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Foot, Ankle, Lower leg Lesson 1 – bone and ligament anatomy.

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Presentation on theme: "Foot, Ankle, Lower leg Lesson 1 – bone and ligament anatomy."— Presentation transcript:

1 Foot, Ankle, Lower leg Lesson 1 – bone and ligament anatomy

2 Foot bones  Foot bones –26 bones  14 phalangeal  5 metatarsals  7 tarsals

3 Toes  Each toe except for the big toe has three phalanges –Toes 2-5 are also known as digits –The big toe, a.k.a. hallux, has two.  The toes are designed to widen our base for balance and propelling our body.  Two sesamoid bones are located under the 1 st metatarsalphalangeal joint (MTP joint) –These bones help increase the mechanical advantage of the flexor tendons that run under the big toe.


5 Metatarsals  Five bones that lie between the toes and the tarsal bones  The first metatarsal is the biggest and the strongest. –This helps it function as the main weight bearing support during walking and running.  The fifth metatarsal protrudes on the lateral aspect of the foot. –Place where ligaments and muscle tendons attach

6 Tarsal bones  Calcaneus –Largest of tarsal bones –Shapes the heel and sits below the talus –Conveys body weight to the ground –Attachment for achilles tendon and several structures on plantar side –Palpate on the posterior bottom of the foot

7 Tarsal bone cont…  Talus –Located above the calcaneus –Fits between the lateral and medial malleoli forming the talocural joint (a.k.a ankle joint) - mortise –Irregular shaped  The bone is broader anterior than posterior –Which gives the ankle more stability in dorsiflexion as it makes a tight fit between the malleoli (10 deg in DF vs. 23 deg in PF)

8 Tarsal bones cont.  Navicular –Located anterior of the talus on the medial aspect of the foot. –Small tubercle may be palpated on the medial foot. –Anteriorly articulates with the cuneiforms  Cuboid –Located on lateral aspect of foot. (palpate on lateral foot) –Posterior articulates with the calcaneus and anterior with the 4 th and 5 th metatarsals  Cuneiforms –Three bones located between the navicular and 3-5 metatarsals –Palpate from mid foot to the medial side


10 Lower leg bones  Tibia –Second longest bone in body –Principle weight bearing –Located on medial side of lower leg –The shaft has three sides – posterior, medial, lateral  Lateral and posterior covered by muscle –Triangle shaped on the top and round near the bottom  Causes a anatomical weakness – bone more dense in this area  Forms medial malleolus

11 Lower leg bones cont.  Fibula –Long slender bone located on lateral leg –Non weight bearing –Primary function is to provide attachment for muscles –Distal portion forms the lateral malleolus  Malleolus extends further distally than medial to give it more stability


13 Arches of the foot  Medial longitudinal arch –Runs along the medal side of the foot from the calcaneus to distal head of the first metatarsal –Bony support are the medial bones –The soft tissue support is the plantar calcaneolnavicular ligament (a.k.a spring ligament) and posterior tibialis muscle  Lateral Longitudinal arch –Runs along lateral portion of the foot. –Much lower and less flexible than the medial

14 Arches cont…  Transverse arch –Half dome over the anterior portion foot over the tarsal bones, primarily the cuboid and internal cuneiform  Anterior metatarsal arch –Shaped by the distal heads of the metatarsal heads


16 Foot ligaments  Spring ligament –a.k.a plantar calcaneonavicular ligament –Located on medial side of foot –Gives support to the medial arch –Helps with shock absorption  Bifurcate ligament –Located on lateral side of foot  Located under fat pad on foot –Connects cuboid to calcaneus and calcaneus to the navicular

17 PPPPlantar fascia –L–L–L–Lies on the bottom of the foot from the calcaneus to the head of each metatarsal head –H–H–H–Helps support the foot against downward forces

18 Ankle/lower leg ligaments  Interroseous membrane –Connective tissue that connects the tibia and fibula –The membrane fills the whole space between the tibia and fibula in the lower leg –The membrane helps diffuse forces placed on the lower leg

19 Lateral ankle ligaments  Anterior/Posterior talofibular ligaments –Both are located on lateral ankle –Helps prevent against anterior/posterior torsion and inversion of the ankle (talus specifically)  Calcaneofibular ligament –Located laterally it traverses inferiorly of the lateral malleolus –Protects against inversion of the calcaneus

20 Lateral ankle ligaments cont…  Calcaneofibular ligament –Located laterally it traverses inferiorly of the lateral malleolus –Protects against inversion of the calcaneus

