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Lesson 1 – bone and ligament anatomy

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1 Lesson 1 – bone and ligament anatomy
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 1st metatarsalphalangeal joint (MTP joint) These bones help increase the mechanical advantage of the flexor tendons that run under the big toe.

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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 Cuboid Cuneiforms
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 4th and 5th metatarsals Cuneiforms Three bones located between the navicular and 3-5 metatarsals Palpate from mid foot to the medial side

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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

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13 Arches of the foot Medial longitudinal arch Lateral 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 Anterior metatarsal 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

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16 Foot ligaments Spring ligament Bifurcate 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 Plantar fascia Lies on the bottom of the foot from the calcaneus to the head of each metatarsal head 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
Anterior/posterior tibiofibular ligaments Sometimes called the syndesmotic ligaments 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 Peroneal Longus
Origin or proximal attachment - lower 2/3 of outer surface of fibula Insertion or distal attachment – base of 5th metatarsal Action – eversion of foot and plantar flexion Peroneal Longus Origin – upper 2/3 of fibula Insertion – undersurface of medial cuneiform and 1st metatarsal Action – plantar flexion and eversion

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26 Medial muscles Tibialis posterior Flexor Hallicus Longus
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 (1st) 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

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29 Anterior Muscles Anterior Tibialis Extensor Hallicus longus
Proximal attachment – Upper 2/3 of anterior tibia Distal attachment – inner surface medial cuneiform and 1st 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.

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33 Posterior Muscles Gastrocnemius Soleus
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

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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

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

39 Heel Bruise Contusion to the calcaneus Etiology Signs and symptoms
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

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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 signs and symptoms management 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 Lesson 4 – ankle injuries
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 Management
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 Lesson 5 – lower leg injuries
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 Symptoms Treatment
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 Interosseus strain
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 Symptoms Treatment Blow to the area
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 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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