY LIGAMENTOUS STABILITY TESTSTESTS

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Anterior Drawer Test Talar Tilt Inversion Stress Test

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Distal tibiofibular Distal tibiofibular ligaments/syndesmosisligaments/syndesmosis Kleiger’s (External rotation) testKleiger’s (External rotation) test

Place the ankle in dorsiflexionPlace the ankle in dorsiflexion Squeeze (Compression) testSqueeze (Compression) test

Stress fractures of lower leg: tibia, fibular, Stress fractures of lower leg: tibia, fibular, talus, and/or calcaneustalus, and/or calcaneus Bump (Percussion) testBump (Percussion) test

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Kleiger’s (External rotation) Test

Squeeze (Compression) Test

Bump (Percussion) Test

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Homan’s Test

Thompson Test

For Achilles tendon For Achilles tendon rupturerupture

For Deep Vein For Deep Vein ThrombosisThrombosis

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NEUROGIC TESTINGNEUROGIC TESTING

L4 – S2 L4 – S2 dermatomes/myotomes/reflexdermatomes/myotomes/reflex

Tibial nerveTibial nerve Deep peroneal nerveDeep peroneal nerve Superficial peroneal nerveSuperficial peroneal nerve

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VASCULAR TESTINGVASCULAR TESTING

Anterior compartmentAnterior compartment Lateral compartmentLateral compartment Deep posterior compartmentDeep posterior compartment Superficial posterior compartmentSuperficial posterior compartment