Chapter 16 Foot, Ankle, and Lower Leg Conditions

1. Chapter 16 Foot, Ankle, and Lower Leg Conditions

2. Anatomy Skeletal features of the lower leg, ankle, and foot

3. Anatomy (cont’d) • Forefoot • Metatarsals and phalanges; numerous joints • Support and distribute body weight throughout the foot • Toes • Smooth the weight shift to the opposite foot during walking • Help maintain stability during weight-bearing • 1st digit – hallux or “great toe” – main body stabilizer during walking or running

4. Anatomy (cont’d) • Midfoot • Navicular, cuboid, 3 cuneiforms; numerous joints • Talocalcaneonavicular joint (TCN) • Talus moves simultaneously on calcaneus and navicular • Combined action of talonavicular and subtalar joint

5. Anatomy (cont’d) • Hindfoot • Calcaneus and talus • Talocrural joint (ankle joint) • Hinge joint; plantarflexion and dorsiflexion • Articulation of talus, tibia, and fibula • Fibula extends farther distally than tibia – limits eversion • Talar dome wider anteriorly – more stable in dorsiflexion

6. Anatomy (cont’d) • Hindfoot (cont’d) • Talocrural joint (ankle joint) (cont’d) • Ligaments • Medial: deltoid • Lateral :anterior talofibular; posterior talofibular; calcaneofibular • Subtalar joint • Behaves as a flexible structure

7. Anatomy (cont’d) • Ligaments supporting the midfoot and hindfoot region Ligaments supporting the midfoot and hindfoot region, lateral and medial views

8. Anatomy (cont’d) • Tibiofibular joints • Superior—proximal • Inferior—distal • Interosseous membrane

9. Anatomy (cont’d) • Plantar arches • Support and distribute body weight • Longitudinal arch—medial and lateral • Transverse arch • Ligaments • Spring (calcaneonavicular) • Long plantar • Short plantar

10. Anatomy (cont’d) Medial longitudinal arch Arches of the foot

11. Anatomy (cont’d) • Plantar fascia • Plantar arches • Plantar fascia • Provides support for the longitudinal arch

12. Anatomy (cont’d) • Nerves • Sciatic nerve • Tibial nerve • Common peroneal nerve—deep and superficial peroneal nerves • Femoral—saphenous

13. Anatomy (cont’d) • Blood supply • Femoral artery • Popliteal • Anterior and posterior tibial • Anterior tibial • Dorsal pedal Blood supply to the leg, ankle, and foot region

14. Kinematics and Major Muscle Actions Muscles of the lower leg and foot. A. Lateral and medial view

15. Kinematics and Major Muscle Actions (cont’d) Muscles of the lower leg and foot. B. Posterior view

16. Kinematics and Major Muscle Actions (cont’d) Intrinsic muscles of the foot. A. Dorsal view

17. Kinematics and Major Muscle Actions (cont’d) Intrinsic muscles of the foot. B. Plantar view

18. Kinematics and Major Muscle Actions (cont’d)

19. Kinematics and Major Muscle Actions (cont’d)

20. Kinematics and Major Muscle Actions (cont’d) • Gait cycle • Consists of alternating periods of single-leg and double-leg support • Requires a set of coordinated, sequential joint actions of the lower extremity • Gait

21. Kinematics and Major Muscle Actions (cont’d) • Motions • Toe—flexion and extension • Ankle (subtalar)—dorsiflexion and plantarflexion • Foot and ankle • Inversion and eversion • Pronation and supination

22. Kinematics and Major Muscle Actions (cont’d) Motions of the foot and ankle. A. Dorsiflexion and plantar flexion. B. Eversion and inversion. C. Supination of the subtalar joint

23. Injury Prevention • Physical conditioning • Strengthening • Extrinsic muscles • Intrinsic muscles • Flexibility • Achilles tendon

24. Injury Prevention (cont’d) • Protective equipment • Braces; orthotics • Footwear • Demands of sport; wear shoe for its intended purpose • Proper fit

25. Toe and Foot Conditions • Toe deformities • Hallux rigidus • Degenerative arthritis in first MTP • S&S • Tender, enlarged first MTP joint • Loss of motion • Difficulty wearing shoes with an elevated heel • Hallmark sign—restricted toe extension

26. Toe and Foot Conditions (cont’d) • Toe deformities • Hallux valgus • Thickening of the medial capsule and bursa, resulting in severe valgus deformity • Asymptomatic or symptomatic • Treatment—symptomatic

