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Chapter 16 Foot, Ankle, and Lower Leg Conditions

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1 Chapter 16 Foot, Ankle, and Lower Leg Conditions

2 Skeletal features of the lower leg, ankle, and foot
Anatomy Skeletal features of the lower leg, ankle, and foot

3 Anatomy (cont’d) Forefoot Metatarsals and phalanges; numerous joints
Support and distribute body weight throughout the foot Toes Smooth the weight shift to the opposite foot during walking Help maintain stability during weight-bearing 1st digit – hallux or “great toe” – main body stabilizer during walking or running

4 Anatomy (cont’d) Midfoot
Navicular, cuboid, 3 cuneiforms; numerous joints Talocalcaneonavicular joint (TCN) Talus moves simultaneously on calcaneus and navicular Combined action of talonavicular and subtalar joint

5 Anatomy (cont’d) Hindfoot Calcaneus and talus
Talocrural joint (ankle joint) Hinge joint; plantarflexion and dorsiflexion Articulation of talus, tibia, and fibula Fibula extends farther distally than tibia – limits eversion Talar dome wider anteriorly – more stable in dorsiflexion

6 Anatomy (cont’d) Hindfoot (cont’d)
Talocrural joint (ankle joint) (cont’d) Ligaments Medial: deltoid Lateral :anterior talofibular; posterior talofibular; calcaneofibular Subtalar joint Behaves as a flexible structure

7 Anatomy (cont’d) Ligaments supporting the midfoot and hindfoot region
Ligaments supporting the midfoot and hindfoot region, lateral and medial views

8 Anatomy (cont’d) Tibiofibular joints Superior—proximal Inferior—distal
Interosseous membrane

9 Anatomy (cont’d) Plantar arches Support and distribute body weight
Longitudinal arch—medial and lateral Transverse arch Ligaments Spring (calcaneonavicular) Long plantar Short plantar

10 Medial longitudinal arch
Anatomy (cont’d) Arches of the foot Medial longitudinal arch

11 Anatomy (cont’d) Plantar arches Plantar fascia
Provides support for the longitudinal arch Plantar fascia

12 Anatomy (cont’d) Nerves Sciatic nerve Tibial nerve
Common peroneal nerve—deep and superficial peroneal nerves Femoral—saphenous

13 Blood supply to the leg, ankle, and foot region
Anatomy (cont’d) Blood supply to the leg, ankle, and foot region Blood supply Femoral artery Popliteal Anterior and posterior tibial Anterior tibial Dorsal pedal

14 Kinematics and Major Muscle Actions
Muscles of the lower leg and foot. A. Lateral and medial view

15 Kinematics and Major Muscle Actions (cont’d)
Muscles of the lower leg and foot. B. Posterior view

16 Kinematics and Major Muscle Actions (cont’d)
Intrinsic muscles of the foot. A. Dorsal view

17 Kinematics and Major Muscle Actions (cont’d)
Intrinsic muscles of the foot. B. Plantar view

18 Kinematics and Major Muscle Actions (cont’d)
COMPARTMENT PRIMARY ACTION Tibialis anterior Anterior Dorsiflexion, inversion Extensor digitorum longus Toe extension, dorsiflexion Extensor hallucis longus Extension of great toe Peroneus tertius Eversion, dorsiflexion Peroneus longus Lateral Eversion, plantar flexion Peroneus brevis

19 Kinematics and Major Muscle Actions (cont’d)
COMPARTMENT PRIMARY ACTION Flexor digitorum longus Posterior, deep Toe flexion, plantar flexion Flexor hallucis longus Flexion of he great toe, plantar flexion Tibialis posterior Inversion, plantar flexion Gastrocnemius Posterior, superficial Plantar flexion, knee flexion Soleus Plantar flexion Plantaris

20 Kinematics and Major Muscle Actions (cont’d)
Gait cycle Consists of alternating periods of single-leg and double-leg support Requires a set of coordinated, sequential joint actions of the lower extremity Gait

21 Kinematics and Major Muscle Actions (cont’d)
Motions Toe—flexion and extension Ankle (subtalar)—dorsiflexion and plantarflexion Foot and ankle Inversion and eversion Pronation and supination

