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192 MUSCULOSKELETAL FACTORS IN LEG ULCERS
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emptying of the venous system, which can lead to venous hypertension and VLUs (Yang et al. 1999; Houghton etal. 2021). Optimal
movement of the ankle is also important for ecient ambulation. A
reduction in ankle movement is known to have an impact on knee
and hip function, which can lead to gait dysfunction and compromise the eciency of the lower limb VMPs (Simonsen 2014). Pain
can also cause a person to restrict movement of a joint and when this
occurs at the ankle it can result in an antalgic gait pattern. An antalgic gait pattern is dened as a way of walking that ooads or reduces
pain in an area of the body and can result in a limp or irregular walking pattern (Simonsen2014).
An example of the impact in the lower limb when an antalgic
gait is present is when a patient ooads a painful ulcer in the medial
ankle by lifting the heel during gait. This change in the position and
movement of the ankle results in a contracture of the calf muscle
complex, a change in the alignment of the ankle and subtalar joint
and reduced ankle joint ROM leading to an equinus foot position.
Over time, this equinus foot position can become rigid which can
cause malalignment at the knee, hip and pelvis. This has an impact
on the CMP and will restrict its ecacy due to the malalignment of
the foot and ankle.
The National Wound Care Strategy Programme (National Wound
Care Strategy 2023) recognises the importance of assessing ankle
joint mobility: ‘joint mobility, particularly that of the ankle, is an
important component of calf muscle pump function and should be
carefully recorded’ (National Wound Care Strategy2023). Therefore,
recognition of reduced ankle joint ROM and its impact on wound
healing and gait dysfunction is important within clinical practice, as
this loss can lead to complications and impaired wound healing
(Wounds2016).
LOWER LIMB VENO- MUSCULAR PUMPS
The underlying factors in the development of CVD and VLUs are
multifactorial (NWCSP2020). There are three important physiological factors that can exist in isolation or in any combination that can
lead to the development and longevity of CVD and VLUs (NICE2021).
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These are valvular insuciency, venous obstruction and CMP dysfunction (NICE2021).
Arterial blood ow is operated by the rhythmic pumping action
of the heart and through the elastic recoil of the arterial walls (Horwood2021).The venous system is subject to lower pressures compared
with, and is structurally dierent from, the arterial system within the
systemic circulation (Kan and Delis2001). Veins contain valves. The
venous bicuspid valves in the lower limb work through antegrade
pressure gradients, causing the opening and closure of the valves
when there is a reversal in the pressure gradient above and below the
valves moving blood ow proximally (Horwood2019). However, in
the presence of CVD these valves can fail. That coupled with the force
of gravity and the fact that humans are bipedal can inhibit venous
return. To overcome factors that inhibit venous return, the VMPs have
evolved in the lower limb and work to activate MSK pumps through
movement (Horwood 2019). These VMPs are vital in mitigating
increased venous pressure by aiding venous return when standing
upright and walking through a pumping action when moving, especially during walking (Padberg etal.2004; Williams etal.2014).
There are three VMPs located in the lower limb: one on the foot,
the calf muscle complex in the posterior lower leg and the posterior
thigh. These pumps, particularly the CMP, act as a peripheral heart
by mechanically generating venous return from the foot pump via
the CMP to the thigh pump during the cyclical, synchronised movements in the gait cycle (Ricci2020).
Foot Pump
The foot pump is located within the venous network of the plantar
and dorsal foot. There are ve venous systems located in the foot: the
supercial and deep veins on the plantar surface of the foot, the
supercial dorsal plexus, and the marginal and dorsal arch perforating systems (Ricci2020). The foot pump was considered historically
to be insignicant in the physiological return of blood proximally in
the lower limb and was theorised to work during weight- bearing only
(Gardner etal.1983). However, it is now theorised that the operation
of the foot pump depends on many factors, which include compliance
of the soft tissues surrounding the foot veins, the deep fascia, intrinsic
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muscle activity and ankle kinematics (motion) (Horwood 2019).
Therefore, ecient function of the foot pump also depends on intact
and fully functioning structures in the foot.
Calf Muscle Pump
The CMP can be divided into two anatomical locations (Ricci2020).
