Training Of The Lower Leg Muscles

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Injuries to the lower leg or immobilisation of the ankle joint often lead to atrophy of the lower leg muscles and reduced power output in ankle plantar flexion with straight knee (m gastrocnemius) and with flexed knee (m soleus, m tibialis posterior, m flexor hallucis longus, m flexor digitorum longus) and in dorsi-flexion (m tibialis anterior and m extensor digitorum). The lower leg muscles are of vital importance for activities like jumping, running on hard surfaces and most ball sports. Strength training of the calf muscles can be performed with toe raises in standing or sitting positions, with both straight and flexed knees.

Muscle endurance can be trained by cycling with the pedal under the forefoot, with a high saddle (m gastrocnemius), with a low saddle (m soleus and other deep flexors), with a step machine, on a treadmill or in a cross-trainer.

Fig. 17 Toe raises with straight knee predominantly train the gastrocnemius muscles

Fig. 18 Toe raises with flexed knee predominantly train the deep plantar flexors and the soleus muscle

Fig. 19 Stretching of the calf muscles does not require specific equipment (straight knee for gastrocnemius, flexed knee for soleus muscle)

Fig. 20 A simple step-up test can be valuable for testing endurance, strength and function z <

Fig. 21 A stationary bike is an essential tool in all rehabilitation

Flexibility can be achieved by stretching of the calf muscles and is performed standing, with a flexed knee for m soleus and other deep flexors or a straight knee for m gastrocnemius.

Proprioceptive training can be done with classical ballet training at a barre or by using a more demanding standing surface, such as a wobble board. This training is essential, as different parts of the Achilles tendon and the calf muscles are being trained during different parts of the ankle movement.

Functional training of the calf muscle should be done individually depending on the patient's needs.

The figures below show the anatomical appearances of the ankle from different angles, with arrows indicating the locations of symptoms of the injuries.

This chapter deals with some of the more common ankle injuries but it should be stressed that there are a number of other injuries that require specialist advice from a foot surgeon or podiatrist.

Multi-Ligament ruptures of the ankle

Multi-Ligament ruptures of the ankle

Syndesmosis ligament Cartilage rupture injury of the talus dome

Syndesmosis ligament Cartilage rupture injury of the talus dome

Tibialis posterior syndrome

Tarsal tunnel syndrome

Fig. 23

Tibialis posterior syndrome

Tarsal tunnel syndrome

Fig. 22

Fig. 23

Anterior impingement syndrome

Anterior impingement syndrome

Posterior impingement of the ankle

Peroneus tendon dislocation

Lateral ankle ligament ruptures

Posterior impingement of the ankle

Fig. 24

Lateral ankle ligament ruptures

Peroneus tendon dislocation

Peroneus tendon rupture

1. ANTERIOR IMPINGEMENT SYNDROME

Fig. 25 View of the talocrural joint where synovitis causes anterior impingement and pain

SYMPTOMS There is a gradually increasing stiffness of the ankle and exercise-induced pain around the anterior part of the ankle joint, often after previous sprain.

AETIOLOGY Impingement syndrome is not a diagnosis but a symptom and may be caused by repetitive trauma to the anterior ankle joint, for example from striking footballs, recurrent sprains causing fibrosis or chondral damage, or be secondary to a chondral injury to the talus dome or caused by loose bodies. Several underlying pathoanatomical factors can cause impingement, including loose bodies, fibrosis, chondral flap tears, synovitis and impinging soft tissue flaps.

CLINICAL FINDINGS There is effusion and localised tenderness on palpation over the anterior talus dome during forced dorsi-flexion while compressing the extensor tendons and capsule. This is the 'anterior impingement test'. INVESTIGATIONS X-ray can show intra-articular loose bodies or osteophytes. MRI may show sub-chondral oedema of the talus and effusion. Clinical findings and

Fig. 26 Pain on forced dorsiflexion while compressing the anterior compartment of the ankle is a positive anterior impingement test patient history are more important for clinical decisions. MRI often misses superficial cartilage injuries. TREATMENT NSAID can give short-term relief, as can intra-articular cortisone injections. If there are persistent or severe symptoms, arthroscopy with debriding and excision of impinged structures is recommended and curative. REFERRALS Refer to orthopaedic ankle surgeon for consideration of arthroscopy. EXERCISE PRESCRIPTION Rest will not help so allow all kinds of sporting activities using well-fitting shoes. If there is pain on impact suggest low-impact activities such as cycling and swimming. EVALUATION OF TREATMENT OUTCOMES Monitor decrease of clinical symptoms and signs. The anterior impingement test should be negative. DIFFERENTIAL DIAGNOSES As mentioned above, several underlying problems can cause impingement, including loose bodies, fibrosis, chondral flap tears, synovitis or impinging soft tissue flaps. PROGNOSIS Excellent if treated properly.

