SPORT INJURIES: ANKLE AND LOWER LEG

Presenter:Nazri Azeli

Mohd Sharul AzrinJeff Fakhruddin ShamsudinAzham Afzanizam Hamzah

Mohd Razmi Rozan

BONES OF LOWER LEG

LATERAL VIEW OF FOOT BONES AND LIGAMENTS

MEDIAL VIEW OF FOOT BONES AND LIGAMENTS

MUSCLES OF THE LOWER LEG AND FOOT

Muscles of the Lower Leg and Foot

ANATOMY: MUSCLESAction Muscles

Ankle dorsiflexion

Extensor Digitorium longus, extensor hallucis longus, tibialis anterior

Ankle plantarflexion

Soleus, gastrocnemius

Ankle inversion Tibialis posterior, flexor digitorium longus, flexor hallucis longus

Ankle Eversion Peroneus longus, peroneus brevis

Functional Tests

While weight bearing the following should be performed Walk on toes (plantar flexion) Walk on heels (dorsiflexion) Walk on lateral borders of feet (inversion) Walk on medial borders of feet (eversion) Hop on injured ankle Start and stop running Change direction rapidly Run figure eights

ANKLE SPRAIN Ankle Injuries: Sprains

Single most common injury in athletics caused by sudden inversion or eversion moments

Inversion SprainsMost common and result in injury to the lateral

ligamentsAnterior talofibular ligament is injured with

inversion, plantar flexion and internal rotation

• EVERSION- ANKLE SPRAIN

-The foot is twisted outwards.

-The inner ligament, called the

deltoid ligament, is stretched too far.

-Patients will have pain on the inner

side of the ankle

HIGH ANKLE SPRAIN injury to the

ligaments around the ankle

ligaments above the joint, syndesmosis ligaments injured

Graded Ankle Sprains Signs of Injury

Grade 1Grade I ankle sprains cause stretching of the

ligament. The symptoms tend to be limited to pain and swelling. Most patients can walk without crutches, but may not be able to jog or jump.

Grade 2A grade II ankle sprain is more severe partial

tearing of the ligament. There is usually more significant swelling and bruising caused by bleeding under the skin. Patients usually have pain with walking, but can take a few steps.

Grade 3Grade III ankle sprains are complete tears of the

ligaments. The ankle is usually quite painful, and walking can be difficult. Patients may complain of instability, or a giving-way sensation in the ankle joint.

SEVERITY OF ANKLE SPRAINS BY GRADE

Sign/symptom Grade I Grade II Grade III

Tendon No tearPartial

tearComplete

tear

Loss of functional ability Minimal Some Great

Pain MinimalModerat

e Severe

Swelling MinimalModerat

e Severe

EcchymosisUsually

notFrequentl

y Yes

Difficulty bearing weight No UsuallyAlmost

always

Care Must manage pain and swelling Apply horseshoe-shaped foam pad

for focal compression Apply wet compression wrap to

facilitate passage of cold from ice packs surrounding ankle

Apply ice for 20 minutes and repeat every hour for 24 hours

Continue to apply ice over the course of the next 3 days

Keep foot elevated as much as possible

Avoid weight bearing for at least 24 hours

Begin weight bearing as soon as tolerated

Return to participation should be gradual and dictated by healing process

FOOT FRACTURE

YOU MAY HAVE FRACTURED A BONE IN YOUR FOOT, DO

REALIZE IT? There are 2 common type of bone

fracture in your feet:i. Hairline stress fracturesii. Traumatic fractures

Ankle Fractures/Dislocations Cause of Injury

Number of mechanisms – often similar to those seen in ankle sprains

Signs of Injury Swelling and pain may be extreme with possible

deformity Care

Splint and refer to physician for X-ray and examination RICE to control hemorrhaging and swelling Once swelling is reduced, a walking cast or brace may be

applied, immobilization lasting 6-8 weeks Rehabilitation is similar to that of ankle sprains once

range of motion is normal

HAIRLINE STRESS FRACTURES(HSF)

Tiny litle hairline cracks in bones. Some fractures are Straight and spiral in

nature. This tiny cracks from excessive

pounding, twisting and repetitive actions during activities.(own explainations)

