KIN 188 – Prevention and KIN 188 – Prevention and Care of Athletic InjuriesCare of Athletic Injuries

Foot, Ankle and Leg Foot, Ankle and Leg Evaluation and InjuriesEvaluation and Injuries

AnatomyAnatomy

Foot AnatomyFoot Anatomy

Bony anatomyBony anatomy– Phalanges (proximal, middle, distal) – 14Phalanges (proximal, middle, distal) – 14– Metatarsals (5 – great toe=1, little toe=5, styloid process)Metatarsals (5 – great toe=1, little toe=5, styloid process)– Tarsals (calcaneus, talus, navicular, cuboid, 1/2/3 cuneiforms)Tarsals (calcaneus, talus, navicular, cuboid, 1/2/3 cuneiforms)– Medial/lateral longitudinal and transverse metatarsal archesMedial/lateral longitudinal and transverse metatarsal arches

Muscular anatomyMuscular anatomy– Extensor digitorum brevis/sinus tarsiExtensor digitorum brevis/sinus tarsi– Tendons from ankle/leg musclesTendons from ankle/leg muscles

Ligamentous anatomyLigamentous anatomy– Collateral ligaments at PIP/IP/DIP/MP jointsCollateral ligaments at PIP/IP/DIP/MP joints– Spring ligamentSpring ligament– Intertarsal/tarsometatarsal ligamentsIntertarsal/tarsometatarsal ligaments

Ankle AnatomyAnkle Anatomy

Bony anatomyBony anatomy– Calcaneus/talus (dome)Calcaneus/talus (dome)– Tibia (medial malleolus), fibula (lateral malleolus)Tibia (medial malleolus), fibula (lateral malleolus)

Muscular anatomyMuscular anatomy– Discussed with leg anatomyDiscussed with leg anatomy

Ligamentous anatomyLigamentous anatomy– Medial ligament (deltoid)Medial ligament (deltoid)– Lateral ligaments (anterior/posterior talofibular, Lateral ligaments (anterior/posterior talofibular,

calcaneofibular, anterior/posterior tibiofibular)calcaneofibular, anterior/posterior tibiofibular)

Leg AnatomyLeg Anatomy

Bony anatomyBony anatomy– Tibia and fibulaTibia and fibula

Muscular anatomyMuscular anatomy– Anterior compartment (anterior tibialis, extensor digitorum Anterior compartment (anterior tibialis, extensor digitorum

longus, extensor hallicus longus)longus, extensor hallicus longus)– Lateral compartment (peroneus longus/brevis)Lateral compartment (peroneus longus/brevis)– Deep posterior compartment (posterior tibialis, flexor digitorum Deep posterior compartment (posterior tibialis, flexor digitorum

longus, flexor hallicus longus)longus, flexor hallicus longus)– Superficial posterior compartment (gastrocnemius, soleus, Superficial posterior compartment (gastrocnemius, soleus,

plantaris)plantaris)

Ligamentous anatomyLigamentous anatomy– Interosseous membraneInterosseous membrane

EvaluationEvaluation

HistoryHistory

Mechanism of injury/etiologyMechanism of injury/etiology– Direct trauma (contusion, fracture, compartment Direct trauma (contusion, fracture, compartment

syndrome, Achilles rupture)syndrome, Achilles rupture)– Hyperextension of great toe (turf toe)Hyperextension of great toe (turf toe)– Inversion/eversion (ankle sprain, muscle strain)Inversion/eversion (ankle sprain, muscle strain)– Insiduous/unknown (tendonitis, stress fracture)Insiduous/unknown (tendonitis, stress fracture)

Unusual sounds/sensationsUnusual sounds/sensations– ““Giving way”, pop/snapGiving way”, pop/snap

History of previous injuryHistory of previous injury

HistoryHistory

Change in activityChange in activity– Intensity, duration, frequency, surface change, Intensity, duration, frequency, surface change,

footwear changefootwear change

Acute/gradual onset of symptomsAcute/gradual onset of symptoms– Macrotraumatic vs. microtruamaticMacrotraumatic vs. microtruamatic

Characterize painCharacterize pain– Location (point with 1 finger)Location (point with 1 finger)– Dull, sharp, burning, throbbing, etc.Dull, sharp, burning, throbbing, etc.– Rate on scale (1-10)Rate on scale (1-10)– What increases or decreases?What increases or decreases?

