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Chapter 16
Foot, Ankle, and Lower Leg
Conditions
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Anatomy
Skeletal features of the lower leg, ankle, and foot
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Anatomy (cont’d)
• Forefoot
– Metatarsals and phalanges; numerous joints
– Support and distribute body weight throughout the
foot
– Toes
• Smooth the weight shift to the opposite foot
during walking
• Help maintain stability during weight-bearing
– 1st digit – hallux or “great toe” – main body
stabilizer during walking or running
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Anatomy (cont’d)
• Midfoot
– Navicular, cuboid, 3 cuneiforms; numerous
joints
– Talocalcaneonavicular joint (TCN)
• Talus moves simultaneously on calcaneus and
navicular
• Combined action of talonavicular and subtalar
joint
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Anatomy (cont’d)
• Hindfoot
– Calcaneus and talus
– Talocrural joint (ankle joint)
• Hinge joint; plantarflexion and dorsiflexion
• Articulation of talus, tibia, and fibula
• Fibula extends farther distally than tibia – limits
eversion
• Talar dome wider anteriorly – more stable in
dorsiflexion
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Anatomy (cont’d)
• Hindfoot (cont’d)
– Talocrural joint (ankle joint) (cont’d)
• Ligaments
• Medial: deltoid
• Lateral :anterior talofibular; posterior
talofibular; calcaneofibular
– Subtalar joint
• Behaves as a flexible structure
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Anatomy (cont’d)
• Ligaments supporting the midfoot and hindfoot region
Ligaments supporting the midfoot and hindfoot region, lateral and medial views
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Anatomy (cont’d)
• Tibiofibular joints
– Superior—proximal
– Inferior—distal
– Interosseous membrane
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Anatomy (cont’d)
• Plantar arches
– Support and distribute body weight
– Longitudinal arch—medial and lateral
– Transverse arch
– Ligaments
• Spring (calcaneonavicular)
• Long plantar
• Short plantar
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Anatomy (cont’d)
Arches of the foot
Medial longitudinal arch
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Anatomy (cont’d)
• Plantar arches
Plantar fascia
– Plantar fascia
• Provides support for
the longitudinal arch
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Anatomy (cont’d)
• Nerves
– Sciatic nerve
• Tibial nerve
• Common peroneal nerve—deep and
superficial peroneal nerves
– Femoral—saphenous
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Anatomy (cont’d)
• Blood supply
Blood supply to the leg, ankle,
and foot region
– Femoral artery
– Popliteal
– Anterior and
posterior tibial
– Anterior tibial
• Dorsal pedal
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Kinematics and Major Muscle Actions
Muscles of the lower leg and foot. A. Lateral and medial view
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Kinematics and Major Muscle Actions
(cont’d)
Muscles of the lower leg and foot. B. Posterior view
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Kinematics and Major Muscle Actions
(cont’d)
Intrinsic muscles of the foot. A. Dorsal view
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Kinematics and Major Muscle Actions
(cont’d)
Intrinsic muscles of the foot. B. Plantar view
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Kinematics and Major Muscle Actions
(cont’d)
MUSCLE
COMPARTMENT
PRIMARY ACTION
Tibialis anterior
Anterior
Dorsiflexion, inversion
Extensor digitorum
longus
Anterior
Toe extension,
dorsiflexion
Extensor hallucis
longus
Anterior
Extension of great toe
Peroneus tertius
Anterior
Eversion, dorsiflexion
Peroneus longus
Lateral
Eversion, plantar
flexion
Peroneus brevis
Lateral
Eversion, plantar
flexion
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Kinematics and Major Muscle Actions
(cont’d)
MUSCLE
COMPARTMENT
PRIMARY ACTION
Flexor digitorum
longus
Posterior, deep
Toe flexion, plantar
flexion
Flexor hallucis longus
Posterior, deep
Flexion of he great toe,
plantar flexion
Tibialis posterior
Posterior, deep
Inversion, plantar
flexion
Gastrocnemius
Posterior, superficial
Plantar flexion, knee
flexion
Soleus
Posterior, superficial
Plantar flexion
Plantaris
Posterior, superficial
Plantar flexion, knee
flexion
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Kinematics and Major Muscle Actions
(cont’d)
• 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
Gait
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Kinematics and Major Muscle Actions
(cont’d)
• Motions
– Toe—flexion and extension
– Ankle (subtalar)—dorsiflexion and
plantarflexion
– Foot and ankle
• Inversion and eversion
• Pronation and supination
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Kinematics and Major Muscle Actions
(cont’d)
Motions of the foot and ankle. A. Dorsiflexion and plantar flexion. B.