TRAUMATIC FRACTURES(TF) Cause from blow, impact or accident are much

more obvious. TF are very painful and related with pain and

swelling. If skin broken, the injury susceptible to

infection.(need medical)

FIBULAR FRACTURE

Tibial and Fibular Fracture

Acute Leg FracturesCause of Injury

Result of direct blow or indirect trauma Fibular fractures seen with tibial fractures or as the result

of direct traumaSigns of Injury

Pain, swelling, soft tissue insult Leg will appear hard and swollen (Volkman’s contracture) Deformity – may be open or closed

Care X-ray, reduction, casting up to 6 weeks depending on the

extent of injury

INTERNAL FIXATION

Stress Fracture of Tibia or FibulaCause of Injury

Common overuse condition, particularly in those with structural and biomechanical insufficiencies

Result of repetitive loading during training and conditioning

Signs of Injury Pain with activity Pain more intense after exercise than before Point tenderness; difficult to discern bone and soft

tissue pain Bone scan results (stress fracture vs. periostitis)

Care Eliminate offending activity Discontinue stress

inducing activity 14 days Use crutch for walking Weight bearing may return

when pain subsides After pain free for 2 weeks

athlete can gradually return to activity

Biomechanics must be addressed

Medial Tibial Stress Syndrome (Shin Splints)Cause of Injury

Pain in anterior portion of shin Stress fractures, muscle strains, chronic anterior

compartment syndrome, periosteum irritation Caused by repetitive microtrauma Weak muscles, improper footwear, training errors, varus

foot, tight heel cord, hypermobile or pronated feet and even forefoot supination can contribute to MTSS

May also involve stress fractures or exertional compartment syndrome

Shin Splints (continued) Signs of Injury

Diffuse pain about disto-medial aspect of lower leg As condition worsens ambulation may be painful, morning

pain and stiffness may also increase Can progress to stress fracture if not treated

Care Physician referral for X-rays and bone scan Activity modification Correction of abnormal biomechanics Ice massage to reduce pain and inflammation Flexibility program for gastroc-soleus complex Arch taping and orthotics

LOCATIONS OF PAIN

Compartment SyndromeCause of Injury

Rare acute traumatic syndrome due to direct blow or excessive exercise

May be classified as acute, acute exertional, or chronic

Signs of Injury Excessive swelling compresses muscles, blood

supply and nerves Deep aching pain and tightness is experienced Weakness with foot and toe extension and

occasionally numbness in dorsal region of foot

Care If severe acute or chronic case, may present as

medical emergency that requires surgery to reduce pressure or release fascia

RICE, NSAID’s and analgesics as needed Avoid use of compression wrap = increased

pressure Surgical release is generally used in recurrent

conditionsMay require 2-4 month recovery (post surgery)

Conservative management requires activity modification, icing and stretchingSurgery is required if conservative management

fails

Achilles Tendonitis Cause of Injury

Inflammatory condition involving tendon, sheath or paratenon

Tendon is overloaded due to extensive stress Presents with gradual onset and worsens with continued

use Decreased flexibility exacerbates condition

Signs of Injury Generalized pain and stiffness, localized proximal to

calcaneal insertion, warmth and painful with palpation, as well as thickened

May progress to morning stiffness

Care Resistant to quick resolution due to slow healing

nature of tendon Must reduce stress on tendon, address structural

faults (orthotics, mechanics, flexibility) Aggressive stretching and use of heel lift may be

beneficial Use of anti-inflammatory medications is suggested

Achilles Tendon RuptureCause

Occurs when sudden stop and go; forceful plantar flexion when

Commonly seen in athletes > 30 years old Generally has history of chronic inflammation

Signs of Injury Sudden snap (kick in the leg) with immediate pain

which rapidly subsides Point tenderness, swelling, discoloration; decreased

ROM Obvious indentation and positive Thompson test

Care Usual management involves surgical repair for

serious injuries Non-operative treatment consists of RICE, NSAID’s,

analgesics, and a non-weight bearing cast for 6 weeks to allow for proper tendon healing

Must work to regain normal range of motion followed by gradual and progressive strengthening program

INABILITY TO PLANTARFLEX

Before surgery During

surgery

Shin Contusion Cause of Injury

Direct blow to lower leg (impacting periosteum anteriorly) Signs of Injury

Intense pain, rapidly forming hematoma Increased warmth

Care RICE, NSAID’s and analgesics as needed Maintaining compression for hematoma (which may need

to aspirated) Fit with doughnut pad and orthoplast shell for protection

ANKLE REHABILITATION PROGRAM

Attach elastic to secure object.

