[CN]CHAPTER 17



CHAPTER 17

The Foot, Ankle, and Lower Leg

Preparation and Resources Needed

Materials: None.

Equipment: One or more models of the ankle showing ligament and tendon attachments.

Personnel: Podiatrist to talk about the complications found in the foot and how the field of podiatry came to be so specialized.

Recommended Time to Complete: Seven days (based on two class periods per day, 170 school days per year). More activities are available through the textbook, workbook, and instructor’s manual than can be fit into the recommended time. The instructor should select activities that best suit his or her own teaching situation and training program duration.

Key Terms

Achilles tendon A tendon in the back of the ankle and foot that attaches the gastrocnemius and soleus muscles to the calcaneus.

anterior compartment Contains the tibialis anterior, extensor digitorum longus, peroneus tertius, and extensor hallucis muscles.

compartment syndrome A serious condition that can develop when swelling exists in one or more of the four compartments of the leg or arm.

cramp A sudden, involuntary contraction of a muscle.

deep posterior compartment Contains the popliteus, flexor digitorum longus, flexor hallucis longus, and tibialis posterior muscles.

extrinsic muscle Muscle that is outside a body part or bone.

intrinsic muscle Muscle that relates to a specific body part or bone.

lateral longitudinal arch One of the three arches of the foot; composed of the calcaneus, talus, cuboid, and the fourth and fifth metatarsals; lower and flatter than the medial longitudinal arch.

malleoli Large, bony prominences located on either side of the ankle.

medial longitudinal arch The highest of the three arches of the foot; composed of the calcaneus, talus, navicular, cuneiforms, and the first three metatarsals.

medial tibial stress syndrome (shin splints) Pain that occurs below the knee, on either the front outside portion or the inside of the leg.

peroneal compartment Contains the peroneus longus and peroneus brevis muscles.

plantar fascia Wide, nonelastic ligamentous tissue that extends from the anterior portion of the calcaneus to the heads of the metatarsals.

subtalar joint A joint in the ankle found between the talus and calcaneus.

superficial posterior compartment Contains the gastrocnemius, soleus, and plantaris muscles.

talocrural joint A joint in the ankle found between the tibia, fibula, and talus.

transverse arch One of the three arches of the foot; composed of the cuneiforms, the cuboid, and the fifth metatarsal bones.

Lecture Outline

I. The Lower Leg

a. Exposed to numerous types of trauma during athletic practices and events

i. Common injuries include:

. Contusions

. Strains

. Tendonitis and tendon ruptures

. Medial tibial stress syndrome

. Stress fractures and other fractures

. Compartment syndrome

II. The Foot and Ankle

a. 15 percent of sports injuries involve ankle ligaments, bones, and tendons

b. Basic anatomy

c. Ligaments of the foot and ankle

Key Concept

• The foot has three arches: transverse, medial longitudinal, and lateral longitudinal.

• The foot has 26 bones (7 tarsals, 5 metatarsals, and 14 phalanges).

• The foot has 38 joints.

• The ankle joint is made up of the talocrural and subtalar joints.

• There are five main ligaments in the ankle: anterior talofibular, anterior tibiofibular, calcaneofibular, posterior talofibular, and deltoid.

III. Basic Anatomy of the Lower Leg

IV. Common Injuries of the Foot and Ankle

Key Concept

The intrinsic muscles cause movement of the toes and help support the arches of the foot. The extrinsic muscles aid in movement of the ankle and foot. Table 17-1 in the textbook lists the names and functions of each muscle in the lower leg and foot.

a. Ankle sprains

i. First degree (mild)

ii. Second degree (moderate)

iii. Third degree (severe)

. Treatment: protection, rest, ice, compression, and elevation (PRICE), followed by rehabilitation

d. Arch sprains

i. Caused by overuse, overweight, fatigue, training on hard surfaces, and nonsupportive shoes

. Treatment: cold, compression, and elevation

e. Blisters

i. Occur anywhere there is friction

. Treatment: relieve pain, keep from enlarging, and avoid infection

ii. Great toe sprain

iii. Big toe hyperextends

. Treatment: protection, rest, ice, compression, elevation, and support

f. Plantar fasciitis

i. Tissue becomes strained from overuse, nonsupportive footwear, a tight Achilles tendon, or running on hard surfaces

