Foot, Ankle, and Lower-Leg Injuries

1. Foot, Ankle, and Lower-Leg Injuries Chapter 15

2. Overview • Foot, ankle and lower leg support the weight and transfer force as a person walks and runs • Feet and lower legs work to maintain balance and adapt to various surgaces • Ankle injuries are one of the most common injuries in athletics

3. Anatomy • Bones & Joints • 28 bones in foot • Toes = phalanges • Numbered 1 through 5 • Great toe = #1 • Except for Great toe, each toe has 3 bones • Distal phalanx • Middle phalanx • Proximal phalanx • Joints referred to as interphalangeal joints

4. Anatomy • Bones and Joints • Seasmoids – bones or cartilage located within a tendon, especially at a joint • Ease muscular movement over a bony surface • Under the great toe • 2 small bones • Assist with flexion of the toe

5. Anatomy • Bones and Joints • Metatarsals • Long bones of foot • Numbered 1 through 5 • Joints between phalanges and the metatarsals are metatarsalphalangeal joints

6. Anatomy • Bones and Joints • Talus • Calcaneus = heel bone • Below talus • Achilles tendon attaches here • Ankle joint • Between talus and calcaneus of foot and the fibula and tivia of leg • Held together by ligaments

7. Anatomy • Bones and Joints • Tibia • Medial malleolus – end of tibia on medial side • Fibula • End of lateral side = lateral malleolus • Extends past the ankle joint and will stop severe eversion • These bones articulate at both the distal and proximal end • MM and ligaments between the bones hold the 2 bones together from one end to the other

8. Anatomy • Muscles of the Lower Leg • Tibialis anterior • Find and color green • Peroneus longus • Find and color red • Peroneus brevis • Find and color blue • Gastrocnemius • Find and color yellow • Soleus • Find and color orange • Plantaris • Find and color pink

9. Anatomy • Muscles of the Lower Leg • Tibialis posterior • Find and color brown

10. Anatomy • MM, cont’d • Control movement of foot and leg • Peroneal MM (longus and brevis) • Attach to lateral aspect of lower leg • Help stabilize the lateral aspect of ankle • Gastrocnemius and Soleus MM – share a common attachment known as the Achilles tendon • Gastrocnemius • Powerful • Allows athlete to propel him/herself when running

11. Anatomy • Arches of the foot • 3 arches on plantar surface (bottom) • Function as shock absorbers • Transverse arch 0 in front of heel and goes from 5th metatarsal to navicular • Longitudinal arch – runs from calcaneus to metatarsal heads • Metatarsal arch – runs along the metatarsal heads

12. Anatomy • Ligaments - Names given by attachment points • Strong • Lateral • Anterior talofibular • Posterior talofibular • Calcaneofibular ligaments • Hold bony structures together on lateral side, but not as strong as medial side • Medial • Deltoid ligament • Covers entire surface of medial side of ankle • Maintains stability, esp during eversion • Stronger than all lateral ligaments combined • Plantar surface

13. Evaluation Map • History • Ocation of the Pain • Nature or type of pain • Onset • MOI • Level of activity and conditioning regimen • History of injury

14. Evaluation Map • Inspection • General Inspection • Weight-bearing status • General bilateral comparison • Swelling • Lateral Structures • Peroneal muscle group • Distal one-third of the fibula • Lateral malleolus

15. Evaluation Map • Inspection • Anterior Structures • Appearance of the lower leg • Contous of the malleoli • Talus • Sinus tarsi • Medial Strucutres • Medial malleolus • Medial longitudinal arch

16. Evaluation Map • Inspection • Posterior structures • Gastrocnemius-soleus complex • Achilles tendon • Bursae • Calcaneus

17. Evaluation Map • Palpation • Lateral Structures • Fibular Shaft • Inerosseous membrane • Anterior and posterior tibiofibular ligament • Calcaneofibular ligament • Anterior talofibular ligament • Posterior talofibular ligament • Peroneal tubercle • Cuboid • Base of the 5th metatarsal • Peroneus longus and brevis • Peroneal retinaculum

18. Evaluation Map • Palpation • Anterior Structures • Anterior tivial shaft • Dome of the talus • Extensor retinacula • Sinus tarsi • Tibialis anterior • Lont toe extensors • Peroneus tertius

