CHAPTER 15 – FOOT AND ANKLE FOOT ANATOMY • It is complex! • 26 bones • 33 joints • Over 100 muscles, tendons and ligaments ANATOMY – 26 BONES • TARSAL BONES – 7 • • • • • Calcaneus – heel bone Talus – forms the ankle Navicular – medial in respect to the talus Cuboid - lateral Cuneiforms (3) ANATOMY - BONES • METATARSALS – 5 • 1ST one is medial and 5th one is lateral ANATOMY - BONES • PHALANGES (Toes) – 14 • • Big toe has two phalanges, the rest of the toes have three Proximal, middle, and distal ANATOMY - BONES • SESAMOIDS • • • Sesamoid bones sit in tendons These are on ball on foot below big toe Helps distribute weight ANATOMY - ARCHES • Support body weight and absorb shock • There are four arches: • • • • MEDIAL LONGITUDINAL ARCH LATERAL LONGITUDINAL ARCH METATARSAL ARCH TRANSVERSE ARCH ANATOMY • PLANTAR FASCIA • • • Broad, flat tendonous structure that runs on the undersurface of the foot Starts on the calcaneus and inserts onto the heads of the metatarsals Supports the arch of the foot ANKLE ANATOMY • BONES • Two bones in the lower leg • Tibia – medial, larger, weight bearing • Medial Malleolus • Fibula • Lateral Malleolus • Two tarsal bone • • Talus Calcaneus ANKLE ANATOMY • TRUE ANKLE JOINT • • Tibia, fibula and talus Mortise • Definition: where the talus fits into the tibia and the fibula ANKLE ANATOMY • TRUE ANKLE JOINT • • Tibia, fibula and talus Mortise • Definition: where the talus fits into the tibia and the fibula LIGAMENTS • LATERAL – • 3 ligaments named for bones • Anterior talofibular • • Calcaneofibular • • (ATF) (CF) Posterior talofibular • (PTF) LIGAMENTS • MEDIAL • Deltoid • • Strong ligament 4 parts that form one ligament LIGAMENTS • TIBIOFIBULAR LIGAMENTS – holds tibia and fibula together • Anterior tibiofibular • Posterior tibiofibular FOOT INJURIES • PLANTAR FASCIITIS • Common with athletes who are on toes and/or have high arches • Causes: Not enough arch support in shoes, tight calf muscle • Signs/Symptoms: Pain occurs in the heel to mid-foot, especially with dorsiflexion • Hurts in the morning, feels better as they warm up • Treatment: Gentle stretches, roll on tennis ball or frozen can, arch taping or orthotics. FOOT INJURIES • RETROCALCANEAL BURSITIS • ‘Pump bump’ • Cause: Pressure from back of shoe • Signs/Symptoms: Swelling where the Achilles attaches to the calcaneus • Treatment: RICE, stretching, shoes with wider heel cups, donut pad. FOOT INJURIES • FRACTURES • Toes • Metatarsals • DISLOCATIONS • Interphalangeal Joints • SPRAINS • STRAINS FOOT INJURIES • JONES FRACTURE • Fracture of the base of the 5th metatarsal • Causes: overuse; inversion; rotational forces • S/S: Feels and hears a ‘pop’; pain in the lateral foot • Tx: immobilization (cast) 6-8 weeks or longer, often requires surgery FOOT INJURIES • BUNIONS (HALLUX VALGUS) • Deformity of the head of the 1st metatarsal • Cause: extra bone is laid down on head of 1st metatarsal • Great toe becomes malaligned • S/S: Pain, swelling and deformity of big toe joint • Treatment: Proper shoes; doughnut pad over the bunion; surgery? • TURF TOE FOOT INJURIES • Great Toe sprain • Cause: Hyperextension of the big toe at the metatarsal phalangeal joint; kicking something • Common on artificial turf b/c turf shoes allow more motion • S/S: swelling and pain in the joint • Tx: RICE, rigid insoles or toe boxes, taping to prevent hyperextension of toe FOOT INJURIES • INGROWN TOENAILS • Cause: leading side of toenail grows into skin, usually results in infection and pain • May trim nails too short or ill-fitting shoes • S/S: Inflammed nail bed, may have drainage/pus • Tx: May need to refer to doctor; soak in betadine bath; pack cotton under toenail PUBLIC SERVICE ANNOUNCEMENT • HIGH HEELS • Loads 5 times your body weight onto your heel • Overloads forefoot • Deforms the arch • • Reduces shock absorption Plantar fasciitis • Morton’s Neuroma • Achilles tendinitis • Have to extend back to compensate • Leads to inflamed nerves in your toes • Shortens your calf • Changes your center of gravity – more forward BIOMECHANICAL PROBLEMS • PRONATION • Cause of many, many leg, knee, back problems • What does it look like • Fallen arch with toes pointed outward • Looking at feet from behind, the Achilles will angle outward ANKLE SPRAINS • Review: 3 Degrees of Sprains • Abnormal (too much) motion causes ankle injuries • Named for motions that cause them • What are those motions? TYPES OF ANKLE SPRAINS • Inversion • Most common type of ankle sprain • Accounts for 80% of all sprains • AKA ‘a lateral ankle sprain’ • First degree sprain • Only involves the anterior talofibular ligament • Mild pain, tenderness, and swelling • No instability TYPES OF ANKLE SPRAINS • Inversion • Second degree sprain • Anterior talofibular ligament is torn and calcaneofibular ligament is injured as well • Most painful • Moderate swelling • Mild Instability TYPES OF ANKLE SPRAINS • Inversion • Third degree sprain • Complete tear of all three lateral ligaments • Uncommon • Lots of pain, but it can subside • Very