Transcript Injuries to the Foot, Ankle and Lower Leg

Injuries to the Foot, Ankle
and Lower Leg
SPHS Sports Medicine
John Hardin, Instructor
Bony Anatomy
Tibia
 Fibula
 Tarsals
 Metatarsals
 Phalanges
 Sesamoid Bones

Tibia
Weight bearing bone
 Articulates with fibula both inferiorly and
superiorly
 Landmarks

 Tibial
tuberosity (proximal)
 Tibial Plateau
 Medial Malleolus
 Shaft
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
Tarsals
Talus—articulates with the tibia/fibula
 Calcaneus
 Navicular
 Cuboid
 Medial, intermediate and lateral
cuneiforms

Joints
Tibiofibular joint--syndesmosis
 Ankle joint (talocrural) Ankle mortise
 Subtalar joint
 Metatarsalphalangeal joints (MP)
 Interphalangeal joints

 PIP
 DIP
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

Muscles of lateral compartment
Peroneus longus
 Peroneus brevis

 Both
do eversion
Muscles of the anterior
compartment
Tibialis Anterior
 Extensor Digitorum Longus
 Extensor Hallicus Longus

 All
do dorsiflexion and some inversion
 EDL—extension of toes 2-5
 EHL—extension of great toe

**EDB—extends toes 2-4 (dorsum of foot)
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
 FHL—flexion of great toe
Muscles of Deep Posterior
Compartment
Gastrocnemius—crosses knee and ankle
joint. Knee flexion/plantar flexion
 Soleus---crosses ankle joint.
Plantarflexion

 Join

together at the Achilles tendon
Plantaris—cross ankle and knee joints.
Knee flexion/plantar flexion
 Tendon
medially
run parallel to the Achilles tendon
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
Plantar fasica
Medial Ligaments

Deltoid ligament



4 parts
Very strong
Not injured as often
Lateral ligaments
Anterior talofibular
 Posterior talofibular
 Calcaneofibular

Other ligaments
Anterior inferior
tibiofibular ligament
 Posterior inferior
tibiofibular ligament

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)
Heel Bruise
(Stone Bruise)
Mxn: Landing on heels, hitting heel on
something hard—causing 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

Plantar Fasciitis

Mxn: tight heel cord, inflexibility of
longitudinal arch, improper footwear, leg
length discrepancy, rapid increase/change
in training

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
TX: long term—8-12 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 for—surgery to remove it
Metatarsal Fracture
Mxn: direct force or twisting/torsion force
or overuse
 Most common is the Jone’s fracture—near
base of 5th, avulsion (at the base),
midshaft


S/S: POT over metatarsal, swelling, pain,
“pop” or “crack”, possible deformity
Tx: Ice, Compression wrap, crutches, send
to Dr. for x-ray.
 Possibly on crutches for 6-8 weeks, nonweight bearing to allow for healing


Complication: Non union fracture. May
require surgery to fix
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

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

TX: Rest, ice, reduction of weight bearing
until relatively pain free
 Ultrasound
 Arch
taping
Turf Toe
Sprain of the MP joint of the great to
 Mxn: Hyperextension of great toe—
trauma or overuse

 Usually
occurs on an unyielding surface such
as turf
 Kicking an unyielding object

S/S: POT over MP joint of great toe
 Swelling
 Discoloration
 Pain
with movement especially pushing off big
toe when taking a step

TX: Rest, ice, compression
 Insert
a hard insole into shoe to prevent
hyperextension of MP joint
 Tape for hyperextension
Subungual Hematoma

Mxn: being stepped on or something
being dropped onto the toe
 Toes
being jammed into the end of the shoe
while running

S/S: Bleeding into the nail bed (under
nail)
 Throbbing
pain
 Pressure against nail exacerbates the problem

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
Blisters

Mxn: shearing force on the skin that
causes fluid to accumulate below top layer
of skin
 May
be clear, bloody or become infected

S/S: area of fluid under skin
 Can
be painful
 May break open
 May become infected—redness, heat, pus

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
Ankle Sprains
Inversion
 Eversion
 High Ankle Sprain

