Ankle/Foot and Lower Leg

1. Ankle/Foot and Lower Leg

2. Abbreviations • Fx: Fracture • MOI: Mechanism of Injury • ROM: Range of Motion • Inv: Inversion • EV: Eversion • PF: Plantarflexion • DF: Dorsiflexion • Rx: Management • Lig: ligament • c/o: complains of

3. Foot Injuries • Fractures • Avulsion FX: • Jones Fracture: Peroneus brevis pulls off proximal 5th metatarsal with forced inversion. • Stress FX: • March Fx: Stress Fx to metatarsals due to repetitive activity • Dislocations • Plantar Facsiitis

4. Ankle Injuries • Fractures • Avulsion fxATF Lig: A fracture to the lateral malleolus (looks like 3rd Degree sprain) • Dislocations • Sprains: Lateral, Medial, and High • Strains and Tendonitis

5. Lower Leg Injuries • Fractures • Growth Plate (Epiphyseal) Fractures • Distal plated in fibula and tibia may fracture with inversion/eversion • Strains and Tendonitis • Achilles Tendon Rupture • Compartment Syndrome • Medial Tibial Stress Syndrome

6. Foot Conditions • Morton’s Toe: Longer 2nd phalange then 1st due to a shorter 1st metatarsal. • PesPlanus: Flat foot, it is a lowering of the medial longitudinal arch • PesCavus: High medial longitudinal arch • Jones FX: Fx to the diaphysis of the 5th metatarsal. • Retrocalcaneal Bursitis: Pump Bump inflammation of the bursa behind the achilles tendon.

7. Foot Conditions • Lisfranc Injury: tarsometatarsal injury can be a fracture or a sprain of this area. • Morton’s Neuroma: the nerve sheath at the plantar nerve becomes thick at the 4th and 5th met heads, causing pain. • Turf Toe: Hyperextension of the great toe, spraining the metatarsophalangeal joint

8. Lateral Ankle Sprains • Also known as Inversion ankle sprains, it is the most common type of ankle sprain. • The injury is to the lateral ligaments, the weakest being the anterior talofibular ligament. • Sprains are classified into 3 different grades • 1 is a slight stretching of the ligaments, mild pain • 2 is micro tearing or stretch of the ligament, hear a pop • 3 is a complete tear of the ligament, extremely disabling

9. Lateral Ankle Sprains • MOI: • Anterior Talofibular (ATF) Ligament- plantarflexion and inversion • Calcaneofibular Ligament- inversion • Posterior Talofibular Ligament- severe inversion or dislocation (rare) • Stress Test: • Anterior Drawer Test: ATF ligament • Talar Tilt Test: CF and Deltoid ligaments

10. Medial Ankle Sprains • Also known as eversion ankle sprain, less common then a inversion sprain due to the bony structure of the ankle. • Follows the same grading system as other sprains. • MOI: • Deltoid Ligaments: eversion and dorsiflexion • Stress Test: • Talar Tilt Test- CF and Deltoid ligaments

11. High Ankle Sprain • Syndesmotic Sprain is the other name for a high ankle sprain. • Syndesmosis injury is an injury to the distal tibiofibular joint, injuring the interosseous or syndesmotic ligaments. • MOI: • Anterior Inferior Tib/fib Ligament: excessive dorsiflexion or plantarflexion • Stress Test: • Kleiger’s Test

12. Ankle Sprains General • Signs and Symptoms: • Swelling • Pain with WB (weight bearing) • Instability • Ecchymosis (bruising/discoloration) • Management: • RICE with horseshoe • NSAIDs • Crutches: Depend on the severity of the injury • Referral to Doctor for further evaluation and xrays

13. OsteochondritisDissecans • OCD lesions is when one or several fragments of articular cartilage and its underlying subchondral bone are either partially or completely detached and moving within the joint space. Can be from a single injury or repeated episodes. • Signs: pain, swelling, and may c/o catching or locking • Management: x-ray for diagnosis, immobilization or surgery depending on severity.

