Foot, Ankle, and Lower-Leg Injuries

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

2. Overview Ankle Injuries are one of the most common injuries in athletics

3. Overview • Foot, ankle and lower leg • Support weight • Transfer force as a person walks and runs • Maintain balance • Adapt to various surfaces

4. 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 • On Figure 16.1 and 16.2 Color the phalangespink • Joints referred to as interphalangeal joints • DIP, PIP

5. 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

6. Anatomy • Bones and Joints • Metatarsals • Long bones of foot • Numbered 1 through 5 • On figures 16.1 and 16.2 color the metatarsals purple • Joints between phalanges and the metatarsals are metatarsalphalangeal joints • On figure 16.1 circle the MTP joint label purple • On figure 16.2 label the MTP joint (write MTP), circle with purple and draw a purple arrow

7. Anatomy • Bones and Joints • Talus • Find the talus on figures 16.1 and 16.2, color it blue • Calcaneus = heel bone • Below talus • Achilles tendon attaches here • On figures 16.1 and 16.2 find the calcaneus and color it black • Ankle joint • Between talus and calcaneus of foot and the fibula and tibia of leg

8. Anatomy • Tibia • Major weight bearing bone of lower leg • Tibial condyles • Intercondylar eminence • Tibial tuberosity – attachment of quad • Medial Malleolus • Find the medial malleolus on your ankle • Fibular notch

9. Bones and Joints • Tibia • Articulations • Condyles of femur - proximally • Fibula -proximally and distally • Talus – inferior surface • M attachments • Hamstrings cross knee posteriorly

10. Anatomy • Fibula • End of lateral side = lateral malleolus • Find the lateral malleolus on your left ankle • Extends past the ankle joint and will stop severe eversion

11. Anatomy • Tibia and Fibula • 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

12. Anatomy • Bones of the foot, cont’d • Navicular • Find and color GREEN • Cuboid • Find and color ORANGE • Cuneiforms • Find and color RED • Other Pertinent Joints • Subtalor joint – articulation formed by the inferior surface of the talus and the superior surface of the calcaneus

13. Anatomy • Muscles of the Lower Leg • Items you need to know • Action – the movement(s) caused by the contraction of specific MM • Compartment –area of the body surrounded by fascia • Fascia – a tough, connective tissue • Origin – the attachment of the proximal end of M • Insertion – the attachment of the distal end of M • Review of Movement • Dorsiflexion – bending toward the dorsum or rear, pulling the foot toward the shin; opposite of plantarflexion • Plantarflexion – moving the foot toward the plantar surface; pushing the foot toward the floor; opposite of dorsiflexion • Inversion – to turn the foot inward; inner border of the foot lifts • Eversion – to turn the foot outward

14. Anatomy • Peroneus longus • Find and color RED • Action • Eversion • Assists with plantarflexion • Compartment • Lateral • Origin • Lateral fibula • Insertion • Base of the first metatarsal and medial cuneiform • Help stabilize the lateral aspect of ankle

15. Peroneus Longus

16. Peroneus Longus

17. Anatomy • Peroneus brevis • Find and color BLUE • Action • Eversion • Assists with plantarflexion • Compartment • Lateral • Origin • Fibula • Insertion • Lateral aspect of 5th metatarsal • Help stabilize the lateral aspect of ankle

18. Peroneus Brevis

19. Anatomy • Soleus • Find and color ORANGE • Action • Plantarflexion • Compartment • Posterior • Origin • Fibula and Tibia • Insertion • Calcaneus (via the Achilles tendon) • Shares the Achilles with the Gastrocnemius

20. Soleus

21. Anatomy • Gastrocnemius • Find and color YELLOW • Action • Plantarflexion • Assists with knee flexion • Compartment • Posterior • Origin • Femur • Insertion • Calcaneus (via the Achilles tendon) • Powerful • Allows athlete to propel him/herself when running

22. Gastrocnemius

23. Anatomy • Plantaris • Find and color PINK • Action • Ankle plantarflexion • Assist with knee flexion • Compartment • Posterior • Origin • Femur • Insertion • Calcaneus

24. Plantaris

25. Anatomy • Tibialis posterior • Find and color GREEN • Action • Inversion • Origin • Tibia and fibula • Insertion • Second cuneiform and the bases of the 2nd, 3rd, and 4th metatarsals.