Eversion and inversion. C. Supination of the subtalar joint
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Injury Prevention
• Physical conditioning
– Strengthening
• Extrinsic muscles
• Intrinsic muscles
– Flexibility
• Achilles tendon
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Injury Prevention (cont’d)
• Protective equipment
– Braces; orthotics
• Footwear
– Demands of sport; wear shoe for its intended
purpose
– Proper fit
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Toe and Foot Conditions
• Toe deformities
– Hallux rigidus
• Degenerative arthritis in first MTP
• S&S
• Tender, enlarged first MTP joint
• Loss of motion
• Difficulty wearing shoes with an elevated heel
• Hallmark sign—restricted toe extension
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Toe and Foot Conditions (cont’d)
• Toe deformities
– Hallux valgus
• Thickening of the medial capsule and bursa,
resulting in severe valgus deformity
• Asymptomatic or symptomatic
• Treatment—symptomatic
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Toe and Foot Conditions (cont’d)
Hallux valgus
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Toe and Foot Conditions (cont’d)
• 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
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Toe and Foot Conditions (cont’d)
• S&S: painful callus formation on dorsum
IP joints
Toe deformities
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Toe and Foot Conditions (cont’d)
• Pes cavus
– Excessively high arch that does
not flatten during weight bearing
– Causes can vary
– Rigid foot
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Toe and Foot Conditions (cont’d)
• Pes planus
– Flat foot; arch or instep of the foot collapsing &
contacting the ground
– Typically, acquired deformity resulting from
injury or trauma
– Mobile foot
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Toe and Foot Conditions (cont’d)
• Both conditions can be asymptomatic, but associated
with common injuries
Common foot deformities
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Contusions
• Heel contusion
– Thick padding of adipose tissue—does not
always suffice
– Stress in running, jumping, changing directions
– S&S
• Severe pain in heel
• Unable to bear weight
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Contusions (cont’d)
• Heel contusion (cont’d)
– Management: cold; heel cup or doughnut pad;
referral
– Condition may persist for months
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Contusions (cont’d)
• Gastrocnemius contusion
– S&S
• Immediate pain and weakness
• Rapid hemorrhage and muscle spasm → palpable
mass
– Management:
• Cold with gentle stretch
• If symptoms persist > 2-3 days, physician referral
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Contusions (cont’d)
• Tibial contusion (shin bruise)
– Vulnerable lack of padding
– Minor injury—caution: repeated blows →
damage periosteum
– Management: standard acute
– Key: prevention
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Lower Leg Contusions
• Acute compartment syndrome
– Lower leg includes 4 nonyielding compartments
– MOI: direct blow anterolateral aspect of the tibia
– Rapid ↑ in tissue pressure → neurovascular
compromise
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Lower Leg Contusions (cont’d)
• Acute compartment syndrome (cont’d)
– S&S
• History of trauma
• Increasingly severe pain—out of proportion to
situation
• Firm and tight skin over anterior shin
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Lower Leg Contusions (cont’d)
• Acute compartment syndrome (cont’d)
– S&S (cont’d)
• Loss of sensation between 1st and 2nd toes
on dorsum of foot
• Diminished pulse—dorsalis pedis artery
• Functional abnormalities within 30 minutes
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Lower Leg Contusions (cont’d)
• Acute compartment syndrome (cont’d)
– Management:
• Cold
• NO compression or elevation
• immediate referral to ER or summon EMS
– Irreversible damage can occur within 12–24
hours
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Toe and Foot Sprains
• IP & MP joints
– MOI: tripping or stubbing the toe
– S&S
• Pain, dysfunction, immediate swelling
• Dislocation—gross deformity
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Toe and Foot Sprains (cont’d)
• Midfoot sprains
– MOI: severe dorsiflexion, plantarflexion, or pronation
– More frequent in activities in which foot is
unsupported
– S&S
• Pain and swelling is deep on medial aspect of foot
• Weight bearing may be too painful
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Toe and Foot Sprains (cont’d)
• Turf toe
– Sprain of the plantar capsular ligament of 1st
MTP joint
– MOI: forced hyperflexion or hyperextension of
great toe
