FOOT, ANKLE AND LOWER LEG

1. FOOT, ANKLE AND LOWER LEG Care and Prevention

2. Bony Anatomy • Toes=phalanges • Have 3 joints, except big toe has only 2 • Metatarsals-long bones in the foot • Joins with phalanges to make MTP joint • Talus & Calcaneus bigger bones in foot & ankle • Tibia and fibula • Form medial & lateral malleolus

3. Arches of the Foot • Arches are found on plantar aspect • Shock absorbers • Transverse: front of heel to 5th metatarsal • Longitudinal: calcaneus to metatarsals • Metatarsal: across distal metatarsals

4. Muscles and Tendons • Peroneal muscles • Perform eversion • Gastrocnemius and soleus attach via achilles tendon • Perform plantarflexion • Tibialis anterior, extensor digitorum, and extensor hallucis-TDH muscles • Perform dorsiflexion

5. Ligaments • Lateral ankle: • Anterior talofibular (ATF) • *Most commonly sprained • Posterior talofibular (PTF) • Calcaneofibular (CF) • Medial ankle: • Deltoid ligament • Stronger than all the lateral ligs combined

6. INJURIES • Bone injuries: • Jones Fx • Tibia/Fibula Fx • Stress Fx • Muscle/Tendon injuries: • Medial tibial stress syndrome (Shin splints) • Achilles Tendinitis • Achilles Tendon Rupture • Ligament Injuries • Great Toe sprain (Turf toe) (check this) • Plantar fasciitis • Lateral/Medial ankle sprains • Ankle dislocation • Tissue Injuries • Contusions • Toe abnormalities • Anterior compartment syndrome

7. Jones Fracture • What is it? • Avulsion fx of peroneus brevis tendon • MOI: Inversion • Perenous brevis muscle contracts quickly and forcefully to stabilize ankle • Direct impact • Signs and Symptoms: • Pain, ttp over 5th metatarsal,swelling • HIGH reinjury rate • Why? • Immobolize in boot and use crutches along with rehab

8. Tibia/Fibula Fractures • MOI: direct or indirect impact • Fibular fractures are most common • Signs and symptoms: • Obvious deformity (sometimes) • Loss of function • Severe pain • Swelling • Management: • EMS for displaced tibia fracture • Casting and in severe cases surgery to reduce fracture

9. Stress Fractures • Hairline fx • Common areas: • Tibia, fibula, metatarsals • MOI: repetitive stress i.e. running • S&S: • Pain and swelling • TTP over stress fx site • Pain with walking, running, night pain • Management: • Xrays • Rest • If not diagnosed in time can lead to complete fx

10. Medial Tibial Stress Syndrome A.K.A. Shin Splints • What is it? • Tiny tears of the muscle from the tibia on the medial aspect of the lower leg. • MOI: • overuse • Tight calves • Old shoes • Low arches • Management: • Rest, ice massage • Change running shoes, add arch supports if needed • Tape lower leg to pull muscle towards the tibia • Stretch calves & strengthen tibialis anterior muscle

11. Achilles Tendonitis • Connects Gastroc muscle to calcaneus • MOI: overuse from running and jumping • Signs & Symptoms: • TTP, swelling, crepitus • ↓ strength in PF • Visible thickened tendon • Management: • Rest, ice, anti-inflammatories • Stretch calves • Strengthening calves • Complications?

12. Achilles Tendon Rupture • MOI: • Forced DF • Blow over achilles tendon • Sudden, strong contraction of gastroc • Signs & symptoms: • Ath c/o…. • Pain • Obvious deformity/depression • Unable to complete PF • Management: • Splint, ice, crutches • Refer to MD for surgery

13. Great Toe Sprain • A.K.A. “Turf Toe” • MOI: forced hyperextension • Sprains lig of MTP joint • Happens more on artificial turf than real grass • Signs & Symptoms: • Pain, swelling, ttp • Inability to DF/ “push off” • Discoloration • Management: • Rest, ice • Ice in bucket rather than w/bag • Rehab • Taping

14. PLANTAR FASCIITIS • What is it? • Inflammation of fasica (thick band/layer) on plantar asepct of foot. • MOI: • Overuse, tight calves • Signs & Symptoms: • Pain on calcaneus, moves towards the toes • Pain when taking the first steps in the morning • Pain with excessive DF • Management: • Rest, ice • Stretch calves • Provide orthotics/arch supports if necessary • Anti-inflammatory (oral vs injection)

15. Lateral/Inversion Ankle Sprain • 85% of ankle sprains are inversion sprains • 2 reasons: • Deltoid ligament is stronger than lateral ligs • Fibula prevents excessive eversion • MOI: Plantarflexion and excessive inversion • Some examples? • Severity depends on force, strength of muscles, protective devices worn • Signs & Symptoms: • Pain, swelling, discoloration • TTP over ATF ligament typically • Loss of ROM and strength (depends on severity) • Management: • RICE • Anti-inflammatories • Stretching and strengthening • Bracing • Balance exercises • Refer for XRAYs if rapid swelling occurs or TTP over bone

16. Medial/Eversion Ankle Sprains • Only account for 15% of ankle injuries. • More severe than inversion sprains • Longer recovery time • MOI: Excessive eversion • Signs & Symptoms: • Pain, swelling, TTP over deltoid ligament • Bruising • Loss of ROM and strength especially eversion • Management: • RICE • NWB • XRays to rule out fracture of fibula • Rehab and balance activities

17. ANKLE DISLOCATION • Can occur either anteriorly or posteriorly. • MOI: • Anterior: Forceful heel strike against the ground. • Posterior: Direct blow to the anterior portion of the lower leg when ankle is in PF. • Signs & Symptoms: • Obvious deformity and severe pain • Swelling • Management: • Activate EMS • Emergency because nerves and blood vessels can be damaged • Splint lower leg and ankle and transport to ER

18. TOE ABNORMALITIES

19. TOE ABNORMALITIES

20. Anterior Compartment Syndrome • Muscles are covered by fascia. • Pressure can accumulate between the fascia and muscle. • MOI: Overuse or direct impact • Signs & Symptoms: • Severe pain that doesn’t go away after activity • Heat, redness • Hardness of area • Loss of ROM/Strength • Management: • Refer to Dr. immediately • Increased pressure places pressure on blood vessels and nerves • Surgery to relieve pressure • Fasciotomy: Remove piece of fascia

21. References • Cartwright AL, Pitney AW, Fundamentals of Athletic Training. 3rd edition. Human kinetics. Champaign, IL.