The leg pump is located in the veins of the soleus muscle and the
popliteal pump ends in the popliteal vein (Ricci2020). The medial
gastrocnemius veins have a distinct plexus (network of blood vessels)
of veins above the knee (Uhl and Gillot 2015; Ricci 2020). In the
lower leg the lateral veins of the soleus are larger than the medial
veins. These drain vertically into the peroneal veins. The medial
veins of the soleus are smaller and join the posterior tibial veins horizontally (Uhl and Gillot2015). At the popliteal level within the lower
limb, the medial gastrocnemius veins are the largest veins that end
uniquely as a large collector into the popliteal vein above the knee
joint. When walking, with each step muscular activity exerts pressure
on the venous system and there is a high- speed ejection within the
venous network that propels a powerful jet of venous blood into the
popliteal vein (Uhl and Gillot2015).
Thigh Pump
The most proximal pump within the lower limb is the thigh pump.
The semimembranosus muscles and the femoral vein work in tandem in this anatomical area to generate venous return during walking and movement (Uhl and Gillot2015).
Mechanism ofAction ofthe Veno- muscular Pumps
The VMPs are musculo- venous pumps that perform an important
role in venous return in the lower limb through a chain of events
that occurs through the activation of the muscles located in the
lower limb during walking (Uhl and Gillot2015). However, these
are not the only mechanisms through which pressure is generated
within the VMPs.
The muscle groups that make up the VMPs in the lower limb are
organised into myofascial compartments of the lower limb – for
example, the posterior compartment of the lower leg has a deep and
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supercial region, and the group of muscles is encased in a fascia
(Meissner 2005; Palastanga and Soames 2018). These myofascial
compartments are encased in connective fascial tissue, which further
helps increase pressures within the compartments and assists antegrade blood ow.
During gait or on joint movement, muscles within these compartments in the lower limb will eccentrically (lengthen) or concentrically (shorten) contract, and this tightens the fascial compartments
and associated connective tissues (Palastanga and Soames2018). The
net result is increased pressure on the venous system passing through
the muscle or the compartment of the leg (Horwood 2019). This
mechanism of action occurs regardless of the type of muscular contraction, whether this be eccentric or concentric contraction. These
mechanisms when working optimally result in unhampered venous
return (Horwood2019).
Calf Muscle Pump Dysfunction
Research suggests that CMP dysfunction is estimated to be present in
55% of people who have CVD (Williams etal.2014). Adequate venous
return is dependent on a patent, healthy venous system, optimal gait
and an operational CMP. The CMP is considered the ‘second heart’
and is a contributor to the cardiovascular system by enabling venous
return from the lower limb to the right atrium (Halkar etal.2020).
In understanding how CMP dysfunction can develop from a
mechanical aspect, it is important to understand the basic function
of the ankle joint.
In terms of its structure, the appearance of the ankle joint is
like that of a mortise and tenon and it is constructed at the distal
ends of the tibia and fibula with the superior aspect of the talus
(Palastanga and Soames2018). The ankle joint is a synovial hinge
joint. The ankle joint is classically considered to move around
asingle axis, within the sagittal plane, and the primary motion
in this plane is dorsiflexion and plantarflexion (Brockett and
Chapman2016). The ankle joint is a complex of the talocalcaneal
(subtalar), tibiotalar (talocrural) and transverse tarsal (talocalcaneonavicular) joints (Brockett and Chapman 2016). Although
dorsiflexion and plantarflexion are the primary movements, there
is also a smaller degree of movement in the transverse (adduction
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and abduction) and frontal planes (inversion and eversion) (Brockett
and Chapman2016; Palastanga and Soames2018).
It is the movements of dorsiexion and plantarexion that
occur at the ankle joint that inuence muscle activity and tissue
tension in the triceps surae (calf muscle) complex in the posterior
compartment of the lower leg. These movements trigger CMP activation (Horwood2021). Any alteration in dorsiexion and plantarexion clinically is of relevance and will have the greatest mechanical
impact on a patient’s gait and CMP function. The possible reasons
behind a reduction in ankle joint ROM or biomechanical alteration
are multifactorial and should be considered when taking a holistic
history.
ANKLE JOINT ASSESSMENT
The ankle joint is complex and forms the link between the interface
of the lower leg and the ground via the foot (Brockett and Chapman2016). It is crucial in the operation of the VMPs in the lower
limb. Its function is key not only as the simple machine that helps the
CMP to function, but also as an important joint that aids sagittal
plane (dorsiexion and plantarexion) movement in the lower limb,
allowing people to walk eciently and perform other activities of
daily life (Brockett and Chapman2016).
