Transcript Injuries to the Lower Leg, Ankle, and Foot

Injuries to the Lower Leg, Ankle,
and Foot…
 For an athlete to move well, there must be excellent
functioning of the lower leg, ankle, and foot
 The foot must provide a stable base of support and as
the same time be flexible and extremely mobile
 This chapter discusses the skeletal and muscular
anatomy of the foot and lower leg
 We will discuss:
 Ligaments of the ankle, compartments of the lower leg,
muscular actions of each compartment
 Fractures as well as common sprains of ankle ligaments
Injuries to the Lower Leg, Ankle,
and Foot…
 Treatment of ankle sprains and control of possible
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future sprains
Recognition, care, and treatment of tendon injuries
along with compartment problems
Treatment and care of athletes with shin splints and
considers ways to enhance the performance of these
athletes
Discuss foot disorders such as plantar fasciitis, heel
spurs, Morton's neuroma, arch problems, bunions,
blisters and calluses, providing guidelines for
recognition, first aid treatment, and long term care
And FINALLY ANKLE TAPING 
Anatomy Review 
 The lower leg, ankle, and
foot work together to
provide a stable base of
support and a dynamic
system of movement
 The skeleton of the lower
leg consist of the tibia
and fibula
Anatomy Review 
 Tibia is the larger and
stronger of the two
(commonly called the
shin bone)
 Supports 98% of body
wgt
 Acts as an attachment
for various muscles and
helps to provide a
mechanical advantage
for some of them
Anatomy Review
 Normal foot contains 26
bones that are
interconnected and
supported by numerous
ligaments
 Many joints within the
foot also assist with
support and movement
Anatomy Review
Anatomy Review
 The ankle joint (talocrural
joint) is where the tibia,
fibula, and talus join
 Provides mainly plantar
flexion and dorsiflexion of
the foot
 Subtalar joint is the
articulation of the talus
and the calcaneus
 Responsible for inversion
and eversion of the foot
 Both joints are synovial,
which means they are
surrounded by a capsule
and supported by
ligaments
Anatomy Review 
 The ankle joint is
supported on the medial
side by the large and
strong deltoid ligament
 On the lateral side, the
joint is supported by the
anterior talofibular, the
posterior talofibular, and
the calcanefibular
ligaments
Anatomy Review
 These ligaments are not as large or strong as the
deltoid ligament
 Additional lateral stability for the ankle joint is
provided by the length of the fibula on the lateral side
of the ankle
 The ankle joint is strongest when placed in
dorsiflexion
 The talus fits much tighter between the tibia and fibula
in this position
 Joint is weakest when placed in plantar flexion
Anatomy Review
 Joints, ligaments, and
muscles help to create
and maintain the two
basic arches in the foot
 Longitudinal arch has
medial lateral divisions
 Transverse arch runs
from side to side
 These arches assist the
foot as shock absorbers;
also provide propulsion
off surfaces during
movement
Anatomy Review
 Muscles are divided into anterior (front), posterior
(back), and lateral (side) compartments
 Muscles of the anterior compartment essentially
produce dorsiflexion and extension of the toes
 Tibialis anterior, extensor digitorum longus, extensor
hallucis longus, and peroneus tertius
 Very compact area with little room for any extra tissue or
fluid
Anatomy Review
 Posterior compartment mainly functions to produce
plantar flexion of the foot
 Referred to as the calf muscles
 Is divided into two compartments, superficial section
and deep section
 Superficial section
 Gastrochnemius, soleus, and plantar muscles
 Gastrochnemius and soleus attach on the calcaneus via
the achilles tendon
 Plantars muscle is small and insignificant in action
Anatomy Review
 Deep section of this compartment houses the tibialis
posterior, flexor digitorum longus, flexor hallucis
longus, and popliteus muscles
 Besides the popliteus these muscles course behind the
medial mallelous of the tibia and along the bottom of
the foot
 They help with the plantar flexion as well as flexion of
the toes
 The popliteus muscle is important in knee flexion
Anatomy Review
 Lateral compartment of the lower leg contains the
peroneus longus and peroneus brevis muscles
 Mainly evertors (to turn the foot outward) of the foot but do
assist with some plantar flexion
 Both of these muscles course behind the lateral mallelous of
the fibula
 Peroneus longus courses under the lateral side of the foot