Fig. 27 Full-thickness cartilage flap tear of the talus dome, as seen by arthroscopy

SYMPTOMS The patient presents with stiffness, diffuse exercise-induced aching or occasional sharp pain, clicking, locking and effusion of the ankle joint, most often after a severe previous sprain or recurrent instability.

AETIOLOGY The aetiology is direct or indirect trauma to the talus dome cartilage, often occurring in contact sports like soccer and rugby. This is the most common cause for ankle pain persisting for more than three weeks after an ankle sprain. CLINICAL FINDINGS There is effusion and tenderness on palpation over the talus dome. Plantar flexion provides better access to the dome. Sometimes the anterior impingement test is positive. Occasionally there is combined pain and instability of the ankle joint after a previous sprain that makes the diagnosis difficult. Instability from insufficient lateral ligaments seldom causes pain, however when the syndesmosis ligament is damaged pain can be the predominant symptom.

Fig. 28 MRI often under-represents or does not reveal superficial cartilage tears of the ankle but sub-chondral oedema and cystic formations (as above) should raise this suspicion

INVESTIGATIONS X-ray is often normal. MRI may show sub-chondral oedema and effusion in the joint but cartilage injuries are often missed on MRI. When there is a bony component (osteochondral injury) MRI often underestimates the extent of the injury.

Nurse Labor And Delivery Room

Fig. 29 Arthroscopy of the ankle can be done as an outpatient procedure and is very useful in diagnosing and treating inter-articular ankle injuries

Fig. 29 Arthroscopy of the ankle can be done as an outpatient procedure and is very useful in diagnosing and treating inter-articular ankle injuries

2. CARTILAGE INJURY OF THE TALUS DOME Cont.

TREATMENT NSAID can give short-term relief but arthroscopy is usually indicated and curative. Loose bodies are excised, cartilage defects are trimmed and underlying bone is sometimes micro-fractured. Direct weight bearing is usually allowed. REFERRALS Refer to podiatrist and physiotherapist for mild symptoms and to orthopaedic ankle surgeon if symptoms are severe or when there is persistent pain, effusion and the above signs more than one month after a severe ankle sprain. EXERCISE PRESCRIPTION Rest will not help so allow all kinds of sporting activities using well-fitting shoes and avoiding impact. If there is pain on impact suggest low-impact activities such as cycling and swimming.

EVALUATION OF TREATMENT OUTCOMES

Monitor decrease of clinical symptoms and signs. DIFFERENTIAL DIAGNOSES OCD, which has a typical appearance on MRI but is treated in the same manner, with arthroscopy.

Fig. 30 MRI showing a typical OCD of the medial talus dome which usually requires surgery

PROGNOSIS Excellent-Good. Osteoarthritis of the ankle joint after mild to moderate cartilage injuries is rare.

SYMPTOMS The patient refers to a sudden sharp tearing pain around the lateral aspect of the ankle joint after an acute inversion sprain or, on occasions, of recurrent instability after previous sprains.

not required for the diagnosis, but rather to rule out associated injuries to other major structures. TREATMENT After an acute sprain rest, ice, compression, elevation (RICE) is advocated. Early proprio-

Anterior Talofibular Ligament Tear
Fig. 31 Anterior view of the ankle, illustrating the anterior talofibular ligament (ATFL)

AETIOLOGY The anterior talo-fibular (ATF) and fibulo-calcanear (FC) ligaments are the most commonly damaged structures in uncomplicated inversion-plantar flexion ankle sprain. Most of these ruptures heal well within three months but recurrent instability develops in around 20 per cent of cases. CLINICAL FINDINGS After an acute episode there is tenderness on palpation over the lateral ligaments, localised bruising or swelling and/or haemarthrosis/ effusion of the joint if both ligaments rupture. Positive anterior drawer (ATF) and talar tilt (FC) tests are typical for these two ligament ruptures. INVESTIGATIONS X-ray is often normal but should be taken to rule out fractures, in particular in growing athletes with open growth plates and in elderly athletes when osteoporosis is suspected. MRI may show localised oedema over the lateral ligaments though is

