Download Ch 18 - Lower Leg Ankle and Foot Conditions

Lower Leg, Ankle, and Foot
Conditions
Anatomy (Cont’d)
• Forefoot
– Metatarsals and phalanges; numerous joints
– Support and distribute body weight throughout
the foot
• Midfoot
– Navicular, cuboid, 3 cuneiforms; numerous joints
• Hindfoot
– Calcaneus and talus
Anatomy (cont.)
• Ligaments supporting the midfoot and
hindfoot region
Anatomy (cont.)
• Plantar arches
– Support and distribute
body weight
– Longitudinal arch—
medial and lateral
– Transverse arch
– Ligaments
• Spring
(calcaneonavicular)
• Long plantar
• Short plantar
Anatomy (cont.)
• Plantar arches
– Plantar fascia
Anatomy (cont.)
• Muscles
– Lateral and medial view
Anatomy (cont.)
• Muscles
– Posterior view
Kinematics
• 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
Kinematics
• Motions
– Toe — flexion and extension
– Ankle (subtalar) — dorsiflexion and plantarflexion
– Foot and ankle
• Inversion and eversion
• Pronation and supination
Kinetics
• Bones subject to several loading patterns
• Running
– Foot sustains forces 2–3× body weight
– Bones are typically 2–4× strength needed
• Repeated forces—stress fractures
• Foot deforms during weight bearing
– Absorbing a smaller force of longer duration than if
it were rigid
– Deformation causes storage of mechanical energy in
the stretched tendons, ligaments, and plantar fascia
Injury Prevention
• Physical conditioning
– Strengthening
• Extrinsic muscles
• Intrinsic muscles
– Flexibility
• Achilles tendon
• Footwear
– Demands of sport; wear shoe for its intended purpose
– Proper fit
• Protective equipment
– Taping; braces; orthotics
Toe and Foot Conditions
• Bunion
– Medial aspect of MTP joint of great toe; lateral
aspect of the 5th toe
– Thickening of capsule and bursa
– Due to constant rubbing against inside of shoe
– S&S (as condition worsens)
• Lateral shift of great toe
• Rigid, nonfunctional hallux valgus deformity
– Once deformity occurs, little can be done to
correct condition
Toe and Foot Conditions (cont’d.)
• Toe deformities
– Hallux valgus
• Thickening of the medial capsule and bursa,
resulting in severe valgus deformity of great toe
• Asymptomatic or
symptomatic
• Treatment—
symptomatic
Toe and Foot Conditions (cont.)
• 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
• Difficult to treat conservatively
Hammer Toe
Claw Toe
Mallet Toe
Toe and Foot Conditions (cont.)
• Turf toe
–
–
–
–
–
Sprain of the plantar capsular ligament of 1st MTP joint
Mechanism: forced hyperflexion or hyperextension of great toe
Acute or repetitive overload
Valgus ↑ susceptibility
S&S
• 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
– Management: standard acute; rest; protection from excessive
motion
Toe and Foot Conditions (cont.)
• Ingrown toenail
– Preventable with proper hygiene and nail care
– Edge of nail grows into lateral nail fold and
surrounding skin
– Nail margin reddens; painful
– Paronychia—fungal or bacterial infection
Toe and Foot Conditions (cont.)
• Retrocalcaneal bursitis
– Due to external pressure—constrictive heel cup,
coupled with excessive pronation or varus
hindfoot
– “Pump bump”
– Management: standard
acute; shoe modification;
AT stretching
Lower Leg Contusions
• Gastrocnemius contusion
– S&S
• Immediate pain and weakness
• Rapid hemorrhage and muscle spasm → palpable mass
– Management: cold with gentle stretch
• Tibial contusion (shin bruise)
– Vulnerable lack of padding
– Minor injury—caution: repeated blows → damage
periosteum
– Key: prevention
Lower Leg Contusions (cont.)
