Injuries to the Lower Leg, Ankle, and Foot

1. Injuries to the Lower Leg, Ankle, and Foot

2. Injuries to the Lower Leg, Ankle, and Foot… • For an athlete to move well, there must be excellent functioning of the lower leg, ankle, and foot • The foot must provide a stable base of support and as the same time be flexible and extremely mobile • This chapter discusses the skeletal and muscular anatomy of the foot and lower leg • We will discuss: • Ligaments of the ankle, compartments of the lower leg, muscular actions of each compartment • Fractures as well as common sprains of ankle ligaments

3. Injuries to the Lower Leg, Ankle, and Foot… • Treatment of ankle sprains and control of possible future sprains • Recognition, care, and treatment of tendon injuries along with compartment problems • Treatment and care of athletes with shin splints and considers ways to enhance the performance of these athletes • Discuss foot disorders such as plantar fasciitis, heel spurs, Morton's neuroma, arch problems, bunions, blisters and calluses, providing guidelines for recognition, first aid treatment, and long term care • And FINALLY ANKLE TAPING 

4. Anatomy Review  • The lower leg, ankle, and foot work together to provide a stable base of support and a dynamic system of movement • The skeleton of the lower leg consist of the tibia and fibula

5. Anatomy Review  • Tibia is the larger and stronger of the two (commonly called the shin bone) • Supports 98% of body wgt • Acts as an attachment for various muscles and helps to provide a mechanical advantage for some of them

6. Anatomy Review • Normal foot contains 26 bones that are interconnected and supported by numerous ligaments • Many joints within the foot also assist with support and movement

7. Anatomy Review

8. Movements of the Ankle • http://www.youtube.com/watch?v=0R4zRSE_-40 • Volunteer please  • Dorsiflexion • Plantar flexion • Inversion • Eversion

9. Anatomy Review • The ankle joint (talocrural joint) is where the tibia, fibula, and talus join • Provides mainly plantar flexion and dorsiflexion of the foot • Subtalar joint is the articulation of the talus and the calcaneus • Responsible for inversion and eversion of the foot • Both joints are synovial, which means they are surrounded by a capsule and supported by ligaments

10. Anatomy Review  • The ankle joint is supported on the medial side by the large and strong deltoid ligament • On the lateral side, the joint is supported by the anterior talofibular, the posterior talofibular, and the calcanefibular ligaments

11. Anatomy Review • These ligaments are not as large or strong as the deltoid ligament • Additional lateral stability for the ankle joint is provided by the length of the fibula on the lateral side of the ankle • The ankle joint is strongest when placed in dorsiflexion • The talus fits much tighter between the tibia and fibula in this position • Joint is weakest when placed in plantar flexion

12. Anatomy Review • Joints, ligaments, and muscles help to create and maintain the two basic arches in the foot • Longitudinal arch has medial lateral divisions • Transverse arch runs from side to side • These arches assist the foot as shock absorbers; also provide propulsion off surfaces during movement

13. Anatomy Review • Muscles are divided into anterior (front), posterior (back), and lateral (side) compartments • Muscles of the Anterior compartment essentially produce dorsiflexion and extension of the toes • Tibialis anterior, extensor digitorumlongus, extensor hallucislongus, and peroneustertius • Very compact area with little room for any extra tissue or fluid

14. Anatomy Review • Posterior compartment mainly functions to produce plantar flexion of the foot • Referred to as the calf muscles • Is divided into two compartments, superficial section and deep section • Superficial section • Gastrochnemius, soleus, and plantar muscles • Gastrochnemius and soleus attach on the calcaneus via the achilles tendon • Plantars muscle is small and insignificant in action

15. Anatomy Review • Deep section of this compartment houses the tibialis posterior, flexor digitorumlongus, flexor hallucislongus, and popliteus muscles • Besides the popliteus these muscles course behind the medial mallelous of the tibia and along the bottom of the foot • They help with the plantar flexion as well as flexion of the toes • The popliteus muscle is important in knee flexion

16. Anatomy Review • Lateral compartment of the lower leg contains the peroneuslongus and peroneusbrevis muscles • Mainly evertors (to turn the foot outward) of the foot but do assist with some plantar flexion • Both of these muscles course behind the lateral mallelous of the fibula • Peroneuslongus courses under the lateral side of the foot and runs across the bottom to the first metatarsal and cuneiform bones • The peroneusbrevis attaches at the base of the 5th metatarsal and is subject to avulsion (forcible tearing away or separation)

