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Injuries to the Foot, Ankle and Lower Leg

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Presentation on theme: "Injuries to the Foot, Ankle and Lower Leg"— Presentation transcript:

1 Injuries to the Foot, Ankle and Lower Leg
SPHS Sports Medicine John Hardin, Instructor

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

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 Heel Bruise (Stone Bruise)
Mxn: 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

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

23 S/S: POT 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

24 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

25 Metatarsal Fracture Mxn: direct force or twisting/torsion force or overuse Most common is the Jone’s fracture—near base of 5th, avulsion (at the base), midshaft

26 S/S: POT over metatarsal, swelling, pain, “pop” or “crack”, possible deformity

27 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

28 Longitudinal Arch Strain
Mxn: 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

29 S/S: Pain felt just distal to the medial malleolus when running
Swelling and POT along the calcaneonavicular ligament (spring ligament) and the first cuneiform POT over the FHL tendon as a result of compensation for stress on ligament

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

31 Turf Toe Sprain of the MP joint of the great to
Mxn: Hyperextension of great toe—trauma or overuse Usually occurs on an unyielding surface such as turf Kicking an unyielding object

32 S/S: POT over MP joint of great toe
Swelling Discoloration Pain with movement especially pushing off big toe when taking a step

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

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

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

36 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

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

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

39 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

40 Ankle Sprains Inversion Eversion High Ankle Sprain

41 Inversion Ankle Sprain
Most common, resulting in injury to the lateral ligaments ATF ligament is the weakest of the 3 Mxn: “rolling” the ankle, landing on another athlete’s foot, stepping in a hole, etc. Inversion/plantar flexion

42 The inversion mxn

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

44 3rd degree Lateral Ankle sprain


46 S/S: Pain, Swelling, discoloration, POT 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

47 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

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

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

50 Mxn: 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, POT over medial malleolus and deltoid ligament Will vary depending on severity

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

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

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

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

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

56 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

57 Complications Fracture to the dome of the talus
Tear of the interosseus membrane

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

59 What do these injuries look like?
After the mxn See the placement of the foot?

60 Sliding into base He’s there!

61 Getting help

62 And the open ones? Open Fx/dislocation Open fracture

63 And some x-rays

64 S/S: Immediate swelling
immense pain possible deformity and/or open wound POT over the bone + compression and percussion tests

65 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

66 Tendonitis Tendons most often affected Tibialis posterior
Tibialis anterior Peroneals Achilles

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

68 S/S: pain with active movements and passive stretching
POT over insertion of tendon warmth Crepitus Thickening of tendon (achilles) Stiffnes and pain following periods of inactivity

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

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

71 Mxn: direct trauma to the tibia/fibula or both
Indirect trauma such as combination rotation/compressive force

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

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

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

75 Mxn: repetitive loading during training and conditioning and jumping
Faulty biomechanics combined with excessive/change in training

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

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

78 Medial Tibial Stress Syndrome
Shin splints

79 Mxn: 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

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

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

82 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

83 Anterior compartment syndrome
Mxn: 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

84 Tx: initially ice to reduce swelling
If circulation/sensory changes occur—emergency room visit Fasciotomy Return to activity 2-4 months post surgery

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

86 S/S: felt/heard a “pop” at back of leg
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

87 Achilles tendon defect

88 Thompson Test

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

90 Open achilles tendon rupture

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

92 And other weird things

93 Another view

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

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