and runs across the bottom to the first metatarsal and
cuneiform bones
 The peroneus brevis attaches at the base of the 5th
metatarsal and is subject to avulsion (forcible tearing away
or separation)
Compartments of the Leg
Anatomy Review
 Included is also the peroneal nerve, a superficial nerve
that is susceptible to injury
 The posterior tibial artery supplies blood to the
peroneal muscles because there is no major artery in
the lateral compartment
Common Sports Injuries
 Many injuries occur to the lower leg, ankle, and foot
 Some can be classified as traumatic, and others are
chronic in nature
 Traumatic injuries typically involve skeletal structures
 Chronic injuries usually involve damage to soft tissues
Skeletal Injuries…Fractures
 Direct trauma through
contact causes most
fractures to the lower leg
 Magnitude of contact
necessary to fracture a
bone such as the tibia or
fibula can vary
 A fracture can be caused
by being kicked by an
opponent in a soccer
match or by having a 300
pound lineman land on a
leg
 http://www.youtube.co
m/watch?v=I-iEOoM1Nw
Skeletal Injuries…Fractures
 Fractures to the foot can
also occur from trauma
 However, violent trauma
is not always required in
fractures of the bones of
the leg and foot
 Stress fractures can occur
from overuse or
microtrauma
(microscopic
lesion/injury)
Skeletal Injuries…fractures
 In running, for example, each time the foot strikes the
ground it produces a small amount of trauma to the bone
 This trauma damages a few bone cells, which the body
must repair as quickly as possible
 When the body cannot maintain the repair process and
keep up with repeated microtrauma to a specific bone, a
stress fracture results
 Additionally, an avulsion fracture of the 5th metatarsal can
occur in association with a lateral ankle sprain
 Therefore the possibility of such a fracture should be
examined when an athlete sprains his/her ankle
Skeletal Injuries…fractures
 S&S
 Swelling and/or deformity at the location of the trauma
 Discoloration at the site of the trauma
 Possible broken bone end projecting through the skin
 Athlete reports that a snap or a pop was heard or felt
 The athlete may not be able to bear weight on the
affected extremity
 In the case of a stress fracture or a growth plate fracture
that did not result from a traumatic event, the athlete
complains of extreme point tenderness and pain at the
site of suspected injury
Skeletal Injuries…fractures
 TX:
 Watch and treat for shock if necessary
 Apply sterile dressings to any related wounds (ex open
fx)
 Carefully immobilize the foot and leg using a splint
 Arrange for transport to a medical facility
 In the event that bones are fractured, apply a cast
 Athlete will be immobilized for a specified time
Skeletal Injuries…fractures
 When the fracture has healed properly, the physician
will release the athlete for rehabilitation, practice, and
competition in that order
 Participation while a fracture is healing is NOT
recommended because it may slow the healing process
 There is a possibility of nonunion of a fracture,
especially in the 5th metartasal of the foot, as a result of
a diminished blood supply
Soft-Tissue Injuries…ankle injuries
 One of the most common
sports injuries to the lower
leg and ankle is a sprained
ankle
 Are abnormal stresses
placed on ligamentous
structures and cause
various levels of damage
 Sprains can occur to the
lateral or medial ligaments
of the ankle depending on
which direction the foot
moves when abnormal
stress is placed on the
ligaments and the foot
rolls to one side
Soft-Tissue Injuries…ankle injuries
 The noncontractile structures
on the lateral aspect of the
ankle are most susceptible to
injury
 The formation of the bones of
the ankle helps to stabilize it;
the fibula extends inferiorly,
approximating the lateral
talus completely
 The ligaments on the lateral
side, the anterior talofibular,
the posterior talofibular, and
the calcaneofibular ligaments
are not as large or strong as
the deltoid ligament on the
medial side of the ankle joint
Soft-Tissue Injuries…ankle injuries
 It is estimated that 80% to 85% of ankle sprains occur
to the lateral ligaments (Ryan et al., 1986)
 An interesting note is that authors are suggesting that
serious ankle sprains in the adolescent athlete are
unusual because the ligaments are typically stronger
than the bones (Omey & Micheli, 1999)
Soft-Tissue Injuries…ankle injuries
 Can occur in virtually any sport and can limit the abilities
of the athlete in performance until resolution of the injury