. Treatment: correct training errors; icing and massage

g. Heel bruise

i. Heel receives, absorbs, and transfers impact from sports activities

ii. Ligaments, tendons, and fat pad are subject to stress and injury

. Treatment: cold application before activity, cold and elevation afterward, heel cups or pads

h. Heel spur

i. Bony growth on calcaneus that causes painful inflammation of soft tissue

. Treatment: taping or shoe inserts

i. Fractures

i. Immediately impairs ability to perform

ii. Often, point tenderness is present, and an obvious deformity may be seen

V. Rehabilitation of Foot and Ankle Injuries

VI. Common Injuries to the Lower Leg

a. Contusions

iii. Occur most often over the shin

. May also involve muscular areas of the leg

iv. Result of a direct blow

j. Strains

i. Occur anywhere along the muscles

ii. Normally result from a violent contraction, overstretching, or continued overuse

k. Muscle cramps

i. Sudden, involuntary contraction of a muscle

ii. Contributing factors may include fatigue, fractures, dehydration, lack of nutrients, poor flexibility, improperly fitted equipment

. Treatment: passive stretching, fluid replacement, massage, rest, and ice

l. Achilles tendonitis

i. Caused by inflammation of the Achilles tendon

ii. Tearing of tendon tissues caused by excessive stress

. Treatment: prevention (stretching), ice, anti-inflammatory medication, physical therapy, rest

m. Achilles tendon rupture

i. Caused by poor conditioning and overexertion

. Treatment: must be surgically repaired

n. Medial tibial stress syndrome (shin splints)

i. Normally the result of doing too much too soon

. Treatment: ice, reducing activity level, and gentle stretching of posterior leg muscles

. Long-term treatment: biomechanical assessment of lower extremities, physical therapy, orthotic devices, anti-inflammatory medications, and a strengthening and flexibility program

o. Stress fractures

i. Incomplete crack in the bone

ii. Signs include a “hot spot” of sharp, intense pain

p. Compartment syndrome

i. Develops when there is swelling within one or more lower leg compartments

. Treatment: immediate transportation to the nearest medical facility (surgery will usually be needed)

q. Fractures

i. Tibia can be fractured by a direct blow, a twisting force, or occasionally from repetitive overuse

ii. Fibula is normally fractured by a direct blow to the outside of the leg

Key Concept

• Ankle sprains are usually the result of excessive inversion or plantar flexion. Sprains are treated with cold, compression, and elevation.

• Arch sprains result from overstretched ligaments in the arch, which then cannot support the foot or absorb shocks. Sprains are treated with cold, compression, and elevation.

• Blisters result from friction that causes the layers of the skin to separate; fluid seeps in between the layers and creates the blister. Blisters should be covered and padded.

• Turf toe is caused by hyperextension of the great toe. It is treated with ice, rest, compression, elevation, and support.

• Plantar fasciitis is a strain of the ligamentous tissues in the bottom of the foot due to chronic overuse, overstretching, and irritation. Treatment is targeted at correcting training errors, ice, and massage.

• Heel bruises occur due to repeated stress. They are treated with cold application, elevation, and padding.

• Heel spurs are a bony growth on the calcaneus that causes painful inflammation of the soft tissues. Management includes taping the arch and using shoe inserts.

• Fractures are breaks in bones. Treatment must be sought from a physician and will depend on the severity of the break.

• Contusions are injuries to the soft tissues.

• The exact cause of muscle cramps is unknown. Cramps can be relieved by passive stretching, fluid replacement, massage, rest, and ice.

• Achilles tendonitis is an inflammation of the Achilles tendon. The best treatment is prevention by stretching before beginning exercise.

• An Achilles tendon rupture is a complete tear of the tendon. This injury usually requires surgical treatment.

• Medial tibial stress syndrome (shin splints) is pain that occurs in the lower portion of the leg. Treatment consists of icing, reducing activity levels, and gentle stretching.

• Stress fractures are microscopic breaks in the bone due to repeated stress and overuse. Treatment from a physician should be sought.

• Compartment syndrome is damage to tissues resulting from swelling of one or more of the compartments in the legs. Immediate emergency treatment should be sought.

VII. Additional Tests for the Foot, Ankle, and Lower Leg

a. Standard methods of testing various structures of the lower extremity:

iii. Anterior drawer test

iv. Plantar fascia test

v. Talar tilt test

vi. Tinel’s sign

VIII. Conclusion

a. Injuries to the lower extremity are common in athletics

r. Solid understanding of anatomy will help the examiner assess injuries

s. Proper conditioning, equipment, and training are essential to the overall health of the athlete

Lesson Plans and Teaching Strategies

Follow the lecture outline to present material to students, using a variety of teaching strategies described in the Instructional Strategies, such as modified lecture and cooperative/collaborative learning.

