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Original Author: Sabino Sports Medicine Connie Rauser, Instructor • • • • • • Tibia Fibula Tarsals Metatarsals Phalanges Sesamoid Bones • Weight bearing bone • Articulates with fibula both inferiorly and superiorly • Landmarks • • • • Tibial tuberosity (proximal) Tibial Plateau Medial Malleolus Shaft • Non-weight bearing bone • Extends down past calcaneus providing bony support to prevent eversion • Serves as site for muscle attachments • Landmarks • Head of fibula (proximal) • Lateral malleolus • • • • • Talus—articulates with the tibia/fibula Calcaneus Navicular Cuboid Medial, intermediate and lateral cuneiforms • • • • • Tibiofibular joint--syndesmosis Ankle joint (talocrural) Ankle mortise Subtalar joint Metatarsalphalangeal joints (MP) Interphalangeal joints • PIP • DIP • Transverse: proximal across tarsals • Medial longitudinal arch: from calcaneus to 1st metatarsal • Strengthened by spring ligament (plantar calcaneonavicular ligament) • Lateral longitudinal arch: from calcaneus to 5th metatarsal • Metatarsal arch: shaped by distal heads of metatarsals • Peroneus longus • Peroneus brevis • Both do eversion • Tibialis Anterior • Extensor Digitorum Longus • Extensor Hallicus Longus • All do dorsiflexion and some inversion • EDL—extension of toes 2-5 • EHL—extension of great toe • **EDB—extends toes 2-4 • (dorsum of foot) • Tibialis Posterior (Tom) • Flexor Digitorum Longus (Dick) • Flexor Hallicus Longus (Harry) • All do Plantar Flexion and Inversion • FDL– flexion of toes 2-5 • FHL—flexion of great toe • Gastrocnemius—crosses knee and ankle joint. Knee flexion/plantar flexion • Soleus---crosses ankle joint. Plantarflexion • Join together at the Achilles tendon • Plantaris—cross ankle and knee joints. Knee flexion/plantar flexion • Tendon run parallel to the Achilles tendon medially • Plantar Fascia • From calcaneus to heads of metatarsals. • Maintain stability of foot and supports medial longitudinal arch • Interosseus Membrane • Thick connective tissue runs length of tib/fib and holds them together Plantar fasica • Deltoid ligament • 4 parts • Very strong • Not injured as often • Anterior talofibular • Posterior talofibular • Calcaneofibular • Anterior inferior tibiofibular ligament • Posterior inferior tibiofibular ligament • • • • Wear properly fitting shoes Ankle support Protective equipment Maintain adequate strength and flexibility • Heel cord stretching • Strengthening in inversion, eversion, plantar and dorsiflexion • Proprioception (balance training) • MOI: Landing on heels, hitting heel on something hard—causing a contusion to the bottom of calcaneus • S/S: Severe pain in heel, difficulty weight bearing, POT • TX: ice, rest/non weight bearing til pain subsides, heel cup or doughnut when returning • Complication: inflammation of periosteum • MOI: tight heel cord, inflexibility of longitudinal arch, improper footwear, leg length discrepancy, rapid increase/change in training • S/S: Pt tender over the anteriomedial calcaneus and plantar fascia, stiffness and pain in AM or after prolonged sitting, pain with passive extension of toes combined with dorsiflexion • TX: long term—8-12 weeks vigorous heel cord stretching, ice massage, heel cup, taping, ultrasound, NSAIDS, Last resort: surgery to cut the fascia Complications: can develop a bone spur if not cared for— surgery to remove it • MOI: direct force or twisting/torsion force or overuse • Most common is the Jone’s fracture—near base of 5th, avulsion (at the base), midshaft • S/S: Pt. tenderover metatarsal, swelling, pain, “pop” or “crack”, possible deformity • Tx: Ice, Compression wrap, crutches, send to Dr. for x-ray. • Possibly on crutches for 6-8 weeks, non-weight bearing to allow for healing • Complication: Non union fracture. May require surgery to fix • MOI: Unaccustomed stresses/forces placed on foot when in contact with a hard playing surface. • Flattening of the foot (arch) when in midsupport phase • May occur suddenly or over a longer period of time • S/S: Pain felt just distal to the medial malleolus when running • Swelling and Pt. tenderalong the calcaneonavicular ligament (spring ligament) and the first cuneiform • Pt. tenderover the FHL tendon as a result of compensation for stress on ligament • TX: Rest, ice, reduction