Treatment, medication, evaluation to dateTreatment, medication, evaluation to date

Inspection/ObservationInspection/Observation

ALWAYSALWAYS compare bilaterally compare bilaterally

Obvious deformityObvious deformity– Pes cavus/planus (high arch/flat feet)Pes cavus/planus (high arch/flat feet)– Bunion (hallux valgus)Bunion (hallux valgus)

BleedingBleeding

Discoloration/ecchymosisDiscoloration/ecchymosis

SwellingSwelling

ScarsScars

Palpation - FootPalpation - Foot

CalcaneusCalcaneusTalus (dome/head)Talus (dome/head)Sustentaculum taliSustentaculum taliNavicular tuberosityNavicular tuberosity1/2/3 cuneiforms1/2/3 cuneiformsCuboidCuboidMetatarsalsMetatarsalsPhalangesPhalangesPIP/IP/DIP/MP jointsPIP/IP/DIP/MP jointsPlantar fasciaPlantar fascia

Palpation - AnklePalpation - Ankle

CalcaneusCalcaneus

Tibia (medial Tibia (medial malleolus)malleolus)

Fibula (lateral Fibula (lateral malleolus)malleolus)

Dome of talusDome of talus

Navicular tuberosityNavicular tuberosity

Styloid process of 5Styloid process of 5thth metatarsalmetatarsal

Sinus tarsiSinus tarsi

Deltoid ligamentDeltoid ligament

Anterior talofibular Anterior talofibular ligamentligament

Calcaneofibular Calcaneofibular ligamentligament

Anterior tibiofibular Anterior tibiofibular ligamentligament

Palpation - LegPalpation - Leg

Tibia (shaft)Tibia (shaft)

Fibula (proximal/distal 1/3s, head)Fibula (proximal/distal 1/3s, head)

Tendons ofTendons of– Anterior tibialisAnterior tibialis– Extensor digitorum/hallicus longusExtensor digitorum/hallicus longus– Peroneus longus/brevisPeroneus longus/brevis– Gastrocnemius/soleus (Achilles)Gastrocnemius/soleus (Achilles)– Posterior tibialisPosterior tibialis

Special TestsSpecial Tests

ROMROM– Active – patient/athlete moves jointActive – patient/athlete moves joint– Passive – clinician moves joint, evaluates end feelPassive – clinician moves joint, evaluates end feel– Resistive – proximal stabilization and distal Resistive – proximal stabilization and distal

application of resistance (“break” test vs. resistance application of resistance (“break” test vs. resistance through ROM)through ROM)

NeurovascularNeurovascular

Special testsSpecial tests

ROMROM

ToeToe– Great toe flexion/extensionGreat toe flexion/extension– Lateral 4 toes flexion/extensionLateral 4 toes flexion/extension

Foot/ankleFoot/ankle– DorsiflexionDorsiflexion– PlantarflexionPlantarflexion– InversionInversion– EversionEversion

NeurovascularNeurovascular

Neurological evalationNeurological evalation– Nerve root level and peripheral nerve sensory Nerve root level and peripheral nerve sensory

and motor distributionsand motor distributions

Vascular evaluationVascular evaluation– Skin temperature/colorSkin temperature/color– Capillary refillCapillary refill– Dorsal pedal pulseDorsal pedal pulse– Posterior tibial pulsePosterior tibial pulse

Special TestsSpecial Tests

FootFoot– Tap/bump/longitudinal stress tests – fractureTap/bump/longitudinal stress tests – fracture– Metatarsal head compression – neuromaMetatarsal head compression – neuroma– Toe hyperextension – stress medial archToe hyperextension – stress medial arch

AnkleAnkle– Anterior drawer – anterior talofibular ligamentAnterior drawer – anterior talofibular ligament– Talar tilt/inversion stress – calcaneofibular ligamentTalar tilt/inversion stress – calcaneofibular ligament– Kleiger’s test (DF/ER) – anterior tibiofibular ligamentKleiger’s test (DF/ER) – anterior tibiofibular ligament– Eversion stress – deltoid ligamentEversion stress – deltoid ligament

LegLeg– ““Squeeze” test – fractureSqueeze” test – fracture– Thompson test – Achilles tendon ruptureThompson test – Achilles tendon rupture

InjuriesInjuries

Foot InjuriesFoot Injuries

Hallux valgus (bunion)Hallux valgus (bunion)– Great toe points toward other toesGreat toe points toward other toes– Almost never traumatic, but associated with biomechanical Almost never traumatic, but associated with biomechanical

insufficiencies, poor flexibility, poor fitting shoesinsufficiencies, poor flexibility, poor fitting shoes– If severe, often corrected surgicallyIf severe, often corrected surgically

Turf toeTurf toe– Hyperextension of great toe MP jointHyperextension of great toe MP joint– Pain with active movements and passive extensionPain with active movements and passive extension– Treat with tape, shoe inserts, conservative measuresTreat with tape, shoe inserts, conservative measures