• Acute compartment syndrome
– Lower leg includes 4 nonyielding compartments
– Mechanism: direct blow anterolateral aspect of the tibia
– Consequence: rapid ↑ in tissue pressure → neurovascular
compromise
– S&S
•
•
•
•
•
•
History of trauma
Increasingly severe pain—out of proportion to situation
Firm and tight skin over anterior shin
Loss of sensation between 1st and 2nd toes on dorsum of foot
Diminished pulse—dorsalis pedis artery
Functional abnormalities within 30 minutes
– Management: cold; no compression or elevation; immediate physician
referral
– Irreversible damage can occur within 12–24 hours
Ankle Sprains
• Inversion ankle sprain
– Mechanism: plantarflexion
and inversion
– Predisposing factors
• Lateral malleolus projects
farther downward
• Weakness in peroneals
• ↓ ROM in Achilles tendon
Ankle Sprains (cont.)
• Eversion ankle sprain
– Mechanism: excessive
dorsiflexion and eversion
– Deltoid ligament
– Potential
• Lateral malleolus fracture;
bimalleolar fracture
• Tear of anterior tibiofibular
ligament and interosseous
membrane
– Predisposing factors
• Excessive pronation
• Hypomobile foot
Ankle Sprains (cont.)
– S&S (eversion sprain)
• Mild to moderate injuries
 Often unable to recall the mechanism
 Some initial pain at time of injury, but often
subsides and individual continues to play
 Swelling
» May not be as evident as a lateral sprain
» Between posterior aspect of lateral malleolus
and Achilles tendon
» Point tenderness in involved ligaments
• Severe injuries
 PROM pain-free in all motions except dorsiflexion
Ankle Sprains (cont.)
• Syndesmosis sprain
– Spreading of space at distal tibiofibular joint
– Mechanism: dorsiflexion and external rotation
– Common: anterior inferior tibiofibular ligament
– Assessment based on:
•
•
•
•
External rotation test
Squeeze test
Syndesmosis ligament palpation
Passive dorsiflexion test
Ankle Sprains (cont.)
• Management of ankle sprains
– Standard acute
– Assessment for additional damage (e.g., fracture)
– Use of appropriate immobilization
– Moderate/severe—physician referral
Strains of Foot and Lower Leg
• Gastrocnemius strain
– Medial head or musculotendinous junction
– Mechanism
• Forced dorsiflexion while knee is extended
• Forced knee extension while foot is dorsiflexed
• Muscular fatigue with fluid–electrolyte depletion and
cramping
– S&S
• Immediate pain, swelling, loss of function
– Management: standard acute; gentle stretching; heel
lifts
Strains of Foot and Lower Leg (cont.)
• Achilles tendinitis
– Risk factors
• Tight heel cords
• Foot malalignment deformities
• Recent change in shoes or running surface
• Sudden increase in workload or change in exercise environment
– Acute S&S
• Aching or burning pain in posterior heel, ↑ with passive dorsiflexion and
resisted plantarflexion
• Point tenderness and crepitus at bony insertion
• Local nodules
– Chronic S&S
• Pain worse after exercise
• Thickened tendon
• Tightness in gastrocnemius–soleus
– Management: cryotherapy; NSAIDs; activity modification
Strains of Foot and Lower Leg (cont.)
• Achilles tendon rupture
– Mechanism: push-off of forefoot while knee is extending
– More common in athletes over age 30
– S&S
•
•
•
•
•
“Pop”
Inability to stand on toes
Visible defect
Excessive passive dorsiflexion
+ Thompson’s test
– Management
• Compression wrap and splint; immediate physician referral
Overuse Conditions
• Plantar fasciitis
– Extrinsic and intrinsic risk factors
– S&S
•
•
•
•
•
Pain with first steps in the morning
Point tenderness at medial calcaneal tubercle
↑ pain with passive extension of great toe and ankle dorsiflexion
↑ pain with weight bearing
Pain relieved with activity, but recurs after rest
– Management: standard acute; refer to Field Strategy 18.4
Overuse Conditions (cont.)