Given these factors and the impact of reduced ankle joint ROM,
which can contribute to the development and chronicity of VLUs,
it is vital that ankle joint mobility is assessed on a regular basis
(NWCSP2020). Ideally, when assessing if joint ROM is impaired, then
the joint under measurement should be compared to matched controls to determine if there is an impairment (Norkin and White2016).
However, when this is not possible the contralateral limb should be
used for comparison if it is not impaired (Norkin and White2016).
Assessing ankle joint ROM can be done in several ways using
quantitative and qualitative measures. There are several instruments
that are available to measure joint ROM that range from tape measures to manual and digital goniometers (Figure 4.2), inclinometers
and motion capture devices (Norkin and White2016).
A goniometer is a device that measures angles and allows the
rotation of an object to a dened position. It is still the most used,
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Musculoskeletal Factors in Leg Ulcers 197
(a) (b)
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FIGURE 4.2 (a) Universal and (b) digital goniometers.
economical, portable device for the evaluation of ROM (Nussbaumer
et al. 2010; Norkin and White 2016). Competency in goniometry
requires that the examiner is knowledgeable in the structure and
function of each joint measured and demands a specic skill set to
enable accurate results (Norkin and White2016). The use of a goniometer is not always common within nursing practice. Therefore,
when in- depth assessment of ankle joint ROM using the goniometer
is required, the patient should be referred to a therapist who can
accurately carry out these measurements.
One method of assessing ankle ROM is by looking at, feeling and
moving the joint. These skills would be within the clinical skill set
of nursing:
Look: Visually inspect the position of the ankle when the patient
is on the couch. Look at the alignment of the ankle and check if
there is any visual oedema around the ankle joint, as this can lead
to a restriction in ROM.
Feel: Palpate around the joint, as this enables the clinician to
determine the type of oedema present, and/or if there are any
unusual anatomical changes in the ankle joint or any bony
pathology, like osteoarthritis or any other anatomical variation.
Move: Moving the joint by way of dorsiexing and plantarexing
the foot will enable the clinician to determine if the ankle is rigid,
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semi- rigid, exible or hypermobile. Compare to the contralateral
side if this is not impaired to gain an awareness of the possible
impairment on the side being assessed.
HOLISTIC HISTORY TAKING RELATING TOFACTORS
THAT INFLUENCE BIOMECHANICAL LOWER
LIMB FUNCTION
Taking a thorough medical history that includes social and patientrelated factors like injuries is key to understanding a patient’s issues
and establishing information that may relate to their mobility
(Day 2015). The information gained in the history will guide the
practitioner in their physical examination and determine the relevant
clinical tests that may be required. Thorough history taking facilitates the collection of important information that will be relevant
when communicating with other practitioners involved in the care
of the patient or gathering information that will be required when
making a referral (Franks et al.2016). Knowledge of the medical
history that relates to lower limb function is vital, because it identies those patients with modiable biomechanical risk factors that
can result in CMP dysfunction or gait issues that can have an impact
on wound healing.
People with CVD and VLUs typically have a disproportionate
number of co- morbidities and may report lower levels of activity and
decreased mobility compared to the population. (Clarke- Moloney
et al. 2007). Many patients with VLUs may be physically deconditioned and have compromised core strength and lower limb weakness,
and may present with gait and biomechanical issues (Clarke- Moloney
etal.2007; Farrelly2018). Therefore, identifying the patient- related
factors and managing biomechanical- related issues is paramount for
optimising mobility and biomechanical function.
Immobility andImpaired Mobility History
Impaired and reduced mobility is a signicant issue that needs to be
explored during history taking, as impaired mobility will have a
deleterious impact on the lower limb in terms of the development
and progression of CVD. Impaired or reduced mobility can be due to
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several causes and these need to be established initially so that a
tailored management approach can be instigated.
Causes of immobility that are implicated in the development of
VLUs can include inammatory and nondiseases, peripheral arterial disease (PAD), neural disease and other
acquired or congenital MSK diseases, obesity, injury or secondary to
surgery or isolation (Davies etal.2017). Mobility impairments can be
the result of a dysfunction of joint ROM, especially of the ankle,
which can lead to reduced CMP function and venous backow within
the lower limb (Corley etal.2010; Ricci2020). Impaired mobility can
aect a person’s QoL and this can be amplied in people with CVD
(Meulendijks etal.2020b).
