Download Session III

The Foot, Ankle, & Lower Leg Injuries
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Foot Anatomy
– Bones
• 26 bones
– 7 tarsal-talus, calcaneous, navicular, cuboid, 3 cuneiforms
– 5 metatarsal
– 14 phalanges- 1st toe has 2; toes 2-5 has 3
– Arches
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Anterior metatarsal - shaped by the distal heads of the MT; stretches across the 1st to the 5th
• Transverse - extends across the transverse tarsal bones; forms a half dome; gives protection to
soft tissue and increases the foot’s mobility
• Medial longitudinal – originates along the medial border of the calcaneus and extends to the
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distal head of the 1st MT; supports the medial arch
Lateral longitudinal – outer aspect of foot & follows the same pattern as the medial longitudinal;
much lower & less flexible than the medial longitudinal
Muscles and Movements
– Dorsiflexion
• Tibialis anterior
• Extensor digitorium longus
• Extensor hallicus longus
• Peroneus tertius
– Plantarflexion
• Peroneus longus/brevis
• Tibialis posterior
• Flexor digitorium longus
• Flexor hallicus longus
– Inversion, adduction, and supination
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• Tibialis posterior
• Flexor digitorium longus
• Flexor hallicus longus
• Tibialis anterior
• Extensor hallicus longus
Eversion, abduction, and pronation
• Peroneus longus/brevis
• Peroneus tertius
• Extensor digitorium longus
Foot assessment
– History
• Type of surface for training?
• Type of footwear worn?
• Is discomfort increased when footwear is worn?
– Observation
• Is athlete favoring the foot, walking with a limp, or unable to bear weight?
• Does the foot change color weight bearing vs. non weight bearing?
• Pes planus (flatfoot) or pes cavus (high arch)?
• Toe abnormalities?
• Is the foot well-aligned? Does it maintain its shape on weight bearing? Shoe patterns?
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Palpation
• Medial, lateral, dorsal, and plantar aspects of foot
• Pulses
– Tibialis posterior-behind medial malleolus
– Dorsal pedal-midpoint between medial & lateral malleolus to the proximal end of the 1 st
intermetatarsal space
Recognition and management of specific injuries
– Heel bruise
• Cause – sudden stop & go; sudden horizontal & vertical movement
• Signs – severe pain in heel; unable to bear weight
• Care – ice; rest; NWB for 24 hours; heel cup; doughnut
– Plantar fascitis
• Cause – leg length discrepancy; inflexibility of longitudinal arch; Gastroc/soleus tightness;
shoes without arch support
• Signs – pain worse in morning; pain with long sitting periods, but lessens after first few steps
• Care – vigorous heel cord stretching; PF stretching; heel cup; arch tape; orthotics
– Fractures of the metatarsal
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• Cause – direct force
• Signs of injury – swelling; pain; deformity; pt. tenderness
• Care – rest; immobilization
Jones fracture
• Cause – neck of 5th MT-overuse; acute inversion; high velocity rotation
• Signs – sharp pain of lateral border of foot; “pop”; Care – cast 6-8 weeks; longer with surgery;
long rehab due to poor blood supply
– Bunions
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• Cause – painful deformity of head of 1st MT; shoes-pointed, too narrow, to short, high heels
• Signs – tenderness, swelling, enlargement with calcification of head of 1 st MT
• Care – shoes; doughnut; orthotics
Blisters
• Cause – shearing forces acting on skin
• Signs – fluid-clear, bloody, or infected
• Care – petroleum jelly; doughnut; second skin; drain; antibiotic ointment; wearing socks with no
folds/wrinkles
– Morton’s Neuroma
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• Cause – mass that occurs about the nerve sheath of the common plantar nerve; collapse of the
transverse arch of the foot; excessive foot pronation
• Signs – burning paresthesia; severe intermittent pain in the forefoot
• Care – padding; shoes; surgery
Turf toe
• Cause – hyperextension of 1st MTP joint from sudden trauma or overuse; turf
• Signs – pain; swelling
• Care – steel insoles; tape to prevent DF
– Calluses
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• Cause – shoes too narrow/short; friction; faulty foot mechanics
• Signs – hard, cracked, layers of skin usually found on calcaneus and plantar aspect of foot
• Care – emery callus file; wedges; doughnuts; orthotics
Ingrown toenail
• Cause – toenail grown into soft tissue
• Signs – inflammation; infection
• Care – soak in hot water for 20 minutes; cotton; trimming nail across
Toenail hematoma
• Cause – stepped on; dropping object on toe; kicking another object
• Signs – extreme pain; bleeding in nail bed
• Care – ice; drill nail
The Ankle and Lower Leg Anatomy
– Bones
• Tibia
• Fibula
• Talus
• Calcaneus
– Ligaments
• Lateral
• Tibiofibular-anterior & posterior; holds the tibia & fibula together
• Anterior talofibular (ATF) – prevents anterior displacement of talus
• Posterior talofibular (PTF) – prevents posterior displacement of talus
• Calcaneofibular – restrains inversion of calcaneous
• Medial
• Deltoid – triangular in shape; restrains eversion of calcaneous
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Musculature
Anterior Compartment
extensor digitorium longus
extensor hallicus longus
tibialis anterior
Superficial posterior compartment
gastrocnemius
soleus
Deep posterior compartment
tibialis posterior
flexor digitorium longus
flexor hallicus longus
Lateral compartment
peroneus longus
peroneus brevis
Prevention
– Heel cord stretching
• Before and after activity
– Strength training
• Achieving static & dynamic joint stability
– Neuromuscular control
• Enhanced by locomotion on uneven surfaces or balance board
– Footwear
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• Shoes for which they are intended
Taping/bracing
• Prophylactic protection
Assessing the Lower Leg
– History
• Is there any sense of muscle weakness or difficulty in walking?
