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Sports Medicine IISports Medicine II

THE 4 BONES OF THE ANKLE JOINT

TIBIA

FIBULA

CALCANEUS

TALUS

ANKLE LIGAMENTS – MEDIAL

• Deltoid Ligament Complex – 4 ligaments– Broad– Flat– Overlapping– = STRONG!

A

BC

D

ANKLE LIGAMENTS - LATERAL

• Lateral Collateral Ligaments– ATF

• Anterior• From Talus to Fibula• Weakest of 3 ligaments

– PTF• Posterior• From Talus to Fibula• Strongest/Deepest of 3

ligaments

– CF• Anterior• From Calcaneus to Fibula• Largest; Strong and Cord-like

ANKLE MUSCLES: ANTERIOR SIDE

• TIBIALIS ANTERIOR– Muscle starts @ top of Tibia– Tendon crosses over Ankle Joint @ Talus– Attaches at the base of the 1st foot

bone– Cross over at joint allows for multiple

motions

• Major Motion:– Dorsiflexion of the ankle joint– Inversion of the foot – Prevents the forefoot slapping AND

scrapping the ground

ANKLE MUSCLES: LATERAL SIDE

• PERONEAL GROUP– 3 muscles (peroneus

brevis/longus/tertius)– Muscle group starts @ top of Fibula– Peroneal tendon hooks around the back

of Lateral Malleolus– Insertion of Peroneal Tendon is at the

base of the 5th foot bone

• Major Motion:Eversion of the Foot @ the Ankle

ANKLE MUSCLES: POSTERIOR

• GASTROCNEMIUS– Muscle starts on distal femur– 1 muscle with two points of origin– Achilles Tendon is other attachment– Crosses two joints

Major Motion:Plantarflexion @ the Ankle

•ACHILLES TENDON Large Tendon/Cord from Gastroc.

Inserts firmly at Calcaneus Largest, Strongest Tendon in Body Combination of Gastroc and Soleus Tendons

Compartments of the Leg1. Anterior

2. Lateral (peroneal)

3. Deep posterior

4. Superficial posterior

Anterior Compartment Musculature

• Tibialis anterior• Extensor digitorum

longus• Extensor hallucis

longus• Peroneus tertius

Tibialis Anterior

• DF and inversion• O: lateral tibial condyle

and shaft• I: medial/plantar 1st

cuneiform and metatarsal• N: deep peroneal

Extensor Digitorum

Longus• Extension of 2nd-5th MP joints,

assists with eversion and DF

• O: lateral tibial condyle, proximal ¾ of anterior fibula

• I: via 4 tendons into distal phalanges of 2nd-5th toes

• N: deep peroneal

Extensor Hallucis Longus

• Extension of 1st MP and IP joints

• O: middle 2/3 of anterior fibula

• I: base of distal 1st phalanx• N: deep peroneal

Peroneus Tertius

• Eversion of foot, assists in PF

• O: distal 1/3 of anterior fibula

• I: dorsal base of 5th metatarsal

• N: deep peroneal

Lateral Compartment Musculature

• Peroneus longus• Peroneus brevis

Peroneus Longus

• Eversion of the foot, assists with PF

• O: lateral tibial condyle, fibular head, upper 2/3 of lateral fibula

• I: lateral base of 1st metatarsal, lateral and dorsal aspect of 1st cuneiform

• N: superficial peroneal

Peroneus Brevis

• Eversion of the foot, assists with PF

• O: distal 2/3 of lateral fibula

• I: styloid process at base of 5th metatarsal

• N: superficial peroneal

Superficial Posterior Compartment Muscles

• Gastrocnemius• Soleus• Plantaris

Gastrocnemius

• Ankle PF, assists knee flexion• O: medial head – posterior

medial femoral condyle, lateral head – posterior lateral femoral condyle

• I: calcaneus via Achilles tendon

• N: tibial

Soleus• Ankle PF• O: posterior fibular head, upper 1/3

of posterior fibular, soleal line on posterior tibial shaft, middle 1/3 of medial tibial border

• I: calcaneus via Achilles tendon• N: tibial

Plantaris• Ankle PF, assists knee

flexion

• O: distal supracondylar line of lateral femoral condyle, femoral popliteal surface

• I: calcaneus via Achilles tendon

• N: tibial

Deep Posterior Compartment Musculature

• “Tom, Dick, AND Harry”• Tibialis posterior

•Flexor Hallucis Longus •Flexor Digitorum Longus

Tibialis Posterior

• Inversion of the foot, assists with PF

• O: posterior/lateral tibia, upper 2/3 of medial fibula

• I: navicular tuberosity, via slips into sustentaculum tali, cuneiforms, cuboid and bases of 2nd-4th metatarsals

• N: tibial

Flexor Digitorum

Longus

• Flexion of 2nd-5th PIP/DIP/MP joints, assists with foot inversion and PF

• O: posterior medial 2/3 of distal tibia

• I: plantar surface of base of 2nd-5th distal phalanges

• N: tibial

Flexor Hallucis Longus

• Flexion of 1st IP joint, assists with flexion of 1st MP joint, foot inversion and PF

• O: posterior/distal 2/3 of fibula• I: plantar surface of 1st proximal

phalanx• N: tibial

Interosseous membrane (Syndesmosis) isn't a compartment but ligamentous sheathe that holds the tibia and the fibula together.

Syndesmosis

Nerves and Blood Vessels• Nerves:

– Peroneal N.– Tibialis Anterior/ Posterior N.– Saphenous N.

• Blood Vessels– Dorsal Pedal A.– Posterior Tibial A.– Greater/ Lesser Saphenous V.

Neuroanatomy• Anterior compartment

– Deep branch of Peroneal nerve• Lateral compartment

– Superficial branch of Peroneal nerve• Deep posterior compartment

– Tibial nerve• Superficial posterior compartment

– Tibial nerve

Deep Branch of Peroneal

Nerve• Branches from

common Peroneal nerve near fibular head

• “Dives” into anterior compartment

Superficial Branch of Peroneal Nerve

• Branches from common Peroneal nerve near fibular head

• Stays superficial and lateral in lateral compartment

Tibial Nerve• Runs in fascial

sheath between deep and superficial posterior compartments

• Provides innervation to both, but not “in” either

Vascular Anatomy

• Anterior compartment– Anterior tibial artery

• Lateral compartment– Peroneal artery

• Deep posterior compartment– Posterior tibial artery

• Superficial posterior compartment– Posterior tibial artery

Anterior Tibial Artery

• Traverses similar path to deep Peroneal nerve

• Terminating as dorsal pedal artery

Peroneal

Artery• Branches off of

posterior tibial artery

Posterior Tibial Artery

• Runs in fascial sheath between deep and superficial posterior compartments

• Provides vascular supply to both, but not “in” either

Special TestsThe Squeeze Test

• Squeeze test – check malleolus – Check tibia and fibula– May indicate FX

• Feel for any abnormalities• Feeling for grinding or

movement

Anterior drawer tests should always be performed with the knee bent to eliminate the Achilles and Gastrocnemius muscles from providing any stability to the ankle.

A lateral talar tilt test can be conducted at the same time.

Special TestsAnterior Drawer/Tilt

Anterior Drawer Test

Tilt Test

Special TestsFunctional Tests

• Functional tests(Return to play)

a) walking - check gait

b) toe raises

1) both feet

2) one foot

c) jump and land on both feet and then on one foot