is complete
 As the severity of the ankle sprain increases, so does the
instability of the ankle
 It is generally accepted that an eversion (move outward)
ankle sprain is more severe, with greater instability, and
should be cared for more conservatively (Ryan et al., 1986)
 However, an inversion (move inward) ankle sprain is more
common, with the lateral ligaments being involved in 80%
to 85% of all ankle sprains
Soft-Tissue Injuries…ankle injuries
 S&S of a lateral ankle
sprain
 1st degree sprain
 pain, mild disability, point
tenderness, little laxity,
little or no swelling
 2nd degree sprain
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Pain, mild-moderate
disability, point tenderness,
loss of function, some laxity
(abnormal movement),
swelling (moderate to
severe)
Soft-Tissue Injuries…ankle injuries
 3rd degree sprain
 Pain and severe
disability, point
tenderness, loss of
function, laxity
(abnormal movement),
swelling, (moderate to
severe)
Soft-Tissue Injuries…ankle injuries
 TX:
 Immediately apply ice,
compression, and
elevation
 A horse-shoe or doughnut
shaped pad kept in place
by an elastic bandage aids
at this stage in the
compression and
reduction of fluid
 Have the athlete rest and
use crutches to ambulate
with a 3 or 4 point gait if a
2nd or 3rd degree sprain has
occurred
 If there is any hesitation
about the severity, splint
and refer for further eval
Soft-Tissue Injuries…ankle injuries
 It is important to recognize the possibility of a
tibiofibular (tib/fib) syndesmosis sprain in
conjunction with or masquerading as a lateral ankle
sprain
 Too often a syndesmosis sprain is treated as a lateral
ankle sprain, which is inappropriate and will not allow
the athlete to progress in the healing process
Soft-Tissue Injuries…ankle injuries
 It is important to know that there is a significant difference
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in the etiology of the injury
With the lateral ankle sprain, there is an inversion
mechanism, which includes supination
In the tib-fib syndesmosis sprain, the mechanism is one of
dorsiflexion followed by axial loading of the lower leg, with
external rotation of the foot and internal rotation of the
lower leg
Typically, athletes have their foot planted firmly with the
foot in external rotation, and the lower leg twist medially,
forcing the talus into the ankle mortise
The axial load forces the tibia and fibula to separate slightly
and sprain the syndesmosis
Soft-Tissue Injuries…ankle injuries
 S&S of a tib/fib
syndesmosis sprain
 Mechanism of injury is
different from a lateral
ankle sprain; ankle
dorsiflexion and foot
external rotation are
combined with internal
rotation of the lower leg
 Typical ankle sprain test
may be positive but the
athlete will c/o a great deal
of pain and point
tenderness in the area of
the tib/fib syndesmosis
Soft-Tissue Injuries…ankle injuries
 Performing the “squeeze” test (squeezing the tibia and fibula
together superior to the syndesmosis); elicits pain in the
syndesmosis area
 TX
 Immediately apply ice, compression, and elevation
 A horse-shoe or doughnut shaped pad kept in place by an
elastic bandage aids
 Have the athlete rest and use crutches to ambulate for the
first 72 hours, followed by use of a walking boot for a
minimum of 3 days and preferably for 7 days following the
initial injury
 If there is any question refer for further evaluation
Soft-Tissue Injuries…ankle injuries
 It is recognized that either taping or bracing can reduce the
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number of ankle sprains (Verhagen, van Mechelen, & de
Vente, 2000)
Some prefer to use the standard ankle-taping procedure as
a prophylactic tx for ankles with no HX of an injury
Others choose to augment the taping procedure to prevent
future ankle sprains if one has occurred before
In published research studies, ankle taping as been
demonstrated to help with the neuromuscular response of
the muscles and to provide stability if done in a specific
manner
Both contribute to reduction of ankle sprains
Soft-Tissue Injuries…ankle injuries
 Most researchers agree that the
best known method of ankle
support, the prophylactic
adhesive-taping procedure,
supports the ankle for only a
short period of time after
exercise begins (Frankeny et al.,
1993)
 Therefore, some researchers
now maintain that bracing is
better than taping for the
prevention of ankle injuries,
owing to the reduction in ROM,
either at excessive points or
within normal ranges (Cordova,
Ingersoll, & LeBlanc, 2000)
