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Injuries to the Foot, Ankle and Lower Leg

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Title: Injuries to the Foot, Ankle and Lower Leg


1
Injuries to the Foot, Ankle and Lower Leg
  • Sabino Sports Medicine
  • Connie Rauser, Instructor

2
Bony Anatomy
  • Tibia
  • Fibula
  • Tarsals
  • Metatarsals
  • Phalanges
  • Sesamoid Bones

3
Tibia
  • Weight bearing bone
  • Articulates with fibula both inferiorly and
    superiorly
  • Landmarks
  • Tibial tuberosity (proximal)
  • Tibial Plateau
  • Medial Malleolus
  • Shaft

4
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

5
Tarsals
  • Talusarticulates with the tibia/fibula
  • Calcaneus
  • Navicular
  • Cuboid
  • Medial, intermediate and lateral cuneiforms

6
Joints
  • Tibiofibular joint--syndesmosis
  • Ankle joint (talocrural) Ankle mortise
  • Subtalar joint
  • Metatarsalphalangeal joints (MP)
  • Interphalangeal joints
  • PIP
  • DIP

7
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

8
Muscles of lateral compartment
  • Peroneus longus
  • Peroneus brevis
  • Both do eversion

9
Muscles of the anterior compartment
  • Tibialis Anterior
  • Extensor Digitorum Longus
  • Extensor Hallicus Longus
  • All do dorsiflexion and some inversion
  • EDLextension of toes 2-5
  • EHLextension of great toe
  • EDBextends toes 2-4 (dorsum of foot)

10
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11
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12
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
  • FHLflexion of great toe

13
Muscles of Deep Posterior Compartment
  • Gastrocnemiuscrosses knee and ankle joint. Knee
    flexion/plantar flexion
  • Soleus---crosses ankle joint. Plantarflexion
  • Join together at the Achilles tendon
  • Plantariscross ankle and knee joints. Knee
    flexion/plantar flexion
  • Tendon run parallel to the Achilles tendon
    medially

14
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15
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

16
  • Plantar fasica

17
Medial Ligaments
  • Deltoid ligament
  • 4 parts
  • Very strong
  • Not injured as often

18
Lateral ligaments
  • Anterior talofibular
  • Posterior talofibular
  • Calcaneofibular

19
Other ligaments
  • Anterior inferior tibiofibular ligament
  • Posterior inferior tibiofibular ligament

20
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)

21
Heel Bruise (Stone Bruise)
  • Mxn Landing on heels, hitting heel on something
    hardcausing 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

22
Plantar Fasciitis
  • Mxn tight heel cord, inflexibility of
    longitudinal arch, improper footwear, leg length
    discrepancy, rapid increase/change in training

23
  • 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

24
  • TX long term8-12 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 forsurgery to remove it

25
Metatarsal Fracture
  • Mxn direct force or twisting/torsion force or
    overuse
  • Most common is the Jones fracturenear base of
    5th, avulsion (at the base), midshaft

26
  • S/S POT over metatarsal, swelling, pain, pop
    or crack, possible deformity

27
  • 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

28
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

29
  • 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

30
  • TX Rest, ice, reduction of weight bearing until
    relatively pain free
  • Ultrasound
  • Arch taping

31
Turf Toe
  • Sprain of the MP joint of the great to
  • Mxn Hyperextension of great toetrauma or
    overuse
  • Usually occurs on an unyielding surface such as
    turf
  • Kicking an unyielding object

32
  • S/S POT over MP joint of great toe
  • Swelling
  • Discoloration
  • Pain with movement especially pushing off big toe
    when taking a step

33
  • TX Rest, ice, compression
  • Insert a hard insole into shoe to prevent
    hyperextension of MP joint
  • Tape for hyperextension

34
Subungual Hematoma
  • Mxn being stepped on or something being dropped
    onto the toe
  • Toes being jammed into the end of the shoe while
    running

35
  • S/S Bleeding into the nail bed (under nail)
  • Throbbing pain
  • Pressure against nail exacerbates the problem

36
  • 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

37
Blisters
  • Mxn shearing force on the skin that causes
    fluid to accumulate below top layer of skin
  • May be clear, bloody or become infected

38
  • S/S area of fluid under skin
  • Can be painful
  • May break open
  • May become infectedredness, heat, pus

39
  • 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

40
Ankle Sprains
  • Inversion
  • Eversion
  • High Ankle Sprain

41
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
    athletes foot, stepping in a hole, etc.
  • Inversion/plantar flexion

42
The inversion mxn
43
Structures injured
  • ATF lig. injured with the plantar
    flexion/inversion mxn
  • Calcaneofibular lig. and posterior talofibular
    lig. injured when then inversion force is
    increased

