Transcript Injuries to the Foot, Ankle and Lower Leg

Original Author:
Sabino Sports Medicine
Connie Rauser, Instructor
• Tibia
• Fibula
• Tarsals
• Metatarsals
• Phalanges
• Sesamoid Bones
• Calcaneus
• Weight bearing bone
• Articulates with fibula both inferiorly and
superiorly
• Landmarks
• Tibial tuberosity (proximal)
• Tibial Plateau
• Medial Malleolus
• Shaft
• 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
• Talus—articulates with the
tibia/fibula
• Calcaneus
• Navicular
• Cuboid
• Medial, intermediate and
lateral cuneiforms
• Tibiofibular joint--syndesmosis
• Ankle joint (talocrural) Ankle
mortise
• Subtalar joint
• Metatarsalphalangeal joints
(MP)
• Interphalangeal joints
• PIP
• DIP
• 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
• Peroneus longus
• Peroneus brevis
• Both do eversion
and plantarflex
• Peroneus tertius
• Dorsiflex and
evert
• 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)
• 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
• 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 run parallel to the Achilles
tendon medially
• 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
• Deltoid ligament
• 4 parts
• Very strong
• Not injured as often
• Anterior
talofibular
• Posterior
talofibular
• Calcaneofibular
• Anterior inferior
tibiofibular ligament
• Posterior inferior
tibiofibular ligament
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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)
• MOI: 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
• MOI: tight heel cord, inflexibility of longitudinal arch, improper
footwear, leg length discrepancy, rapid increase/change in
training
• S/S: Pt tender 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
• MOI: 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: Pt. tender 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
• MOI: 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 Pt. tender along the
calcaneonavicular ligament (spring ligament)
and the first cuneiform
• Pt. tender 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
• Sprain of the MP joint of the great toe
• MOI: Hyperextension of great toe—trauma or
overuse
• Usually occurs on an unyielding surface such as turf
• Kicking an unyielding object
• S/S: Pt. tender 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
• MOI: 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
• MOI: 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
• Inversion
• Eversion
• (Syndesmotic)
High Ankle Sprain
• Most common, resulting in
injury to the lateral
ligaments
• ATF ligament is the
weakest of the 3
• MOI: “rolling” the ankle,
landing on another
athlete’s foot, stepping in
a hole, etc.
• Inversion/plantar flexion
• ATF lig. injured with the plantar
flexion/inversion MOI
• Calcaneofibular lig. and posterior talofibular
lig. injured when then inversion force is
increased
3rd degree Lateral Ankle sprain
• S/S: Pain, Swelling, discoloration, Pt. tender 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
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Anterior Drawer Test – Tests ATF
Talar Tilt – Calcaneofib and Deltoid Ligaments
Kleiger Test – High Ankle
Calcaneus (Bump) Test – Calcaneus Fx
• Tx: RICE, “horseshoe” shaped felt/foam pad fit
around the lateral malleolus
• Treat for shock (only in severe cases)
• crutches if necessary
• Medical attention if severe or possibility of fracture
• Avulsion fracture of lateral malleolus
• Avulsion fracture of base of 5th metatarsal
• Push-off fracture of medial malleolus
• Less common due to bony structure of ankle
• Deltoid ligament damage (any or all 4 portions)
• MOI: 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,
Pt. tender over medial malleolus
and deltoid ligament
• Will vary depending on
severity
• Tests:
• Talar Tilt
• Tx: RICE, “horseshoe” shaped felt/foam pad,
• crutches if necessary
• Treat for shock
• Medical attention with severe sprain or if fracture is suspected
• Avulsion fracture of medial malleolus
• Contused deltoid ligament due to impingement
between medial malleolus and calcaneus
• Fracture of lateral malleolus
• Also called syndesmotic
• Anterior and posterior tibiofibular ligaments damage
• MOI: 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
• Pt. tender 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
• Fracture to the dome of the talus
• Tear of the interosseus membrane
• MOI: similar to those of the ankle sprains
but generally more force is applied
• Can be open or closed
After the MOI
See the placement of the foot?
Sliding into base
He’s there!
Open Fx/dislocation
Open fracture
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S/S: Immediate swelling
immense pain
possible deformity and/or open wound
Pt. tender over the bone
+ compression and percussion tests
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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
• Tendons most often affected
• Tibialis posterior
• Tibialis anterior
•Peroneals
• Achilles
• MOI: 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
• Pt. tender over insertion of tendon
• warmth
• Crepitus
• Thickening of tendon (achilles)
• Stiffness 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
• Shin splints
• What is it?
• Theories
• Fascia pulling off of the bone (Soleus)
• Bone Reaction (bone not being able to keep up between
osteoclasts and osteoblasts)
• Posterior tibialis pulling off of the medial surface of the
bone
• MOI: strain of tibialis posterior tendon and its fascial
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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
• Pt. tender in the same area
• Pain after activity—then before/after—then all
the time
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Tx: Modify activity
Correct foot biomechanics (orthotics)
Heel cord stretching (slant board)
Strengthening of muscles in Posterior compartment
Ice massage
Friction massage
Taping—arch support/ankle
• Demonstrate Arch Taping
• Tibia is most commonly fractured long bone in the
body
• MOI: 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
• Tibial (mid shaft)
• Fibular (distal third)
• Metatarsal (2nd is most common)
• MOI: 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
• Pt. tender 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 footwear
• Medical referral
• Xrays
• Bone scan
• 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
• MOI: 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—MEDICAL
EMERGENCY
• Fasciotomy
• Return to activity 2-4 months post surgery
• Largest tendon in body
• Most common in athletes over 30 yrs
• Seen in sports with ballistic movements—tennis,
raquetball, basketball, etc.
• MOI: sudden forceful plantar flexion of ankle
• S/S: felt/heard a “pop” at back of leg (sounds
like a twig snap or gun shot)
• 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
• Tx: immobilize
• ice
• Send to ER
•Requires surgery w/ 6-8 weeks immobilization
• Rehab to regain full ROM/Strength
• MOI: direct trauma to
area
• S/S: pain, swelling,
increased warmth,
hematoma
• Tx: RICE, protective
padding, modify activity
if necessary
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Immoblize object
Cut object at each end to allow for transport
Treat for shock
Surgery to remove impaled object
• Apply Tuf-Skin
• Heel and Lace Pads
• Pre-wrap from midfoot to 2 finger widths below calf
belly
• 2 anchor strips
• Begin 3 Stirrups
• In between each stirrup is
a horseshoe/C strip
• ALWAYS GO MEDIAL TO
LATERAL….unless
• Once 3 stirrups and C
strips are in place
• 4 heel locks
• 2 medial
• 2 lateral
• 2 figure 8s
• Once all parts are on
the ankle
• Close out
• Make it Pretty
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2.
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7.
Spray
Heel and Lace Pads
Pre-Wrap
2 Anchors
3 Stirrups
3 C Strips
4 Heel locks
1. 2 medial
2. 2 lateral
8. 2 Figure 8s
9. Close Out