22 Kinematics and Major Muscle Actions (cont’d)
Motions of the foot and ankle. A. Dorsiflexion and plantar flexion. B. Eversion and inversion. C. Supination of the subtalar joint

23 Injury Prevention Physical conditioning Strengthening
Extrinsic muscles Intrinsic muscles Flexibility Achilles tendon

24 Injury Prevention (cont’d)
Protective equipment Braces; orthotics Footwear Demands of sport; wear shoe for its intended purpose Proper fit

25 Toe and Foot Conditions
Toe deformities Hallux rigidus Degenerative arthritis in first MTP S&S Tender, enlarged first MTP joint Loss of motion Difficulty wearing shoes with an elevated heel Hallmark sign—restricted toe extension

26 Toe and Foot Conditions (cont’d)
Toe deformities Hallux valgus Thickening of the medial capsule and bursa, resulting in severe valgus deformity Asymptomatic or symptomatic Treatment—symptomatic

27 Toe and Foot Conditions (cont’d)
Hallux valgus

28 Toe and Foot Conditions (cont’d)
Hammer toe Extension of MTP joint, flexion at PIP joint, and hyperextended at the DIP joint Claw toe Hyperextension of MTP joint and flexion of DIP and PIP joints Mallet toe Neutral position at MTP and PIP joints, flexion at DIP joint

29 Toe and Foot Conditions (cont’d)
S&S: painful callus formation on dorsum IP joints Toe deformities

30 Toe and Foot Conditions (cont’d)
Pes cavus Excessively high arch that does not flatten during weight bearing Causes can vary Rigid foot

31 Toe and Foot Conditions (cont’d)
Pes planus Flat foot; arch or instep of the foot collapsing & contacting the ground Typically, acquired deformity resulting from injury or trauma Mobile foot

32 Toe and Foot Conditions (cont’d)
Both conditions can be asymptomatic, but associated with common injuries Common foot deformities

33 Contusions Heel contusion
Thick padding of adipose tissue—does not always suffice Stress in running, jumping, changing directions S&S Severe pain in heel Unable to bear weight

34 Contusions (cont’d) Heel contusion (cont’d)
Management: cold; heel cup or doughnut pad; referral Condition may persist for months

35 Contusions (cont’d) Gastrocnemius contusion S&S
Immediate pain and weakness Rapid hemorrhage and muscle spasm → palpable mass Management: Cold with gentle stretch If symptoms persist > 2-3 days, physician referral

36 Contusions (cont’d) Tibial contusion (shin bruise)
Vulnerable lack of padding Minor injury—caution: repeated blows → damage periosteum Management: standard acute Key: prevention

37 Lower Leg Contusions Acute compartment syndrome
Lower leg includes 4 nonyielding compartments MOI: direct blow anterolateral aspect of the tibia Rapid ↑ in tissue pressure → neurovascular compromise

38 Lower Leg Contusions (cont’d)
Acute compartment syndrome (cont’d) S&S History of trauma Increasingly severe pain—out of proportion to situation Firm and tight skin over anterior shin

39 Lower Leg Contusions (cont’d)
Acute compartment syndrome (cont’d) S&S (cont’d) Loss of sensation between 1st and 2nd toes on dorsum of foot Diminished pulse—dorsalis pedis artery Functional abnormalities within 30 minutes

40 Lower Leg Contusions (cont’d)
Acute compartment syndrome (cont’d) Management: Cold NO compression or elevation immediate referral to ER or summon EMS Irreversible damage can occur within 12–24 hours

41 Toe and Foot Sprains IP & MP joints MOI: tripping or stubbing the toe
S&S Pain, dysfunction, immediate swelling Dislocation—gross deformity

42 Toe and Foot Sprains (cont’d)
Midfoot sprains MOI: severe dorsiflexion, plantarflexion, or pronation More frequent in activities in which foot is unsupported S&S Pain and swelling is deep on medial aspect of foot Weight bearing may be too painful