14. Achilles Tendon Rupture • Signs and Symptoms: • Pain • inability to plantarflex • Feels like they were “kicked in calf” • Positive Thompson Test • Deformity • Management: • RICE • Referral is rupture is suspected • Surgery needed to repair full rupture

15. Muscle Strains • MOI: • Due to violent contraction/twisting of foot • Awkward landing • Signs and Symptoms: • Pain with ROM or RROM • Possible pain with WB • Swelling or crepitus • Management: • RICE • Taping/bracing • Monitor for acute compartment syndrome

16. Contusions • MOI: direct blow to the extremity • Signs and Symptoms: • Limited ROM • Swelling • Ecchymosis • Management: • RICE • Padding for protection • Monitor for acute compartment syndrome with contusions to the lower leg

17. Dislocations • Rare in ankle, but common in phalanges • MOI: • Traction or twisting • Signs and Symptoms: • Deformity • Possible fractures • Inability to move extremity • Management: • Immobilize • Cold • Referral for reduction or Emergency Action Plan (EAP)

18. Acute Fractures • In lower leg fractures there is a higher incidence of fibular fractures. • Fractures to both the tibia and fibula can occur from direct or indirect forces

19. Acute Fractures • MOI: • Direct blows • Twisting • Associated with avulsions/dislocations • Signs and Symptoms: • Localized Pain • Deformity: may or may not be obvious • Swelling • Ecchymosis • Crepitus • Pain with WB

20. Acute Fracture • Stress Tests: • Tap Test (Bump or Flick Test): phalanges, tibia, fibula, talus or calcaneus • Compression or Squeeze Test: tibia or fibula • Management: • RICE • Referral for x-ray • Be prepared to activate Emergency Action Plan (EAP) if open fracture or signs of shock

21. Stress Fractures • Extremely common due to repetitive action, seen in distance runners • S/S: point tenderness; especially in WB position • Rx: • NWB (non-weight bearing) > week or more • Walking boot or cast possible • Out of activity 3-4 weeks • Gradual resumption of activity

22. Compartment Syndrome • Is excessive swelling within the confines of a fascia compartment compresses muscles, blood vessels, and nerves. • MOI: direct blow or tearing of muscle fibers causing swelling in the compartments of the lower leg • Leads to increased fluid pressure causing muscle ischemia.

23. Compartment Syndrome • Signs and Symptoms: • Pain becoming worse; eventually numbness • Loss of foot ROM • Leg swelling • Management: • Medical Emergency! Refer Immediately • Apply cold and elevate the limb • Surgical intervention is probably necessary

24. Plantar Fasciitis • Is a catchall term that is commonly used to describe pain in the proximal arch and heel. It is inflammation of the plantar aponeurosis, that runs the length of the sole of the foot. • MOI: • Shoes • Overweight • Activity on hard surfaces • Overuse • Poor mechanics • Fatigue

25. Plantar Fasciitis • Signs and Symptoms : • Morning pain • Swelling • Pain with WB • Crepitus • Management: • Good shoes/orthotics • Stretching • Ice • Taping • Referral to podiatrist

26. Shinsplints • Shinsplints is a catch-all term for tendonitis, chronic compartment syndrome or a stress fracture • Medial Tibial Stress Syndrome (MTSS) is the more appropriate term for shinsplint-type pain • MTSS is caused by repetitive microtrauma and may evolve to be a stress fracture or compartment syndrome if not taken care of .

27. Medial Tibial Stress Syndrome • MOI: • Pesplanus (flat feet) • Overweight • Poor conditioning • Poor shoes • Activity on hard surfaces • Overuse/Muscle weakness • Poor running technique • Genetics

28. Medial Tibial Stress Syndrome • Signs and Symptoms: • Pain: usually found on medial side of leg • Pain with activity that gets progressively worse over time • Management: • RICE before/after • Check shoes • Stretch • Strengthen • NSAIDs • Cross Train • Rest • Refer for fracture or compartment syndrome

29. Gait Two Phases of Gait: Stance or Support Phase – weight bearing Swing Phase – non-weight bearing