Fig. 32 Anterior drawer test (ATFL rupture); tibia is fixed with one hand, the other hand grips as shown and pulls the foot anteriorly. If there is increased laxity and no distinct endpoint the test is positive

Fig. 33 Talar tilt test (FC rupture); tibia is fixed with one hand. The foot is tilted and translated medially with the other hand. If there is increased laxity and no distinct endpoint the test is positive. Compare with the other ankle

3. LATERAL ANKLE LIGAMENT RUPTURES Cont.

ceptive training and weight-bearing exercises are often recommended. Rehabilitation is usually curative and the athlete can resume sport within two to three weeks, occasionally using a brace or strapping during the first 12 weeks. If there is persistent pain or effusion after three weeks, suspect associated injuries to cartilage or other structures. Reconsider the pathoanatomical diagnosis. REFERRALS Refer to physiotherapist for mild symptoms and to orthopaedic surgeon if there is severe pain or effusion persists for more than three weeks.

EXERCISE PRESCRIPTION Rest will not help so allow all kinds of non-impact sporting activities using well-fitting shoes. During the convalescence and early return to sport an ankle brace or strapping may be used. Suggest low-impact activities such as cycling and swimming.

EVALUATION OF TREATMENT OUTCOMES

Monitor decrease of clinical symptoms and signs. Anterior drawer and talar tilt tests should be negative. However it is important to differentiate joint laxity from joint instability. Thus, these two tests may well reflect increased laxity, while the player does not experience subjective or functional instability. Compare with the non-injured side. There are different functional tests for ankle stability for different kinds of sports.

Fig. 34 Strapping the ankle is very useful in the early period after returning to play, to avoid re-injury, but it cannot replace proper training

DIFFERENTIAL DIAGNOSES Syndesmosis ligament tear (positive syndesmosis test); intra-articular cartilage injuries (pain and effusion); dislocation or longitudinal tear of the peroneus tendons (positive peroneus test); MT V fracture (localised pain on palpation); infection (increased temperature); tumour (X-ray); inflammatory diseases (gout, rheumatoid arthritis, systemic diseases etc). PROGNOSIS Usually excellent or good. More than 80 per cent of these injuries fully heal within a few weeks. Of the 20 per cent remaining, some may require surgery, but it is unlikely any will lead to long-term sequelae.

SYMPTOMS Almost immediate effusion/ haemarthrosis after severe inversion or eversion or hyper-extension/flexion sprain, sometimes complicated by direct impact from a block tackle, which is common in contact sports.

Fig. 35 Ankle bruising like this after a spain indicates a severe ligament injury or fracture, and also shows that acute compression and ice have not been applied

AEATIOLOGY This injury may cause ruptures of anterior talo-fibular and fibulo-calcanear ligaments in combination with deltoid or syndesmosis ligament ruptures or posterior capsule injuries with or without fracture of the ankle. CLINICAL FINDINGS In the acute phase there is haemarthrosis and or bruising if the capsule has torn. There is tenderness on palpation over the affected ligaments. There is often a combination of positive tests, such as positive anterior drawer and talar tilt tests, combined with positive reverse talar tilt and syndesmosis tests. Often gross multidirectional laxity can be identified. INVESTIGATIONS X-ray must be undertaken to rule out fracture but may be normal. MRI may miss

Talar Tilt Test
Fig. 36 If the calcaneus can be shifted laterally while fixating the lower leg, this indicates a deltoid ligament tear. This is a positive reverse talar tilt
Fig. 37 If a forceful dorsiflexion and eversion of the ankle causes pain over the anterior syndesmosis that is palpated, it indicates injury to this very important stabiliser

the ligament injuries in the initial phase, due to extra- and intra-articular bleeding. This injury must be investigated through the mechanism of injury, the forces involved and clinical signs. TREATMENT In the acute phase RICE, crutches and non-weight-bearing exercise should be advised until the extent of the injury is determined. Initial rehabilitation aims to control and reduce swelling to

4. MULTI-LIGAMENT RUPTURES OF THE ANKLE Cont.

Fig. 38 This is the clinical apperance of an acute ankle injury with haemarthrosis, caused by a severe deltoid ligament and syndesmosis ligament tear, but no fracture

allow a thorough examination of the joint. Early arthroscopy and examination under anaesthesia is sometimes indicated, with or without surgical stabilisation of the affected ligaments. The deltoid and lateral ligaments often heal without surgery and can be dealt with at a later stage if symptoms persist. These injuries can take the athletes out from sport for 12 to 26 weeks. Occasionally they may need bracing or strapping during the first weeks after the return to sport. These injuries are often combined with intra-articular cartilage injuries that increase the need for early surgical intervention.