43 Toe and Foot Sprains (cont’d)
Turf toe Sprain of the plantar capsular ligament of 1st MTP joint MOI: forced hyperflexion or hyperextension of great toe Acute or repetitive overload Valgus ↑ susceptibility

44 Toe and Foot Sprains (cont’d)
Turf toe (cont’d) S&S (cont’d) Pain, point tenderness, and swelling on plantar aspect of MP joint Extreme pain with extension Potential for tear in flexor tendons or fracture of sesamoid bones

45 Toe and Foot Sprains (cont’d)
Management toe and foot sprains Standard acute Physician referral

46 Ankle Sprains Inversion ankle sprain MOI: plantarflexion and inversion
Predisposing factors Lateral malleolus projects farther downward Least stable position of ankle is plantar flexion Weakness in peroneals ↓ ROM in Achilles tendon

47 Ankle Sprains (cont’d)
Inversion ankle sprain

48 Ankle Sprains (cont’d)
SIGNS AND SYMPTOMS 1st Pain and swelling on anterolateral aspect of lateral malleolus Point tenderness over ATFL 2nd Tearing or popping sensation felt on lateral aspect Pain and swelling on anterolateral and inferior aspect of lateral malleolus Painful palpation over ATFL and CFL May also be tender over PTFL, deltoid ligament, and anterior capsule area 3rd Diffuse swelling over entire lateral aspect with or without anterior swelling Can be very painful or absent of pain

49 Ankle Sprains (cont’d)
Eversion ankle sprain Mechanism: excessive dorsiflexion and eversion Deltoid ligament Potential Lateral malleolus fx; bimalleolar fx Tear of anterior tibiofibular ligament & interosseous membrane

50 Ankle Sprains (cont’d)
Eversion ankle sprain (cont’d) Predisposing factors Excessive pronation Hypomobile foot

51 Ankle Sprains (cont’d)
Eversion Sprain (cont’d) S&S Mild to moderate injuries Often unable to recall the mechanism Some initial pain at time of injury, but often subsides and individual continues to play

52 Ankle Sprains (cont’d)
Eversion sprain (cont’d) S&S (eversion sprain) Mild to moderate injuries Swelling May not be as evident as a lateral sprain Between posterior aspect of lateral malleolus and Achilles tendon Point tenderness in involved ligaments

53 Ankle Sprains (cont’d)
Eversion Sprain (cont’d) S&S Severe injuries PROM pain-free in all motions except dorsiflexion

54 Ankle Sprains (cont’d)
Syndesmosis sprain (High Ankle Sprain) Spreading of space at distal tibiofibular joint MOI: dorsiflexion and external rotation Common: anterior inferior tibiofibular ligament S&S Point tenderness over the anterolateral tibiofibular joint Significant pain and swelling Difficulty bearing weight

55 Ankle Sprains (cont’d)
Management of ankle sprains Standard acute Use of crutches if unable to walk without limp Physician referral

56 Ankle Sprains (cont’d)
Subtalar dislocation MOI: fall from a height (as in basketball or volleyball); foot lands in inversion Disrupts interosseous talocalcaneal & talonavicular ligament

57 Ankle Sprains (cont’d)
Subtalar dislocation (cont’d) S&S Extreme pain and total loss of function is present Gross deformity may not be clearly visible Foot may appear pale and feel cold to the touch Individual may show signs of shock

58 Ankle Sprains (cont’d)
Subtalar dislocation Concern: potential for peroneal tendon entrapment and neurovascular damage Management: medical emergency; activate EMS; monitor neurovascular function

59 Tendinopathies of the Foot & Lower Leg
Strains & Tendinitis Common sites Achilles tendon just proximal to insertion on calcaneus Tibialis posterior just behind medial malleolus Tibialis anterior on dorsum of foot just under extensor retinaculum Peroneal tendons just behind lateral malleolus and at distal attachment on base of 5th metatarsal

60 Tendinopathies of the Foot & Lower Leg (cont’d)
Strains & Tendinitis Predisposing factors Training errors Direct trauma Infection from a penetrating wound into tendon Abnormal foot mechanics producing friction between shoe, tendon, and bony structure Poor footwear that is not properly fitted to foot