• Could you bear weight right away?
• Have you hurt the ankle before?
• Was there immediate swelling, or did the swelling occur later (or at all)?
– Observation
• Is there a normal walking pattern?
• Are the bony contours of the ankle normal and symmetrical, or is there a deviation such as a
bony deformity?
• Are the color and texture of the skin normal?
• Is there crepitus or abnormal sound in the ankle joint?
– Palpation
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• Bony & soft tissue
• Determine obvious structural deformities, areas of swelling, or points of tenderness
Special tests
• Thompson test – squeeze the calf muscle while the leg is extended and the foot is hanging over
the edge of the table; + test is one in which squeezing the calf muscle does not cause the heel to
move or pull upward
• Homan’s sign – athlete is in a supine position with the knee fully extended; the ankle is
passively dorsiflexed so that the calf muscles are stretched; + test is pain in the calf – indication
of deep vein thrombophlebitis
• Bump, lever, and compression - + test indicates a possible fracture to lower leg and/or ankle
• Anterior drawer test – athlete sits with legs and feet relaxed; grasping the lower leg in one hand
and the calcaneus in the palm of the other hand, the tibia is pushed backward as the calcaneus is
pulled forward; + test occurs when the foot slides forward and sometimes makes a clunking
sound as it reaches its end point indicating a tear in the ATF ligament
• Talar tilt test – with the foot positioned at 90° to the lower leg and stabilized, the calcaneus is
inverted; + test is excessive motion of the talus indicating injury to the CF and possibly the ATF
and PTF ligaments
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Functional Exam
– If the following movements aggravate a recent injury, they should be avoided
• Walks on toes (tests PF)
• Walks on heels (tests DF)
• Walks on lateral border of feet (tests inversion)
• Walks on medial border of feet (tests eversion)
• Hops on the injured ankle
• Start/stop run motion
• Changing directions quickly
• Figure 8’s
Injuries to the Ankle
– Ankle sprains
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• Cause – INV/PF most common; EV may involve avulsion-longer to heal
• Signs – tearing of ligament; swelling; joint instability; grades
• Care – RICE; NSAIDs; horseshoe; splint; NWB; rehab
Ankle fractures
• Cause – same MOI as sprains
• Signs – immediate swelling; point tenderness over bone; apprehension to bear weight
• Care – splint; referral; cast for 6 weeks; rehab
Tendinitis
• Cause – faulty foot mechanics; footwear; acute trauma; tight heel cord; training errors
• Signs – pain with active and passive movement; swelling; crepitus; stiffness
• Care – rest; ice; NSAIDs; orthotics/tape
Injuries to the Lower Leg
– Tibial and fibular fractures
• Cause – tibia – most common long bone fx; direct or indirect trauma-combination of rotation &
compression force
• Signs – immediate pain; swelling; deformity; pain with ambulation
• Care – referral; immobilization for weeks/months
– Tibial and fibular stress fractures
• Cause – tibia > fibula; repetitive loading; jumping athletes
• Signs – pain with activity; worse when stopped; focal pt. tenderness on bone vs. diffuse
• Care – REST; weight bearing is OK-sometimes with a walking boot
– Shin splints (Medial Tibial Stress Syndrome)
• Cause – strain of tibialis posterior in running activities; secondary to faulty foot mechanics; heel
cord tightness; muscle weakness; shoes; changing surfaces
• Signs – diffuse pain distal tibia; initially pain is post activity, but as the condition progresses,
pain is with daily ambulation, and in the morning there is pain and stiffness
• Care – rule out stress fracture; G/S stretching; ice; strengthening of lower leg muscles; correct
foot mechanics
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Compartment syndrome
– Cause – increase in pressure causes compression of muscle & neurovascular structures; acute –
direct trauma; acute exertional – no trauma; evolves with minimal to excessive activity; chronic –
symptoms consistent at certain point in activity & ceases post activity
– Signs – deep aching pain; tightness/swelling of compartment; pain with passive stretch; neurological
involvement is rare
– Care – ice; elevation; no compression NSAIDs; surgery (fasciotomy)
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Achilles’ tendon rupture
– Cause – sudden, forceful PF; 30 + - ballistic movement
• Signs – feel/hear pop; kicked/shot; PF is painful & limited; palpable defect
• Care – surgery; 6-8 weeks immobilization
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Achilles’ tendinitis
– Cause – repetitive stresses/strains; increase in duration/intensity is too soon; hill workouts increase
the pain
– Signs – general pain & stiffness; gradual onset; morning pain/stiffness; warm & painful to
palpation; thickening; crepitus
– Care – decrease activity; G/S stretching
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Shin contusions
• Cause – forceful blow to the anterior leg
• Signs – intense pain; hematoma forms & is jellylike; possible compartment syndrome or
fracture
• Care – RICE; NSAIDs; padding
Leg cramps and spasms
• Cause – fatigue; excess loss of fluid
• Signs – pain with contraction of the calf muscle
• Care – mild, gradual stretching; ice massage; water/electrolyte replacement
Gastrocnemius strain
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Cause – medial head is particularly susceptible; sports that require quick stops/starts and jumping;
quick stop with foot planted flat and suddenly extends the knee
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Signs – pain; swelling; muscle disability; “hit in the calf with a stick”
Care – gentle, gradual stretch after muscle cooling; wedge in shoe; elastic wrap