Session III - Saddleback College



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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