Injuries to the Foot, Ankle and Lower Leg

1. Injuries to the Foot, Ankle and Lower Leg Original Author: Sabino Sports Medicine Connie Rauser, Instructor

2. Bony Anatomy • Tibia • Fibula • Tarsals • Metatarsals • Phalanges • Sesamoid Bones

3. Tibia • Weight bearing bone • Articulates with fibula both inferiorly and superiorly • Landmarks • Tibial tuberosity (proximal) • Tibial Plateau • Medial Malleolus • Shaft

4. Fibula • 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

5. Tarsals • Talus—articulates with the tibia/fibula • Calcaneus • Navicular • Cuboid • Medial, intermediate and lateral cuneiforms

6. Joints • Tibiofibular joint--syndesmosis • Ankle joint (talocrural) Ankle mortise • Subtalar joint • Metatarsalphalangeal joints (MP) • Interphalangeal joints • PIP • DIP

7. Arches • 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

8. Muscles of lateral compartment • Peroneus longus • Peroneus brevis • Both do eversion

9. Muscles of the anterior compartment • 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)

12. Muscles of Superficial Posterior compartment • 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

13. Muscles of Deep Posterior Compartment • 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

15. Miscellaneous • 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

16. Plantar fasica

17. Medial Ligaments • Deltoid ligament • 4 parts • Very strong • Not injured as often

18. Lateral ligaments • Anterior talofibular • Posterior talofibular • Calcaneofibular

19. Other ligaments • Anterior inferior tibiofibular ligament • Posterior inferior tibiofibular ligament

20. Prevention of Injuries • 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)

21. Injuries to the Foot, Ankle and Lower Leg

22. Heel Bruise (Stone Bruise) • 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

23. Plantar Fasciitis • MOI: tight heel cord, inflexibility of longitudinal arch, improper footwear, leg length discrepancy, rapid increase/change in training

24. 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

25. 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

26. Metatarsal Fracture • 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

27. S/S: Pt. tenderover metatarsal, swelling, pain, “pop” or “crack”, possible deformity

28. 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

29. Longitudinal Arch Strain • 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

30. 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

31. TX: Rest, ice, reduction of weight bearing until relatively pain free • Ultrasound • Arch taping

32. Turf Toe • 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

33. S/S: Pt. tenderover MP joint of great toe • Swelling • Discoloration • Pain with movement especially pushing off big toe when taking a step

34. TX: Rest, ice, compression • Insert a hard insole into shoe to prevent hyperextension of MP joint • Tape for hyperextension

35. Subungual Hematoma • MOI: being stepped on or something being dropped onto the toe • Toes being jammed into the end of the shoe while running

36. S/S: Bleeding into the nail bed (under nail) • Throbbing pain • Pressure against nail exacerbates the problem

37. 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

38. Blisters • MOI: shearing force on the skin that causes fluid to accumulate below top layer of skin • May be clear, bloody or become infected

39. S/S: area of fluid under skin • Can be painful • May break open • May become infected—redness, heat, pus

40. 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

41. Ankle Sprains • Inversion • Eversion • High Ankle Sprain

42. Inversion 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

43. The inversion MOI

44. Structures injured • ATF lig. injured with the plantar flexion/inversion MOI • Calcaneofibular lig. and posterior talofibular lig. injured when then inversion force is increased

45. 3rd degree Lateral Ankle sprain

47. 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 • Anterior Drawer Test – Tests ATF • Talar Tilt – Calcaneofib and Deltoid Ligaments • Kleiger Test – High Ankle • Calcaneus (Bump) Test – Calcaneus Fx

48. 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

49. Complications • Avulsion fracture of lateral malleolus • Avulsion fracture of base of 5th metatarsal • Push-off fracture of medial malleolus

50. Eversion Ankle Sprain • Less common due to bony structure of ankle • Deltoid ligament damage (any or all 4 portions)