26. Tibialis Posterior

27. Tibialis Anterior • Tibialis Anterior • Find and color PURPLE • Action • Dorsiflexion of ankle • Inversion • Compartment • Anterior • Origin • Tibia • Insertion • Medial cuneiform and base of 1st metatarsal

28. Tibialis Anterior

29. Anatomy • Arches of the foot • 3 arches on plantar surface (bottom) • Function as shock absorbers • Transverse arch - 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

30. Anatomy • Ligaments - Names given by attachment points • Strong • Lateral • Anterior talofibular (ATFL) –runs from talus to fibula (anteriorly) • Posterior talofibular (PTFL) – runs from talus to fibula (posteriorly) • Calcaneofibular ligaments (CFL) – runs from calcaneus to fibula • 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

31. 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

32. 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

33. Treating Lower Leg Injuries & Conditions • Great toe sprain • Great toe (halux) • 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) • Turf toe

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

35. 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

36. 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

37. 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

38. 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

39. Treating Lower Leg Injuries & Conditions • Ankle Sprains • S & S • 1st degree • Pain • Mild disability • Point tenderness • Little laxity (looseness) • Little or no swelling

40. Treating Lower Leg Injuries & Conditions • Ankle Sprains • S&S • 2nd degree • Pain • Mild to moderate disability • Point tenderness • Loss of function • Some laxity (abnormal movement/looseness) • Swelling (mild to moderate)

41. Treating Lower Leg Injuries & Conditions • Ankle Sprains • S&S • 3rd degree • Pain • Severe disability • Point tenderness • Loss of function • Laxity (abnormal movement/looseness) • Swelling (moderate to severe)

42. Treating Lower Leg Injuries & Conditions • Ankle sprains • Treatment/First aid • RICE • Horseshoe or doughnut-shaped pad with elastic bandage (aids in compression and reduction of fluid) • Crutches if needed • Probably needed with 3rd degree sprain • Referral to MD if… • Crepitus • Rapid swelling • Bony deformity

43. Treating Lower Leg Injuries & Conditions • Tibiofibular (“tib/fib”) syndesmosis sprain • Tib/fib syndesmosis – ligament that connects the tibia and fibula along the length of the bones • MOI • Foot planted firmly with foot in external rotation and lower legs twists medially • Forces the talus into the ankle mortise • Axial loading causes the tibia and fibula to separate slightly and sprain the syndesmosis

44. Treating Lower Leg Injuries & Conditions • Tibiofibular (“tib/fib”) syndesmosis sprain • S & S • MOI is different from lateral/medial ankle sprain • Ankle dorsiflexion and foot external rotation combined with internal rotation of lower leg • Typical tests will be positive • Athlete will c/o pain and point tenderness in the area of the tib/fib syndesmosis • Squeeze test will elicit pain in the syndesmosis area

45. Treating Lower Leg Injuries & Conditions • Tibiofibular (“tib/fib”) syndesmosis sprain • First aid care • RICE • Horseshoe or doughnut • Crutches for 72 hours, followed by the use of a walking boot for a minimum of 3 days and preferably for 7 days following initial injury • Send to doctor if uncertain about severity of injury

46. Treating Lower Leg Injuries & Conditions • Compartment Syndrome • Lower leg made up of 4 compartments • Most problems occur in anterior compartment • Because compartments are surrounded by fascia, there is little room for swelling or effusion, esp. in the anterior compartment • Causes • Overuse • Violent trauma

47. Treating Lower Leg Injuries & Conditions • Compartment Syndrome • S & S • Pain and swelling in lower leg • C/o chronic or acute injury to area • Loss of sensation to lower leg or foot • Loss of motor control to lower leg or foot • Loss of pulse to foot • Inability to extend the great toe or dorsiflex the foot

48. Treating Lower Leg Injuries & Conditions • Compartment Syndrome • First aid care/Treatment • Ice • Elevation • NO COMPRESSION – already too much pressure • Medical attention asap if • Foot becomes numb • Loss of movement • Loss of pulse in foot • Seek medical attention early to prevent the above from happening.

49. Treating Lower Leg Injuries & Conditions • Plantar Fascitis • “-itis” – inflammation of • Inflammation of the plantar fascia – dense collection of tissues, including MM and tendons, that traverses from the plantar aspect of metatarsal heads to the calcaneal tuberosity

50. Treating Lower Leg Injuries & Conditions • Plantar Fascitis • S & S • Pain • Plantar surface of foot • May also include medial arch and/or heel pain • Pain in morning, but eases with movement • Point tenderness on plantar surface of calcaneal tuberosity