19. Evaluation Map • Palpation • Medial structures • Medial malleolus • Deltoid ligament • Sustentaculum tali • Spring ligament • Navicular and navicular tubercle • Talar head • Tibialis posterior • Long toe flexors

20. Evaluation Map • Posterior Structures • Gastrocnemius-soleus complex • Achilles tendon • Subtendinous calcaneal bursa • Subcutaneous calcaneal bursa • Dome of the calcaeus • Pulses • Posterior tivial artery • Dorsalis pedis artery

21. Evaluation Map • Range of Motion Tests • AROM • PF/DF • INV/EV • PROM • PF/DF • INV/EV

22. Evaluation Map • Range of Motion Tests • RROM • DF • PF • Gastrocnemius • Soleus • INV • EV

23. Evaluation Map • Ligamentous Tests • Anterior Talofibular Ligament instability • Anterior drawer test • Calcaneofibular Ligament instability • Inversion stress test (talor tilt) • Ankle Syndesmosis Instability • Kleiger’s test • Squeeze test • Deltoid Ligament Instability • Eversion stress test (talor tilt) • External rotation test

24. Evaluation Map • Neurologic Tests • Special tests • Lower Leg Fractures • Squeeze test • Stress fracture • Bump test • Achilles Tendon Pathology • Thompson’s test

25. Preventing Foot, Ankle and Lower Leg Injuries • Shoes • Ankle and arch support • Supportive taping • Shin guards • Strength and Conditioning • Proper conditioning can prevent stress • Stretching

26. Treating Lower Leg Injuries & Conditions • Ligament Injuries • Sprain = stretching or tearing of ligaments • Usually occurs as a result of trauma to a joint that is forced to an extreme of its ROM • Most common in this region: • Great toe • Arch • Lateral ankle joint • Medial ankle joint

27. Treating Lower Leg Injuries & Conditions • Great toe sprain • Great toe • Aids the athlete in… • Kicking ball • Pushes off when walking or running • Maintains balance • Sprains • When excessive force is applied to the great toe (i.e. flexion or extension)

28. Treating Lower Leg Injuries & Conditions • Great toe sprain • S & S • Pain • Swelling • Discoloration • Inability to walk or run normally • Treatment • Rest • Ice • Compression • Elevation

29. Treating Lower Leg Injuries & Conditions • Arch Sprain (Transverse and Longitudinal) • Causes • Running on a hard surface • Improper footwear • Repetitive stress • S & S • Swelling • Possible discoloration over the plantar surface • Treatment • PRICE • Arch pad – relieve pain, because the foot flattens somewhat during walking or running • Exercise the arch by exercising the muscles of the foot and by stretching the Achilles tendon

30. Treating Lower Leg Injuries & Conditions • Lateral and Medial Ankle Sprains • 85% of ankle sprain are cause by excessive inversion • 15% are cause by excessive eversion • Deltoid ligament is strong compared to lateral ligaments • Fibula prevents severe eversion

31. Treating Lower Leg Injuries & Conditions • Inversion Ankle Sprain • Lateral ligaments are injured • Severity depends on… • Amount of force • Amount of taping • Type of shoe • Strength of MM • Eversion Ankle Sprain • Deltoid ligament will be injured • Often a fx associated with this kind of sprain

32. Treating Lower Leg Injuries & Conditions • Ankle Sprains • The ankle must be evaluated to determine severity • Therefore… • Shoe has to be removed • Sock must be cut off or removed by athlete

33. Treating Lower Leg Injuries & Conditions • Ankle Sprains • S & S • Swelling • Discoloration • IF decreased ROM – treat w/ PRICE • IF no decreased ROM or strength– athlete may play with tape or brace • Referral to MD if… • Crepitus • Rapid swelling • Bony deformity

34. Treating Lower Leg Injuries & Conditions • Ankle Dislocations • Anterior • Heel of foot strikes the ground forcefully • Posterior • Blow to the anterior aspect of the leg while the ankle is plantar flexed • S & S • Obvious pain • Athlete will likely refuse to move or allow touching of the foot

