Foot, Ankle, Lower leg Foot, Ankle, Lower leg

Lesson 1 – bone and ligament Lesson 1 – bone and ligament anatomyanatomy

Foot bonesFoot bones

Foot bones Foot bones – 26 bones26 bones

14 phalangeal14 phalangeal 5 metatarsals5 metatarsals 7 tarsals7 tarsals

ToesToes

Each toe except for the big toe has three Each toe except for the big toe has three phalangesphalanges– Toes 2-5 are also known as digitsToes 2-5 are also known as digits– The big toe, a.k.a. hallux, has two.The big toe, a.k.a. hallux, has two.

The toes are designed to widen our base for The toes are designed to widen our base for balance and propelling our body.balance and propelling our body.

Two sesamoid bones are located under the 1Two sesamoid bones are located under the 1stst metatarsalphalangeal joint (MTP joint)metatarsalphalangeal joint (MTP joint)– These bones help increase the mechanical advantage These bones help increase the mechanical advantage

of the flexor tendons that run under the big toe.of the flexor tendons that run under the big toe.

MetatarsalsMetatarsals

Five bones that lie between the toes and the tarsal Five bones that lie between the toes and the tarsal bonesbones

The first metatarsal is the biggest and the The first metatarsal is the biggest and the strongest.strongest.– This helps it function as the main weight bearing support This helps it function as the main weight bearing support

during walking and running.during walking and running.

The fifth metatarsal protrudes on the lateral aspect The fifth metatarsal protrudes on the lateral aspect of the foot. of the foot. – Place where ligaments and muscle tendons attachPlace where ligaments and muscle tendons attach

Tarsal bonesTarsal bones

CalcaneusCalcaneus– Largest of tarsal bonesLargest of tarsal bones– Shapes the heel and sits below the talusShapes the heel and sits below the talus– Conveys body weight to the groundConveys body weight to the ground– Attachment for achilles tendon and several Attachment for achilles tendon and several

structures on plantar sidestructures on plantar side– Palpate on the posterior bottom of the footPalpate on the posterior bottom of the foot

Tarsal bone cont…Tarsal bone cont…

TalusTalus– Located above the calcaneusLocated above the calcaneus– Fits between the lateral and medial malleoli Fits between the lateral and medial malleoli

forming the talocural joint (a.k.a ankle joint) - forming the talocural joint (a.k.a ankle joint) - mortisemortise

– Irregular shapedIrregular shaped The bone is broader anterior than posteriorThe bone is broader anterior than posterior

– Which gives the ankle more stability in Which gives the ankle more stability in dorsiflexion as it makes a tight fit between the dorsiflexion as it makes a tight fit between the malleoli (10 deg in DF vs. 23 deg in PF)malleoli (10 deg in DF vs. 23 deg in PF)

Tarsal bones cont.Tarsal bones cont.

NavicularNavicular– Located anterior of the talus on the medial aspect of the foot. Located anterior of the talus on the medial aspect of the foot. – Small tubercle may be palpated on the medial foot.Small tubercle may be palpated on the medial foot.– Anteriorly articulates with the cuneiformsAnteriorly articulates with the cuneiforms

CuboidCuboid– Located on lateral aspect of foot. (palpate on lateral foot)Located on lateral aspect of foot. (palpate on lateral foot)– Posterior articulates with the calcaneus and anterior with the 4Posterior articulates with the calcaneus and anterior with the 4 thth

and 5and 5thth metatarsals metatarsals CuneiformsCuneiforms

– Three bones located between the navicular and 3-5 metatarsalsThree bones located between the navicular and 3-5 metatarsals– Palpate from mid foot to the medial sidePalpate from mid foot to the medial side

Lower leg bonesLower leg bones

TibiaTibia– Second longest bone in bodySecond longest bone in body– Principle weight bearingPrinciple weight bearing– Located on medial side of lower legLocated on medial side of lower leg– The shaft has three sides – posterior, medial, lateralThe shaft has three sides – posterior, medial, lateral

Lateral and posterior covered by muscleLateral and posterior covered by muscle

– Triangle shaped on the top and round near the bottomTriangle shaped on the top and round near the bottom Causes a anatomical weakness – bone more dense in this areaCauses a anatomical weakness – bone more dense in this area Forms medial malleolusForms medial malleolus

Lower leg bones cont.Lower leg bones cont.