Place elastic around forefoot.

Pull foot toward shin

• Place elastic around ball of foot.

• Push down against elastic.

ANKLE REHABILITATION PROGRAM

Attach elastic to secure object.

Pull forefoot outward.

Loop elastic around forefoot.

• Attach elastic to secure object.

• Pull forefoot inward against.

• Loop elastic around forefoot.

• Place bandage on floor

• Slide the bandage backward from the forward using one foot only.

Plantar fasciitis injury

• The “plantar fascia” is a piece of connective tissue that runs from the heel bone (calcaneus) to the base of the toes, on the sloe of your foot.

Sign and symptoms• Sharp pain at the bottom of your heel, almost like

walking on glass.• Mild swelling within your foot and around your heel.• The pain, tends to be worse with the first few steps in

the morning, going up stairs or standing on tiptoes.• Pain after long periods of standing or getting up from

sitting.• Post exercise pain, usually wont occur during exercise.

Treatment..?• Wearing a splint fitted to your calf and foot while you sleep,

to stretch the fasica, tendons and surrounding tissue.• Doctors may prescribe off-the-shelf or make custom-fitted

orthotics to help distribute pressure to your feet more effectively.

• Physiotherapy can provide you with a series

of exercises and stretches designed to decrease

pain, improve range of motion and strengthen

lower leg muscles, all of which will help your

ankle and heel.

Penilaian kecederaan pergelangan kaki dan bahagian bawah kaki

Komponen penilaian

• Mekanisme kecederaan• Tanda-tanda• Simptom-simptom• Ujian ketahanan• Ujian yang khas atau spesifik

Terkoyak bahagian sisi pergelangan kaki

• Mekanisme kecederaan

- plantarflexion

- inversion• Tanda:

- bengkak (swell)

- perubahan warna (discoloration)• Simptom-simptom:

- merasa sakit sepanjang sisi pergelangan kaki(ankle)

julat pergerakan yang normal untuk pergelangan kaki(ankle)

• Dorsifleksi - 20 darjah• Plantarfleksi - 50 darjah• Inversi - 20 darjah• Eversi - 5 darjah

Pemegangan bahagian utama pada pergelangan kaki:

• Anterior talofibular ligamen (ATF)• Calcaneal fibular (CF)• Poterior talofibular (PTF)• Bahagian sisi (lateral) molleolus• Kuboid (cuboid)• Sinus tarsi• Metatarsal• Peroneal tendon

Menilai pergelangan sisi kaki

• Anterior drawer

- penilaian ligamen anterior talofibular (ATF)

• Inversi talar tilt

- penilaian ke atas ligamen Calcaneal fibular.

• Eversi talar tilt Untuk menilai deltoid ligamen Tekanan akan diberikan sedikit demi sedikit

untuk melihat tahap kecederaan melalui dorsifleksi dan plantarfleksi.

Terseliuh (sprain) bahagian tengah(medial)

• Mekanisme kecederaan:

- Dorsifleksi

- eversi

- Putaran ekternal(external rotation)• Tanda :

- Bengkak

- Perubahan warna (discoloration/subacute)• Simptom-simptom :

-kesakitan sepanjang bahagian tengah (medial) pergelangan kaki

Pemegangan bahagian utama pada pergelangan kaki:

• Anterior tibiotalar• Tibionavicular• Tibiocalcaneal• Posterior tibiotalar• Medial malleolus• Lateral malleolus• Sustentaculum tali• Navicular• Sendi talocrural

Penilaian keretatkan bahagian bawah kaki dan

Pergelangan kaki

• Bump test

- Tekan pada bahagian atas tumit

- Beri tekanan sehingga

merasa sakit pada bahagian

yang retak.

- Tekanan di tambah dan berhenti

apabila kesakitan di rasai oleh

pesakit

That’s ALL…..

Thank you…….