– Acute or repetitive overload
– Valgus ↑ susceptibility
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Toe and Foot Sprains (cont’d)
• Turf toe (cont’d)
– S&S (cont’d)
• 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
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Toe and Foot Sprains (cont’d)
• Management toe and foot sprains
– Standard acute
– Physician referral
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Ankle Sprains
• Inversion ankle sprain
– MOI: plantarflexion and inversion
– Predisposing factors
• Lateral malleolus projects
farther downward
• Least stable position of ankle
is plantar flexion
• Weakness in peroneals
• ↓ ROM in Achilles tendon
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Ankle Sprains (cont’d)
Inversion ankle sprain
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Ankle Sprains (cont’d)
SIGNS AND SYMPTOMS
1st
Pain and swelling on anterolateral aspect of lateral malleolus
Point tenderness over ATFL
2nd
Tearing or popping sensation felt on lateral aspect
Pain and swelling on anterolateral and inferior aspect of lateral
malleolus
Painful palpation over ATFL and CFL
May also be tender over PTFL, deltoid ligament, and anterior
capsule area
3rd
Tearing or popping sensation felt on lateral aspect
Diffuse swelling over entire lateral aspect with or without
anterior swelling
Can be very painful or absent of pain
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Ankle Sprains (cont’d)
• Eversion ankle sprain
– Mechanism: excessive dorsiflexion and eversion
– Deltoid ligament
– Potential
• Lateral malleolus fx; bimalleolar fx
• Tear of anterior tibiofibular ligament &
interosseous membrane
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Ankle Sprains (cont’d)
• Eversion ankle sprain (cont’d)
– Predisposing factors
• Excessive pronation
• Hypomobile foot
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Ankle Sprains (cont’d)
• Eversion Sprain (cont’d)
– S&S
• 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
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Ankle Sprains (cont’d)
• Eversion sprain (cont’d)
– S&S (eversion sprain)
• Mild to moderate injuries
• Swelling
• May not be as evident as a lateral sprain
• Between posterior aspect of lateral malleolus
and Achilles tendon
• Point tenderness in involved ligaments
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Ankle Sprains (cont’d)
• Eversion Sprain (cont’d)
– S&S
• Severe injuries
• PROM pain-free in all motions except
dorsiflexion
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Ankle Sprains (cont’d)
• Syndesmosis sprain (High Ankle Sprain)
– Spreading of space at distal tibiofibular joint
– MOI: dorsiflexion and external rotation
– Common: anterior inferior tibiofibular ligament
– S&S
• Point tenderness over the anterolateral tibiofibular
joint
• Significant pain and swelling
• Difficulty bearing weight
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Ankle Sprains (cont’d)
• Management of ankle sprains
– Standard acute
– Use of crutches if unable to walk without limp
– Physician referral
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Ankle Sprains (cont’d)
• Subtalar dislocation
– MOI: fall from a height (as in basketball or
volleyball); foot lands in inversion
– Disrupts interosseous talocalcaneal &
talonavicular ligament
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Ankle Sprains (cont’d)
• Subtalar dislocation (cont’d)
– S&S
• Extreme pain and total loss of function is
present
• Gross deformity may not be clearly visible
• Foot may appear pale and feel cold to the
touch
• Individual may show signs of shock
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Ankle Sprains (cont’d)
• Subtalar dislocation
– Concern: potential for peroneal tendon
entrapment and neurovascular damage
– Management: medical emergency; activate EMS;
monitor neurovascular function
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Tendinopathies of the Foot & Lower Leg
• Strains & Tendinitis
– Common sites
• Achilles tendon just proximal to insertion on
calcaneus
• Tibialis posterior just behind medial malleolus
• Tibialis anterior on dorsum of foot just under
extensor retinaculum
• Peroneal tendons just behind lateral malleolus and
at distal attachment on base of 5th metatarsal
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Tendinopathies of the Foot & Lower Leg
(cont’d)
• Strains & Tendinitis
– Predisposing factors
• Training errors
• Direct trauma
• Infection from a penetrating wound into tendon
• Abnormal foot mechanics producing friction
between shoe, tendon, and bony structure
• Poor footwear that is not properly fitted to foot
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Tendinopathies of the Foot & Lower Leg
(cont’d)
– S&S (tendinitis)
