Session III
The Foot, Ankle, & Lower Leg Injuries
Foot Anatomy
Bones
26 bones
7 tarsal-talus, calcaneous, navicular, cuboid, 3 cuneiforms
5 metatarsal
14 phalanges- 1st toe has 2; toes 2-5 has 3
Arches
Anterior metatarsal - shaped by the distal heads of the MT; stretches across the 1st to the 5th
Transverse - extends across the transverse tarsal bones; forms a half dome; gives protection to soft tissue and increases the foot’s mobility
Medial longitudinal – originates along the medial border of the calcaneus and extends to the distal head of the 1st MT; supports the medial arch
Lateral longitudinal – outer aspect of foot & follows the same pattern as the medial longitudinal; much lower & less flexible than the medial longitudinal
Muscles and Movements
Dorsiflexion
Tibialis anterior
Extensor digitorium longus
Extensor hallicus longus
Peroneus tertius
Plantarflexion
Peroneus longus/brevis
Tibialis posterior
Flexor digitorium longus
Flexor hallicus longus
Inversion, adduction, and supination
Tibialis posterior
Flexor digitorium longus
Flexor hallicus longus
Tibialis anterior
Extensor hallicus longus
Eversion, abduction, and pronation
Peroneus longus/brevis
Peroneus tertius
Extensor digitorium longus
Foot assessment
History
Type of surface for training?
Type of footwear worn?
Is discomfort increased when footwear is worn?
Observation
Is athlete favoring the foot, walking with a limp, or unable to bear weight?
Does the foot change color weight bearing vs. non weight bearing?
Pes planus (flatfoot) or pes cavus (high arch)?
Toe abnormalities?
Is the foot well-aligned? Does it maintain its shape on weight bearing? Shoe patterns?
Palpation
Medial, lateral, dorsal, and plantar aspects of foot
Pulses
Tibialis posterior-behind medial malleolus
Dorsal pedal-midpoint between medial & lateral malleolus to the proximal end of the 1st intermetatarsal space
Recognition and management of specific injuries
Heel bruise
Cause – sudden stop & go; sudden horizontal & vertical movement
Signs – severe pain in heel; unable to bear weight
Care – ice; rest; NWB for 24 hours; heel cup; doughnut
Plantar fascitis
Cause – leg length discrepancy; inflexibility of longitudinal arch; Gastroc/soleus tightness; shoes without arch support
Signs – pain worse in morning; pain with long sitting periods, but lessens after first few steps
Care – vigorous heel cord stretching; PF stretching; heel cup; arch tape; orthotics
Fractures of the metatarsal
Cause – direct force
Signs of injury – swelling; pain; deformity; pt. tenderness
Care – rest; immobilization
Jones fracture
Cause – neck of 5th MT-overuse; acute inversion; high velocity rotation
Signs – sharp pain of lateral border of foot; “pop”; Care – cast 6-8 weeks; longer with surgery; long rehab due to poor blood supply
Bunions
Cause – painful deformity of head of 1st MT; shoes-pointed, too narrow, to short, high heels
Signs – tenderness, swelling, enlargement with calcification of head of 1st MT
Care – shoes; doughnut; orthotics
Blisters
Cause – shearing forces acting on skin
Signs – fluid-clear, bloody, or infected
Care – petroleum jelly; doughnut; second skin; drain; antibiotic ointment; wearing socks with no folds/wrinkles
Morton’s Neuroma
Cause – mass that occurs about the nerve sheath of the common plantar nerve; collapse of the transverse arch of the foot; excessive foot pronation
Signs – burning paresthesia; severe intermittent pain in the forefoot
Care – padding; shoes; surgery
Turf toe
Cause – hyperextension of 1st MTP joint from sudden trauma or overuse; turf
Signs – pain; swelling
Care – steel insoles; tape to prevent DF
Calluses
Cause – shoes too narrow/short; friction; faulty foot mechanics
Signs – hard, cracked, layers of skin usually found on calcaneus and plantar aspect of foot
Care – emery callus file; wedges; doughnuts; orthotics
Ingrown toenail
Cause – toenail grown into soft tissue
Signs – inflammation; infection
Care – soak in hot water for 20 minutes; cotton; trimming nail across
Toenail hematoma
Cause – stepped on; dropping object on toe; kicking another object
Signs – extreme pain; bleeding in nail bed
Care – ice; drill nail
The Ankle and Lower Leg Anatomy
Bones
Tibia
Fibula
Talus
Calcaneus
Ligaments
Lateral
Tibiofibular-anterior & posterior; holds the tibia & fibula together
Anterior talofibular (ATF) – prevents anterior displacement of talus
Posterior talofibular (PTF) – prevents posterior displacement of talus
Calcaneofibular – restrains inversion of calcaneous
Medial
Deltoid – triangular in shape; restrains eversion of calcaneous
Musculature
(Anterior Compartment
extensor digitorium longus
extensor hallicus longus
tibialis anterior
(Superficial posterior compartment
gastrocnemius
soleus
(Deep posterior compartment
tibialis posterior
flexor digitorium longus
flexor hallicus longus
(Lateral compartment
peroneus longus
peroneus brevis
Prevention
Heel cord stretching
Before and after activity
Strength training
Achieving static & dynamic joint stability
Neuromuscular control
Enhanced by locomotion on uneven surfaces or balance board
Footwear
Shoes for which they are intended
Taping/bracing
Prophylactic protection
Assessing the Lower Leg
History
Is there any sense of muscle weakness or difficulty in walking?