17. Compartments of the Leg

18. Lateral compartment of the leg

19. Anatomy Review • Included is also the peroneal nerve, a superficial nerve that is susceptible to injury • The posterior tibial artery supplies blood to the peroneal muscles because there is no major artery in the lateral compartment

20. Common Sports Injuries • Many injuries occur to the lower leg, ankle, and foot • Some can be classified as traumatic, and others are chronic in nature • Traumatic injuries typically involve skeletal structures • Chronic injuries usually involve damage to soft tissues

21. Skeletal Injuries…Fractures • Direct trauma through contact causes most • Magnitude of contact necessary to fracture a bone such as the • A fracture can be caused by being kicked by an opponent in a soccer match or by having a 300 pound lineman land on a leg • http://www.youtube.com/watch?v=I-iEOoM1N-w

22. Skeletal Injuries…Fractures • Fractures to the foot can also • However, violent trauma is not always required in • Stress fractures can occur from overuse or microtrauma( )

23. Skeletal Injuries…fractures • In running, for example, each time the foot strikes the ground it • This trauma damages a few bone cells, which the body must repair as quickly as possible • When the body cannot maintain the repair process and keep up with • Additionally, an avulsion fracture of the • Therefore the possibility of such a fracture should be examined when an athlete sprains his/her ankle

24. Skeletal Injuries…fractures • S&S • Swelling of the trauma • Discoloration at the site of the trauma • Possible through the skin • Athlete reports that a • The athlete may not be able to bear weight on the affected extremity • In the case of a stress fracture or a growth plate fracture that did not result from a traumatic event, the

25. Skeletal Injuries…fractures • TX: • Watch and • Apply sterile dressings to any related wounds (ex open fx) • Carefully • Arrange for transport to a medical facility • In the event that • Athlete will be immobilized for a specified time

26. Skeletal Injuries…fractures • When the fracture has healed properly, practice, and competition in that order • Participation while a fracture is healing is • There is a possibility of nonunion of a fracture, ,as a result of a diminished blood supply

27. Soft-Tissue Injuries…ankle injuries • One of the most common sports injuries to the • Are abnormal stresses placed on of damage • Sprains can occur to the lateral or medial ligaments of the ankle depending on which direction the foot moves when • http://www.youtube.com/watch?v=Da5Dumbo2Hs

28. Soft-Tissue Injuries…ankle injuries • The of the ankle are most susceptible to injury • The formation of the bones of the ankle helps to stabilize it; • The ligaments on the lateral side, are not as large or strong as the deltoid ligament on the medial side of the ankle joint

29. Soft-Tissue Injuries…ankle injuries • It is estimated that occur to the lateral ligaments (Ryan et al., 1986) • An interesting note is that authors are suggesting that (Omey & Micheli, 1999)

30. Soft-Tissue Injuries…ankle injuries • Can occur in virtually any sport and can limit the abilities of the athlete in performance until resolution of the injury is complete • As the severity of the ankle sprain increases, so does the • It is generally accepted that ankle sprain is more severe, with greater instability, and should be cared for more conservatively (Ryan et al., 1986) • However, an is more common, with the lateral ligaments being involved in

31. Soft-Tissue Injuries…ankle injuries • S&S of a lateral ankle sprain • 1st degree sprain • pain, mild disability, point tenderness, • 2nd degree sprain • Pain, mild-moderate disability, point tenderness, loss of function, some laxity

32. Soft-Tissue Injuries…ankle injuries • 3rd degree sprain • Pain and severe disability, point tenderness, loss of function, laxity

33. Soft-Tissue Injuries…ankle injuries • TX: • Immediately apply ice, compression, and elevation • A kept in place by an elastic bandage aids at this stage in the compression and reduction of fluid • Have the athlete rest and use crutches to ambulate with a • If there is any hesitation about the severity, splint and refer for further eval

34. Soft-Tissue Injuries…ankle injuries • It is important to recognize the possibility of a in conjunction with or masquerading as a lateral ankle sprain • Too often a , which is inappropriate and will not allow the athlete to progress in the healing process

35. Soft-Tissue Injuries…ankle injuries • It is important to know that there is a significant difference • With the lateral ankle sprain, there is an inversion mechanism, • In the followed by axial loading of the lower leg, with external rotation of the foot and internal rotation of the lower leg • Typically, athletes have their foot planted firmly with the foot in external rotation, and the lower leg twist medially, forcing the talus into the ankle mortise • The axial load forces the tibia and fibula to separate slightly and