 The combination of high-top
shoes and taping or bracing can
be helpful to athletes in
reducing the number of ankle
sprains they experience
Soft-Tissue Injuries…ankle injuries
 Proprioception and the
ankle is a very intense area
of study
 Proper ankle
proprioception is a critical
element in reducing
chronic ankle instability
(Hintermann, 1999)
 Also be important part of
both the preventative and
rehabilitative aspects of
ankle functioning (Hertel,
2000)
Soft-Tissue Injuries…ankle injuries
 Whatever the choice of the coach or athlete, many
factors must be considered in preventing ankle sprains
 These include:
 Type of activity, compliance of the athlete in wearing
braces or prophylactic taping, cost to the school or
athlete, effectiveness of the brace as reported in research
studies
 There are some consequences of using adhesive tape,
including:
 Blisters, tape cuts, and loss of circulation
Tendon-related Injuries
 The achilles tendon is
commonly injured by long
distance runners,
basketball players, and
tennis players
 The onset of tendinitis may
be slow among runners,
but much more rapid
among basketball or tennis
players
 Great many of short-burst
movements requiring
jumping or rapid motion
from side to side
Tendon-related injuries
 Some controversy exsist
about the actual injury that
constitutes Achilles
tendinitis
 The Achilles tendon itself,
which attaches the
gastrocnemius and soleus
muscles to the calcaneus,
can become inflamed
 However, either tendon
sheath or the
subcutaneous bursa dorsal
to the tendon can become
inflammed
Tendon-related injuries
 Most agree that athletes who dramatically increase
their running distance or workout times and who do so
running on hard, uneven, or uphill surfaces are prone
to Achilles tendinitis (Omey & Micheli, 1999)
 It is estimated that 11% of runners and up to 52% of
former elite runners experience an Achilles
tendinopathy (tiny tears (microtears) in the tissue in
and around the tendon caused by overuse)
 http://www.youtube.com/watch?v=F2e6LmQsJps
Tendon-related injuries
 Superficially, Achilles tendinitis can produce an
increased temperature in the immediate area;
moreover, the tendon is painful on touch and
movement and appears thickened
 This pain associated with this condition is localized to
a small area of the tendon and typically intensifies
when movement is initiated after rest
 Can be seen over an extended period of time (days to
weeks)
 Or over a shorter period of time (days)
Tendon-related injuries
 TX for chronic Achilles tendinitis:
 Immediate rest until the swelling subsids
 NSAIDS, small heel lift assist the reduction of swelling
and the return to practice and competition
 Stretching has also been shown to be beneficial to
athletes with Achilles Tendinitis (Taylor et al., 1990)
 Controlled stretching on a slant board or against a wall
each day will aid in a return to participation
 Additionally, if an athlete must exercise or run, it is
advised this be done in a controlled environment
(swimming pool)
Tendon-related injuries
 Controlled gradual stressing exercises using the
eccentric contraction of the Achilles assist the athlete in
returning to activity
 An athletes activity level and type of exercise must be
closely monitored during the healing phase
 Without the proper amount of rest, the body has a
hard time repairing injury, thereby increasing the
amount of time the athlete experiences difficulty with
the condition
Tendon-related injuries
 Explosive jumping or
direct trauma from some
type of impact can cause
traumatic injuries to the
Achilles tendon by
tearing or rupturing the
tendon
 Can occur in many
different sports
Tendon-related injuries
 S&S
 Swelling and deformity
at the site of injury
 Reports a pop or snap
associated with the
injury
 Pain in the lower leg,
which may range from
mild to extreme
 Loss of function, mainly
in plantar flexion
 TX:
 Immediately apply rice
and compression to the
area
 Immobilize the foot by
an air cast or splint
 Arrange for
transportation to the
nearest medical facility
Tendon-related issues
 During the acute phase of the healing process,
minimize dorsiflexion and eliminate forced
dorsiflexion
 This movement can produce more damage and
inflammation to the area
 The long term effects of a ruptured Achilles tendon
depend on the severity or completeness of the rupture
 If surgery is necessary, the athlete will most likely be
out of commission for the rest of the season
 The athlete will need to be careful and aware of the
value of stretching and warming up