FibulaFibula– Long slender bone located on lateral legLong slender bone located on lateral leg– Non weight bearingNon weight bearing– Primary function is to provide attachment for Primary function is to provide attachment for

musclesmuscles– Distal portion forms the lateral malleolusDistal portion forms the lateral malleolus

Malleolus extends further distally than medial to give Malleolus extends further distally than medial to give it more stabilityit more stability

Arches of the footArches of the foot

Medial longitudinal archMedial longitudinal arch– Runs along the medal side of the foot from the Runs along the medal side of the foot from the

calcaneus to distal head of the first metatarsalcalcaneus to distal head of the first metatarsal– Bony support are the medial bonesBony support are the medial bones– The soft tissue support is the plantar calcaneolnavicular The soft tissue support is the plantar calcaneolnavicular

ligament (a.k.a spring ligament) and posterior tibialis ligament (a.k.a spring ligament) and posterior tibialis musclemuscle

Lateral Longitudinal archLateral Longitudinal arch– Runs along lateral portion of the foot.Runs along lateral portion of the foot.– Much lower and less flexible than the medialMuch lower and less flexible than the medial

Arches cont…Arches cont…

Transverse archTransverse arch– Half dome over the anterior portion foot over the Half dome over the anterior portion foot over the

tarsal bones, primarily the cuboid and internal tarsal bones, primarily the cuboid and internal cuneiform cuneiform

Anterior metatarsal archAnterior metatarsal arch– Shaped by the distal heads of the metatarsal Shaped by the distal heads of the metatarsal

headsheads

Foot ligamentsFoot ligaments

Spring ligamentSpring ligament– a.k.a plantar calcaneonavicular a.k.a plantar calcaneonavicular

ligamentligament– Located on medial side of footLocated on medial side of foot– Gives support to the medial Gives support to the medial

archarch– Helps with shock absorptionHelps with shock absorption

Bifurcate ligament Bifurcate ligament – Located on lateral side of footLocated on lateral side of foot

Located under fat pad on footLocated under fat pad on foot

– Connects cuboid to calcaneus Connects cuboid to calcaneus and calcaneus to the navicularand calcaneus to the navicular

Plantar fasciaPlantar fascia– Lies on the bottom of Lies on the bottom of

the foot from the the foot from the calcaneus to the head calcaneus to the head of each metatarsal of each metatarsal headhead

– Helps support the foot Helps support the foot against downward against downward forcesforces

Ankle/lower leg ligamentsAnkle/lower leg ligaments

Interroseous membraneInterroseous membrane– Connective tissue that Connective tissue that

connects the tibia and fibulaconnects the tibia and fibula– The membrane fills the The membrane fills the

whole space between the whole space between the tibia and fibula in the lower tibia and fibula in the lower legleg

– The membrane helps diffuse The membrane helps diffuse forces placed on the lower forces placed on the lower legleg

Lateral ankle ligamentsLateral ankle ligaments

Anterior/Posterior Anterior/Posterior talofibular ligamentstalofibular ligaments– Both are located on lateral Both are located on lateral

ankleankle– Helps prevent against Helps prevent against

anterior/posterior torsion and anterior/posterior torsion and inversion of the ankle (talus inversion of the ankle (talus specifically)specifically)

Calcaneofibular ligamentCalcaneofibular ligament– Located laterally it traverses Located laterally it traverses

inferiorly of the lateral inferiorly of the lateral malleolus malleolus

– Protects against inversion of Protects against inversion of the calcaneus the calcaneus

Lateral ankle ligaments cont…Lateral ankle ligaments cont…

Calcaneofibular Calcaneofibular ligamentligament– Located laterally it Located laterally it

traverses inferiorly of traverses inferiorly of the lateral malleolus the lateral malleolus

– Protects against Protects against inversion of the inversion of the calcaneus calcaneus

Ankle/lower leg ligamentsAnkle/lower leg ligaments

Anterior/posterior Anterior/posterior tibiofibular ligamentstibiofibular ligaments– Sometimes called the Sometimes called the

syndesmotic ligamentssyndesmotic ligaments– They connect the tibia They connect the tibia

and fibula together at and fibula together at the distal end of the the distal end of the bones – forms the distal bones – forms the distal portion of the portion of the interroseous membraneinterroseous membrane

