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

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 Interosseus Membrane
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

24. 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

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

26. 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

27. 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

28. 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

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

30. 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

31. 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

32. 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

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

34. 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

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

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

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

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

39. 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

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

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

42. 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

43. Ankle Sprains
Inversion
Eversion
High Ankle Sprain

44. 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

45. The inversion MOI

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

47. 3rd degree Lateral Ankle sprain

49. S/S: Pain, Swelling, discoloration, Pt
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

50. 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

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

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

53. MOI: ankle everts due to----someone/something landing on the lateral aspect of leg during weight bearing or---
S/S: Pain, swelling, discoloration, joint instability, joint stiffness, decreased ROM, Pt. tenderover medial malleolus and deltoid ligament
Will vary depending on severity
Tests:
Talar Tilt

54. Tx: RICE, “horseshoe” shaped felt/foam pad,
crutches if necessary
Treat for shock
Medical attention with severe sprain or if fracture is suspected

55. Complications Avulsion fracture of medial malleolus
Contused deltoid ligament due to impingement between medial malleolus and calcaneus
Fracture of lateral malleolus

56. “High” Ankle Sprain Also called syndesmotic
Anterior and posterior tibiofibular ligaments damage

57. MOI: forced dorsiflexion or extreme plantar flexion/inversion
Someone landing on the back of the leg with the foot in contact with the ground (dorsiflexion)

58. S/S: may be swelling or not, may have discoloration or not
pain
Pt. tender over ATF and proximal to that at the junction of the tibia and fibula
painful to bear weight, unable to go up on toes

59. Tx: RICE, Crutches, medical attention if unable to bear weight or if significant swelling occurs
Treat for shock
Hard to treat and can take weeks to heal

60. Complications Fracture to the dome of the talus
Tear of the interosseus membrane

61. Ankle Fractures and Dislocations
MOI: similar to those of the ankle sprains but generally more force is applied
Can be open or closed

62. What do these injuries look like?
After the MOI
See the placement of the foot?

63. Sliding into base
He’s there!

64. Getting help

65. And the open ones?
Open Fx/dislocation
Open fracture

66. And some x-rays

67. S/S: Immediate swelling
immense pain
possible deformity and/or open wound
Pt. tender over the bone
+ compression and percussion tests

68. Tx: Splint in the position you find it
Care for open wound if necessary
Treat for shock
Call 911 if the injury is severe/open
ER visit

69. Tendonitis Tendons most often affected Tibialis posterior
Tibialis anterior
Peroneals
Achilles

70. MOI: faulty foot biomechanics
Inappropriate or poor/worn footwear
Acute trauma to tendon
Tightness of heel cord
Training errors
Excessive running, jumping, hills

71. S/S: pain with active movements and passive stretching
Pt. tender over insertion of tendon
warmth
Crepitus
Thickening of tendon (achilles)
Stiffness and pain following periods of inactivity

72. Tx: Rest
Modalities: ice, heat, ultrasound
NSAIDS
Exercise to strengthen muscle(s) involved
Stretching
Orthotics or taping to relieve stress on tendon

73. Tib/Fib fracture
Tibia is most commonly fractured long bone in the body

74. MOI: direct trauma to the tibia/fibula or both
Indirect trauma such as combination rotation/compressive force

75. S/S: Immediate pain
Swelling
Possible deformity
May be open or closed

76. Tx: Splint in the position you find it
Treat for shock
Call 911 if necessary
ER visit

77. Stress Fractures Tibial (mid shaft) Fibular (distal third)
Metatarsal (2nd is most common)

78. MOI: repetitive loading during training and conditioning and jumping
Faulty biomechanics combined with excessive/change in training

79. S/S: pain with activity
Increase in pain when activity is finished
Gradually gets worse
Pt. tender on one specific point on the bone
Can limit ability to participate

80. Tx: stop activity (2-4 weeks)
Alternate conditioning—non weight bearing
Ice
Crutches/protective footwear
Medical referral
Xrays
Bone scan

81. Medial Tibial Stress Syndrome
Shin splints
What is it?
Theories
Fascia pulling off of the bone (Soleus)
Bone Reaction (bone not being able to keep up between osteoclasts and osteoblasts)
Posterior tibialis pulling off of the medial surface of the bone

82. MOI: strain of tibialis posterior tendon and its fascial sheath at attachment to periosteum of distal tibia due to running/etc.
Faulty biomechanics
Improper footwear
Tight heel cord/Achilles tendon
Training errors

83. S/S: diffuse pain along the distal tibia (2/3) medially
Pt. tender in the same area
Pain after activity—then before/after—then all the time

84. Tx: Modify activity
Correct foot biomechanics (orthotics)
Heel cord stretching (slant board)
Strengthening of muscles in Posterior compartment
Ice massage
Friction massage
Taping—arch support/ankle
Demonstrate Arch Taping

85. Compartment Syndromes
Increased pressure in the compartment(s) of the leg
Causes compression of the muscles & neurovascular structures
Anterior, lateral, deep posterior common
3 types
Acute
Acute exertional
Chronic

86. Anterior compartment syndrome
MOI: direct blow to the anterior compartment
S/S: deep aching pain
Tightness & swelling
Pain with passive stretching
Reduced circulation/sensory changes in foot
May have LOM

87. Tx: initially ice to reduce swelling
If circulation/sensory changes occur—MEDICAL EMERGENCY
Fasciotomy
Return to activity 2-4 months post surgery

88. Achilles Tendon Rupture
Largest tendon in body
Most common in athletes over 30 yrs
Seen in sports with ballistic movements—tennis, raquetball, basketball, etc.
MOI: sudden forceful plantar flexion of ankle

89. S/S: felt/heard a “pop” at back of leg (sounds like a twig snap or gun shot)
Felt as is someone hit them with a rock
Pain with plantar flexion/dorsiflexion
Inability to plantar flex
Palpable/visible defect at the achilles tendon
+ Thompson test

90. Achilles tendon defect

91. Thompson Test

92. Tx: immobilize
ice
Send to ER
Requires surgery w/ 6-8 weeks immobilization
Rehab to regain full ROM/Strength

93. Open achilles tendon rupture

94. Contusions MOI: direct trauma to area
S/S: pain, swelling, increased warmth, hematoma
Tx: RICE, protective padding, modify activity if necessary

95. And other weird things

97. Treatment for this? Immoblize object
Cut object at each end to allow for transport
Treat for shock
Surgery to remove impaled object

98. Ankle Taping Procedures
Apply Tuf-Skin
Heel and Lace Pads
Pre-wrap from midfoot to 2 finger widths below calf belly
2 anchor strips

99. Begin 3 Stirrups
In between each stirrup is a horseshoe/C strip
ALWAYS GO MEDIAL TO LATERAL….unless

100. Once 3 stirrups and C strips are in place 4 heel locks
2 medial
2 lateral
2 figure 8s

101. Once all parts are on the ankle
Close out
Make it Pretty

102. All Together Spray Heel and Lace Pads Pre-Wrap 2 Anchors 3 Stirrups
3 C Strips
4 Heel locks
2 medial
2 lateral
2 Figure 8s
Close Out