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Injuries to the Foot, Ankle and Lower Leg SPHS Sports Medicine John Hardin, Instructor Bony Anatomy Tibia Fibula Tarsals Metatarsals Phalanges Sesamoid Bones Tibia Weight bearing bone Articulates with fibula both inferiorly and superiorly Landmarks Tibial tuberosity (proximal) Tibial Plateau Medial Malleolus Shaft Fibula 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 Tarsals Talus—articulates with the tibia/fibula Calcaneus Navicular Cuboid Medial, intermediate and lateral cuneiforms Joints Tibiofibular joint--syndesmosis Ankle joint (talocrural) Ankle mortise Subtalar joint Metatarsalphalangeal joints (MP) Interphalangeal joints PIP DIP Arches 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 Muscles of lateral compartment Peroneus longus Peroneus brevis Both do eversion Muscles of the anterior compartment 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) Muscles of Superficial Posterior compartment 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 Muscles of Deep Posterior Compartment 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 medially run parallel to the Achilles tendon Miscellaneous 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 Medial Ligaments Deltoid ligament 4 parts Very strong Not injured as often Lateral ligaments Anterior talofibular Posterior talofibular Calcaneofibular Other ligaments Anterior inferior tibiofibular ligament Posterior inferior tibiofibular ligament Prevention of Injuries 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) Heel Bruise (Stone Bruise) Mxn: 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 Plantar Fasciitis Mxn: tight heel cord, inflexibility of longitudinal arch, improper footwear, leg length discrepancy, rapid increase/change in training S/S: POT 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 Metatarsal Fracture Mxn: 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: POT over 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, nonweight bearing to allow for healing Complication: Non union fracture. May require surgery to fix Longitudinal Arch Strain Mxn: 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 POT along the calcaneonavicular ligament (spring ligament) and the first cuneiform POT over 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 Turf Toe Sprain of the MP joint of the great to Mxn: Hyperextension of great toe— trauma or overuse Usually occurs on an unyielding surface such as turf Kicking an unyielding object S/S: POT over 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 Subungual Hematoma Mxn: 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 Blisters Mxn: 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 Ankle Sprains Inversion Eversion High Ankle Sprain Inversion Ankle Sprain Most common, resulting in injury to the lateral ligaments ATF ligament is the weakest of the 3 Mxn: “rolling” the ankle, landing on another athlete’s foot, stepping in a hole, etc. Inversion/plantar flexion The inversion mxn Structures injured ATF lig. injured with the plantar flexion/inversion mxn Calcaneofibular lig. and posterior talofibular lig. injured when then inversion force is increased 3rd degree Lateral Ankle sprain S/S: Pain, Swelling, discoloration, POT 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 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 Complications Avulsion fracture of lateral malleolus Avulsion fracture of base of 5th metatarsal Push-off fracture of medial malleolus Eversion Ankle Sprain Less common due to bony structure of ankle Deltoid ligament damage (any or all 4 portions Mxn: 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, POT over medial malleolus and deltoid ligament Will vary depending on severity Tx: RICE, “horseshoe” shaped felt/foam pad, crutches if necessary Treat for shock Medical attention with severe sprain of if fracture is suspected Complications Avulsion fracture of medial malleolus Contused deltoid ligament due to impingement between medial malleolus and calcaneus Fracture of lateral malleolus “High” Ankle Sprain Also called syndesmotic Anterior and posterior tibiofibular ligaments damage Mxn: 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 POT 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 Complications Fracture to the dome of the talus Tear of the interosseus membrane Ankle Fractures and Dislocations Mxn: similar to those of the ankle sprains but generally more force is applied Can be open or closed What do these injuries look like? After the mxn See the placement of the foot? Sliding into base He’s there! Getting help And the open ones? Open Fx/dislocation Open fracture And some x-rays S/S: Immediate swelling immense pain possible deformity and/or open wound POT 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 Tendonitis Tendons most often affected Tibialis posterior Tibialis anterior Peroneals Achilles Mxn: 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 POT over insertion of tendon warmth Crepitus Thickening of tendon (achilles) Stiffnes 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 Tib/Fib fracture Tibia is most commonly fractured long bone in the body Mxn: 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 Stress Fractures Tibial (mid shaft) Fibular (distal third) Metatarsal (2nd is most common) Mxn: 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 POT 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 Medical referral Xrays Bone scan footwear Medial Tibial Stress Syndrome Shin splints Mxn: 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 POT in the same area Pain after activity—then before/after— then all the time Tx: Modify activity Correct foot biomechanics (orthotics) Heel cord stretching Strengthening of muscles in Posterior compartment Ice massage Friction massage Taping—arch support/ankle Compartment Syndromes 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 Anterior compartment syndrome Mxn: 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— emergency room visit Fasciotomy Return to activity 2-4 months post surgery Achille Tendon Rupture Largest tendon in body Most common in athletes over 30 yrs Seen in sports with ballistic movements— tennis, raquetball, basketball, etc. Mxn: sudden forceful plantar flexion of ankle S/S: felt/heard a “pop” at back of leg 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 Achilles tendon defect Thompson Test Tx: immobilize ice Send to ER Requires surgery w/ 6-8 weeks immobilization Rehab to regain full ROM/Strength Open achilles tendon rupture Contusions Mxn: direct trauma to area S/S: pain, swelling, increased warmth, hematoma Tx: RICE, protective padding, modify activity if necessary And other weird things Another view Treatment for this? Immoblize object Cut object at each end to allow for transport Treat for shock Surgery to remove impaled object