21 Ankle/lower leg ligaments AAAAnterior/posterior tibiofibular ligaments –S–S–S–Sometimes called the syndesmotic ligaments –T–T–T–They connect the tibia and fibula together at the distal end of the bones – forms the distal portion of the interroseous membrane

22 Medial ankle ligaments  Deltoid ligaments –Located medially on the ankle –Technically three ligaments – treat as one –Triangle shape that begins on the medial malleolus and ends on the medial talus, calcaneus, and navicular bone –Protects against eversion, pronation, and anterior displacement of the ankle (talus specifically)

23 Foot, ankle, and lower leg Lesson 2 – muscles, movement and other structures

24 Lateral muscles  Peroneal brevis –Origin or proximal attachment - lower 2/3 of outer surface of fibula –Insertion or distal attachment – base of 5 th metatarsal –Action – eversion of foot and plantar flexion  Peroneal Longus –Origin – upper 2/3 of fibula –Insertion – undersurface of medial cuneiform and 1 st metatarsal –Action – plantar flexion and eversion


26 Medial muscles  Tibialis posterior –Proximal attachment – posterior surface of tibia, fibula, and interroseous membrane –Distal attachment – undersurface of navicular, cuneiforms, and base of 2-4 metatarsals –Action – inversion and plantar flexion of foot/ankle  Flexor Hallicus Longus –Proximal attachment – Lower 2/3 of posterior fibula –Distal attachment – Undersurface of base of distal phalanx of the Big toe (1 st ) –Action – Plantar flexion of big toe and inversion and plantar flexion of foot/ankle  Flexor Digitorum longus –Proximal attachment – Lower 2/3 of posterior tibia –Distal attachment – Base of distal phalanx of toes 2-5 –Action – plantar flexion of toes 2-5 and plantar flexion and inversion of ankle/foot



29 Anterior Muscles  Anterior Tibialis –Proximal attachment – Upper 2/3 of anterior tibia –Distal attachment – inner surface medial cuneiform and 1 st metatarsal –Action – Dorsal flexion of ankle and inversion of foot  Extensor Hallicus longus –Proximal attachment – Anterior/inner surface of middle 2/3 of fibula –Distal attachment – top of distal phalanx of big toe –Action – dorsal flexion of ankle and big toe and foot inversion  Extensor Digitorum longus –Proximal attachment – Lateral condyle of Tibia, head of fibula, and upper 2/3 of fibula –Distal attachment – top of middle and distal phalanx of toes 2-5 –Action – Dorsal flexion of ankle and toes 2-5, eversion of foot.




33 Posterior Muscles  Gastrocnemius –Proximal attachment – posterior surface of medial and lateral condyles of femur –Distal attachment – posterior surface of the calcaneus –Action – plantar flexion of the ankle and flexion of the knee  Soleus –Proximal attachment – Upper 2/3 of posterior surface of tibia and fibula –Distal attachment – posterior surface of calcaneus –Action – plantar flexion of the ankle  Achilles tendon – formed from the gastrocnemius and soleus



36 Other structures  Anterior and Posterior tibial arteries –Main blood supply for the ankle and foot –Located in the anterior portion of the foot and behind medial malleolus  Common peroneal nerve –Located on lateral side  Tibial nerve –Located behind medial malleolus  Retrocalcaneal bursa –Located under the achilles tendon attachment  Retinaculum –Fascia that holds down ankle tendons as they curl from the lower leg into the foot keeping them in place  Joint capsule –Fascia tissue that encompasses the ankle


38 Foot, ankle, and Lower leg Lesson 3 – foot injuries

39 Heel Bruise –Contusion to the calcaneus –Etiology  Landing directly on the heel without or with limited protection –Signs and symptoms  Pain, pt tenderness, and swelling over calcaneus  Difficulty walking –Management  RICE immediately  Use of crutches for first few days  Use of donut pad when beginning walking  Use of other modalities; US, whirlpool, ect for help in healing.

