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Injuries%20to%20the%20Foot,%20Ankle%20and%20Lower%20Leg

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Title: Injuries%20to%20the%20Foot,%20Ankle%20and%20Lower%20Leg


1
Injuries to the Foot, Ankle and Lower Leg
  • Original Author
  • 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
Injuries to the Foot, Ankle and Lower Leg
22
Heel Bruise (Stone Bruise)
  • MOI 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

23
Plantar Fasciitis
  • MOI tight heel cord, inflexibility of
    longitudinal arch, improper footwear, leg length
    discrepancy, rapid increase/change in training

24
  • S/S Pt tender 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

25
  • 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

26
Metatarsal Fracture
  • MOI direct force or twisting/torsion force or
    overuse
  • Most common is the Jones fracturenear base of
    5th, avulsion (at the base), midshaft

27
  • S/S Pt. tenderover metatarsal, swelling, pain,
    pop or crack, possible deformity

28
  • 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

29
Longitudinal Arch Strain
  • MOI 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

30
  • S/S Pain felt just distal to the medial
    malleolus when running
  • Swelling and Pt. tenderalong the
    calcaneonavicular ligament (spring ligament) and
    the first cuneiform
  • Pt. tenderover the FHL tendon as a result of
    compensation for stress on ligament

31
  • TX Rest, ice, reduction of weight bearing until
    relatively pain free
  • Ultrasound
  • Arch taping

32
Turf Toe
  • Sprain of the MP joint of the great toe
  • MOI Hyperextension of great toetrauma or
    overuse
  • Usually occurs on an unyielding surface such as
    turf
  • Kicking an unyielding object

33
  • S/S Pt. tenderover MP joint of great toe
  • Swelling
  • Discoloration
  • Pain with movement especially pushing off big toe
    when taking a step

34
  • TX Rest, ice, compression
  • Insert a hard insole into shoe to prevent
    hyperextension of MP joint
  • Tape for hyperextension

35
Subungual Hematoma
  • MOI being stepped on or something being dropped
    onto the toe
  • Toes being jammed into the end of the shoe while
    running

36
  • S/S Bleeding into the nail bed (under nail)
  • Throbbing pain
  • Pressure against nail exacerbates the problem

37
  • 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

38
Blisters
  • MOI shearing force on the skin that causes
    fluid to accumulate below top layer of skin
  • May be clear, bloody or become infected

39
  • S/S area of fluid under skin
  • Can be painful
  • May break open
  • May become infectedredness, heat, pus

40
  • 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

41
Ankle Sprains
  • Inversion
  • Eversion
  • High Ankle Sprain

42
Inversion Ankle Sprain
  • Most common, resulting in injury to the lateral
    ligaments
  • ATF ligament is the weakest of the 3
  • MOI rolling the ankle, landing on another
    athletes foot, stepping in a hole, etc.
  • Inversion/plantar flexion

43
The inversion MOI
44
Structures injured
  • ATF lig. injured with the plantar
    flexion/inversion MOI
  • Calcaneofibular lig. and posterior talofibular
    lig. injured when then inversion force is
    increased

45
  • 3rd degree Lateral Ankle sprain

46
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47
  • S/S Pain, Swelling, discoloration, Pt. tender
    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
  • Anterior Drawer Test Tests ATF
  • Talar Tilt Calcaneofib and Deltoid Ligaments
  • Kleiger Test High Ankle
  • Calcaneus (Bump) Test Calcaneus Fx

48
  • 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

49
Complications
  • Avulsion fracture of lateral malleolus
  • Avulsion fracture of base of 5th metatarsal
  • Push-off fracture of medial malleolus

50
Eversion Ankle Sprain
  • Less common due to bony structure of ankle
  • Deltoid ligament damage (any or all 4 portions)

51
  • MOI 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, Pt.
    tenderover medial malleolus and deltoid ligament
  • Will vary depending on severity
  • Tests
  • Talar Tilt

52
  • Tx RICE, horseshoe shaped felt/foam pad,
  • crutches if necessary
  • Treat for shock
  • Medical attention with severe sprain or if
    fracture is suspected

53
Complications
  • Avulsion fracture of medial malleolus
  • Contused deltoid ligament due to impingement
    between medial malleolus and calcaneus
  • Fracture of lateral malleolus

54
High Ankle Sprain
  • Also called syndesmotic
  • Anterior and posterior tibiofibular ligaments
    damage

55
  • MOI forced dorsiflexion or extreme plantar
    flexion/inversion
  • Someone landing on the back of the leg with the
    foot in contact with the ground (dorsiflexion)

56
  • S/S may be swelling or not, may have
    discoloration or not
  • pain
  • Pt. tender over ATF and proximal to that at the
    junction of the tibia and fibula
  • painful to bear weight, unable to go up on toes

57
  • 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

58
Complications
  • Fracture to the dome of the talus
  • Tear of the interosseus membrane

59
Ankle Fractures and Dislocations
  • MOI similar to those of the ankle sprains but
    generally more force is applied
  • Can be open or closed

60
What do these injuries look like?
  • After the MOI
  • See the placement of the foot?

61
  • Sliding into base
  • Hes there!

