Transcript Injuries to the Foot, Ankle and Lower Leg

Original Author:
Sabino Sports Medicine
Connie Rauser, Instructor
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Tibia
Fibula
Tarsals
Metatarsals
Phalanges
Sesamoid Bones
• Weight bearing bone
• Articulates with fibula both inferiorly and superiorly
• Landmarks
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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
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Talus—articulates with the tibia/fibula
Calcaneus
Navicular
Cuboid
Medial, intermediate and lateral cuneiforms
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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
• 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. tenderover 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, non-weight 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. tenderalong the calcaneonavicular ligament (spring
ligament) and the first cuneiform
• Pt. tenderover 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. tenderover 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
• Use a drill bit
• Heat a paperclip and burn through nail
• Use a scalpel to make hole in 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
• 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
• 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. tenderover 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
• 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)
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Alternate conditioning—non weight bearing
Ice
Crutches/protective footwear
Medical referral
• Xrays
• Bone scan
• 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 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
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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)
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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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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