Transcript Chapter 15 Powerpoint – Foot, Ankle and Lower Leg

CHAPTER 15 – FOOT AND
ANKLE
FOOT ANATOMY
• It is complex!
• 26 bones
• 33 joints
• Over 100 muscles, tendons and ligaments
ANATOMY – 26 BONES
• TARSAL BONES – 7
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Calcaneus – heel bone
Talus – forms the ankle
Navicular – medial in respect to the talus
Cuboid - lateral
Cuneiforms (3)
ANATOMY - BONES
• METATARSALS – 5
• 1ST one is medial and 5th one is
lateral
ANATOMY - BONES
• PHALANGES (Toes) – 14
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Big toe has two phalanges, the rest of the
toes have three
Proximal, middle, and distal
ANATOMY - BONES
• SESAMOIDS
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Sesamoid bones sit in tendons
These are on ball on foot below big toe
Helps distribute weight
ANATOMY - ARCHES
• Support body weight and absorb shock
• There are four arches:
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MEDIAL LONGITUDINAL ARCH
LATERAL LONGITUDINAL ARCH
METATARSAL ARCH
TRANSVERSE ARCH
ANATOMY
• PLANTAR FASCIA
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Broad, flat tendonous structure that runs on
the undersurface of the foot
Starts on the calcaneus and inserts onto the
heads of the metatarsals
Supports the arch of the foot
ANKLE ANATOMY
• BONES
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Two bones in the lower leg
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Tibia – medial, larger, weight
bearing
• Medial Malleolus
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Fibula
• Lateral Malleolus
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Two tarsal bone
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Talus
Calcaneus
ANKLE ANATOMY
• TRUE ANKLE JOINT
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Tibia, fibula and talus
Mortise
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Definition: where the talus fits into
the tibia and the fibula
ANKLE ANATOMY
• TRUE ANKLE JOINT
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Tibia, fibula and talus
Mortise
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Definition: where the talus fits into
the tibia and the fibula
LIGAMENTS
• LATERAL –
• 3 ligaments named for bones
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Anterior talofibular
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Calcaneofibular
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(ATF)
(CF)
Posterior talofibular
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(PTF)
LIGAMENTS
• MEDIAL
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Deltoid
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Strong ligament
4 parts that form one
ligament
LIGAMENTS
• TIBIOFIBULAR
LIGAMENTS – holds
tibia and fibula together
• Anterior tibiofibular
• Posterior tibiofibular
FOOT INJURIES
• PLANTAR FASCIITIS
• Common with athletes who are on toes and/or have high
arches
• Causes: Not enough arch support in shoes, tight calf
muscle
• Signs/Symptoms: Pain occurs in the heel to mid-foot,
especially with dorsiflexion
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Hurts in the morning, feels better as they warm up
• Treatment: Gentle stretches, roll on tennis ball or frozen
can, arch taping or orthotics.
FOOT INJURIES
• RETROCALCANEAL BURSITIS
• ‘Pump bump’
• Cause: Pressure from back of shoe
• Signs/Symptoms: Swelling where the Achilles
attaches to the calcaneus
• Treatment: RICE, stretching, shoes with wider
heel cups, donut pad.
FOOT INJURIES
• FRACTURES
• Toes
• Metatarsals
• DISLOCATIONS
• Interphalangeal Joints
• SPRAINS
• STRAINS
FOOT INJURIES
• JONES FRACTURE
• Fracture of the base of the 5th metatarsal
• Causes: overuse; inversion; rotational forces
• S/S: Feels and hears a ‘pop’; pain in the lateral
foot
• Tx: immobilization (cast) 6-8 weeks or longer,
often requires surgery
FOOT INJURIES
• BUNIONS (HALLUX VALGUS)
• Deformity of the head of the 1st metatarsal
• Cause: extra bone is laid down on head of 1st
metatarsal
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Great toe becomes malaligned
• S/S: Pain, swelling and deformity of big toe joint
• Treatment: Proper shoes; doughnut pad over the
bunion; surgery?