62
Getting help
63
And the open ones?
  • Open Fx/dislocation
  • Open fracture

64
And some x-rays
65
  • S/S Immediate swelling
  • immense pain
  • possible deformity and/or open wound
  • Pt. tender over the bone
  • compression and percussion tests

66
  • 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

67
Tendonitis
  • Tendons most often affected
  • Tibialis posterior
  • Tibialis anterior
  • Peroneals
  • Achilles

68
  • MOI faulty foot biomechanics
  • Inappropriate or poor/worn footwear
  • Acute trauma to tendon
  • Tightness of heel cord
  • Training errors
  • Excessive running, jumping, hills

69
  • S/S pain with active movements and passive
    stretching
  • Pt. tender over insertion of tendon
  • warmth
  • Crepitus
  • Thickening of tendon (achilles)
  • Stiffness and pain following periods of inactivity

70
  • Tx Rest
  • Modalities ice, heat, ultrasound
  • NSAIDS
  • Exercise to strengthen muscle(s) involved
  • Stretching
  • Orthotics or taping to relieve stress on tendon

71
Tib/Fib fracture
  • Tibia is most commonly fractured long bone in the
    body

72
  • MOI direct trauma to the tibia/fibula or both
  • Indirect trauma such as combination
    rotation/compressive force

73
  • S/S Immediate pain
  • Swelling
  • Possible deformity
  • May be open or closed

74
  • Tx Splint in the position you find it
  • Treat for shock
  • Call 911 if necessary
  • ER visit

75
Stress Fractures
  • Tibial (mid shaft)
  • Fibular (distal third)
  • Metatarsal (2nd is most common)

76
  • MOI repetitive loading during training and
    conditioning and jumping
  • Faulty biomechanics combined with
    excessive/change in training

77
  • S/S pain with activity
  • Increase in pain when activity is finished
  • Gradually gets worse
  • Pt. tender on one specific point on the bone
  • Can limit ability to participate

78
  • Tx stop activity (2-4 weeks)
  • Alternate conditioningnon weight bearing
  • Ice
  • Crutches/protective footwear
  • Medical referral
  • Xrays
  • Bone scan

79
Medial Tibial Stress Syndrome
  • Shin splints
  • What is it?
  • Theories
  • Fascia pulling off of the bone (Soleus)
  • Bone Reaction (bone not being able to keep up
    between osteoclasts and osteoblasts)
  • Posterior tibialis pulling off of the medial
    surface of the bone

80
  • MOI 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

81
  • S/S diffuse pain along the distal tibia (2/3)
    medially
  • Pt. tender in the same area
  • Pain after activitythen before/afterthen all
    the time

82
  • Tx Modify activity
  • Correct foot biomechanics (orthotics)
  • Heel cord stretching (slant board)
  • Strengthening of muscles in Posterior compartment
  • Ice massage
  • Friction massage
  • Tapingarch support/ankle
  • Demonstrate Arch Taping

83
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

84
Anterior compartment syndrome
  • MOI 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

85
  • Tx initially ice to reduce swelling
  • If circulation/sensory changes occurMEDICAL
    EMERGENCY
  • Fasciotomy
  • Return to activity 2-4 months post surgery

86
Achilles Tendon Rupture
  • Largest tendon in body
  • Most common in athletes over 30 yrs
  • Seen in sports with ballistic movementstennis,
    raquetball, basketball, etc.
  • MOI sudden forceful plantar flexion of ankle

87
  • S/S felt/heard a pop at back of leg (sounds
    like a twig snap or gun shot)
  • 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

88
Achilles tendon defect
89
Thompson Test
90
  • Tx immobilize
  • ice
  • Send to ER
  • Requires surgery w/ 6-8 weeks immobilization
  • Rehab to regain full ROM/Strength

91
Open achilles tendon rupture
92
Contusions
  • MOI direct trauma to area
  • S/S pain, swelling, increased warmth, hematoma
  • Tx RICE, protective padding, modify activity if
    necessary

93
And other weird things
94
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95
Treatment for this?
  • Immoblize object
  • Cut object at each end to allow for transport
  • Treat for shock
  • Surgery to remove impaled object

96
Ankle Taping Procedures
  • Apply Tuf-Skin
  • Heel and Lace Pads
  • Pre-wrap from midfoot to 2 finger widths below
    calf belly
  • 2 anchor strips

97
  • Begin 3 Stirrups
  • In between each stirrup is a horseshoe/C strip
  • ALWAYS GO MEDIAL TO LATERAL.unless

98
  • Once 3 stirrups and C strips are in place
  • 4 heel locks
  • 2 medial
  • 2 lateral
  • 2 figure 8s

99
  • Once all parts are on the ankle
  • Close out
  • Make it Pretty

100
All Together
  1. Spray
  2. Heel and Lace Pads
  3. Pre-Wrap
  4. 2 Anchors
  5. 3 Stirrups
  6. 3 C Strips
  7. 4 Heel locks
  8. 2 medial
  9. 2 lateral
  1. 2 Figure 8s
  2. Close Out
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