• Medial tibial stress syndrome
– Periostitis along posteromedial tibial border (distal third)
– Believed to be related to periostitis of the soleus insertion along
the posterior medial tibial border
• Excessive pronation causes an eccentric contraction of soleus →
periostitis
– Other contributing factors
• Recent changes in running distance, speed, footwear, or running
surface
– S&S
• Dull pain begins at any point in the workout; occasionally sharp
and penetrating
• Pain along posteromedial border of tibia in distal third
• Pain is relieved with rest, but may recur hours after activity stops
Overuse Conditions (cont.)
• Exertional compartment syndrome
– Characterized by exercise-induced pain and swelling that is
relieved by rest
– Compartments most frequently affected—anterior (50%–
60%)
– Usually seen in well-conditioned individuals younger than
40
– S&S
•
•
•
•
•
Aching leg pain and sense of fullness over involved compartment
Often affects both legs
Symptoms relieved with cessation of exercise
Activity-related pain begins at a predictable time
Anterior compartment—mild foot drop; paresthesia on dorsum of
the foot
– Perform evaluation after exercise strenuous enough to
reproduce symptoms
– Management: assessing contributing factors
Neurologic Conditions
• Plantar interdigital neuroma (Morton’s neuroma)
– Trauma or repetitive stress → abnormal pressure on
plantar digital nerves
– Common—web space between 3rd and 4th
metatarsals; less common, between 2nd and 3rd
metatarsals
– S&S
• Sensation of having a stone in the shoe that worsens when standing
• Tingling or burning, radiating to the toes, along with intermittent
symptoms of a sharp shock-like sensation
• Pain subsides when activity is stopped or when the shoe is removed;
desire to remove the shoe and massage foot—classic sign
– Management: metatarsal pad; broad, soft-soled shoe
with a low heel
Foot and Lower Leg Fractures
• Stress fractures
– Often seen in running and jumping, especially after
significant ↑ training mileage; change in surface,
intensity, or shoe type
– Common sites
•
•
•
•
2nd metatarsal
Navicular
Calcaneus
Tibia and fibula
– S&S
• Pain begins insidiously; ↑ with activity and ↓ with rest
• Pain usually limited to fracture site
• Pain with percussion, tuning fork, or ultrasound
– Management: standard acute; physician referral
Foot and Lower Leg Fractures (cont.)
• Avulsion fractures
– Eversion sprain—deltoid ligament avulses portion of distal
medial malleolus
– Inversion sprain—plantar aponeurosis or peroneus brevis
tendon avulses base of 5th metatarsal (type II)
– Jones fracture
• Type I transverse fracture into the proximal shaft of 5th metatarsal
at junction of diaphysis and metaphysis
• Often overlooked in conjunction with a severe ankle sprain
• Complications: nonunions and delayed unions are common
– Management: standard acute; physician referral
Foot and Lower Leg Fractures (cont.)
• Ankle fracture–dislocation
– Mechanism
•
•
•
•
Landing from a height with foot in excessive eversion or inversion
Being kicked from behind while the foot is firmly planted
Foot displaced laterally at a gross angle to lower leg; extreme pain
Can compromise the posterior tibial artery and nerve
• Fracture management
– Remove shoe and sock to expose injured area
– Assess neurovascular integrity
– Mild
• Standard with physician referral
– Serious conditions
• Assess and treat for shock
• Activate EMS
Assessment
•
•
•
•
History
Observation/inspection
Palpation
Physical examination tests
Range of Motion (ROM)
•
•
•
•
AROM
AAROM
PROM
RROM
Stress Tests
• Anterior drawer test
• Talar tilt
Stress Tests (cont.)
• External rotation (Kleiger’s) test
• Thompson’s test
Stress Tests (cont.)
• Homan’s test
• Tinel’s sign
Stress Tests (cont.)
• Morton’s test
Ankle Taping Steps
1.
2.
3.
4.
5.
6.
7.
8.
9.
Anchor
Anchor
Anchor
Stirrup
Anchor
Stirrup
Anchor
Stirrup
Anchor
10. Close down
(eventually horseshoes)
11. J-Strap (or Figure 8)
12. Lateral Heel Lock
13. Medial Heel Lock
14. Lateral Heel Lock
15. Medial Heel Lock
16. Close down
17. Final closing strip