CASE 10 A 42-year-old man is brought to the emergency room complaining of intense pain in his left calf and ankle.

He had entered a tennis tournament with his 15-year-old son and states that, as he lunged after a hard-hit serve, he heard a snap, fell to the court in tremendous pain, and could not walk. On examination, the left calf is tender and indurated, with an irregular mass noted in the back of the midcalf area. What is the most likely diagnosis? What type of excessive abnormal ankle movement would be present? ANSWERS TO CASE 10: ACHILLES TENDONRUPTURE Summary: A 42-year-old man heard a snap while playing tennis and experienced left calf pain after lunging for a ball. The left calf is tender and indurated and has a lump. Most likely diagnosis: Achilles tendon rupture Likely abnormal ankle movement present: Dorsiflexion CLINICAL CORRELATION The gastrocnemius and soleus muscles form a three-headed muscle group (triceps surae) that unite to form a single tendon, the calcaneal or Achilles tendon, which inserts into the calcaneus bone. These muscles produce plantar flexion of the foot at the ankle and limit dorsiflexion. Running or quick-start athletic activity, such as described in this case, may lead to strain or rupture of the tendon. The snap heard by this patient is fairly common in calcaneal tendon avulsion. The mass noted in the left calf is due to foreshortening of the triceps surae. Compared with the opposite side, the affected foot will have greater range of motion in dorsiflexion and loss of plantar flexion. Treatment is usually surgical repair of the tendon. Due to the limited blood supply to this tendon, a long immobilization is typically required. Postoperative physical therapy to prevent tendon contracture is critical. APPROACH TO THE ANKLE JOINT Objectives 1. Be able to describe the anatomy of the ankle joint. 2. Be able to describe the muscles that cross the ankle joint, the movements they produce, and the ligaments that limit these movements. Definitions Indurated: Process in which usually soft tissue becomes extremely hard. Strain: Injury that results from overuse or inappropriate use. Avulsion: Violent separation or tearing away.

DISCUSSION Movements of the foot at the ankle occur at two joints: the ankle joint proper or talocrural joint, which is formed by the distal ends or malleoli of the fibula and tibia, and the trochlea of the talus bone. A mortiseshaped joint is formed at which the hinged movements of dorsi- and plantarflexion occur. The ankle

joint is more stable in dorsiflexion because the anterior aspect of the trochlea is tightly wedged between the lateral and medial malleoli. The movements of inversion and eversion of the foot occur primarily at the subtalar joint (between the talus and calcaneus bones), but also at the transverse tarsal joint with articulation of the talus and calcaneus bones with the navicular and cuboid bones (Figures 10-1 and 10-2).

The capsule of the ankle joint is thin anteriorly and posteriorly, but ligaments reinforce the capsule laterally and medially to provide much of the stability. A relatively weak lateral ligament is formed by three individual ligaments, all of which attach to the lateral malleolus of the fibula: anterior and posterior talofibular ligaments and calcaneofibular ligaments. The lateral ligament limits excessive inversion. The medial (deltoid) ligament is a very strong ligament composed of four individual ligaments that attach to the tibia tibionavicular, anterior and posterior tibiotalar, and tibiocalcaneal ligaments. The medial ligament limits eversion. The muscles that produce dorsiflexion at the ankle are located in the anterior compartment of the leg, whereas the muscles that cause plantar flexion and eversion are located in the posterior and lateral compartments, respectively. The muscles that produce movements of the foot at the ankle are listed in Table 10-1. COMPREHENSION QUESTIONS [10.1] When will a patient s ankle joint have the greatest stability? A. When the knee is flexed B. When the foot is dorsiflexed C. When the foot is plantarflexed D. When the foot is everted E. When the foot is inverted [10.2] You are concerned that your patient s medial deltoid ligament may have been torn from its proximal attachment. Which of the following would you palpate for tenderness? A. The medial aspect of the tibial shaft B. The lateral aspect of the fibular shaft C. The lateral malleolus D. The medial malleolus E. The calcaneus [10.3] Your female patient is unable to walk on her tiptoes. You immediately suspect damage to which of the following nerves?

A. Sural nerve B. Tibial nerve C. Common fibular nerve D. Superficial fibular nerve E. Deep fibular nerve Answers [10.1] B. The talocrural or ankle joint proper has the greatest stability in dorsiflexion. [10.2] D. The four components of the deltoid ligament arise from the medial malleolus. [10.3] B. Plantarflexion of the foot at the ankle is produced by the muscles in the calf, which are innervated by the tibial nerve. ANATOMY PEARLS Dorsiflexion and plantarflexion occur at the ankle joint proper, whereas inversion and eversion occur primarily at the subtalar joint. A patient with a lesion of the tibial nerve above the knee would be unable to stand on tiptoes (plantarflex the foot at the ankle). A patient with foot drop and inability to evert the foot (walk on the instep) has a lesion of the common fibular nerve (which is at risk as it passes around the neck of the fibula).

Toy, E.C., et. al. (2008). Case Files Anatomy (2nd Ed.). Lange