40 Base of Fifth Tendonitis –Inflammation of Peroneal brevis at the insertion point at the base of the fifth metatarsal. –Etiology  Overuse from running, poor support in shoes, complication of ankle sprain. –Signs and symptoms  Pain, point tenderness, and swelling over base of fifth.  Difficulty walking  Weakness and pain with eversion –Management  RICE  Other modalities – e-stim, ultrasound, WP  Walking boot if becomes to severe –Complications  If not treated and cured quickly can lead to avulsion of Peroneal tendon off base of fifth (Jones fracture) – leads to surgery

41 Retrocalcaneal Bursitis –Bursa irritation over the Achilles/calcaneal insertion –Etiology  Overuse – running, jumping –Symptoms  Pain and swelling on insertion  Strength loss minimum  Pain with passive dorsiflexion –Treatment  RICE – similar too Severs disease

42 Sesmoiditis –Irritation to sesmoid bones under 1st metatarsal/phalangeal joint –Etiology  Running or jumping – excessive force on joint –Symptoms  Pain and swelling over joint  Pain with passive extension  Pain with active flexion –Treatment  Bracing – tape - donut  Ice and other modalities

43 Plantarfascitis –Irritation of fascia that lays on the plantar foot – especially around ½” from base of calcaneus –Etiology  Overuse – arch taking to much pressure. Not enough padding on heel of shoes  Running on toes instead of heel to toe  Poor support of arch –Symptoms  Pain around calcaneus ½” from origin. Hurts immensely first thing in the morning. –Treatment  Arch taping  Getting proper shoes  Ice massage  Stretching  Takes along time to heal


45 Turf Toe –Hyperextension or hyperflexion of 1st metatarsal –Etiology  Forceful flex or over extension of big toe while running  Stubbing toe –Symptoms  Swelling and pain over joint –Treatment  RICE  Tape  Modalities

46 Bifurcate sprain –Sprain of ligament that holds talus, cuboid and navicular together  Located around fat pad on lateral side of foot –Etiology  Inversion of foot –symptoms  similar to ankle  swelling and pain over fat pad in foot and lateral foot  pain and mild weakness with eversion –Treatment  Similar to ankle  RICE  Foot strengthening  Heals faster than regular ankle sprain

47 Medial and Lateral arch –Etiology  Poor shoes, overweight, postural anomalies, weakened support structures –Signs and symptoms  Soreness, tiredness around arch  Pain when running –Management  Tape  Strengthening of surrounding structures

48 Fallen Metatarsal heads –Etiology  Weakened surrounding structures due to undue stress being placed on toes 2-5 causing them to splay apart. –Signs and symptoms  Transverse arch becomes flattened and may see one or two head of metatarsals depress  Pain when walking –Management  Place small pad behind fallen metatarsal head helping push back up  Strengthen surrounding structures

49 Fractures  Dome of Talus –etiology  severe inversion or forceful dorsiflexion –signs and symptoms  pain located in center of ankle in mortise area –management  RICE  refer to doctor

50 Fractures –Navicular  Etiology –high arches –poor shoes  signs and symptoms –pain when running and jumping around Navicular –point tender over tubercle  management –RICE –x-rays –walking boot

51 Fractures  March fracture –fracture of metatarsal – usually 2nd or 3rd –etiology  overuse on running or marching  people with atypical conditions more disposed to injury  short first metatarsal, hallix valgus, flat foot –signs and symptoms  pain, swelling and pt tender over specified metatarsal –management  RICE  x-rays  crutches and walking boot

52 Fractures –Jones fracture  Fracture of base of fifth  etiology –forceful inversion  signs and symptoms –pain and swelling over base of fifth –weakness with eversion  management –RICE –x-rays - crutch

53 Foot, Ankle, Lower Leg Lesson 4 – ankle injuries

54 Lateral ankle sprain –Injury to one or more the lateral ligaments (Ant TaloFib, PTF, CalcFib) –Etiology  Due to inversion or plantarflexion and inversion of the ankle. Landing wrong or stepping on someone’s foot or object are main occurrences –Sign and symptoms  Pain, point tenderness, redness, swelling in the area of lateral malleolus. ROM and strength limited. Possible abnormal joint motion  Severity graded on a scale of 3 depending on severity of above symptoms

55 Three degrees of Lateral ankle sprains

56 Lateral ankle sprains –Special tests  Anterior drawer – tests anterior talofibular ligament  Posterior drawer – tests posterior talofibular ligament  Calcaneal tilt – (dorsiflexion – inversion) – calcaneal fibular –Management  RICE with acute injuries –Goal is to reduce swelling quickly as possible and allow the 1st stage and 2nd stage of healing to take effect. –Use of walking boot may be needed if 2nd degree or higher  Next goal is to regain full ROM and strength  Regain normal running and agilities  Anything over grade 2 with adolescence should consider x-rays

57 Special tests  Anterior drawer test –Patient positions foot in slight plantar flexion –Brace anterior shin with left hand –Pull heel anteriorly with right hand –Positive test findings  Laxity and poor endpoint on forward translation