• History of morning stiffness
• Localized tenderness over tendon
• Swelling or thickness in tendon and
peritendon tissues
• Pain with passive stretching and with active
and resisted motion
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Tendinopathies of the Foot & Lower Leg
(cont’d)
– Management
• Do not permit to continue activity until seen
by a physician
• Suggest the application of cold to the area to
decrease pain and potential spasm
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Tendiopathies of the Foot & Lower Leg
(cont’d)
• 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 & cramping
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Tendinopathies of the Foot & Lower Leg
(cont’d)
• Gastrocnemius strain (cont’d)
– S&S
• Immediate pain, swelling, loss of function
– Management:
• standard acute; crutches if unable to walk
w/out a limp
• If symptoms persist > 2-3 days or modsevere injury, physician referral
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Tendinopathies of the Foot & Lower Leg
(cont’d)
Gastrocnemius muscle strain
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Tendinopathies of the Foot & Lower Leg
(cont’d)
• Achilles tendon rupture
– MOI: push-off of forefoot while knee is extending
– More common in individuals over age 30
– S&S
• “Pop”
• Inability to stand on toes
• Visible defect
• Excessive passive dorsiflexion
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Tendinopathies of the Foot & Lower Leg
(cont’d)
• Achilles tendon rupture (cont’d)
– Management
• Compression wrap; immediate transport to
emergency care facility or physician
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Tendinopathies of the Foot & Lower Leg
(cont’d)
• Achilles tendon rupture
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Overuse Conditions
• Plantar fasciitis
– Extrinsic and intrinsic risk factors
– S&S
• Pain at plantar, medial heel
• Pain with first steps in the morning, but diminshes
5-10 min
• ↑ pain with passive extension of great toe and
ankle dorsiflexion
• Pain relieved with activity, but recurs after rest
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Overuse Conditions (cont’d)
• Plantar fasciitis (cont’d)
– Management:
• Do not permit to continue activity until seen
by a physician
• Suggest application of cold to decrease pain
and spasm
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Overuse Conditions (cont’d)
• Medial tibial stress syndrome
– Periostitis along posteromedial tibial border (distal
third)
• Soleus insertion
• Excessive pronation → eccentric contraction of
soleus → periostitis
– Other contributing factors
• Recent changes in running distance, speed,
footwear, or running surface
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Overuse Conditions (cont’d)
• Medial tibial stress syndrome (cont’d)
– 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
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Overuse Conditions (cont’d)
– S&S (MTSS) (cont’d)
• Pain with resisted plantar flexion or standing
on tiptoe
• Often an associated varus alignment of the
lower extremity, including a greater Achilles
tendon angle.
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Overuse Conditions (cont’d)
– Management:
• Do not permit to continue activity until seen
by a physician
• Suggest application of cold to decrease pain
and spasm
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Overuse Conditions (cont’d)
• Exertional compartment syndrome
– Characterized by exercise-induced pain and
swelling that is relieved by rest
– Compartments most frequently affected—
anterior (50%–60%) & deep posterior (20-30%)
– Usually seen in well-conditioned individuals <40
yrs old
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Overuse Conditions (cont’d)
• Exertional compartment syndrome
– S&S
• Exercise-induced pain that is often described as a
tight, cramplike, or squeezing ache and a sense of
fullness
• Often affects both legs
• Relieved with rest, only to recur if exercise
resumes
• Anterior compartment—mild foot drop; paresthesia
dorsum of foot
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Overuse Conditions (cont’d)
• Exertional compartment syndrome
– Management:
• Stop activity
• Assessment by qualified health care
practitioner
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Foot and Lower Leg Fractures
• Repetitive microtraumas → apophyseal or stress
fractures
• Tensile forces associated with severe ankle sprains
→ avulsion fractures of 5th metatarsal
• Severe twisting → displaced and undisplaced
fractures in foot, ankle, or lower leg
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Foot and Lower Leg Fractures (cont’d)
• Freiberg's disease
– Avascular necrosis of 2nd metatarsal head