Medial ankle ligamentsMedial ankle ligaments

Deltoid ligamentsDeltoid ligaments– Located medially on the Located medially on the

ankleankle– Technically three ligaments Technically three ligaments

– treat as one– treat as one– Triangle shape that begins Triangle shape that begins

on the medial malleolus and on the medial malleolus and ends on the medial talus, ends on the medial talus, calcaneus, and navicular calcaneus, and navicular bonebone

– Protects against eversion, Protects against eversion, pronation, and anterior pronation, and anterior displacement of the ankle displacement of the ankle (talus specifically)(talus specifically)

Foot, ankle, and lower legFoot, ankle, and lower leg

Lesson 2 – muscles, movement Lesson 2 – muscles, movement and other structuresand other structures

Lateral musclesLateral muscles

Peroneal brevisPeroneal brevis– Origin or proximal attachment - lower 2/3 of outer Origin or proximal attachment - lower 2/3 of outer

surface of fibulasurface of fibula– Insertion or distal attachment – base of 5Insertion or distal attachment – base of 5thth metatarsal metatarsal– Action – eversion of foot and plantar flexion Action – eversion of foot and plantar flexion

Peroneal LongusPeroneal Longus– Origin – upper 2/3 of fibulaOrigin – upper 2/3 of fibula– Insertion – undersurface of medial cuneiform and 1Insertion – undersurface of medial cuneiform and 1stst

metatarsalmetatarsal– Action – plantar flexion and eversionAction – plantar flexion and eversion

Medial musclesMedial muscles Tibialis posterior Tibialis posterior

– Proximal attachment – posterior surface of tibia, fibula, and interroseous Proximal attachment – posterior surface of tibia, fibula, and interroseous membranemembrane

– Distal attachment – undersurface of navicular, cuneiforms, and base of 2-4 Distal attachment – undersurface of navicular, cuneiforms, and base of 2-4 metatarsalsmetatarsals

– ActionAction – inversion and plantar flexion of foot/ankle– inversion and plantar flexion of foot/ankle Flexor Hallicus LongusFlexor Hallicus Longus

– Proximal attachment – Lower 2/3 of posterior fibulaProximal attachment – Lower 2/3 of posterior fibula– Distal attachment – Undersurface of base of distal phalanx of the Big toe Distal attachment – Undersurface of base of distal phalanx of the Big toe

(1(1stst))– ActionAction – Plantar flexion of big toe and inversion and plantar flexion of – Plantar flexion of big toe and inversion and plantar flexion of

foot/anklefoot/ankle Flexor Digitorum longusFlexor Digitorum longus

– Proximal attachment – Lower 2/3 of posterior tibiaProximal attachment – Lower 2/3 of posterior tibia– Distal attachment – Base of distal phalanx of toes 2-5Distal attachment – Base of distal phalanx of toes 2-5– ActionAction – plantar flexion of toes 2-5 and plantar flexion and inversion of – plantar flexion of toes 2-5 and plantar flexion and inversion of

ankle/footankle/foot

Anterior MusclesAnterior Muscles Anterior TibialisAnterior Tibialis

– Proximal attachment – Upper 2/3 of anterior tibiaProximal attachment – Upper 2/3 of anterior tibia– Distal attachment – inner surface medial cuneiform and 1Distal attachment – inner surface medial cuneiform and 1stst metatarsal metatarsal– Action – Dorsal flexion of ankle and inversion of footAction – Dorsal flexion of ankle and inversion of foot

Extensor Hallicus longusExtensor Hallicus longus– Proximal attachment – Anterior/inner surface of middle 2/3 of fibulaProximal attachment – Anterior/inner surface of middle 2/3 of fibula– Distal attachment – top of distal phalanx of big toeDistal attachment – top of distal phalanx of big toe– Action – dorsal flexion of ankle and big toe and foot inversionAction – dorsal flexion of ankle and big toe and foot inversion

Extensor Digitorum longusExtensor Digitorum longus– Proximal attachment – Lateral condyle of Tibia, head of fibula, and upper Proximal attachment – Lateral condyle of Tibia, head of fibula, and upper

2/3 of fibula2/3 of fibula– Distal attachment – top of middle and distal phalanx of toes 2-5Distal attachment – top of middle and distal phalanx of toes 2-5– Action – Dorsal flexion of ankle and toes 2-5, eversion of foot.Action – Dorsal flexion of ankle and toes 2-5, eversion of foot.