• TURF TOE
FOOT INJURIES
• Great Toe sprain
• Cause: Hyperextension of the big toe at the
metatarsal phalangeal joint; kicking something
• Common on artificial turf b/c turf shoes allow more
motion
• S/S: swelling and pain in the joint
• Tx: RICE, rigid insoles or toe boxes, taping to
prevent hyperextension of toe
FOOT INJURIES
• INGROWN TOENAILS
• Cause: leading side of toenail grows into skin,
usually results in infection and pain
• May trim nails too short or ill-fitting shoes
• S/S: Inflammed nail bed, may have
drainage/pus
• Tx: May need to refer to doctor; soak in
betadine bath; pack cotton under toenail
PUBLIC SERVICE ANNOUNCEMENT
• HIGH HEELS
• Loads 5 times your body weight onto your heel
• Overloads forefoot
• Deforms the arch
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Reduces shock absorption
Plantar fasciitis
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Morton’s Neuroma
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Achilles tendinitis
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Have to extend back to compensate
• Leads to inflamed nerves in your toes
• Shortens your calf
• Changes your center of gravity – more forward
BIOMECHANICAL PROBLEMS
• PRONATION
• Cause of many, many
leg, knee, back
problems
• What does it look like
• Fallen arch with toes
pointed outward
• Looking at feet from
behind, the Achilles will
angle outward
ANKLE SPRAINS
• Review: 3 Degrees of Sprains
• Abnormal (too much) motion causes ankle
injuries
• Named for motions that cause them
• What are those motions?
TYPES OF ANKLE SPRAINS
• Inversion
• Most common type of ankle sprain
• Accounts for 80% of all sprains
• AKA ‘a lateral ankle sprain’
• First degree sprain
• Only involves the anterior talofibular ligament
• Mild pain, tenderness, and swelling
• No instability
TYPES OF ANKLE SPRAINS
• Inversion
• Second degree sprain
• Anterior talofibular ligament is torn and calcaneofibular
ligament is injured as well
• Most painful
• Moderate swelling
• Mild Instability
TYPES OF ANKLE SPRAINS
• Inversion
• Third degree sprain
• Complete tear of all three lateral ligaments
• Uncommon
• Lots of pain, but it can subside
• Very unstable
• Usually requires surgery
TESTING ATF STABILITY
• Drawer Test
• Stablize lower leg with one hand
• Pull heel forward (like opening a drawer)
• Should not move forward if ligament is
intact
TYPES OF ANKLE SPRAINS
• Eversion
• Not as common
• Can occur more on tartan surfaces and artificial turf
• Everything is worse (pain, swelling, etc) when
compared to an inversion injury
• If the deltoid tears, the tibiofibular ligaments may
tear also
High Ankle Sprain
• Involves Anterior Inferior Tibiofibular
(AITFL) Ligament
• Injury allows tibia and fibula to separate
High Ankle Sprain
• Cause: Inversion with rotation; rotation of foot
• S/S: pain with external rotation of foot; tender over
AITFL
• Treatment: RICE, may need to be immobilized;
possible surgery if severe enough
Treatment of Ankle Sprains
• Prevention – once you sprain an ankle it is easy to
do again – tape and rehab
• Rest – No activity for 24-48 hours
• Ice – 20 minutes on, 40 minutes off
• Compression – ace wrap with horseshoe
• Elevation – ankle above the heart
• Support – crutches and aircast if needed
Ankle Rehab
• ABCs
• Circles
• Theraband exercises
• Single Leg Balance
• Balance Board
• Calf Raises
• And so much more….