of weight bearing until relatively pain free • Ultrasound • Arch taping • Sprain of the MP joint of the great toe • MOI: Hyperextension of great toe—trauma or overuse • Usually occurs on an unyielding surface such as turf • Kicking an unyielding object • S/S: Pt. tenderover MP joint of great toe • Swelling • Discoloration • Pain with movement especially pushing off big toe when taking a step • TX: Rest, ice, compression • Insert a hard insole into shoe to prevent hyperextension of MP joint • Tape for hyperextension • MOI: being stepped on or something being dropped onto the toe • Toes being jammed into the end of the shoe while running • S/S: Bleeding into the nail bed (under nail) • Throbbing pain • Pressure against nail exacerbates the problem • TX: drain the blood from the nail • Use a drill bit • Heat a paperclip and burn through nail • Use a scalpel to make hole in nail • MOI: shearing force on the skin that causes fluid to accumulate below top layer of skin • May be clear, bloody or become infected • S/S: area of fluid under skin • Can be painful • May break open • May become infected—redness, heat, pus • TX: cover with skin lube, bandage, foam or felt doughnut around it. • If large, then drain, but clean it and treat as open wound • Cover prior to practices/competitions • Inversion • Eversion • High Ankle Sprain • Most common, resulting in injury to the lateral ligaments • ATF ligament is the weakest of the 3 • MOI: “rolling” the ankle, landing on another athlete’s foot, stepping in a hole, etc. • Inversion/plantar flexion • ATF lig. injured with the plantar flexion/inversion MOI • Calcaneofibular lig. and posterior talofibular lig. injured when then inversion force is increased 3rd degree Lateral Ankle sprain • S/S: Pain, Swelling, discoloration, Pt. tender over the sinus tarsi, the distal end of the lateral malleolus and posterior of the lateral malleolus, joint instability, joint stiffness, decreased ROM, “+” anterior drawer test • Will vary with the degree of the injury • • • • Anterior Drawer Test – Tests ATF Talar Tilt – Calcaneofib and Deltoid Ligaments Kleiger Test – High Ankle Calcaneus (Bump) Test – Calcaneus Fx • Tx: RICE, “horseshoe” shaped felt/foam pad fit around the lateral malleolus • Treat for shock • crutches if necessary • Medical attention if severe or possibility of fracture • Avulsion fracture of lateral malleolus • Avulsion fracture of base of 5th metatarsal • Push-off fracture of medial malleolus • Less common due to bony structure of ankle • Deltoid ligament damage (any or all 4 portions) • MOI: ankle everts due to----someone/something landing on the lateral aspect of leg during weight bearing or--• S/S: Pain, swelling, discoloration, joint instability, joint stiffness, decreased ROM, Pt. tenderover medial malleolus and deltoid ligament • Will vary depending on severity • Tests: • Talar Tilt • Tx: RICE, “horseshoe” shaped felt/foam pad, • crutches if necessary • Treat for shock • Medical attention with severe sprain or if fracture is suspected • Avulsion fracture of medial malleolus • Contused deltoid ligament due to impingement between medial malleolus and calcaneus • Fracture of lateral malleolus • Also called syndesmotic • Anterior and posterior tibiofibular ligaments damage • MOI: forced dorsiflexion or extreme plantar flexion/inversion • Someone landing on the back of the leg with the foot in contact with the ground (dorsiflexion) • S/S: may be swelling or not, may have discoloration or not • pain • Pt. tender over ATF and proximal to that at the junction of the tibia and fibula • painful to bear weight, unable to go up on toes • Tx: RICE, Crutches, medical attention if unable to bear weight or if significant swelling occurs • Treat for shock • Hard to treat and can take weeks to heal • Fracture to the dome of the talus • Tear of the interosseus membrane • MOI: similar to those of the ankle sprains but generally more force is applied • Can be open or closed After the MOI See the placement of the foot? Sliding into base He’s there! Open Fx/dislocation Open fracture • • • • • S/S: Immediate swelling immense pain possible deformity and/or open wound Pt. tender over the bone + compression and percussion tests • • • • • Tx: Splint in the position you find it Care for open wound if necessary Treat for