Could you bear weight right away?
Have you hurt the ankle before?
Was there immediate swelling, or did the swelling occur later (or at all)?
Observation
Is there a normal walking pattern?
Are the bony contours of the ankle normal and symmetrical, or is there a deviation such as a bony deformity?
Are the color and texture of the skin normal?
Is there crepitus or abnormal sound in the ankle joint?
Palpation
Bony & soft tissue
Determine obvious structural deformities, areas of swelling, or points of tenderness
Special tests
Thompson test – squeeze the calf muscle while the leg is extended and the foot is hanging over the edge of the table; + test is one in which squeezing the calf muscle does not cause the heel to move or pull upward
Homan’s sign – athlete is in a supine position with the knee fully extended; the ankle is passively dorsiflexed so that the calf muscles are stretched; + test is pain in the calf – indication of deep vein thrombophlebitis
Bump, lever, and compression - + test indicates a possible fracture to lower leg and/or ankle
Anterior drawer test – athlete sits with legs and feet relaxed; grasping the lower leg in one hand and the calcaneus in the palm of the other hand, the tibia is pushed backward as the calcaneus is pulled forward; + test occurs when the foot slides forward and sometimes makes a clunking sound as it reaches its end point indicating a tear in the ATF ligament
Talar tilt test – with the foot positioned at 90° to the lower leg and stabilized, the calcaneus is inverted; + test is excessive motion of the talus indicating injury to the CF and possibly the ATF and PTF ligaments
Functional Exam
If the following movements aggravate a recent injury, they should be avoided
Walks on toes (tests PF)
Walks on heels (tests DF)
Walks on lateral border of feet (tests inversion)
Walks on medial border of feet (tests eversion)
Hops on the injured ankle
Start/stop run motion
Changing directions quickly
Figure 8’s
Injuries to the Ankle
Ankle sprains
Cause – INV/PF most common; EV may involve avulsion-longer to heal
Signs – tearing of ligament; swelling; joint instability; grades
Care – RICE; NSAIDs; horseshoe; splint; NWB; rehab
Ankle fractures
Cause – same MOI as sprains
Signs – immediate swelling; point tenderness over bone; apprehension to bear weight
Care – splint; referral; cast for 6 weeks; rehab
Tendinitis
Cause – faulty foot mechanics; footwear; acute trauma; tight heel cord; training errors
Signs – pain with active and passive movement; swelling; crepitus; stiffness
Care – rest; ice; NSAIDs; orthotics/tape
Injuries to the Lower Leg
Tibial and fibular fractures
Cause – tibia – most common long bone fx; direct or indirect trauma-combination of rotation & compression force
Signs – immediate pain; swelling; deformity; pain with ambulation
Care – referral; immobilization for weeks/months
Tibial and fibular stress fractures
Cause – tibia > fibula; repetitive loading; jumping athletes
Signs – pain with activity; worse when stopped; focal pt. tenderness on bone vs. diffuse
Care – REST; weight bearing is OK-sometimes with a walking boot
Shin splints (Medial Tibial Stress Syndrome)
Cause – strain of tibialis posterior in running activities; secondary to faulty foot mechanics; heel cord tightness; muscle weakness; shoes; changing surfaces
Signs – diffuse pain distal tibia; initially pain is post activity, but as the condition progresses, pain is with daily ambulation, and in the morning there is pain and stiffness
Care – rule out stress fracture; G/S stretching; ice; strengthening of lower leg muscles; correct foot mechanics
Compartment syndrome
Cause – increase in pressure causes compression of muscle & neurovascular structures; acute – direct trauma; acute exertional – no trauma; evolves with minimal to excessive activity; chronic – symptoms consistent at certain point in activity & ceases post activity
Signs – deep aching pain; tightness/swelling of compartment; pain with passive stretch; neurological involvement is rare
Care – ice; elevation; no compression NSAIDs; surgery (fasciotomy)
Achilles’ tendon rupture
Cause – sudden, forceful PF; 30 + - ballistic movement
Signs – feel/hear pop; kicked/shot; PF is painful & limited; palpable defect
Care – surgery; 6-8 weeks immobilization
Achilles’ tendinitis
Cause – repetitive stresses/strains; increase in duration/intensity is too soon; hill workouts increase the pain
Signs – general pain & stiffness; gradual onset; morning pain/stiffness; warm & painful to palpation; thickening; crepitus
Care – decrease activity; G/S stretching
Shin contusions
Cause – forceful blow to the anterior leg
Signs – intense pain; hematoma forms & is jellylike; possible compartment syndrome or fracture
Care – RICE; NSAIDs; padding
Leg cramps and spasms
Cause – fatigue; excess loss of fluid
Signs – pain with contraction of the calf muscle
Care – mild, gradual stretching; ice massage; water/electrolyte replacement
Gastrocnemius strain
Cause – medial head is particularly susceptible; sports that require quick stops/starts and jumping; quick stop with foot planted flat and suddenly extends the knee
Signs – pain; swelling; muscle disability; “hit in the calf with a stick”
Care – gentle, gradual stretch after muscle cooling; wedge in shoe; elastic wrap
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