REFERRALS Preferably refer to orthopaedic surgeon directly after injury for detailed investigations and treatment.

EXERCISE PRESCRIPTION Immobilisation of the ankle in a non-weight-bearing boot is indicated for a number of weeks, with or without stabilising surgery. Therefore exercise must maintain general fitness of the rest of the body, before specific training of the injured leg can be allowed. Core stability exercises must be done whenever weight bearing is allowed.

EVALUATION OF TREATMENT OUTCOME Monitor decrease of clinical symptoms and signs. Normal clinical laxity tests of the ankle should result. Full strength, RoM and proprioception, compared with other leg should be expected. Functional ankle scores and core stability must be tested at the end of an often long rehabilitation period before resuming full sport.

DIFFERENTIAL DIAGNOSES Extra-articular injuries such as dislocation of peroneus tendons or fracture. Clinical picture, X-ray and MRI will differentiate.

PROGNOSIS Good-Poor. This can be a career-threatening injury.

SYMPTOMS In the acute phase, there is sharp pain and swelling/bruising over the lateral, posterior part of the ankle and distal fibula, after previous sprain. The patient will have a sense of weakness and instability of the ankle and may recall one or two snapping sounds from the time of the injury. If there was one snap, it may be a tear. If there were two, dislocation and reposition of the tendon should be suspected. AETIOLOGY The peroneus brevis and/or longus can dislocate over the tip of the lateral malleoli from its groove during an inversion-plantar flexion ankle sprain. In the acute situation, a tear of the overlying retinaculum will cause sharp pain and a snapping sound and the tendons can rupture longitudinally while dislocating over the malleoli. The dislocation can be permanent but often the tendons reposition themselves spontaneously, which makes the diagnosis difficult. CLINICAL FINDINGS There is distinct tenderness on palpation posterior to the tip of the lateral malleoli over the peroneus retinaculum and localised bruising and swelling, sometimes effusion. Rarely, the dislocated tendon can be palpated on the lateral malleoli. INVESTIGATIONS X-ray is normal. MRI may show localised oedema and swelling over the lateral re-tinaculum or occasionally a tear in one of the tendons. Longitudinal tendon ruptures may be difficult to see unless there is a complete tear, which is very unusual in athletes. Ultrasound examination is very valuable, since a dynamic assessment is possible and subluxation can be provoked by plantar flexion-eversion. TREATMENT In the acute phase RICE is advocated. An athlete with a dislocated tendon can hardly walk. Early proprioceptive training and weight-bearing exercise is sometimes allowed. Rehabilitation is usually curative and the athlete can resume sport

Fig. 39 This photo demonstrates a dislocated peroneus tendon which has to be repositioned and surgically repaired

within two to three weeks, occasionally using a brace or strapping for the first six to twelve weeks. In professional athletes with high demands, surgery may be indicated, including inspection and treatment of ruptures and fixing of the retinaculum, since chronic subluxations can disable the athlete for a long time. Six to twelve weeks after surgery, the athlete can return to sport, using a brace. REFERRALS Refer to an orthopaedic ankle surgeon for early consideration of surgery or immobilisation preferably while the injury is acute or within two weeks.

EXERCISE PRESCRIPTION Rest will not help so allow all kinds of sporting activities using well-fitting shoes but avoiding impact, such as running and jumping.

EVALUATION OF TREATMENT OUTCOMES

Monitor decrease of clinical symptoms and signs. DIFFERENTIAL DIAGNOSES Syndesmosis ligament tear (positive syndesmosis test); MT V fracture (tenderness on palpation, positive X-ray; Fibula fracture (positive X-ray). PROGNOSIS Excellent-Good.

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  • Alvisio Pinto
    What does a torn syndesmosis ligament look like?
    4 months ago

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