44
  • 3rd degree Lateral Ankle sprain

45
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46
  • 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

47
  • 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

48
Complications
  • Avulsion fracture of lateral malleolus
  • Avulsion fracture of base of 5th metatarsal
  • Push-off fracture of medial malleolus

49
Eversion Ankle Sprain
  • Less common due to bony structure of ankle
  • Deltoid ligament damage (any or all 4 portions

50
  • 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

51
  • Tx RICE, horseshoe shaped felt/foam pad,
  • crutches if necessary
  • Treat for shock
  • Medical attention with severe sprain of if
    fracture is suspected

52
Complications
  • Avulsion fracture of medial malleolus
  • Contused deltoid ligament due to impingement
    between medial malleolus and calcaneus
  • Fracture of lateral malleolus

53
High Ankle Sprain
  • Also called syndesmotic
  • Anterior and posterior tibiofibular ligaments
    damage

54
  • 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)

55
  • 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

56
  • 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

57
Complications
  • Fracture to the dome of the talus
  • Tear of the interosseus membrane

58
Ankle Fractures and Dislocations
  • Mxn similar to those of the ankle sprains but
    generally more force is applied
  • Can be open or closed

59
What do these injuries look like?
  • After the mxn
  • See the placement of the foot?

60
  • Sliding into base
  • Hes there!

61
Getting help
62
And the open ones?
  • Open Fx/dislocation
  • Open fracture

63
And some x-rays
64
  • S/S Immediate swelling
  • immense pain
  • possible deformity and/or open wound
  • POT over the bone
  • compression and percussion tests

65
  • 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

66
Tendonitis
  • Tendons most often affected
  • Tibialis posterior
  • Tibialis anterior
  • Peroneals
  • Achilles

67
  • Mxn faulty foot biomechanics
  • Inappropriate or poor/worn footwear
  • Acute trauma to tendon
  • Tightness of heel cord
  • Training errors
  • Excessive running, jumping, hills

68
  • 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

69
  • Tx Rest
  • Modalities ice, heat, ultrasound
  • NSAIDS
  • Exercise to strengthen muscle(s) involved
  • Stretching
  • Orthotics or taping to relieve stress on tendon

70
Tib/Fib fracture
  • Tibia is most commonly fractured long bone in the
    body

71
  • Mxn direct trauma to the tibia/fibula or both
  • Indirect trauma such as combination
    rotation/compressive force

72
  • S/S Immediate pain
  • Swelling
  • Possible deformity
  • May be open or closed

73
  • Tx Splint in the position you find it
  • Treat for shock
  • Call 911 if necessary
  • ER visit

74
Stress Fractures
  • Tibial (mid shaft)
  • Fibular (distal third)
  • Metatarsal (2nd is most common)

75
  • Mxn repetitive loading during training and
    conditioning and jumping
  • Faulty biomechanics combined with
    excessive/change in training

76
  • 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

77
  • Tx stop activity (2-4 weeks)
  • Alternate conditioningnon weight bearing
  • Ice
  • Crutches/protective footwear
  • Medical referral
  • Xrays
  • Bone scan

78
Medial Tibial Stress Syndrome
  • Shin splints

79
  • 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

80
  • S/S diffuse pain along the distal tibia (2/3)
    medially
  • POT in the same area
  • Pain after activitythen before/afterthen all
    the time

81
  • Tx Modify activity
  • Correct foot biomechanics (orthotics)
  • Heel cord stretching
  • Strengthening of muscles in Posterior compartment
  • Ice massage
  • Friction massage
  • Tapingarch support/ankle

82
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

83
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

84
  • Tx initially ice to reduce swelling
  • If circulation/sensory changes occuremergency
    room visit
  • Fasciotomy
  • Return to activity 2-4 months post surgery

85
Achille Tendon Rupture
  • Largest tendon in body
  • Most common in athletes over 30 yrs
  • Seen in sports with ballistic movementstennis,
    raquetball, basketball, etc.
  • Mxn sudden forceful plantar flexion of ankle

86
  • 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

87
Achilles tendon defect
88
Thompson Test
89
  • Tx immobilize
  • ice
  • Send to ER
  • Requires surgery w/ 6-8 weeks immobilization
  • Rehab to regain full ROM/Strength

90
Open achilles tendon rupture
91
Contusions
  • Mxn direct trauma to area
  • S/S pain, swelling, increased warmth, hematoma
  • Tx RICE, protective padding, modify activity if
    necessary

92
And other weird things
93
Another view
94
Treatment for this?
  • Immoblize object
  • Cut object at each end to allow for transport
  • Treat for shock
  • Surgery to remove impaled object
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