Invite a podiatrist to speak about the profession of podiatry and some specialized sports-related cases that involve podiatrists.

This is the first chapter that gets very specific about the anatomy and physiology of the body’s joints. It is important for students to be very familiar with these structures, so some form of testing needs to be developed that will adequately evaluate student knowledge. Experienced athletic training student aides can be of assistance here, allowing students in the program to test orally with models (if available) so that the teacher can continue to move at a steady pace. Oral testing forces students to think not only about anatomical terms, but also how they are pronounced.

Answers to Student Exercises

Textbook Review Questions

1. The foot has three arches that help with shock absorption. They are made up of various combinations of the 26 foot bones, grouped as phalanges, metatarsals, and tarsals. The ankle is made of two joints, involving the lower leg bones; the tibia and fibula; and two of the tarsals, the talus and calcaneus.

2. There are 26 bones in the foot, including the two that make up the ankle joint, the tibia and fibula.

3. The talocrural includes the tibia, fibula, and talus; the subtalar involves the talus and calcaneus.

4. When standing, the lower extremity has to support the entire weight of the body. When walking, running, and especially jumping, the forces on the lower extremity can be much, much greater.

5. The peroneal nerve begins behind the knee, where it wraps around to the anterior lower leg, passing in front of the tibia and fibula.

6. The ligament most often injured is the anterior talofibular ligament because it withstands the most common type of movement, which is excessive inversion and plantar flexion.

7. Common injuries include ankle sprains, usually the result of excessive inversion or plantar flexion; arch sprains, from overstretched ligaments causing failure in the arch to support the foot and absorb shocks; blisters, from friction that causes the layers of the skin to separate and fluid to seep between the layers; turf toe, caused by hyperextension of the big toe; plantar fasciitis, a strain on the ligamentous tissues in the bottom of the foot due to chronic irritation; heel bruises, from repeated stress on the heel of the foot; heel spurs, bony growths on the calcaneus that cause painful inflammation of the soft tissues; fractures, breaks in the bones; contusions, injuries to the soft tissues of the leg and foot; muscle cramps; Achilles tendonitis, an inflammation of the Achilles tendon; Achilles tendon rupture, a complete tear of the Achilles tendon; stress fractures, microscopic breaks in the bone due to repeated stress and overuse; and compartment syndrome, damage to tissues resulting from swelling of one or more leg compartments.

8. Contributing factors include fatigue, fractures, dehydration, lack of nutrients, poor flexibility, and improperly fitted equipment. Prevention includes proper hydration and passive stretching.

9. The name comes from the warrior of Greek mythology, Achilles, whose heel was the only vulnerable spot on his body; he was killed by an arrow striking his heel.

10. Causes could include poor conditioning, overexertion, the application of a sudden force to a dorsiflexed foot, or direct trauma.

11. Pain occurs below the knee, either on the front outside part of the leg or the inside of the leg. Treatment includes icing immediately after practice or competition, reducing activity level, and gently stretching the posterior leg muscles. Determining the likely cause and correcting it determines the long-term therapy and treatment.

12. A stress fracture is an incomplete crack in the bone that starts out microscopic in size and eventually leads to a full fracture if not treated.

13. There are four compartments in the lower leg, each of which contains certain muscles that control the movement of the ankle and foot.

14. The cross-sectional view in Figure 17-26 in the textbook is that of the lower right leg. The location of the nerves, compartments, and bones assists in identification of the leg displayed.

Workbook Vocabulary Review

Matching

1. C

2. E

3. U

4. M

5. F

6. G

7. A

8. S

9. T

10. N

11. O

12. I

13. M

14. J

15. K

16. P

17. B

18. H

19. L

20. Q

21. R

22. V

Workbook Quiz

1. A

2. B

3. D

4. D

5. A

6. C

7. B

8. B

9. A

10. D

Critical Thinking

1. Initial treatment consists of icing immediately after practice or competition, reducing the activity level, and gentle stretching of the posterior leg muscles. Long-term treatment should include a biomechanical assessment of the lower extremities to rule out any conditions that would expose the athlete to excessive stresses on the lower leg. Physical therapy, orthotic devices, anti-inflammatory medications, and a strengthening and flexibility program to help correct muscle imbalance may be helpful in alleviating and eliminating this condition. Athletes who are out of shape, beginning a new activity, or coming back from an injury are at much greater risk. These athletes must follow a graduated conditioning schedule to avoid overuse injuries. Answer will vary.

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