Download Foot Ankle Lower Leg

Ankle, Foot, & Lower
leg
introduction
• 15% of all sports injuries
involve the ankle.
• More than 20,000 ankle
sprains occur in the US
everyday!
• Most common reason for
ER visits.
• The foot stabilizes and
supports the rest of our
body during walking,
running, and jumping.
• There are 26 bones is the
foot.
• 7 Tarsals, 5 Metatarsals, 14
Phalanges
Range of motion
• Dorsiflexion
• Plantarflexion
• Inversion
• Eversion
• Flexion (toes)
• Extension (toes)
• Pronation (combined motions of calcaneal eversion, foot abduction
and dorsiflexion)
• Supination (combined motions of calcaneal inversion, foot adduction,
and plantarflexion)
Bony anatomy
• Tibia
• Fibula
• Talus
• Calcaneus
• Navicular
• Cuneiforms (1-3)
• Cuboid
• Metatarsals (1-5)
• Phalanges (1-5)
• Lateral/Medial Malleolus
Arches of the foot
• Transverse Arch – composed of the cuneiforms, the
cuboid, and the 5th metatarsal.
Arches of the foot
• Lateral Longitudinal Arch – composed of the
calcaneus, talus, cuboid, and 4th and 5th metatarsals.
Arches of the foot
• Medial Longitudinal Arch – the highest of the three
arches; composed of the calcaneus, talus, navicular,
cuneiforms, and the first three metatarsals.
ligaments
• Reminder - Ligaments connect bone to bone!
• Lateral:
• Anterior Talofibular
• Calcaneofibular
• Posterior Talofibular
• Anterior Tibiofibular
• Medial:
• Deltoid ligaments
Main Joints of the
ankle
• Reminder – Joints are where two bones articulate or meet!
① Talocrural Joint = Formed by the Tibia, Fibula, and Talus (hinge joint
allowing plantar flexion and dorsi flexion)
② Subtalar Joint = Formed by the Talus and Calcaneus (eversion, inversion)
Muscles moving the
foot
MUSCLE
FUNCTION
Gastrocnemius
Plantar flexes foot, flexes leg
Soleus
Plantar flexed foot
Tibialis Anterior
Dorsiflexes foot, inverts and adducts
foot
Tibialis Posterior
Plantar flexes foot, inverts and adducts
foot
Peroneus Tertius
Dorsiflexes foot, everts foot
Peroneus Longus
Everts, plantar flexes foot
Peroneus Brevis
Everts foot
Plantaris
Plantar flexes foot
Muscles moving the
toes
MUSCLE
FUNCTION
Flexor Hallucis Brevis
Flexes great toe
Flexor Hallucis Longus
Flexes great toe
Extensor Hallucis Longus
Extends great toe, dorsiflexes foot
Flexor Digitorum Longus
Flexes toes, plantarflexes foot
Extensor Digitorum Longus
Extends toes, dorsiflexes foot
Abductor Hallucis
Abducts, flexes great toe
Abductor Digiti Minimi
Abducts little toe
muscles
Anatomy Summary
• The foot has 3 arches – transverse,
medial longitudinal, lateral
longitudinal.
• The foot has 26 bones – 7 tarsals, 5
metatarsals, and 14 phalanges.
• The ankle joint is made up of the
talocrural and subtalar joint.
• There are 5 main ligaments in the
ankle – anterior talofibular,
anterior tibiofibular,
calcaneofibular, posterior
talofibular, and the deltoids.
•
https://www.youtube.com/watch?v=ROd1Acma64o
•
https://www.youtube.com/watch?v=4hCS1O2LP_c
Ankle sprains
• One of the most common injuries to
the body.
• Lateral Sprain - the most common type
of sprain.
• More than 80% of ankle sprains are
lateral.
• Involves injury to the lateral ligaments.
• The anterior talofibular is the most
commonly sprained ligament because it
is the first lateral ligament that is
stressed during inversion.
• Eversion Sprain – less common.
• Involves injury to the deltoid ligaments.
Ankle sprains
• Grade 1 (Mild): 1 or
more ligaments are
stretched.
• Grade 2 (Moderate): 1
or more ligaments are
partially torn.