Posterior MusclesPosterior Muscles

GastrocnemiusGastrocnemius– Proximal attachment – posterior surface of medial and lateral Proximal attachment – posterior surface of medial and lateral

condyles of femurcondyles of femur– Distal attachment – posterior surface of the calcaneusDistal attachment – posterior surface of the calcaneus– Action – plantar flexion of the ankle and flexion of the kneeAction – plantar flexion of the ankle and flexion of the knee

SoleusSoleus– Proximal attachment – Upper 2/3 of posterior surface of tibia and Proximal attachment – Upper 2/3 of posterior surface of tibia and

fibulafibula– Distal attachment – posterior surface of calcaneusDistal attachment – posterior surface of calcaneus– Action – plantar flexion of the ankleAction – plantar flexion of the ankle

Achilles tendon – formed from the gastrocnemius and Achilles tendon – formed from the gastrocnemius and soleussoleus

Other structuresOther structures Anterior and Posterior tibial arteriesAnterior and Posterior tibial arteries

– Main blood supply for the ankle and footMain blood supply for the ankle and foot– Located in the anterior portion of the foot and behind medial malleolusLocated in the anterior portion of the foot and behind medial malleolus

Common peroneal nerveCommon peroneal nerve– Located on lateral sideLocated on lateral side

Tibial nerveTibial nerve– Located behind medial malleolusLocated behind medial malleolus

Retrocalcaneal bursaRetrocalcaneal bursa– Located under the achilles tendon attachmentLocated under the achilles tendon attachment

Retinaculum Retinaculum – Fascia that holds down ankle tendons as they curl from the lower leg into Fascia that holds down ankle tendons as they curl from the lower leg into

the foot keeping them in placethe foot keeping them in place Joint capsuleJoint capsule

– Fascia tissue that encompasses the ankleFascia tissue that encompasses the ankle

Foot, ankle, and Lower leg Foot, ankle, and Lower leg

Lesson 3 – foot injuriesLesson 3 – foot injuries

Heel BruiseHeel Bruise

– Contusion to the calcaneusContusion to the calcaneus– EtiologyEtiology

Landing directly on the heel without or with limited protectionLanding directly on the heel without or with limited protection

– Signs and symptomsSigns and symptoms Pain, pt tenderness, and swelling over calcaneusPain, pt tenderness, and swelling over calcaneus Difficulty walkingDifficulty walking

– ManagementManagement RICE immediatelyRICE immediately Use of crutches for first few daysUse of crutches for first few days Use of donut pad when beginning walkingUse of donut pad when beginning walking Use of other modalities; US, whirlpool, ect for help in healing.Use of other modalities; US, whirlpool, ect for help in healing.

Base of Fifth TendonitisBase of Fifth Tendonitis– Inflammation of Peroneal brevis at the insertion point at the base of the Inflammation of Peroneal brevis at the insertion point at the base of the

fifth metatarsal.fifth metatarsal.– EtiologyEtiology

Overuse from running, poor support in shoes, complication of ankle sprain.Overuse from running, poor support in shoes, complication of ankle sprain.– Signs and symptomsSigns and symptoms

Pain, point tenderness, and swelling over base of fifth.Pain, point tenderness, and swelling over base of fifth. Difficulty walkingDifficulty walking Weakness and pain with eversionWeakness and pain with eversion

– ManagementManagement RICERICE Other modalities – e-stim, ultrasound, WPOther modalities – e-stim, ultrasound, WP Walking boot if becomes to severeWalking boot if becomes to severe

– Complications Complications If not treated and cured quickly can lead to avulsion of Peroneal tendon off If not treated and cured quickly can lead to avulsion of Peroneal tendon off

base of fifth (Jones fracture) – leads to surgerybase of fifth (Jones fracture) – leads to surgery

Retrocalcaneal BursitisRetrocalcaneal Bursitis

– Bursa irritation over the Achilles/calcaneal Bursa irritation over the Achilles/calcaneal insertioninsertion

– EtiologyEtiology Overuse – running, jumpingOveruse – running, jumping

– SymptomsSymptoms Pain and swelling on insertionPain and swelling on insertion Strength loss minimumStrength loss minimum Pain with passive dorsiflexionPain with passive dorsiflexion

– TreatmentTreatment RICE – similar too Severs diseaseRICE – similar too Severs disease

SesmoiditisSesmoiditis

– Irritation to sesmoid bones under 1st Irritation to sesmoid bones under 1st metatarsal/phalangeal jointmetatarsal/phalangeal joint

– EtiologyEtiology Running or jumping – excessive force on jointRunning or jumping – excessive force on joint

– SymptomsSymptoms Pain and swelling over jointPain and swelling over joint Pain with passive extensionPain with passive extension Pain with active flexionPain with active flexion

– TreatmentTreatment Bracing – tape - donutBracing – tape - donut Ice and other modalitiesIce and other modalities

PlantarfascitisPlantarfascitis

– Irritation of fascia that lays on the plantar foot – especially Irritation of fascia that lays on the plantar foot – especially around ½” from base of calcaneusaround ½” from base of calcaneus

– EtiologyEtiology Overuse – arch taking to much pressure. Not enough padding on Overuse – arch taking to much pressure. Not enough padding on

heel of shoesheel of shoes Running on toes instead of heel to toeRunning on toes instead of heel to toe Poor support of archPoor support of arch

– SymptomsSymptoms Pain around calcaneus ½” from origin. Hurts immensely first thing in Pain around calcaneus ½” from origin. Hurts immensely first thing in

the morning. the morning. – TreatmentTreatment

Arch tapingArch taping Getting proper shoesGetting proper shoes Ice massageIce massage StretchingStretching Takes along time to healTakes along time to heal

Turf ToeTurf Toe

– Hyperextension or hyperflexion of 1st metatarsalHyperextension or hyperflexion of 1st metatarsal– EtiologyEtiology

Forceful flex or over extension of big toe while runningForceful flex or over extension of big toe while running Stubbing toeStubbing toe

– SymptomsSymptoms Swelling and pain over jointSwelling and pain over joint

– TreatmentTreatment RICERICE TapeTape ModalitiesModalities

Bifurcate sprainBifurcate sprain

– Sprain of ligament that holds talus, cuboid and navicular togetherSprain of ligament that holds talus, cuboid and navicular together Located around fat pad on lateral side of footLocated around fat pad on lateral side of foot

– Etiology Etiology Inversion of footInversion of foot

– symptomssymptoms similar to anklesimilar to ankle swelling and pain over fat pad in foot and lateral footswelling and pain over fat pad in foot and lateral foot pain and mild weakness with eversionpain and mild weakness with eversion

– Treatment Treatment Similar to ankleSimilar to ankle RICERICE Foot strengtheningFoot strengthening Heals faster than regular ankle sprainHeals faster than regular ankle sprain

Medial and Lateral archMedial and Lateral arch

– EtiologyEtiology Poor shoes, overweight, postural anomalies, Poor shoes, overweight, postural anomalies,

weakened support structuresweakened support structures

– Signs and symptomsSigns and symptoms Soreness, tiredness around arch Soreness, tiredness around arch Pain when runningPain when running

– ManagementManagement TapeTape Strengthening of surrounding structuresStrengthening of surrounding structures

Fallen Metatarsal headsFallen Metatarsal heads

– EtiologyEtiology Weakened surrounding structures due to undue stress being Weakened surrounding structures due to undue stress being

placed on toes 2-5 causing them to splay apart.placed on toes 2-5 causing them to splay apart.

– Signs and symptomsSigns and symptoms Transverse arch becomes flattened and may see one or two Transverse arch becomes flattened and may see one or two

head of metatarsals depress head of metatarsals depress Pain when walkingPain when walking

– ManagementManagement Place small pad behind fallen metatarsal head helping push Place small pad behind fallen metatarsal head helping push

back upback up Strengthen surrounding structuresStrengthen surrounding structures

FracturesFractures

Dome of TalusDome of Talus– etiologyetiology

severe inversion or forceful dorsiflexionsevere inversion or forceful dorsiflexion– signs and symptomssigns and symptoms

pain located in center of ankle in mortise areapain located in center of ankle in mortise area– managementmanagement

RICERICE refer to doctorrefer to doctor

FracturesFractures

– NavicularNavicular EtiologyEtiology

– high archeshigh arches– poor shoespoor shoes

signs and symptomssigns and symptoms– pain when running and jumping around Navicular pain when running and jumping around Navicular – point tender over tuberclepoint tender over tubercle

managementmanagement– RICERICE– x-raysx-rays– walking bootwalking boot

FracturesFractures

March fractureMarch fracture– fracture of metatarsal – usually 2nd or 3rd fracture of metatarsal – usually 2nd or 3rd – etiologyetiology

overuse on running or marchingoveruse on running or marching people with atypical conditions more disposed to people with atypical conditions more disposed to

injuryinjury short first metatarsal, hallix valgus, flat footshort first metatarsal, hallix valgus, flat foot

– signs and symptomssigns and symptoms pain, swelling and pt tender over specified metatarsalpain, swelling and pt tender over specified metatarsal

– managementmanagement RICERICE x-raysx-rays crutches and walking bootcrutches and walking boot

FracturesFractures

– Jones fractureJones fracture Fracture of base of Fracture of base of

fifthfifth etiologyetiology

– forceful inversionforceful inversion

signs and symptomssigns and symptoms– pain and swelling pain and swelling

over base of fifthover base of fifth

– weakness with weakness with eversioneversion

managementmanagement– RICERICE

– x-rays - crutchx-rays - crutch

Foot, Ankle, Lower LegFoot, Ankle, Lower Leg

Lesson 4 – ankle injuriesLesson 4 – ankle injuries

Lateral ankle sprainLateral ankle sprain

– Injury to one or more the lateral ligaments (Ant Injury to one or more the lateral ligaments (Ant TaloFib, PTF, CalcFib)TaloFib, PTF, CalcFib)

– EtiologyEtiology Due to inversion or plantarflexion and inversion of the ankle. Due to inversion or plantarflexion and inversion of the ankle.

Landing wrong or stepping on someone’s foot or object are Landing wrong or stepping on someone’s foot or object are main occurrencesmain occurrences

– Sign and symptomsSign and symptoms Pain, point tenderness, redness, swelling in the area of lateral Pain, point tenderness, redness, swelling in the area of lateral

malleolus. ROM and strength limited. Possible abnormal malleolus. ROM and strength limited. Possible abnormal joint motionjoint motion

Severity graded on a scale of 3 depending on severity of Severity graded on a scale of 3 depending on severity of above symptomsabove symptoms

Three degrees of Lateral ankle Three degrees of Lateral ankle sprainssprains

Lateral ankle sprainsLateral ankle sprains

– Special testsSpecial tests Anterior drawer – tests anterior talofibular ligamentAnterior drawer – tests anterior talofibular ligament Posterior drawer – tests posterior talofibular ligamentPosterior drawer – tests posterior talofibular ligament Calcaneal tilt – (dorsiflexion – inversion) – calcaneal fibularCalcaneal tilt – (dorsiflexion – inversion) – calcaneal fibular

– ManagementManagement RICE with acute injuriesRICE with acute injuries

– Goal is to reduce swelling quickly as possible and allow the 1st Goal is to reduce swelling quickly as possible and allow the 1st stage and 2nd stage of healing to take effect.stage and 2nd stage of healing to take effect.

– Use of walking boot may be needed if 2nd degree or higherUse of walking boot may be needed if 2nd degree or higher

Next goal is to regain full ROM and strengthNext goal is to regain full ROM and strength Regain normal running and agilitiesRegain normal running and agilities Anything over grade 2 with adolescence should consider x-raysAnything over grade 2 with adolescence should consider x-rays

Special testsSpecial tests

Anterior drawer testAnterior drawer test– Patient positions foot in slight plantar flexion Patient positions foot in slight plantar flexion – Brace anterior shin with left hand Brace anterior shin with left hand – Pull heel anteriorly with right hand Pull heel anteriorly with right hand – Positive test findings Positive test findings

Laxity and poor endpoint on forward translation Laxity and poor endpoint on forward translation

Special testSpecial test

Talar tilt (calcaneal tilt)Talar tilt (calcaneal tilt)– Brace heel with left hand Brace heel with left hand – Invert foot with right hand Invert foot with right hand – Compare to opposite side Compare to opposite side

Medial ankle sprainsMedial ankle sprains

– Injury to the deltoid ligamentInjury to the deltoid ligament– EtiologyEtiology

Eversion stress placed on the ankle from landing wrong or Eversion stress placed on the ankle from landing wrong or stepping on someone’s footstepping on someone’s foot

– Sign and symptoms Sign and symptoms Similar to lateral ankle sprainSimilar to lateral ankle sprain

– Special testSpecial test Eversion stressEversion stress

– ManagementManagement Same as lateral ankleSame as lateral ankle Grade 2 or above consider x-rays to rule out avulsion fractureGrade 2 or above consider x-rays to rule out avulsion fracture

Anterior Tibiofibular sprainAnterior Tibiofibular sprain

– A.K.A. high ankle sprain. Sprain of ligament that holds tibia and A.K.A. high ankle sprain. Sprain of ligament that holds tibia and fibular together in lower 1/3 of lower legfibular together in lower 1/3 of lower leg

– EtiologyEtiology Severe external rotation of ankle. Foot usually in dorsiflexion when Severe external rotation of ankle. Foot usually in dorsiflexion when

occursoccurs

– Signs and symptomsSigns and symptoms Severe pain over area of anterior Tibiofibular region. Severe pain over area of anterior Tibiofibular region. Usually NO or minimal swelling evidentUsually NO or minimal swelling evident Loss of functionLoss of function

– ManagementManagement Takes along time to heal Takes along time to heal RICERICE Walking bootWalking boot Tape in slight plantar flexionTape in slight plantar flexion

Foot, Ankle, Lower legFoot, Ankle, Lower leg

Lesson 5 – lower leg injuriesLesson 5 – lower leg injuries

Anterior compartment syndromeAnterior compartment syndrome– Severe contusion, bruising of lower leg, swelling accumulates in compartments Severe contusion, bruising of lower leg, swelling accumulates in compartments

does not flow outdoes not flow out Usually in anterior compartmentUsually in anterior compartment

– etiology etiology blow to the area. Kicked, hit by bat or ball, tackled, fall on areablow to the area. Kicked, hit by bat or ball, tackled, fall on area

– symptomssymptoms extreme swelling of lower legextreme swelling of lower leg

– looks wood like - shinylooks wood like - shiny weakness in dorsiflexion and eversionweakness in dorsiflexion and eversion numbness on dorsal footnumbness on dorsal foot

– TreatmentTreatment Elevate legElevate leg Check pulse – dorsal pedis and tibial arteriesCheck pulse – dorsal pedis and tibial arteries Refer to emergency room immediatelyRefer to emergency room immediately 24-48 hrs necrosis sets in24-48 hrs necrosis sets in Surgery – fasciactomySurgery – fasciactomy Prevention most importantPrevention most important

– never wrap a bruised lower legnever wrap a bruised lower leg– elevate with ice as soon as possibleelevate with ice as soon as possible

Chronic compartment syndromeChronic compartment syndrome

– Exercise induced – not emergency like ACS – Exercise induced – not emergency like ACS – fascia too tightfascia too tight

– EtiologyEtiology Running, muscles to big and/or fascia too tight Running, muscles to big and/or fascia too tight

– SymptomsSymptoms numbness during running in toes numbness during running in toes Similar symptoms as ACS but disappear after finish Similar symptoms as ACS but disappear after finish

workout.workout.

– TreatmentTreatment Refer to DoctorRefer to Doctor

““Shin Splints”Shin Splints”

– Five types; muscle strain, stress fracture, chronic Five types; muscle strain, stress fracture, chronic compartment syndrome, irritation to periosteum, strain compartment syndrome, irritation to periosteum, strain to interosseus membraneto interosseus membrane

– Muscle strainMuscle strain EtiologyEtiology

– muscle strain to anterior tibialis, overuse running, poor support muscle strain to anterior tibialis, overuse running, poor support from shoesfrom shoes

SymptomsSymptoms– pain with dorsiflexionpain with dorsiflexion– pain while runningpain while running– palpation – hurts in large area along musclepalpation – hurts in large area along muscle

TreatmentTreatment– reduction of painreduction of pain– strengthen muscle TA and stretch gastrocstrengthen muscle TA and stretch gastroc– look for better support in shoelook for better support in shoe

““Shin Splints”Shin Splints”

– Stress FractureStress Fracture EtiologyEtiology

– overuse on running, changes in workoutoveruse on running, changes in workout– poor support in shoes with high archespoor support in shoes with high arches