61 Tendinopathies of the Foot & Lower Leg (cont’d)
S&S (tendinitis) History of morning stiffness Localized tenderness over tendon Swelling or thickness in tendon and peritendon tissues Pain with passive stretching and with active and resisted motion

62 Tendinopathies of the Foot & Lower Leg (cont’d)
Management Do not permit to continue activity until seen by a physician Suggest the application of cold to the area to decrease pain and potential spasm

63 Tendiopathies of the Foot & Lower Leg (cont’d)
Gastrocnemius strain Medial head or musculotendinous junction Mechanism Forced dorsiflexion while knee is extended Forced knee extension while foot is dorsiflexed Muscular fatigue with fluid–electrolyte depletion & cramping

64 Tendinopathies of the Foot & Lower Leg (cont’d)
Gastrocnemius strain (cont’d) S&S Immediate pain, swelling, loss of function Management: standard acute; crutches if unable to walk w/out a limp If symptoms persist > 2-3 days or mod- severe injury, physician referral

65 Tendinopathies of the Foot & Lower Leg (cont’d)
Gastrocnemius muscle strain

66 Tendinopathies of the Foot & Lower Leg (cont’d)
Achilles tendon rupture MOI: push-off of forefoot while knee is extending More common in individuals over age 30 S&S “Pop” Inability to stand on toes Visible defect Excessive passive dorsiflexion

67 Tendinopathies of the Foot & Lower Leg (cont’d)
Achilles tendon rupture (cont’d) Management Compression wrap; immediate transport to emergency care facility or physician

68 Tendinopathies of the Foot & Lower Leg (cont’d)
Achilles tendon rupture

69 Overuse Conditions Plantar fasciitis
Extrinsic and intrinsic risk factors S&S Pain at plantar, medial heel Pain with first steps in the morning, but diminshes min ↑ pain with passive extension of great toe and ankle dorsiflexion Pain relieved with activity, but recurs after rest

70 Overuse Conditions (cont’d)
Plantar fasciitis (cont’d) Management: Do not permit to continue activity until seen by a physician Suggest application of cold to decrease pain and spasm

71 Overuse Conditions (cont’d)
Medial tibial stress syndrome Periostitis along posteromedial tibial border (distal third) Soleus insertion Excessive pronation → eccentric contraction of soleus → periostitis Other contributing factors Recent changes in running distance, speed, footwear, or running surface

72 Overuse Conditions (cont’d)
Medial tibial stress syndrome (cont’d) S&S Dull pain begins at any point in the workout; occasionally sharp and penetrating Pain along posteromedial border of tibia in distal third Pain is relieved with rest, but may recur hours after activity stops

73 Overuse Conditions (cont’d)
S&S (MTSS) (cont’d) Pain with resisted plantar flexion or standing on tiptoe Often an associated varus alignment of the lower extremity, including a greater Achilles tendon angle.

74 Overuse Conditions (cont’d)
Management: Do not permit to continue activity until seen by a physician Suggest application of cold to decrease pain and spasm

75 Overuse Conditions (cont’d)
Exertional compartment syndrome Characterized by exercise-induced pain and swelling that is relieved by rest Compartments most frequently affected— anterior (50%–60%) & deep posterior (20-30%) Usually seen in well-conditioned individuals <40 yrs old

76 Overuse Conditions (cont’d)
Exertional compartment syndrome S&S Exercise-induced pain that is often described as a tight, cramplike, or squeezing ache and a sense of fullness Often affects both legs Relieved with rest, only to recur if exercise resumes Anterior compartment—mild foot drop; paresthesia dorsum of foot

77 Overuse Conditions (cont’d)
Exertional compartment syndrome Management: Stop activity Assessment by qualified health care practitioner

78 Foot and Lower Leg Fractures
Repetitive microtraumas → apophyseal or stress fractures Tensile forces associated with severe ankle sprains → avulsion fractures of 5th metatarsal Severe twisting → displaced and undisplaced fractures in foot, ankle, or lower leg

79 Foot and Lower Leg Fractures (cont’d)
Freiberg's disease Avascular necrosis of 2nd metatarsal head Active adolescents ages 14–18 S&S: diffuse pain in forefoot