unstable • Usually requires surgery TESTING ATF STABILITY • Drawer Test • Stablize lower leg with one hand • Pull heel forward (like opening a drawer) • Should not move forward if ligament is intact TYPES OF ANKLE SPRAINS • Eversion • Not as common • Can occur more on tartan surfaces and artificial turf • Everything is worse (pain, swelling, etc) when compared to an inversion injury • If the deltoid tears, the tibiofibular ligaments may tear also High Ankle Sprain • Involves Anterior Inferior Tibiofibular (AITFL) Ligament • Injury allows tibia and fibula to separate High Ankle Sprain • Cause: Inversion with rotation; rotation of foot • S/S: pain with external rotation of foot; tender over AITFL • Treatment: RICE, may need to be immobilized; possible surgery if severe enough Treatment of Ankle Sprains • Prevention – once you sprain an ankle it is easy to do again – tape and rehab • Rest – No activity for 24-48 hours • Ice – 20 minutes on, 40 minutes off • Compression – ace wrap with horseshoe • Elevation – ankle above the heart • Support – crutches and aircast if needed Ankle Rehab • ABCs • Circles • Theraband exercises • Single Leg Balance • Balance Board • Calf Raises • And so much more…. Ankle Fractures • Always need to suspect a fracture when evaluating a potential sprained ankle • Cause: Too much motion • S/S: immediate swelling, point tender over the bone, does not want to weight bear • Treatment: splint, ice, x-ray Cast 6-8 weeks The Lower Leg ANATOMY • Bones • Tibia • Fibula MUSCLES • The muscles are in four compartments with 2-4 muscles in each compartment • Compartments are held together by fascia MUSCLE COMPARTMENTS 1. LATERAL – everts the ankle 2. ANTERIOR – dorsiflexes the ankle 3. DEEP POSTERIOR – plantarflexes the ankle (the calf muscle) 4. POSTERIOR MEDIAL – inverts and plantarflexes the ankle Major Muscles and Actions • Anterior Tibialis - dorsiflexor • Peroneals - evertors • Gastrocnemius – plantarflexor • Soleus – plantarflexor • Posterior Tibialis – invertor LOWER LEG INJURIES • Muscle Cramps • Sudden, violent contraction of the calf muscles • Causes: • Fatigue, overtraining, dehydration, poor nutrition, injury, poor flexibility • S/S: – sharp pain in the calf, toe is pointed • Tx: gentle stretch, ice, hydrate, can return to play if subsides and does not continue LOWER LEG INJURIES • STRESS FRACTURE • Cause: Repetitive pounding with training • S/S: Hurts more with and after activity, pain on one spot on bone • Tx: Requires x-ray, possibly a bone scan • If positive, no weight bearing for at least 2 weeks, no running for 4-6 weeks LOWER LEG INJURIES • MEDIAL TIBIAL STRESS SYNDROME • ‘SHIN SPLINTS’ • Occurs in distal 2/3 of posterior/medial tibia • Causes: pronation, lack of flexibility in the lower legs, hard surfaces, hills, muscle weakness, poor shoes, increasing running distance too quickly LOWER LEG INJURIES • MEDIAL TIBIAL STRESS SYNDROME • S/S: resisted plantar flexion and inversion should hurt, pain is just off the tibia • Treatment : prevention (shoes, arch support), strengthening, stretching, ice massage, contrast bath, tape arches • Refer to MD if no improvement to rule out stress fracture LOWER LEG INJURIES • COMPARTMENT SYNDROME • Occurs when pressure increases in compartment and shuts off blood and nerve supply to the foot • Most often occurs in the anterior and deep posterior compartment • THREE TYPES • Acute • Acute Exertional • Chronic LOWER LEG INJURIES • ACUTE COMPARTMENT SYNDROME • Medical emergency • Causes: direct blow to the lower leg • Usually in the anterior lower leg • Symptoms come about several hours later • S/S: compartment is tense, warm, red and shiny; complains of (c/o) deep aching pain; circulation and sensory problems in foot • Tx: ice, elevation – refer to ER immediately LOWER LEG INJURIES • ACUTE EXERTIONAL/CHRONIC COMPARTMENT SYNDROME • Cause: running and jumping activities • S/S: With activity, foot goes to sleep, crampy pain, and tingling. When activity stops, it goes away. Consistent as to when it comes on with activity • Tx: ice, activity modification, stretching, massage, and referral to the doctor (possible surgery) INJURIES • ACHILLES TENDINITIS • Chronic, overuse condition that comes about gradually • Causes: running and jumping, repetitive stress, running up hills, poor flexibility • S/S: achy type pain, Achilles is tender on palpation, pain with standing plantarflexion, may have crepitus, hurts to warm up and to cool down INJURIES • ACHILLES TENDINITIS • TREATMENT • If there is crepitus, no running for 1-2 weeks • Stretch! • Heel lift in both shoes • Orthotics • Heat and/or ice INJURIES • ACHILLES TENDON RUPTURE • Achilles in largest tendon in body • For Gastrocnemius and Soleus muscles • Most common tearing spot is 1” above its insertion on the calcaneus • Causes: Sudden, forceful plantar flexion and extension of the knee, age, previous tendinitis • S/S: Feel and hear a snap, “kicked in the leg”, very weak plantarflexion, no Achilles observed • Tx: Immobilization to ER, surgery?