35. Treating Lower Leg Injuries & Conditions • Ankle Dislocations • S & S cont’d • Deformity • Inability to use foot • Rapid swelling • Treating • Act quickly • 911 • Splint • Ice • Remove from field

36. Treating Lower Leg Injuries & Conditions • Ankle Dislocations • Damage done to • Ligaments • Possible damage to • Nerves • Blood vessels

37. Treating Lower Leg Injuries & Conditions • Achilles Tendinitis • Achilles tendon • Strong tendon • Common attachment of gastrocnemius and soleus muscles into the calcaneus • Running, jumping, and landing can cause cells to break down; this irritation or inflammation is referred to as tendinitis

38. Treating Lower Leg Injuries & Conditions • Achilles tendinitis • S & S • Swelling • Tenderness • Crepitus • Expression of pain with palpation • Weak in resisted PF • Treatment • CP • Referral to MD if necessary for Rx • Gentle stretching • Strengthening

39. Treating Lower Leg Injuries & Conditions • Achilles tendinitis cont’d • Noncompliance or return to play too soon can cause thickening in the Achilles tendon • Limits ROM • Decreases running and jumping ability • May feel crepitus over tendon • Can cause rupture if severe

40. Treating Lower Leg Injuries & Conditions • Achilles tendon rupture • Causes • Forced DF of foot • Blow over Achilles tendon • Sudden forceful contraction of gastrocnemius muscle

41. Treating Lower Leg Injuries & Conditions • Achilles tendon rupture • S & S • Pt feels like he/she was shot in back of leg • Pt will feel tearing • Difficulty walking • Weakness or complete loss of PF will be noticed • Swelling • Obvious depression where Achilles tendon used to attach

42. Treating Lower Leg Injuries & Conditions • Achilles tendon rupture • Treatment • Splint • Ice • Referral to MD • Repaired surgically

43. Treating Lower Leg Injuries & Conditions • Fifth-Metatarsal Avulsion Fx (Jones Fracture) • Cause • Ankle is forced into inversion, MM contract so forcefully to stabilize the lateral aspect of the ankle that the peroneus brevis tendon pulls part of the bone away at its attachment • Treatment • PRICE • Refer to MD • Cast • Sometimes surgery

44. Treating Lower Leg Injuries & Conditions • Epiphyseal Injury of Distal Tibia and Fibula • Cause • Ankle forced into PF and INV • S & S • Pain • Swelling • Difficulty running or walking • Treatment • Splint • Refer to MD

45. Treating Lower Leg Injuries & Conditions • Stress fxs • Most common sites • Tibia • Fibula • Metatarsals • Causes • Repetitive stress • S & S • Pain • Swelling

46. Treating Lower Leg Injuries & Conditions • Stress fxs, cont’d • Diagnosis • X-rays won’t reveal stress fx for approximately 2 weeks • MRI/Bone Scans • Treatment • Rarely casted, sometimes a boot • Crutches used • Decreased activity • Complications • If not taken care of properly, can become a complete fx

47. Treating Lower Leg Injuries & Conditions • Shinsplints, or Medial Tibial Stress Syndrome • Pain in lower leg • M fibers on the medial side of the tibia become torn and irritated • S & S • Pain over distal, medial side of tibia • Swelling over medial AND lateral side as well

48. Treating Lower Leg Injuries & Conditions • Shinsplints, or Medial Tibial Stress Syndrome • Causes • Tight calf MM • Older shoes • Poor conditioning for the running an athlete is currently doing • Treatment • PRICE • IF limp present • Stop activity/change training to biking • Taping • Stretching • New Shoes • Arch Support

49. Treating Lower Leg Injuries & Conditions • Anterior Compartment Syndrome • MM to the anterior aspect of the tibia are enclosed in connective tissue • If the tissue in the compartment swells, it increases pressure on the connective tissue • Causes • Severe impact • Overuse

50. Treating Lower Leg Injuries & Conditions • Anterior Compartment Syndrome • S & S • Severe pain that increases with activity and doesn’t subside when there is no activity or a period of rest* • Hot, red skin • Loss of foot motion* • Hardness of the area • Treatment • Immediate referral to MD • Prevent N damage – incision made to relieve pressure