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

59 Medial ankle sprains –Injury to the deltoid ligament –Etiology  Eversion stress placed on the ankle from landing wrong or stepping on someone’s foot –Sign and symptoms  Similar to lateral ankle sprain –Special test  Eversion stress –Management  Same as lateral ankle  Grade 2 or above consider x-rays to rule out avulsion fracture

60 Anterior Tibiofibular sprain –A.K.A. high ankle sprain. Sprain of ligament that holds tibia and fibular together in lower 1/3 of lower leg –Etiology  Severe external rotation of ankle. Foot usually in dorsiflexion when occurs –Signs and symptoms  Severe pain over area of anterior Tibiofibular region.  Usually NO or minimal swelling evident  Loss of function –Management  Takes along time to heal  RICE  Walking boot  Tape in slight plantar flexion

61 Foot, Ankle, Lower leg Lesson 5 – lower leg injuries

62 Anterior compartment syndrome –Severe contusion, bruising of lower leg, swelling accumulates in compartments does not flow out  Usually in anterior compartment –etiology  blow to the area. Kicked, hit by bat or ball, tackled, fall on area –symptoms  extreme swelling of lower leg –looks wood like - shiny  weakness in dorsiflexion and eversion  numbness on dorsal foot –Treatment  Elevate leg  Check pulse – dorsal pedis and tibial arteries  Refer to emergency room immediately  24-48 hrs necrosis sets in  Surgery – fasciactomy  Prevention most important –never wrap a bruised lower leg –elevate with ice as soon as possible

63 Chronic compartment syndrome –Exercise induced – not emergency like ACS – fascia too tight –Etiology  Running, muscles to big and/or fascia too tight –Symptoms  numbness during running in toes  Similar symptoms as ACS but disappear after finish workout. –Treatment  Refer to Doctor

64 “Shin Splints” –Five types; muscle strain, stress fracture, chronic compartment syndrome, irritation to periosteum, strain to interosseus membrane –Muscle strain  Etiology –muscle strain to anterior tibialis, overuse running, poor support from shoes  Symptoms –pain with dorsiflexion –pain while running –palpation – hurts in large area along muscle  Treatment –reduction of pain –strengthen muscle TA and stretch gastroc –look for better support in shoe

65 “Shin Splints” –Stress Fracture  Etiology –overuse on running, changes in workout –poor support in shoes with high arches  Symptoms –pain in one spot –continually gets worse –may ache at night or during day or pain does not disappear shortly after workout –Pain on Tibia –radiates through leg when running  Treatment –referral to doctor –rest –return three weeks after all pain has disappeared

66 “Shin Splints”  irritation to periosteum –usually low –similar to muscle strain except hurts directly on bone –usually located lower 1/3 of tibia –Treatment  takes longer to heal then muscle strain  modalities  Interosseus strain –Last option –Takes long time to heal –Deep pain  Chronic compartment syndrome –See #2

67 Gastrocnemius strain –Strain at the gastroc-soleus junction or at medial head near origin –Etiology  Forceful action – running or jumping –Symptoms  Pain and muscle weakness in area  Swelling if severe enough –Treatment  RICE  Modalities

68 Achilles strain, tendonitis, and rupture –Etiology  Overuse on running or jumping, or acute contusion or forceful movement –Symptoms  Pain, swelling, weakness with plantar flexion –Treatment  RICE  Modalities  Strengthening  Must be careful – chronic tendonitis my lead to rupture –feel deformity in Achilles –injured feels like they got shot –totally disabled –immediate swelling –Positive Thompson test  Injured lay prone feet hang over edge  Squeeze calf –  negative sign – foot plantar flexes  positive sign – foot does not move

69 Thrombosis –Blood clot –Etiology  Blow to the area –Symptoms  Deep pain in calf  Positive sign on Homan’s sign –Athlete lay supine –Raise leg and passively put foot in dorsiflexion –Feels pain in specific spot deep in calf, may feel bump if clot big enough –Treatment  Referral to Dr.

70 Severs Disease –Similar to Osgood Schlatter’s of the knee –Etiology  Overuse – running and jumping in adolescence 12-18 yrs old  Degeneration of the area just below where the Achilles inserts to the calcaneus –Signs and symptoms  Pain, swelling, and redness in the area where Achilles inserts to the calcaneus  Pain and weakness with plantar flexion  Hurts during activity –rest helps alleviate pain –management  RICE with acute symptoms  Heel cup – which will restrict dorsiflexion for activity  When apophysis closes (around age 18) problem ceases

71 Accessory Bones –Os Trigodom –Located on back of calcaneus –Irritation from overuse plantarflexion

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