inammatory rheumatic
Co- morbidities andMedicines
There are numerous co- morbidities that aect mobility and movement
(Jordan and Osborne 2007). However, any co-morbidities that aect
the musculoskeletal system must be considered when taking history as
they may have a direct or indirect impact on the management of
patients with CVD and VLU’s. These co- morbidities can inuence the
course of management and be barriers to wound healing and optimal
mobility (Davies etal.2019). For example, rheumatoid arthritis (RA)
can cause joint arthropathy, pain and gait dysfunction (Hennessy
etal.2012). RA may be the major underlying factor causing a reduction of ankle joint ROM. The person may be having an inammatory
disease are and may need a medicines review to help control symptoms that can help improve joint ROM at the ankle, for example. Or a
patient with VLUs and Parkinson’s disease may have a festinating gait,
which is characterised by a stooped posture, a narrow base of gait, a
reduced stride length, shuing steps and a propensity to freeze when
approaching an object or doorway (Pirker and Katzenschlager2017).
This gait pattern will impair mobility, which will have an impact on
VMP activity and balance, and can predispose a person to falling. This
patient may need modication or review of their medication to help
with gait impairment and physiotherapy to assist with balance and
gait- related issues, or they may need a walking aid (Pirker and Katzenschlager2017). These issues in relation to co-morbidites that relate to
mobility should be identied as part of holistic assessmentin order to
help improve healing and mobility.
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Injury History
When exploring the area of the medical history that relates to identifying any possible biomechanical risk factors, it is important to ask
about any current injuries or prior injuries during the patient’s life.
An injury in childhood may not seem relevant to the patient in the
present, but this may have great relevance within the context of the
whole clinical picture. For example, an ankle sprain, previous sports
injury or fracture may be the catalyst for their current lower limb
issue, such as venous damage/disease and chronic oedema.
When asking about any injuries, it is important to document the
date, the location and the mechanism of the injury. For example, if it
was an ankle sprain gathering the information in Table4.2 in relation
to the injury is important.
Information gained in this area may also explain the reason
behind a person’s current level of activity, especially if it is reduced
or impaired.
Falls History
It is estimated that 30% of over 65s and 50% of the over 80s will fall
at least once a year (NICE2019). Falls and the injuries that result
from them can be signicant issues, especially for older people
(NICE2019). VLUs are estimated to aect 1in 500 people and become
TABLE 4.2
Area of the injury In what area did the injury occur?
Mechanism of injury How did the injury occur?
Medical treatment Did the patient seek medical help?
Rehabilitation What treatment was undertaken?
Outcome Has the injury resolved itself?
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Important questions toask about injury history.
Were any other areas aected because of the injury?
What movements occurred when the
injury occurred?
Was any medical imaging undertaken?
What was the recovery period?
rehabilitation?
Are there any residual issues?
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more ubiquitous with age (NICE2019). People with VLUs are known
to exhibit impaired muscle strength, reduced gait speed and impairments in joint ROM, and are known to be at greater risk of falling
(Humphreys etal.2016; de Souza etal.2022). Falls can be the result
of deconditioning, which is also a common biomechanical risk factor
for gait dysfunction in people with VLUs (Humphreys et al. 2016).
Falls account for 87% of fractures in the elderly and are estimated to
cost the NHS more than £2.3 billion annually. Fractures and the
immobility associated with falls can have impacts on mobility and
this will have a direct negative impact on the lower limb function in
terms of an increase in venous hypertension, CVD and VLUs. A history of falls can give clues to the practitioner about the possible
decline of mobility or the reason for reduced mobility. Where possible, conduct a mobility screen to gather pertinent information for
onward referral for specialist assessment to mitigate the risk of falls
and their impact on biomechanical function, gait and complications
in patients with VLUs.
Mechanisms ofFalling
Understanding why people fall and the mechanism of the fall is an
integral part of the inquiry. If a fall has been reported, this should
lead to evidenceetal.2013). Table4.3 describes some of the common intrinsic and
extrinsic reasons for falling.
based interventions for the patient (Ambrose
Surgical History
It is important to explore whether any surgical procedure may have
triggered an event for the development of CVD or VLUs. Asking
about surgery should not be limited to surgery relating to the lower
limb; it is important to establish all surgery that the patient has had
in their lifetime. For example, coronary bypass grafting (CABG) surgery may have involved the harvesting of the great saphenous vein in
the leg, and this could be the trigger for the development of CVD.
A triggering event like orthopedic surgery where post- surgical
rehabilitation was not optimal may be the underlying reason for the
development of CVD or VLUs. Research suggests that persistent
post- surgical symptoms can result in poor- quality rehabilitation and
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