shock Call 911 if the injury is severe/open ER visit • Tendons most often affected • Tibialis posterior • Tibialis anterior • Peroneals • Achilles • MOI: faulty foot biomechanics • Inappropriate or poor/worn footwear • Acute trauma to tendon • Tightness of heel cord • Training errors • Excessive running, jumping, hills • S/S: pain with active movements and passive stretching • Pt. tender over insertion of tendon • warmth • Crepitus • Thickening of tendon (achilles) • Stiffness and pain following periods of inactivity • Tx: Rest • Modalities: ice, heat, ultrasound • NSAIDS • Exercise to strengthen muscle(s) involved • Stretching • Orthotics or taping to relieve stress on tendon • Tibia is most commonly fractured long bone in the body • MOI: direct trauma to the tibia/fibula or both • Indirect trauma such as combination rotation/compressive force • S/S: Immediate pain • Swelling • Possible deformity • May be open or closed • Tx: Splint in the position you find it • Treat for shock • Call 911 if necessary • ER visit • Tibial (mid shaft) • Fibular (distal third) • Metatarsal (2nd is most common) • MOI: repetitive loading during training and conditioning and jumping • Faulty biomechanics combined with excessive/change in training • S/S: pain with activity • Increase in pain when activity is finished • Gradually gets worse • Pt. tender on one specific point on the bone • Can limit ability to participate • Tx: stop activity (2-4 weeks) • • • • Alternate conditioning—non weight bearing Ice Crutches/protective footwear Medical referral • Xrays • Bone scan • Shin splints • What is it? • Theories • Fascia pulling off of the bone (Soleus) • Bone Reaction (bone not being able to keep up between osteoclasts and osteoblasts) • Posterior tibialis pulling off of the medial surface of the bone • MOI: strain of tibialis posterior tendon and its fascial sheath at attachment to periosteum of distal tibia due to running/etc. • Faulty biomechanics • Improper footwear • Tight heel cord/Achilles tendon • Training errors • S/S: diffuse pain along the distal tibia (2/3) medially • Pt. tender in the same area • Pain after activity—then before/after—then all the time • • • • • • • Tx: Modify activity Correct foot biomechanics (orthotics) Heel cord stretching (slant board) Strengthening of muscles in Posterior compartment Ice massage Friction massage Taping—arch support/ankle • Demonstrate Arch Taping • • • • Increased pressure in the compartment(s) of the leg Causes compression of the muscles & neurovascular structures Anterior, lateral, deep posterior common 3 types • Acute • Acute exertional • Chronic • MOI: direct blow to the anterior compartment • S/S: deep aching pain • Tightness & swelling • Pain with passive stretching • Reduced circulation/sensory changes in foot • May have LOM • Tx: initially ice to reduce swelling • If circulation/sensory changes occur—MEDICAL EMERGENCY • Fasciotomy • Return to activity 2-4 months post surgery • Largest tendon in body • Most common in athletes over 30 yrs • Seen in sports with ballistic movements—tennis, raquetball, basketball, etc. • MOI: sudden forceful plantar flexion of ankle • S/S: felt/heard a “pop” at back of leg (sounds like a twig snap or gun shot) • • • • • Felt as is someone hit them with a rock Pain with plantar flexion/dorsiflexion Inability to plantar flex Palpable/visible defect at the achilles tendon + Thompson test • Tx: immobilize • ice • Send to ER • Requires surgery w/ 6-8 weeks immobilization • Rehab to regain full ROM/Strength • MOI: direct trauma to area • S/S: pain, swelling, increased warmth, hematoma • Tx: RICE, protective padding, modify activity if necessary • • • • Immoblize object Cut object at each end to allow for transport Treat for shock Surgery to remove impaled object • Apply Tuf-Skin • Heel and Lace Pads • Pre-wrap from midfoot to 2 finger widths below calf belly • 2 anchor strips • Begin 3 Stirrups • In between each stirrup is a horseshoe/C strip • ALWAYS GO MEDIAL TO LATERAL….unless • Once 3 stirrups and C strips are in place • 4 heel locks • 2 medial • 2 lateral • 2 figure 8s • Once all parts are on the ankle • Close out • Make it Pretty 1. 2. 3. 4. 5. 6. 7. Spray Heel and Lace Pads Pre-Wrap 2 Anchors 3 Stirrups 3 C Strips 4 Heel locks 1. 2 medial 2. 2 lateral 8. 2 Figure 8s 9. Close Out