PIP/IP/DIP sprainsPIP/IP/DIP sprains– Almost always treated symptomatically with buddy tape, shoe Almost always treated symptomatically with buddy tape, shoe

inserts and activity as toleratedinserts and activity as tolerated

Foot InjuriesFoot Injuries

FracturesFractures– Toe fractures commonly treated conservatively (like sprains)Toe fractures commonly treated conservatively (like sprains)– Metatarsal fractures usually easy to identifyMetatarsal fractures usually easy to identify– Avulsion fracture – base of 5Avulsion fracture – base of 5thth metatarsal, navicular metatarsal, navicular– Stress fractures – metatarsals (March fractures)Stress fractures – metatarsals (March fractures)

Plantar fascitisPlantar fascitis– Associated with overuse/training errors, tight Achilles, Associated with overuse/training errors, tight Achilles,

biomechanical insufficienciesbiomechanical insufficiencies– Often presents with pain at heel, most pain with first few steps in Often presents with pain at heel, most pain with first few steps in

AMAM– Treated with taping/strapping, orthotics, conservative measures, Treated with taping/strapping, orthotics, conservative measures,

anti-inflammatory medsanti-inflammatory meds

Ankle InjuriesAnkle Injuries

Lateral ankle sprainsLateral ankle sprains– Associated with inversion or PF/inversion Associated with inversion or PF/inversion

mechanisms – can injure ligaments and/or mechanisms – can injure ligaments and/or muscles/tendonsmuscles/tendons

– Ligaments affected in descending order based upon Ligaments affected in descending order based upon positioning and amount of force (ATF-CF-PTF)positioning and amount of force (ATF-CF-PTF)

– Swelling and point tenderness usually occur quicklySwelling and point tenderness usually occur quickly– Positive ligamentous stress testsPositive ligamentous stress tests

Medial ankle sprainsMedial ankle sprains– Associated with eversion mechanismAssociated with eversion mechanism– Otherwise similar to lateral sprain symptomsOtherwise similar to lateral sprain symptoms

Ankle InjuriesAnkle Injuries

Syndesmosis (“high ankle”) sprains Syndesmosis (“high ankle”) sprains – Typically associated with DF/ER mechanismTypically associated with DF/ER mechanism– Shape of talar dome in mortise of ankleShape of talar dome in mortise of ankle– Longer rehabilitation period, frustrating injuryLonger rehabilitation period, frustrating injury– Positive Klieger’s testPositive Klieger’s test

Fractures/dislocationsFractures/dislocations– Associated with obvious deformityAssociated with obvious deformity– Occur from excessive forces landing from height in Occur from excessive forces landing from height in

IV/EV position or being kicked from behind with foot IV/EV position or being kicked from behind with foot planted on groundplanted on ground

– Typically treated surgically for appropriate fixationTypically treated surgically for appropriate fixation

Leg InjuriesLeg Injuries

Compartment syndromesCompartment syndromes– Acute (traumatic) vs. exertionalAcute (traumatic) vs. exertional– Pressure in closed compartment affects neurological and Pressure in closed compartment affects neurological and

vascular structuresvascular structures– Can be limb-threatening emergenciesCan be limb-threatening emergencies

Achilles tendon ruptureAchilles tendon rupture– Usually associated with “jumping” mechanism and feels like got Usually associated with “jumping” mechanism and feels like got

kicked/shot in legkicked/shot in leg– Often hears “pop” in addition to feeling itOften hears “pop” in addition to feeling it– Decreased ability to actively PF ankle and positive Thompson Decreased ability to actively PF ankle and positive Thompson

testtest– Return to physical activity almost always requires surgical Return to physical activity almost always requires surgical

interventionintervention

Leg InjuriesLeg Injuries

Muscle strains Muscle strains – Severity based upon degree of tissue damageSeverity based upon degree of tissue damage– Most common to gastroc/soleus, posterior tibialis, peroneus Most common to gastroc/soleus, posterior tibialis, peroneus

longus/brevislongus/brevis

TendonitisTendonitis– Overuse condition associated with training changes, Overuse condition associated with training changes,

biomechanical insufficiencies, poor flexibility, etc.biomechanical insufficiencies, poor flexibility, etc.– Most common to Achilles, anterior/posterior tibialis, peroneus Most common to Achilles, anterior/posterior tibialis, peroneus

longus/brevislongus/brevis

FracturesFractures– Tibia and/or fibular fractures occur secondary to either direct Tibia and/or fibular fractures occur secondary to either direct

trauma or rotational forces associated with change of directiontrauma or rotational forces associated with change of direction