• Grade 3 (Severe): 1 or
more ligaments are
completely
ruptured/torn.
Ankle sprains
• MOI (Mechanism of Injury):
• Lateral Sprain = Excessive inversion
• Eversion Sprain = Excessive eversion
• S&S:
• Mild – mild discomfort, point tenderness, little or no swelling, no joint
laxity
• Moderate – pain, swelling, point tenderness, loss of function, slight
joint laxity.
• Severe – pain, loss of function, point tenderness, rapid swelling, joint
laxity.
• Special Tests: Anterior Drawer, Talar Tilt, Kleiger Test
Ankle sprains
https://www.youtube.com/watc
http://assets.sbnation.com/assets/2607549/curryankle.gif h?v=VolROn1613o
Ankle sprains
Ankle sprains
Ankle sprain
treatment
• Immediate Treatment:
• Protect – Splinting, taping, or bracing
• Rest – Avoid activity, crutches if needed
• Ice – 20 minute applications
• Compression Wrap – controls swelling (horseshoe method)
• Elevation – above the heart
• Follow-Up Treatment:
• Rehabilitation - ROM exercises, stretching, and strengthening
Ankle sprain
treatment
Syndesmosis sprain
• AKA High Ankle Sprain
• Injury to the Anterior Tibiofibular Ligament
• https://www.youtube.com/watch?v=-gKxAUyKF3c
Syndesmosis sprain
• MOI: Forceful dorsiflexion and external rotation.
• S&S:
• S&S are consistent with other sprain with the exception of
• Pain and point tenderness between the distal tibia and fibula.
• Special Test: Kleiger’s Test
• Much longer healing process
• https://www.youtube.com/watch?v=-nw7lRU223I
Syndesmosis sprain
Achilles tendonitis
• The achilles tendon attaches the
gastrocnemius and the soleus muscles to
the calcaneus.
• The gastrocnemius/soleus muscles give us
the ability to plantarflex.
• Tendonitis = inflammation of the tendon.
• Overpronation makes an athlete more at
risk.
• MOI: Chronic injury due to excessive
stress.
• S&S: Symptoms will develop gradually.
Pain and discomfort that becomes worse
over time, possible crepitus. In extreme
cases, the tendon will appear thickened.
Achilles tendonitis
treatment
• Prevention!!
• Maintaining flexibility of the
achilles tendon will prevent
injury.
• Solve biomechanical problems
such as overpronation.
• Refer to a podiatrist (foot
doctor).
• Rest
• Ice
• Anti-inflammatory medication
Achilles tendon
rupture
• Predisposing factors: Poor conditioning, decreased ROM of the
achilles tendon, athletes over 30 years old, previous history (hx) of
achilles tendonitis.
• MOI: Forceful contraction such as a sudden push off or sudden force
applied to a dorsiflexed foot.
• S&S:
• Will feel and hear a “pop”
• Visible defect
• Inability to stand on toes
• Excessive passive dorsiflexion.
• Special Test: Thompson Test
• *Surgery is required to reattach the tendon*
Achilles tendon
rupture
Achilles tendon
rupture
https:/
/www.
youtub
e.com/
watch?
v=mZ
H9Th
MDq6
c
Warm up
① Lateral ankle sprains are caused by what MOI?
② What ligaments are injured?
③ Medial ankle sprains are caused by what MOI?
④ What ligaments are injured?
⑤ What joint is formed by the talus and calcaneus?
⑥ What joint is formed by the tibia, fibula, and talus?
⑦ What joint allows inversion and eversion?
⑧ What joint allows plantar flexion and dorsi flexion?
Great toe sprain
(aka turf toe)
• Great Toe = 1st Phalange
• The great toe is important for
balance, movement, and speed.
• “Turf Toe” = a sprain to the
ligaments supporting the great
toe.
• MOI: Hyperextension of the
first metatarsophalangeal joint.
• S&S: Pain, point tenderness,
swelling, ecchymosis, limited
mobility.
Great toe sprain
(aka turf toe)
Great toe sprain
(aka turf toe)
• Treatment:
• PRICE Method
• When normal function is
restored and the athlete is
ready to RTP, use taping
techniques to provide
support/limit movement.