– Active adolescents ages 14–18
– S&S: diffuse pain in forefoot
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Foot and Lower Leg Fractures (cont’d)
• Sever's disease
– Traction-type injury of calcaneal apophysis
– Seen in ages 7–10
– S&S
• Heel pain with activity
• Decreased heel cord flexibility
• Pain with standing on tiptoes
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Foot and Lower Leg Fractures (cont’d)
• Stress fractures
– Common:
• Running and jumping, especially after
significant ↑ training mileage; change in
surface, intensity, or shoe type
• Women w/ amenorrhea 6 months+ and
oligomenorrhea
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Foot and Lower Leg Fractures (cont’d)
• Stress fractures (cont’d)
– Common sites
• 2nd metatarsal
• Sesamoid bones
• Navicular
• Calcaneus
• Tibia and fibula
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Foot and Lower Leg Fractures (cont’d)
• Stress fracture (cont’d)
– S&S
• Pain begins
insidiously; ↑ with
activity and ↓ with
rest
• Pain usually
limited to fracture
site
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Foot and Lower Leg Fractures (cont’d)
• Avulsion fractures
– Eversion sprain—deltoid lig. avulses distal
medial malleolus
– Inversion sprain—plantar aponeurosis or
peroneus brevis tendon avulses base of 5th
metatarsal (type II)
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Foot and Lower Leg Fractures (cont’d)
• Avulsion fractures
– 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
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Foot and Lower Leg Fractures (cont’d)
Avulsion fractures
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Foot and Lower Leg Fractures (cont’d)
• Displaced fractures and dislocations
– MOI
• Direct compression (e.g., falling from a
height)
• Compression & shearing (i.e., twisting
mechanism)
– Potential neurovascular complications
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Foot and Lower Leg Fractures (cont’d)
• Displaced fractures and dislocations (cont’d)
• Phalanges
– MOI: axial load (e.g. jamming toe) or direct trauma
(e.g., crushing)
– Swelling; ecchymosis; pain; able to walk
• Metatarsals
– Swelling; pain
– Pain increases with weight bearing
– Potential for displacement
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Foot and Lower Leg Fractures (cont’d)
• Displaced fractures and dislocations (cont’d)
– Metatarsals (cont’d)
• 1st metatarsal dislocated from 1st cuneiform;
other 4 metatarsals are displaced laterally,
usually in combination with fracture at base of
2nd metatarsal
• History of severe midfoot pain, paresthesia, or
swelling in midfoot region with variable
flattening of arch or forefoot abduction
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Foot and Lower Leg Fractures (cont’d)
• Tibia-fibula fractures
– Nearly 60% of tibial fractures involve the middle
and lower third of the tibia.
– MOI: torsional force, resulting in either a spiral
or oblique fracture of the lower third of the tibia.
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Foot and Lower Leg Fractures (cont’d)
• Tibia-fibula fractures (cont’d)
– S&S
• Gross deformity
• Gross bone motion at the suspected fracture
site
• Immediate swelling, extreme pain, or pain
with motion
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Foot and Lower Leg Fractures (cont’d)
• Ankle fracture–dislocation
– MOI
• Landing from a height with foot in excessive
eversion or inversion
• Being kicked from behind while the foot is
firmly planted
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Foot and Lower Leg Fractures (cont’d)
• Ankle fracture–dislocation (cont’d)
– S&S
• Foot displaced laterally at a gross angle to
lower leg
• Extreme pain
• Can compromise the posterior tibial artery and
nerve
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Foot and Lower Leg Fractures (cont’d)
• Fracture management
– Mild
• Standard acute with physician referral
– Serious conditions
• Activate emergency plan, including
summoning EMS
• Assess and treat for shock
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Coach and Onsite Assessment
• S &S that require immediate physician referral
(potential for EMS)
– Obvious deformity suggesting a dislocation,
fracture, or ruptured Achilles tendon
– Significant loss of motion or muscle weakness
– Excessive joint swelling
– Possible epiphyseal or apophyseal injuries
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Coach and Onsite Assessment (cont’d)
• S &S that require immediate physician referral
(potential for EMS) (cont’d)
– Abnormal sensation, or absent or weak pulse
– Gross joint instability
– Any unexplained pain that affects normal
function
• Refer to Application Strategy 16.2
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins