Injuries to the Lower Leg, Ankle, and Foot… For an athlete to move well, there must be excellent...
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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
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
Slide 3
Injuries to the Lower Leg, Ankle, and Foot Treatment of ankle
sprains and control of possible 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
Slide 4
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
Slide 5
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
Slide 6
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
Slide 7
Anatomy Review
Slide 8
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
Slide 9
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
Slide 10
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
Slide 11
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
Slide 12
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
Slide 13
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
Slide 14
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
Slide 15
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 5
th metatarsal and is subject to avulsion (forcible tearing away or
separation)
Slide 16
Compartments of the Leg
Slide 17
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
Slide 18
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
Slide 19
Skeletal InjuriesFractures 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-iEOoM1N- w http://www.youtube.co m/watch?v=I-iEOoM1N-
w
Slide 20
Skeletal InjuriesFractures 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)
Slide 21
Skeletal Injuriesfractures 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 5 th 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
Slide 22
Skeletal Injuriesfractures 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
Slide 23
Skeletal Injuriesfractures 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
Slide 24
Skeletal Injuriesfractures 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 5 th metartasal of the
foot, as a result of a diminished blood supply
Slide 25
Soft-Tissue Injuriesankle 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
Slide 26
Soft-Tissue Injuriesankle 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
Slide 27
Soft-Tissue Injuriesankle 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)
Slide 28
Soft-Tissue Injuriesankle 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
Slide 29
Soft-Tissue Injuriesankle injuries S&S of a lateral ankle
sprain 1 st degree sprain pain, mild disability, point tenderness,
little laxity, little or no swelling 2 nd degree sprain Pain,
mild-moderate disability, point tenderness, loss of function, some
laxity (abnormal movement), swelling (moderate to severe)
Slide 30
Soft-Tissue Injuriesankle injuries 3 rd degree sprain Pain and
severe disability, point tenderness, loss of function, laxity
(abnormal movement), swelling, (moderate to severe)
Slide 31
Soft-Tissue Injuriesankle 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 2 nd or 3 rd
degree sprain has occurred If there is any hesitation about the
severity, splint and refer for further eval
Slide 32
Soft-Tissue Injuriesankle 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
Slide 33
Soft-Tissue Injuriesankle injuries It is important to know that
there is a significant difference 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
Slide 34
Soft-Tissue Injuriesankle 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
Slide 35
Soft-Tissue Injuriesankle 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
Slide 36
Soft-Tissue Injuriesankle injuries It is recognized that either
taping or bracing can reduce the 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
Slide 37
Soft-Tissue Injuriesankle 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
Slide 38
Soft-Tissue Injuriesankle 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)
Slide 39
Soft-Tissue Injuriesankle 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
Slide 40
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
Slide 41
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
Slide 42
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
Slide 43
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)
Slide 44
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)
Slide 45
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
Slide 46
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
Slide 47
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
Slide 48
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