Emerg Med J 26:193-200 doi:10.1136/emj.2008.070508
  • Soft tissue injuries series

Soft tissue injury commissioned series: 6 Lower leg, ankle and foot

  1. A Smith1,
  2. J Sloan2,
  3. A Wass1,
  4. S Draycott3
  1. 1
    Pinderfields Hospital, Wakefield, UK
  2. 2
    Countess of Chester Hospital, Chester, UK
  3. 3
    Leeds General Infirmary, Leeds, UK
  1. Dr J Sloan, Countess of Chester NHS Foundation Trust, Liverpool Road, Chester CH2 1UL, UK; drjohnsloan{at}
  • Accepted 11 December 2008

This sixth paper in the soft tissue series deals with common injuries to the lower leg, together with assessment, imaging and therapy considerations. We have divided the lower leg into five areas, ie, shin, Achilles, calf, ankle and foot. For each section we have used a patient-centred approach with treatment regimes and relevant physiotherapy comments.

The lower leg is subject to much greater forces than most of the body as it bears all of its weight. Often this is carried through one limb and is accompanied by rotational forces and lateral tilting due to uneven surfaces. Extremely rapid responses to proprioceptive stimuli are absolutely key to protection from injury. This, and other aspects of biomechanics, are covered more fully in the second paper in this series.1

Anatomically, the foot and ankle are relatively complicated. The novice should concentrate on naming key structures and understanding their interrelationship. See fig 1 and fig 2.

Figure 1 Posteromedial aspect of the ankle.
Figure 2 Lateral aspect of the ankle.


A good history is essential for the correct diagnosis, especially the relationship of symptoms to activity. An injury such as overuse tendinopathy typically results in a gradual development of symptoms, with pain and stiffness first thing in the morning. The pain is eased with walking and the application of heat. Partial tears of tendons result in a more sudden onset of disabling pain. Sudden, severe pain, with marked disability suggests a complete rupture. The patient may describe the feeling of being “shot” or struck on the back of the lower leg. A history of low back pain of variant nature may suggest referred pain. The possibility of deep vein thrombosis, vascular insufficiency and neuropathy are worthy of consideration.

Examination should follow the classic approach of look, feel and move. However, there are some additional considerations. Movements should include active, passive and resisted movements. Muscle stretching can …

Free sample
This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of EMJ.
View free sample issue >>

Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.


Among patients with minor TBI (GCS 13-15) getting CT scans ≥ 24 hours after injury, what proportion have a traumatic finding?


0.5% - 43% response rate
3% - 41% response rate
10% - 16% response rate

Related original article: PCT head imaging in patients with head injury who present after 24 h of injury: a retrospective cohort study

Navigate This Article