foot, ankle, lower leg s12

MEDIAL BONY ANATOMY

• Tibia-• Medial

Malleolus• Talus• Calcaneus• Navicular

(Tubercle)

LATERAL BONY ANATOMY

Fibula- Lateral Malleolus

Talus

Calcaneus

MEDIAL LIGAMENTOUS ANATOMY

(DELTOID LIGAMENT)

Deep Portion - Anterior Tibiotalar

Superficial Portion - Tibonavicular - Tibialcalcaneal - Posterior Tibiotalar

Inversion Ankle SprainAnterior Talo-fibular (ATF)

CalcaneofibularPosterior Talo-fibular

Eversion Ankle SprainDeltoid Ligament

**What type of sprain is more common? Why?

ANKLE SPRAINS

LATERAL LIGAMENTOUS ANATOMY

Lateral View Posterior View

MEDIAL MUSCULATURE

“Tom” Tibialis Posterior

“Dick “ Flexor Digitorum Longus

“An” Posterior Tibial Artery & Nerve

“Harry” Flexor Hallicus Longus

LATERAL MUSCULATURE

POSTERIOR MUSCULATURE

ANTERIOR MUSCULATURE

ARCHES OF THE FOOT

PLANTAR FASCIA

History

Generic history questions

Questions specific to the foot/ankle

Location of pain - heel, foot, toes, arches?

Training surfaces or changes in footwear?

Changes in training, volume or type?

Does footwear increase discomfort?

FOOT/ANKLE ASSESSMENT

Does athlete favor a foot, limp, or is unable to bear weight?

Is there pes planus/cavus?

How is foot alignment?

Are there structural deformities?

OBSERVATIONS

**Single most common injury in athletics caused by sudden inversion or eversion moments

Inversion Sprains•Most common and result in injury to the lateral

ligaments•Anterior talofibular ligament is injured with

inversion, plantar flexion and internal rotation•Occasionally the force is great enough for an

avulsion fracture to occur w/ the lateral malleolus

ANKLE SPRAINS

Severity of sprains is graded (1-3)

The most common type of sprain in an

inversion ankle sprain

?What structures are injured?

EVERSION ANKLE SPRAINS

Etiology • Bony protection and

ligament strength decreases likelihood of

injury

• Eversion force results in damage to deltoid ligament and possibly fx of the fibula

• Deltoid can also be impinged and contused with inversion sprains

-(Represent 5-10% of all ankle sprains)

• 1st degree

• Mild pain and disability; weight bearing is minimally impaired; point tenderness over ligaments and no laxity

• 2nd degree

• Feel or hear pop or snap; moderate pain w/ difficulty bearing weight; tenderness and edema

• Positive ligament tests

• Possible tearing of the anterior talofibular and calcaneofibular ligaments (inversion sprain) or deltoid ligament (eversion

sprain)

• 3rd degree

• Severe pain, swelling, hemarthrosis, discoloration

• Unable to bear weight

• Positive ligament tests – torn ligaments

SIGNS AND SYMPTOMS

Etiology

• Injury to the distal tibiofemoral joint

(anterior/posterior tibiofibular ligament)

• Torn w/ increased external rotation or dorsiflexion

• Injured in conjunction w/ medial and lateral ligaments

Signs and Symptoms

• Severe pain, loss of function; passive external rotation and

dorsiflexion cause pain

• Pain is usually anterolaterally located

SYNDESMOTIC SPRAIN

Etiology

Number of mechanisms

Signs and Symptoms

Swelling and pain may be extreme with possible deformity

ANKLE FRACTURES/DISLOCATIONS

Etiology• Inflammatory condition involving tendon, sheath or paratenon

• Tendon is overloaded due to extensive stress• Presents with gradual onset and worsens with continued use

• Decreased flexibility exacerbates condition

Signs and Symptoms• Generalized pain and stiffness, localized proximal to

calcaneal insertion • Warm and painful with palpation, also presents with

thickening• May limit strength

• May progress to morning stiffness

• Crepitus with active plantar flexion and passive dorsiflexion

• Chronic inflammation may lead to thickening

ACHILLES TENDINITIS

Etiology

• Occurs w/ sudden stop and go; forceful plantar flexion w/ knee moving into full extension

• Commonly seen in athletes > 30 years old

• Generally has history of chronic inflammation

Signs and Symptoms

• Sudden snap (kick in the leg) w/ immediate pain which rapidly subsides

• Point tenderness, swelling, discoloration; decreased ROM

• Obvious indentation and positive Thompson test

• Occurs 2-6 cm proximal the calcaneal insertion

ACHILLES TENDON RUPTURE

Etiology• Common overuse condition in runners with

foot hypermobility or over pronation• Repetitive microtrauma

Signs and Symptoms• Pain and swelling in area of medial malleolus• Edema, point tenderness and increased pain

during resistive inversion and plantar flexion

POSTERIOR TIBIALIS TENDINITIS

Etiology

• Not common, but can be found with athletes that have pes cavus due to excessive supination placing

stress on peroneal tendon

Signs and Symptoms

• Pain behind lateral malleolus during push-off or when rising on ball of foot

• Pain along distolateral aspect of calcaneus and beneath the cuboid

PERONEAL TENDINITIS

Etiology

• Fibula has highest incidence of fracture, occurring primarily in the middle third

• Tibial fractures occur predominantly in the lower third

• Result of direct blow or indirect trauma

Signs and Symptoms

• Pain, swelling, soft tissue insult

• Leg will appear hard and swollen (Compartment Syndrome)

