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CHAPTER 15 – FOOT, ANKLE AND LOWER LEG

CHAPTER 15 – FOOT, ANKLE AND LOWER LEG. FOOT ANATOMY. FOOT ANATOMY. It is complex! 26 bones 33 joints Over 100 muscles, tendons and ligaments. ANATOMY - BONES. PHALANGES (Toes) – 14 Big toe has two phalanges, the rest of the toes have three Proximal, middle, and distal.

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CHAPTER 15 – FOOT, ANKLE AND LOWER LEG

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  1. CHAPTER 15 – FOOT, ANKLE AND LOWER LEG

  2. FOOT ANATOMY

  3. FOOT ANATOMY • It is complex! • 26 bones • 33 joints • Over 100 muscles, tendons and ligaments

  4. ANATOMY - BONES • PHALANGES (Toes) – 14 • Big toe has two phalanges, the rest of the toes have three • Proximal, middle, and distal

  5. FOOT ANATOMY - BONES • METATARSALS – 5 • 1ST one is medial and 5th one is lateral

  6. FOOT ANATOMY – 26 BONES • TARSAL BONES – 7 • Calcaneus – heel bone • Talus – forms the ankle • Navicular – medial in respect to the talus • Cuboid - lateral • Cuneiforms (3)

  7. FOOT ANATOMY • PLANTAR FASCIA • 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

  8. FOOT ANATOMY - ARCHES • Support body weight and absorb shock • There are four arches: • MEDIAL LONGITUDINAL ARCH • LATERAL LONGITUDINAL ARCH • METATARSAL ARCH • TRANSVERSE ARCH

  9. FOOT - MOTIONS • Toes • Flexion and Extension • Foot • Pronation – like fallen arch • Supination – high arch

  10. ANKLE ANATOMY - BONES • BONES • Two bones in the lower leg • Tibia – medial, larger, weight bearing • Medial Malleolus • Fibula • Lateral Malleolus • Two tarsal bone • Talus • Calcaneus

  11. ANKLE ANATOMY - JOINTS • TRUE ANKLE JOINT • Tibia, fibula and talus • Mortise • Definition: where the talus fits into the tibia and the fibula

  12. ANKLE ANATOMY - JOINTS • Subtalar joint • Between the Talus and the Calcaneus

  13. ANKLE ANATOMY - LIGAMENTS • LATERAL – • 3 ligaments named for bones • Anterior talofibular • (ATF) • Calcaneofibular • (CF) • Posterior talofibular • (PTF)

  14. ANKLE ANATOMY - LIGAMENTS • MEDIAL • Deltoid • Strong ligament • 4 parts that form one ligament

  15. ANKLE ANATOMY - LIGAMENTS • TIBIOFIBULAR LIGAMENTS – holds tibia and fibula together • Anterior tibiofibular • Posterior tibiofibular

  16. ANKLE MOTIONS • Dorsiflexion • Plantarflexion • Inversion • Eversion

  17. LOWER LEG ANATOMY • Bones • Tibia • Fibula

  18. LOWER LEG MUSCLES • The muscles are in four compartments with 2-4 muscles in each compartment • Compartments are held together by fascia

  19. LOWER LEG MUSCLE COMPARTMENTS • LATERAL – everts the ankle • ANTERIOR – dorsiflexes the ankle • DEEP POSTERIOR – plantarflexes the ankle (the calf muscle) • POSTERIOR MEDIAL – inverts and plantarflexes the ankle

  20. LOWER LEG - Major Muscles and Actions • Anterior Tibialis - dorsiflexor • Peroneals - evertors • Gastrocnemius – plantarflexor • Soleus – plantarflexor • Posterior Tibialis – invertor

  21. INJURIES

  22. 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: Sharp pain occurs in the heel to mid-foot, especially with dorsiflexion • Hurts in the morning, feels better as they warm up • Treatment: Gentle stretches, roll on tennis ball or frozen can, arch taping or orthotics.

  23. JONES FRACTURE • Fracture of the base of the 5th metatarsal • Causes: inversion; rotational forces; overuse • S/S: Feel and hear a ‘pop’; pain in the lateral foot over 5th metatarsal, swelling, inability to walk • Tx: immobilization (cast) 6-8 weeks or longer, often requires surgery

  24. BUNIONS (HALLUX VALGUS) • Deformity of the head of the 1stmetatarsal/big toe • Can have bunion on 5thmetatarsal/toe too • Cause: extra bone is laid down on head of 1stmetatarsal – poor shoes, genetics, on toes • Great toe and 1st Metatarsal become malaligned • S/S: Pain, swelling and deformity of big toe joint, shoes are painful • Treatment: Proper shoes; doughnut pad over the bunion; surgery

  25. TURF TOE • 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 MTP joint, pain with hyperextension (pushing off toe) • Tx: RICE, rigid insoles or toe boxes, taping to prevent hyperextension of toe

  26. 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 and red nail bed at corner of toenail, may have drainage/pus • Tx: May need to refer to doctor; soak in betadine bath; pack cotton under toenail, surgical shaping of toenail

  27. PUBLIC SERVICE ANNOUNCEMENT • HIGH HEELS • Loads 5 times your body weight onto your heel • Overloads forefoot • Deforms the arch • Reduces shock absorption • Plantar fasciitis • Leads to inflamed nerves in your toes • Morton’s Neuroma • Shortens your calf • Achilles tendinitis • Changes your center of gravity – more forward • Have to extend back to compensate

  28. 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 • Out 1-2 weeks

  29. TYPES OF ANKLE SPRAINS • Inversion • Second degree sprain • Anterior talofibular ligament is torn and calcaneofibular ligament is injured as well • Most painful • Moderate swelling • Discoloration • Hears/feels a pop • Mild Instability • Out 4-6 weeks

  30. TYPES OF ANKLE SPRAINS • Inversion • Third degree sprain • Complete tear of all three lateral ligaments • Uncommon • Feel and hear multiple pops • Lots of pain, but it can subside • Significant swelling • Very unstable • Usually requires surgery

  31. ANKLE SPRAIN TREATMENT • Prevention • Exercises • Rest • No activity • Ice 20 minutes on, 40 minutes to an hour off • No heat • Compression – Ace Wrap • Elevation – above heart • Support • Crutches, braces

  32. 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

  33. HIGH ANKLE SPRAIN • Involves Anterior Inferior Tibiofibular (AITFL) Ligament • Injury allows tibia and fibula to separate

  34. HIGH ANKLE SPRAIN • Cause: Inversion with rotation; rotation of foot • S/S: pain with external rotation of foot; tender over AITFL, swelling, does not want to weight bear • Treatment: RICE, may need to be immobilized; possible surgery if severe enough

  35. TIBIA/FIBULA 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 malleoli, deformity, does not want to weight bear • Treatment: splint, ice, x-ray Cast 6-8 weeks

  36. 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 • S/S: resisted plantar flexion and inversion should hurt, pain is just off the tibia, achy or sharp pain • Treatment : prevention (shoes, arch support), strengthening, stretching, ice massage, contrast bath, tape arches • Refer to MD if no improvement to rule out stress fracture

  37. 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

  38. 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

  39. 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)

  40. 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 in Achilles, Achilles is tender on palpation, pain with standing plantarflexion, may have crepitus, hurts to warm up and to cool down • TREATMENT • If there is crepitus, no running for 1-2 weeks • Stretch! • Heel lift in both shoes • Orthodics • Heat and/or ice

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