Great toe sprain
(aka turf toe)
Plantar fascitis
• Plantar Fascia = a wide, nonelastic
ligamentous tissue that extends from the
anterior portion of the calcaneus to the
heads of the metatarsals.
• Supports the longitudinal arches of the
foot.
Plantar fascitis
• MOI: Chronic irritation of the plantar fascia
causing inflammation. Examples…..
• Running on hard surfaces
• Unsupportive footwear
• Repetitive running and jumping sports
• Tight achilles tendon
• S&S: Pain and point tenderness on the bottom of
the foot near the heel.
Plantar fascitis
treatment
• Correcting training errors
• Evaluate athlete’s shoes and activity
levels
• Wear shoes with more arch support to
help decrease stress
• Ice
• Massage
• Taping techniques for arch support
• Stretching
Plantar fascitis
treatment
Medial tibial stress
syndrome (Mtss)
• AKA Shin Splints!
• Chronic/Overuse
injury
• Inflammation of the
periosteum (outer layer
of bone).
• Usually occurs on the
distal third of the
medial tibial border.
• Typical in
runners/jumpers.
Medial tibial stress
syndrome (Mtss)
• Causes:
• Tightness of the
gastrocnemius/soleus.
• Running on hard or
uneven surfaces.
• Poor footwear.
• Excessive pronation.
• Recent changes in
running distances, speed,
form, stretching,
footwear, or running
surface.
Medial tibial stress
syndrome (Mtss)
• S&S:
• Dull pain that begins at any point in the workout; occasionally
may be sharp and penetrating.
• Pain occurs along the medial border of the tibia in a 3-6 cm area;
usually in the distal third.
• Pain is relieved with rest, but may recur hours after activity stops.
• Pain aggravated by plantar flexion.
• In later stages, pain will be present before, during, and after
activity and may restrict performance.
Medial tibial stress
syndrome (Mtss)
• Treatment:
• 5-7 days of rest to relieve acute symptoms.
• Cryotherapy (Ice, Whirlpool, Ice massage)
• NSAIDS (Anti-inflammatory medication)
• Increase flexibility/strength in anterior and
posterior musculature.
• Analysis of running mechanics, foot
alignment, running surface, and footwear.
• If pain persists R/O stress fractures.
Evaluation of the
foot/ankle/ lower
leg injuries
H.O.P.S
• H.O.P.S.
• History – How did it happen (MOI), location
of pain, previous hx.?
• Observation – What do you see/observe?
• Palpation – Palpate for crepitus, spasm, point
tenderness, warmth, etc.
• Special Tests – Assess ROM, Manual Muscle
Tests (MMT) and Special tests.
history
 Mechanism of Injury – Acute vs. Chronic?
Example: How did the injury occur?
 Pain – Location, Type, Severity
Example: Where is the location of your pain? What type of pain is it –
sharp, dull, aching, tingling, numbness, burning? On a scale of 1-10 how
bad is your pain?
 Did your hear a Snap, Crack, or Pop?
 What increases and decreases the pain?
 Do you have a previous history of injury?
 Do you have pain with certain motions?
 What sport do you participate in and what position?
observation
CHECKLIST:
Observation =
What you see or
observe.
Remember to
compare
bilaterally!
(Compare the
uninjured side to
the injured side)
Deformity
Guarding
Apprehension
Swelling
Ecchymosis
Hematoma
Abrasions
Scars
Atrophy
palpation
• Palpate bilaterally
• Palpation Checklist:
• Palpate ALL:
Crepitus
①BONEY
Structures
Spasm
②SOFT Tissue
Structures
(Muscles,
Tendons,
Ligaments)
Tension
Point Tenderness
Warmth
Special tests
①Assess ROM in all directions
②MMT’s (Manual Muscle Tests)
③Special Tests:
ROM
• Ask the athlete to perform the appropriate ROM depending
on the joint to the best of their ability (Example: Ankle =
plantarflexion, dorsiflexion, inversion, eversion)
• Check both extremities simultaneously, noting any
differences.
• The motion should be smooth and painless.
• Limited ROM on one side indicates potential injury or
deformity.