27. Toe and Foot Conditions (cont’d) Hallux valgus

28. Toe and Foot Conditions (cont’d) • Hammer toe • Extension of MTP joint, flexion at PIP joint, and hyperextended at the DIP joint • Claw toe • Hyperextension of MTP joint and flexion of DIP and PIP joints • Mallet toe • Neutral position at MTP and PIP joints, flexion at DIP joint

29. Toe and Foot Conditions (cont’d) • S&S: painful callus formation on dorsumIP joints Toe deformities

30. Toe and Foot Conditions (cont’d) • Pes cavus • Excessively high arch that does not flatten during weight bearing • Causes can vary • Rigid foot

31. Toe and Foot Conditions (cont’d) • Pes planus • Flat foot; arch or instep of the foot collapsing & contacting the ground • Typically, acquired deformity resulting from injury or trauma • Mobile foot

32. Toe and Foot Conditions (cont’d) • Both conditions can be asymptomatic, but associated with common injuries Common foot deformities

33. Contusions • Heel contusion • Thick padding of adipose tissue—does not always suffice • Stress in running, jumping, changing directions • S&S • Severe pain in heel • Unable to bear weight

34. Contusions (cont’d) • Heel contusion (cont’d) • Management: cold; heel cup or doughnut pad; referral • Condition may persist for months

35. Contusions (cont’d) • Gastrocnemius contusion • S&S • Immediate pain and weakness • Rapid hemorrhage and muscle spasm → palpable mass • Management: • Cold with gentle stretch • If symptoms persist > 2-3 days, physician referral

36. Contusions (cont’d) • Tibial contusion (shin bruise) • Vulnerable lack of padding • Minor injury—caution: repeated blows → damage periosteum • Management: standard acute • Key: prevention

37. Lower Leg Contusions • Acute compartment syndrome • Lower leg includes 4 nonyielding compartments • MOI: direct blow anterolateral aspect of the tibia • Rapid ↑ in tissue pressure → neurovascular compromise

38. Lower Leg Contusions (cont’d) • Acute compartment syndrome (cont’d) • S&S • History of trauma • Increasingly severe pain—out of proportion to situation • Firm and tight skin over anterior shin

39. Lower Leg Contusions (cont’d) • Acute compartment syndrome (cont’d) • S&S (cont’d) • Loss of sensation between 1st and 2nd toes on dorsum of foot • Diminished pulse—dorsalis pedis artery • Functional abnormalities within 30 minutes

40. Lower Leg Contusions (cont’d) • Acute compartment syndrome (cont’d) • Management: • Cold • NO compression or elevation • immediate referral to ER or summon EMS • Irreversible damage can occur within 12–24 hours

41. Toe and Foot Sprains • IP & MP joints • MOI: tripping or stubbing the toe • S&S • Pain, dysfunction, immediate swelling • Dislocation—gross deformity

42. Toe and Foot Sprains (cont’d) • Midfoot sprains • MOI: severe dorsiflexion, plantarflexion, or pronation • More frequent in activities in which foot is unsupported • S&S • Pain and swelling is deep on medial aspect of foot • Weight bearing may be too painful

43. Toe and Foot Sprains (cont’d) • Turf toe • Sprain of the plantar capsular ligament of 1st MTP joint • MOI: forced hyperflexion or hyperextension of great toe • Acute or repetitive overload • Valgus ↑ susceptibility

44. Toe and Foot Sprains (cont’d) • Turf toe (cont’d) • S&S (cont’d) • Pain, point tenderness, and swelling on plantar aspect of MP joint • Extreme pain with extension • Potential for tear in flexor tendons or fracture of sesamoid bones

45. Toe and Foot Sprains (cont’d) • Management toe and foot sprains • Standard acute • Physician referral

46. Ankle Sprains • Inversion ankle sprain • MOI: plantarflexion and inversion • Predisposing factors • Lateral malleolus projects farther downward • Least stable position of ankle is plantar flexion • Weakness in peroneals • ↓ ROM in Achilles tendon

47. Ankle Sprains (cont’d) Inversion ankle sprain

48. Ankle Sprains (cont’d)

49. Ankle Sprains (cont’d) • Eversion ankle sprain • Mechanism: excessive dorsiflexion and eversion • Deltoid ligament • Potential • Lateral malleolus fx; bimalleolar fx • Tear of anterior tibiofibular ligament &interosseous membrane

50. Ankle Sprains (cont’d) • Eversion ankle sprain (cont’d) • Predisposing factors • Excessive pronation • Hypomobile foot