80 Foot and Lower Leg Fractures (cont’d)
Sever's disease Traction-type injury of calcaneal apophysis Seen in ages 7–10 S&S Heel pain with activity Decreased heel cord flexibility Pain with standing on tiptoes

81 Foot and Lower Leg Fractures (cont’d)
Stress fractures Common: Running and jumping, especially after significant ↑ training mileage; change in surface, intensity, or shoe type Women w/ amenorrhea 6 months+ and oligomenorrhea

82 Foot and Lower Leg Fractures (cont’d)
Stress fractures (cont’d) Common sites 2nd metatarsal Sesamoid bones Navicular Calcaneus Tibia and fibula

83 Foot and Lower Leg Fractures (cont’d)
Stress fracture (cont’d) S&S Pain begins insidiously; ↑ with activity and ↓ with rest Pain usually limited to fracture site

84 Foot and Lower Leg Fractures (cont’d)
Avulsion fractures Eversion sprain—deltoid lig. avulses distal medial malleolus Inversion sprain—plantar aponeurosis or peroneus brevis tendon avulses base of 5th metatarsal (type II)

85 Foot and Lower Leg Fractures (cont’d)
Avulsion fractures Jones fracture Type I transverse fracture into the proximal shaft of 5th metatarsal at junction of diaphysis and metaphysis Often overlooked in conjunction with a severe ankle sprain Complications: nonunions and delayed unions are common

86 Foot and Lower Leg Fractures (cont’d)
Avulsion fractures

87 Foot and Lower Leg Fractures (cont’d)
Displaced fractures and dislocations MOI Direct compression (e.g., falling from a height) Compression & shearing (i.e., twisting mechanism) Potential neurovascular complications

88 Foot and Lower Leg Fractures (cont’d)
Displaced fractures and dislocations (cont’d) Phalanges MOI: axial load (e.g. jamming toe) or direct trauma (e.g., crushing) Swelling; ecchymosis; pain; able to walk Metatarsals Swelling; pain Pain increases with weight bearing Potential for displacement

89 Foot and Lower Leg Fractures (cont’d)
Displaced fractures and dislocations (cont’d) Metatarsals (cont’d) 1st metatarsal dislocated from 1st cuneiform; other 4 metatarsals are displaced laterally, usually in combination with fracture at base of 2nd metatarsal History of severe midfoot pain, paresthesia, or swelling in midfoot region with variable flattening of arch or forefoot abduction

90 Foot and Lower Leg Fractures (cont’d)
Tibia-fibula fractures Nearly 60% of tibial fractures involve the middle and lower third of the tibia. MOI: torsional force, resulting in either a spiral or oblique fracture of the lower third of the tibia.

91 Foot and Lower Leg Fractures (cont’d)
Tibia-fibula fractures (cont’d) S&S Gross deformity Gross bone motion at the suspected fracture site Immediate swelling, extreme pain, or pain with motion

92 Foot and Lower Leg Fractures (cont’d)
Ankle fracture–dislocation MOI Landing from a height with foot in excessive eversion or inversion Being kicked from behind while the foot is firmly planted

93 Foot and Lower Leg Fractures (cont’d)
Ankle fracture–dislocation (cont’d) S&S Foot displaced laterally at a gross angle to lower leg Extreme pain Can compromise the posterior tibial artery and nerve

94 Foot and Lower Leg Fractures (cont’d)
Fracture management Mild Standard acute with physician referral Serious conditions Activate emergency plan, including summoning EMS Assess and treat for shock

95 Coach and Onsite Assessment
S &S that require immediate physician referral (potential for EMS) Obvious deformity suggesting a dislocation, fracture, or ruptured Achilles tendon Significant loss of motion or muscle weakness Excessive joint swelling Possible epiphyseal or apophyseal injuries

96 Coach and Onsite Assessment (cont’d)
S &S that require immediate physician referral (potential for EMS) (cont’d) Abnormal sensation, or absent or weak pulse Gross joint instability Any unexplained pain that affects normal function Refer to Application Strategy 16.2


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