Manual muscle tests
MMT = manually testing an athlete’s
strength to note any abnormalities due to
injury.
Compare the strength between the
involved and uninvolved extremity to
note any differences.
Weakness on one side indications
potential injury or deformity.
Special tests
• Compression/Squeeze Test – Fracture
• Anterior Drawer Test – ATF injury
• Inversion Talar Tilt Test – CF injury
• Eversion Talar Tilt Test– Deltoid Ligament
injury
• Kleiger’s Test – Anterior Tibiofibular injury
• Thompson Test – Achilles Tendon Rupture
Compression/squeeze
test
• Injury: Tibia/Fibula fracture or tibiofibular joint sprain
• Patient Position: Supine or sitting with legs over the edge of the
table
• Examiner Position: At patient’s feet
• Hand Position: Cupped over the tibia and fibula away from the
pain site
• Exam Procedure: Compress or squeeze the tibia and fibula,
repeat towards the injury site.
• + Sign: Pain with compression, pain with release.
Compression/squeeze
test
https://www.youtube.com/watch?v=409QcILpZe0
Anterior Drawer
test
• Injury: Anterior Talofibular ligament laxity
• Patient Position: Sitting with knees flexed at tables edge
• Examiner Position: At patient’s feet
• Hand Position: Stabilizing distal tibia and fibula, cupping the
calcaneus
• Exam Procedure: The gastroc should be relaxed with the ankle at
20-30 degrees of plantarflexion. The examiner will then
anteriorly translate the calcaneus and talus while stabilizing the
distal tibia.
• + Sign: Increased anterior translation or laxity, soft or no end
feel, sometimes pain.
Anterior Drawer
test
https://www.
youtube.com
/watch?v=zja
uu5gXF2A
https://w
ww.youtub
e.com/wat
ch?v=dprn
jn_OTzo
Talar tilt test
(inversion)
• Injury: Calcaneofibular ligament laxity, with possible ATF or
PTF involvement.
• Patient Position: Supine or sitting with legs over the edge of the
table.
• Examiner Position: At patient’s feet.
• Hand Position: On the calcaneus with fingers over the CF
ligament and distal tibia.
• Exam Procedure: With the foot in neutral apply an inversion
stress by rolling the calcaneus medially, creating a talar tilt.
• + Sign: Excessive talar tilt when compared bilaterally, pain.
Talar tilt test
(inversion)
Talar tilt test
(eversion)
• Injury: Deltoid ligament laxity.
• Patient Position: Supine or sitting with legs over the edge of
the table.
• Examiner Position: At patient’s feet.
• Hand Position: On the calcaneus with fingers over the
deltoid ligaments and distal tibia.
• Exam Procedure: With the foot in neutral apply an eversion
stress by rolling the calcaneus laterally, creating a talar tilt.
• + Sign: Excessive talar tilt when compared bilaterally, pain.
Talar tilt test
(eversion)
https://w
ww.youtub
e.com/wat
ch?v=1IrI6
Bks6hY
Kleiger’s test
• Injury: Tibiofibular ligament or syndesmosis injury.
• Patient Position: Sitting with legs over the edge of the
table.
• Examiner Position: At patient’s feet.
• Hand Position: Stabilizing the distal tibia and over the
medial foot keeping the ankle in neutral.
• Exam Procedure: Stabilize tibia and externally rotate the
foot with ankle slightly dorsiflexed.
• + Sign: Anterior lateral ankle pain, distal tibiofibular joint
pain, or syndesmosis pain.
Kleiger’s test
https://ww
w.youtube.c
om/watch?
v=LnB1fta_
rQA
https://ww
w.youtube.c
om/watch?
v=3GrwcyJ
W7lE
thompson test
https://ww
w.youtube.c
om/watch?
v=HPkaNd
G2uus
thompson test
• Injury: Achilles tendon rupture.
• Patient Position: Prone with ankles over the edge
of the table.
• Examiner Position: At patient’s side by their feet.
• Hand Position: Over the belly of the gastroc.
• Exam Procedure: Squeeze gastroc while observing
for plantarflexion of the foot.
• + Sign: Foot will NOT plantarflex with gastroc
squeeze.