36. Soft-Tissue Injuries…ankle injuries • S&S of a • Mechanism of injury is different from a lateral ankle sprain; are combined with internal rotation of the lower leg • Typical ankle sprain test may be positive but the athlete will c/o a great deal

37. Soft-Tissue Injuries…ankle injuries • Performing the “squeeze” test ( );elicits pain in the syndesmosis area • TX • Immediately apply ice, • A kept in place by an elastic bandage aids • Have the athlete rest and use crutches to ambulate for the first 72 hours, followed by use of a walking boot for a minimum of 3 days and preferably for 7 days following the initial injury • If there is any question refer for further evaluation

38. Soft-Tissue Injuries…ankle injuries • It is recognized that either taping or bracing can reduce the number of ankle sprains (Verhagen, van Mechelen, & de Vente, 2000) • Some prefer to use the as a prophylactic tx for ankles with no HX of an injury • Others choose to augment the taping procedure to prevent • In published research studies, ankle taping as been demonstrated to help with the neuromuscular response of the muscles and to provide stability if done in a specific manner • Both contribute to reduction of ankle sprains

39. Soft-Tissue Injuries…ankle injuries • Most researchers agree that the best known method of ankle support, the prophylactic adhesive-taping procedure, supports the ankle for only a short period of time after exercise begins (Frankeny et al., 1993) • Therefore, some researchers now maintain that bracing is better than taping for the prevention of ankle injuries, owing to the reduction in ROM, either at excessive points or within normal ranges ( ) • The combination of high-top shoes and taping or bracing can be helpful to athletes in reducing the number of ankle sprains they experience

40. Soft-Tissue Injuries…ankle injuries • Proprioception and the ankle is a very intense area of study • Proper ankle (Hintermann, 1999) • Also be important part of both the preventative and rehabilitative aspects of ankle functioning (Hertel, 2000)

41. Soft-Tissue Injuries…ankle injuries • Whatever the choice of the coach or athlete, many factors must be • These include: • Type of activity, compliance of the athlete in wearing braces or prophylactic taping, cost to the school or athlete, effectiveness of the brace as reported in research studies • There are some consequences of using adhesive tape, including: • Blisters,

42. Tendon-related Injuries • The , basketball players, and tennis players • The onset of tendinitis may be slow among runners, but much more rapid among basketball or tennis players • Great many jumping or rapid motion from side to side

43. Tendon-related injuries • Some controversy exists about the actual injury that constitutes Achilles tendinitis • The Achilles tendon itself, which attaches the • However, either tendon sheath or the subcutaneous bursa

44. Tendon-related injuries • Most agree that athletes who and who do so running on hard, uneven, or uphill surfaces are prone to Achilles tendinitis (Omey & Micheli, 1999) • It is estimated that 11% of runners and up to 52% of former elite runners experience an Achilles tendinopathy( ) • http://www.youtube.com/watch?v=F2e6LmQsJps

45. Tendon-related injuries • Superficially, ; moreover, the tendon is painful on touch and movement and appears thickened • This pain associated with this condition is localized to a small • Can be seen over an extended period of time (days to weeks) • Or over a shorter period of time (days)

46. Tendon-related injuries • TX for chronic : • Immediate rest until the swelling subsides • NSAIDS, small heel lift assist the reduction of swelling and • Stretching has also been shown to be beneficial to athletes with Achilles Tendinitis (Taylor et al., 1990) • Controlled stretching on a slant board or against a wall • Additionally, if an athlete must exercise or run, it is advised this be done in a controlled environment (swimming pool)

47. Tendon-related injuries • Controlled gradual stressing exercises using the • An athletes activity level and type of exercise must be closely monitored during the healing phase • Without the proper amount of rest, the body has a hard time repairing injury,

48. Tendon-related injuries • Explosive jumping or direct trauma from some type of impact can cause traumatic injuries to the • Can occur in many different sports

49. Tendon-related injuries • S&S • Swelling and deformity at the site of injury • Reports a • Pain in the lower leg, which may range from mild to extreme • Loss of function, • TX: • Immediately apply rice and • Immobilize the foot by • Arrange for transportation to the nearest medical facility

50. Tendon-related issues • During the acute phase of the healing process, minimize • This movement can produce more damage and • The long term effects of a ruptured Achilles tendon depend on the • If surgery is necessary, the athlete will most likely be out of commission for the rest of the season • The athlete will need to be careful and aware of the • http://www.youtube.com/watch?v=hP2medWpDLE