Ankle Fractures
• Always need to suspect a fracture when
evaluating a potential sprained ankle
• Cause: Too much motion
• S/S: immediate swelling, point tender over the
bone, does not want to weight bear
• Treatment: splint, ice, x-ray
Cast 6-8 weeks
The Lower Leg
ANATOMY
• Bones
• Tibia
• Fibula
MUSCLES
• The muscles are in four compartments
with 2-4 muscles in each compartment
• Compartments are held together by
fascia
MUSCLE COMPARTMENTS
1. LATERAL – everts the ankle
2. ANTERIOR – dorsiflexes the ankle
3. DEEP POSTERIOR – plantarflexes the ankle (the calf muscle)
4. POSTERIOR MEDIAL – inverts and plantarflexes the ankle
Major Muscles and Actions
• Anterior Tibialis - dorsiflexor
• Peroneals - evertors
• Gastrocnemius – plantarflexor
• Soleus – plantarflexor
• Posterior Tibialis – invertor
LOWER LEG INJURIES
• Muscle Cramps
• Sudden, violent contraction of the calf muscles
• Causes:
• Fatigue, overtraining, dehydration, poor nutrition,
injury, poor flexibility
• S/S: – sharp pain in the calf, toe is pointed
• Tx: gentle stretch, ice, hydrate, can return to
play if subsides and does not continue
LOWER LEG INJURIES
• STRESS FRACTURE
• Cause: Repetitive pounding with training
• S/S: Hurts more with and after activity, pain
on one spot on bone
• Tx: Requires x-ray, possibly a bone scan
• If positive, no weight bearing for at least 2
weeks, no running for 4-6 weeks
LOWER LEG INJURIES
• MEDIAL TIBIAL STRESS SYNDROME
• ‘SHIN SPLINTS’
• Occurs in distal 2/3 of posterior/medial tibia
• Causes: pronation, lack of flexibility in the
lower legs, hard surfaces, hills, muscle
weakness, poor shoes, increasing running
distance too quickly
LOWER LEG INJURIES
• MEDIAL TIBIAL STRESS SYNDROME
• S/S: resisted plantar flexion and inversion should hurt,
pain is just off the tibia
• Treatment : prevention (shoes, arch support),
strengthening, stretching, ice massage, contrast bath,
tape arches
• Refer to MD if no improvement to rule out stress fracture
LOWER LEG INJURIES
• COMPARTMENT SYNDROME
• Occurs when pressure increases in compartment and
shuts off blood and nerve supply to the foot
• Most often occurs in the anterior and deep posterior
compartment
• THREE TYPES
• Acute
• Acute Exertional
• Chronic
LOWER LEG INJURIES
• ACUTE COMPARTMENT SYNDROME
• Medical emergency
• Causes: direct blow to the lower leg
• Usually in the anterior lower leg
• Symptoms come about several hours later
• S/S: compartment is tense, warm, red and
shiny; complains of (c/o) deep aching pain;
circulation and sensory problems in foot
• Tx: ice, elevation – refer to ER immediately
LOWER LEG INJURIES
• ACUTE EXERTIONAL/CHRONIC
COMPARTMENT SYNDROME
• Cause: running and jumping activities
• S/S: With activity, foot goes to sleep, crampy pain,
and tingling. When activity stops, it goes away.
Consistent as to when it comes on with activity
• Tx: ice, activity modification, stretching, massage,
and referral to the doctor (possible surgery)
INJURIES
• ACHILLES TENDINITIS
• Chronic, overuse condition that comes about gradually
• Causes: running and jumping, repetitive stress, running
up hills, poor flexibility
• S/S: achy type pain, Achilles is tender on palpation, pain
with standing plantarflexion, may have crepitus, hurts to
warm up and to cool down
INJURIES
• ACHILLES TENDINITIS
• TREATMENT
• If there is crepitus, no running for 1-2 weeks
• Stretch!
• Heel lift in both shoes
• Orthotics
• Heat and/or ice
INJURIES
• ACHILLES TENDON RUPTURE
• Achilles in largest tendon in body
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For Gastrocnemius and Soleus muscles
• Most common tearing spot is 1” above its insertion on the
calcaneus
• Causes: Sudden, forceful plantar flexion and extension of
the knee, age, previous tendinitis
• S/S: Feel and hear a snap, “kicked in the leg”, very weak
plantarflexion, no Achilles observed
• Tx: Immobilization to ER, surgery?