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
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. 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