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 athlete’s foot, stepping in a hole,
etc.
 Inversion/plantar
flexion
The inversion mxn
Structures injured
ATF lig. injured with the plantar
flexion/inversion mxn
 Calcaneofibular lig. and posterior
talofibular lig. injured when then inversion
force is increased

3rd degree Lateral Ankle
sprain
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


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
Complications
Avulsion fracture of lateral malleolus
 Avulsion fracture of base of 5th metatarsal
 Push-off fracture of medial malleolus

Eversion Ankle Sprain
Less common due to bony structure of
ankle
 Deltoid ligament damage (any or all 4
portions


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


Tx: RICE, “horseshoe” shaped felt/foam
pad,
 crutches
if necessary
 Treat for shock
 Medical attention with severe sprain of if
fracture is suspected
Complications
Avulsion fracture of medial malleolus
 Contused deltoid ligament due to
impingement between medial malleolus
and calcaneus
 Fracture of lateral malleolus

“High” Ankle Sprain
Also called syndesmotic
 Anterior and posterior tibiofibular
ligaments damage

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)

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

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

Complications
Fracture to the dome of the talus
 Tear of the interosseus membrane

Ankle Fractures and Dislocations
Mxn: similar to those of the ankle sprains
but generally more force is applied
 Can be open or closed

What do these injuries look like?
After the mxn
See the placement of the
foot?
Sliding into base
He’s there!
Getting help
And the open ones?
Open Fx/dislocation
Open fracture
And some x-rays
S/S: Immediate swelling
 immense pain
 possible deformity and/or open wound
 POT over the bone
 + compression and percussion tests

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

Tendonitis

Tendons most often affected
 Tibialis
posterior
 Tibialis anterior
 Peroneals
 Achilles

Mxn: faulty foot biomechanics
 Inappropriate
or poor/worn footwear
 Acute trauma to tendon
 Tightness of heel cord
 Training errors
 Excessive running, jumping, hills

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

Tx: Rest
 Modalities:
ice, heat, ultrasound
 NSAIDS
 Exercise
to strengthen muscle(s) involved
 Stretching
 Orthotics or taping to relieve stress on tendon
Tib/Fib fracture

Tibia is most commonly fractured long
bone in the body
Mxn: direct trauma to the tibia/fibula or
both
 Indirect trauma such as combination
rotation/compressive force


S/S: Immediate pain
 Swelling
 Possible
deformity
 May be open or closed

Tx: Splint in the position you find it
 Treat
for shock
 Call 911 if necessary
 ER visit
Stress Fractures
Tibial (mid shaft)
 Fibular (distal third)
 Metatarsal (2nd is most common)


Mxn: repetitive loading during training
and conditioning and jumping
 Faulty
biomechanics combined with
excessive/change in training

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

Tx: stop activity (2-4 weeks)
 Alternate
conditioning—non weight bearing
 Ice
 Crutches/protective
 Medical
referral
 Xrays
 Bone
scan
footwear
Medial Tibial Stress Syndrome

Shin splints
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

S/S: diffuse pain along the distal tibia
(2/3) medially
 POT in the same area
 Pain after activity—then before/after—
then all the time

Tx: Modify activity
 Correct foot biomechanics (orthotics)
 Heel cord stretching
 Strengthening of muscles in Posterior
compartment
 Ice massage
 Friction massage
 Taping—arch support/ankle

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
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

Tx: initially ice to reduce swelling
 If
circulation/sensory changes occur—
emergency room visit
 Fasciotomy
 Return to activity 2-4 months post surgery
Achille Tendon Rupture
Largest tendon in body
 Most common in athletes over 30 yrs
 Seen in sports with ballistic movements—
tennis, raquetball, basketball, etc.


Mxn: sudden forceful plantar flexion of
ankle

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
Achilles tendon defect
Thompson Test

Tx: immobilize
 ice
 Send
to ER
 Requires surgery w/ 6-8 weeks immobilization
 Rehab to regain full ROM/Strength
Open achilles tendon rupture
Contusions

Mxn: direct trauma to area

S/S: pain, swelling, increased warmth,
hematoma

Tx: RICE, protective padding, modify
activity if necessary
And other weird things
Another view
Treatment for this?
Immoblize object
 Cut object at each end to allow for
transport
 Treat for shock
 Surgery to remove impaled object