SymptomsSymptoms– pain in one spotpain in one spot– continually gets worsecontinually gets worse– may ache at night or during day or pain does not disappear may ache at night or during day or pain does not disappear

shortly after workoutshortly after workout– Pain on TibiaPain on Tibia– radiates through leg when runningradiates through leg when running

TreatmentTreatment– referral to doctorreferral to doctor– restrest– return three weeks after all pain has disappearedreturn three weeks after all pain has disappeared

““Shin Splints”Shin Splints”

irritation to periosteumirritation to periosteum– usually lowusually low– similar to muscle strain except hurts directly on bonesimilar to muscle strain except hurts directly on bone– usually located lower 1/3 of tibiausually located lower 1/3 of tibia– TreatmentTreatment

takes longer to heal then muscle straintakes longer to heal then muscle strain modalitiesmodalities

Interosseus strainInterosseus strain– Last optionLast option– Takes long time to healTakes long time to heal– Deep pain Deep pain

Chronic compartment syndromeChronic compartment syndrome– See #2See #2

Gastrocnemius strainGastrocnemius strain

– Strain at the gastroc-soleus junction or at Strain at the gastroc-soleus junction or at medial head near originmedial head near origin

– EtiologyEtiology Forceful action – running or jumpingForceful action – running or jumping

– Symptoms Symptoms Pain and muscle weakness in areaPain and muscle weakness in area Swelling if severe enoughSwelling if severe enough

– TreatmentTreatment RICERICE ModalitiesModalities

Achilles strain, tendonitis, and Achilles strain, tendonitis, and rupturerupture

– Etiology Etiology Overuse on running or jumping, or acute contusion or forceful movementOveruse on running or jumping, or acute contusion or forceful movement

– SymptomsSymptoms Pain, swelling, weakness with plantar flexionPain, swelling, weakness with plantar flexion

– TreatmentTreatment RICERICE ModalitiesModalities StrengtheningStrengthening Must be careful – chronic tendonitis my lead to ruptureMust be careful – chronic tendonitis my lead to rupture

– feel deformity in Achillesfeel deformity in Achilles– injured feels like they got shotinjured feels like they got shot– totally disabledtotally disabled– immediate swellingimmediate swelling– Positive Positive Thompson testThompson test

Injured lay prone feet hang over edgeInjured lay prone feet hang over edge Squeeze calf – Squeeze calf – negative sign – foot plantar flexesnegative sign – foot plantar flexes positive sign – foot does not movepositive sign – foot does not move

ThrombosisThrombosis

– Blood clotBlood clot– EtiologyEtiology

Blow to the areaBlow to the area

– SymptomsSymptoms Deep pain in calfDeep pain in calf Positive sign on Homan’s signPositive sign on Homan’s sign

– Athlete lay supineAthlete lay supine– Raise leg and passively put foot in dorsiflexion Raise leg and passively put foot in dorsiflexion – Feels pain in specific spot deep in calf, may feel bump if clot big Feels pain in specific spot deep in calf, may feel bump if clot big

enoughenough

– Treatment Treatment Referral to Dr.Referral to Dr.

Severs DiseaseSevers Disease

– Similar to Osgood Schlatter’s of the kneeSimilar to Osgood Schlatter’s of the knee– EtiologyEtiology

Overuse – running and jumping in adolescence 12-18 yrs oldOveruse – running and jumping in adolescence 12-18 yrs old Degeneration of the area just below where the Achilles inserts to the Degeneration of the area just below where the Achilles inserts to the

calcaneus calcaneus – Signs and symptomsSigns and symptoms

Pain, swelling, and redness in the area where Achilles inserts to the Pain, swelling, and redness in the area where Achilles inserts to the calcaneuscalcaneus

Pain and weakness with plantar flexionPain and weakness with plantar flexion Hurts during activityHurts during activity

– rest helps alleviate painrest helps alleviate pain– managementmanagement

RICE with acute symptomsRICE with acute symptoms Heel cup – which will restrict dorsiflexion for activityHeel cup – which will restrict dorsiflexion for activity When apophysis closes (around age 18) problem ceasesWhen apophysis closes (around age 18) problem ceases

Accessory BonesAccessory Bones

– Os TrigodomOs Trigodom– Located on back of calcaneusLocated on back of calcaneus– Irritation from overuse plantarflexionIrritation from overuse plantarflexion