ACUTE LEG FRACTURES

Etiology

• Pain in anterior portion of shin

• Catch all for stress fractures, muscle strains, chronic anterior compartment syndrome

• Accounts for 10-15% of all running injuries, 60% of leg pain in athletes

• Caused by repetitive microtrauma

• Weak muscles, improper footwear, training errors, varus foot, tight heel cord, hypermobile or pronated feet and even forefoot

supination can contribute to MTSS

• May also involve, stress fractures or exertional compartment syndrome

MEDIAL TIBIAL STRESS SYNDROME

Signs and Symptoms

• Four grades of pain• Pain after activity

• Pain before and after activity and not affecting performance

• Pain before, during and after activity, affecting performance

• Pain so severe, performance is impossible

•Recall you may hear “Periostitis”

MTSS CONTINUED

Etiology• Common overuse condition, particularly in those with

structural and biomechanical insufficiencies• Runners tends to develop in lower third of lower leg (dancers

middle third)• Often occur in unconditioned, non-experienced individuals

• Often training errors are involved• Component of female athlete triad

Signs and Symptoms• Pain more intense after exercise than before

• Point tenderness; difficult to discern bone and soft tissue pain• Bone scan results (stress fracture vs. periostitis)

STRESS FRACTURE

Apophysitis of the Calcaneus (Sever’s Disease)

Etiology

• Traction injury at apophysis of calcaneus, where Achilles attaches

Sign and Symptoms

• Pain occurs at posterior heel below Achilles attachment in children and adolescent athletes

• Pain occurs during vigorous activity and ceases following activity

INJURIES TO THE FOOT

(Pump Bump)

Etiology

• Caused by inflammation of bursa beneath Achilles tendon

• Result of pressure and rubbing of shoe heel counter

• Chronic condition that develops over time and may take extensive time to resolve, exostosis may also develop

Sign and Symptoms

• Pain w/ palpation superior and anterior to Achilles insertion, swelling on both sides of the heel cord

RETROCALCANEAL BURSITIS

Etiology

• Caused by sudden starts, stops or changes of direction, irritation of fat pad

• Pain often on the lateral aspect due to heel strike pattern

Sign and Symptoms

• Severe pain in heel and is unable to withstand stress of weight bearing

• Often warmth and redness over the tender area

HEEL CONTUSION

Pes Planus Foot (Flatfoot)

Etiology

• Associated with excessive pronation, forefoot varus, wearing tight shoes (weakening supportive structures)

being overweight, excessive exercise placing undo stress on arch

Sign and Symptoms

• Pain, weakness or fatigue in medial longitudinal arch; calcaneal eversion, bulging navicular, flattening of

medial longitudinal arch and dorsiflexion with lateral splaying of 1st metatarsal

INJURIES TO METATARSAL REGION

Etiology

• Higher arch than normal; associated with excessive supination, accentuated high medial

longitudinal arch

Sign and Symptoms

• Poor shock absorption resulting in metatarsalgia, foot pain, clawed or hammer toes

• Associated with forefoot valgus, shortening of Achilles and plantar fascia; heavy callus

development on ball and heel of foot

PES CAVUS

• Common in athletes and nonathletes

• Attributed to heel spurs, plantar fascia irritation, and bursitis

• Plantar fascia, dense, broad band of connective tissue attaching proximal and

medially on the calcaneus and fans out over the plantar aspect of the foot

PLANTAR FASCIITIS

Etiology

• Increased tension and stress on fascia (particularly during push off of running phase)

• Change from rigid supportive footwear to flexible footwear

• Poor running technique

• Leg length discrepancy, excessive pronation, inflexible longitudinal arch, tight gastroc-soleus complex

• Running on soft surfaces, shoes with poor support

Sign and Symptoms

• Pain in anterior medial heel, along medial longitudinal arch

• Increased pain in morning, loosens after first few steps

• Increased pain with forefoot dorsiflexion

PLANTAR FASCIITIS CONT.

Etiology

• Fracture of metatarsal caused by inversion and plantar flexion, direct force (stepped on) or

repetitive trauma

• Most common = base of 5th metatarsal

Sign and Symptoms

• Immediate swelling, pain over 5th metatarsal

• High nonunion rate and course of healing is unpredictable

JONES FRACTURE

Etiology

• 2nd metatarsal fracture (March fracture)

• Change in running pattern, mileage, hills, or hard surfaces

• Forefoot varus, hallux valgus, flatfoot or short 1st metatarsal

• Occasional 5th metatarsal fracture at base and insertion of peroneus brevis

METATARSAL STRESS FRACTURES

Etiology

• Exostosis of 1st metatarsal head; associated with forefoot varus; shoes that are too narrow, pointed or short

• Bursa becomes inflamed and thickens, enlarging joint, and causing lateral malalignment of great toe

• Bunionette (Tailor’s bunion) impacts 5th metatarsophalangeal joint - causes medial displacement of 5th toe

Sign and Symptoms

• Tenderness, swelling, and enlargement of joint initially

• As inflammation continues, angulation increases causing painful ambulation

• Tendinitis in great toe flexors may develop

BUNION

Etiology

• Hyperextension injury resulting in sprain of 1st metatarsophalangeal joint

• May be the result of single or repetitive trauma

Signs and Symptoms

• Pain and swelling which increases during push off in walking, running, and jumping

TURF TOE

MOI

• Direct pressure, dropping an object on toe, kicking another object

• Repetitive shear forces on toenail

Signs of Injury

• Accumulation of blood underneath toenail

• Likely to produce extreme pain and ultimately loss of nail

SUBUNGUAL HEMATOMA