1. © 2007 McGraw-Hill Higher Education. All rights reserved. Chapter 14: The Foot Chapter 15: The Ankle and Lower Leg

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3. Arches of the Foot

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6. Plantar Fascia

7. © 2007 McGraw-Hill Higher Education. All rights reserved. Muscle of the Foot and Lower Leg

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9. The Ankle Joint Ankle joint = talocrural joint Three bones  Tibia ( )-major weight bearing  Fibula ( )  Talus

10. © 2007 McGraw-Hill Higher Education. All rights reserved. Subtalar Joint The joint between the talus and the calcaneous Shifts during weight bearing (WB)

11. © 2007 McGraw-Hill Higher Education. All rights reserved. Tibiofibular Joint -Fig 15-2 Composed of Tibia and Fibula Ligaments/Membrane  _____________________  Interosseious membrane- connects the tibia and fibula; runs the entire diaphysis of both bones

12. © 2007 McGraw-Hill Higher Education. All rights reserved. Nerves and Blood Supply Nerves  Sciatic nerve branches into the peroneal (ant/lat) and tibial nerves (post) Blood Supply  Femoral Artery →Popliteal artery →  Anterior and Posterior Tibial artery Anterior Tibial becomes the dorsalis pedis artery →dorsal pedal on the dorsum of foot Posterior Tibial is located behind medial malleolus.

13. © 2007 McGraw-Hill Higher Education. All rights reserved. ROM/Actions DF- PF- INV- EV- Toe Ext.- Toe Flexion -

14. © 2007 McGraw-Hill Higher Education. All rights reserved. Review http://www.csuchico.edu/~sbarker/shoc k/Anklequiz.html http://www.csuchico.edu/~sbarker/shoc k/Anklequiz.html http://www.rad.washington.edu/atlas2/ http://www.medicalmultimediagroup.co m/pated/foot/achilles/achilles.html http://www.medicalmultimediagroup.co m/pated/foot/achilles/achilles.html

15. © 2007 McGraw-Hill Higher Education. All rights reserved. Prevention of Foot Injuries Highly vulnerable area to variety of injuries Injuries best prevented by selecting appropriate footwear, correcting biomechanical structural deficiencies through orthotics Foot will adapt to training surfaces over time  Must be aware of potential difficulties associated with non-yielding and absorbent training surfaces

16. © 2007 McGraw-Hill Higher Education. All rights reserved. Foot Assessment Athletes should be referred to qualified personnel for injury evaluation History  Generic history questions  Questions specific to the foot Location of pain - ________________? Training surfaces or changes in footwear? Changes in training, ______________? Does footwear increase discomfort?

17. © 2007 McGraw-Hill Higher Education. All rights reserved. Observations  Does athlete favor a foot, limp, or is unable to bear weight?  Does foot color change w/ weight bearing?  Is there pes planus/cavus?  How is foot alignment?  Structural deformities?  What does wear pattern look like on the sole of the shoe? Is the wear symmetrical?

18. © 2007 McGraw-Hill Higher Education. All rights reserved. Palpation  Should assess the bony anatomy first Checking for deformities and areas of tenderness  Assessment of soft tissue (muscles and tendons) will allow for detection of point tenderness, swelling, muscle spasm or muscle guarding  Circulation must also be monitored using the dorsal pedal pulse Located on anterior surface of ankle and foot Special Test – Fracture Testing  Compression - _________________  Flick/Percussion - _________________

19. © 2007 McGraw-Hill Higher Education. All rights reserved. Recognition and Management of Specific Injuries Foot problems are associated with improper footwear, poor hygiene, anatomical structural deviations or abnormal stresses Sports place exceptional stress on feet __________________________________ __________________________________

20. © 2007 McGraw-Hill Higher Education. All rights reserved. Retrocalcaneal Bursitis or Achilles Bursitis (Pump Bump)  Cause of Injury Caused by inflammation of bursa beneath Achilles tendon Result of pressure and rubbing of shoe heel counter of a shoe Chronic condition that develops over time and may take extensive time to resolve, exostosis (pump bump) may develop __________________

21. © 2007 McGraw-Hill Higher Education. All rights reserved.  Sign and Symptoms Signs of inflammation Tender, palpable bump on calcaneous Pain w/ palpation superior and anterior to Achilles insertion, swelling on both sides of the heel cord  Care Routine stretching of Achilles, heel lifts to reduce stress, donut pad to reduce pressure Select different footwear that results in increasing or decreasing height of heel counter.

22. © 2007 McGraw-Hill Higher Education. All rights reserved. Plantar Fasciitis  Cause of Condition Increased stress on fascia Change from rigid supportive footwear to flexible footwear Poor running technique Leg length discrepancy, excessive pronation, inflexible longitudinal arch, tight gastroc-soleus complex Running on soft surfaces, shoes with poor support  Sign and Symptoms Pain in anterior medial heel, along medial longitudinal arch Increased pain in morning, loosens after first few steps, pain with forefoot dorsiflexion

23. © 2007 McGraw-Hill Higher Education. All rights reserved.  Care Extended treatment (8-12 weeks) is required Orthotic therapy is very useful (soft orthotic with deep heel cup) Simple arch taping, use of a night splint to stretch Vigorous heel cord stretching and exercises that increase great toe dorsiflexion NSAID’s and occasionally steroidal injection

24. © 2007 McGraw-Hill Higher Education. All rights reserved. Jones Fracture  Cause of Injury Fracture of metatarsal caused by inversion or high velocity rotational forces Location = _________________  Sign of Injury Immediate swelling, pain over 5th metatarsal May feel a “pop” ___________________________________  Care Generally requires 6-8 weeks non-weight bearing with short leg cast if non-displaced ___________________________________

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26. Fractures and Dislocations of the Phalanges  Cause of Injury _____________________________________ _____________________________________  Signs of Injury Immediate and intense pain Swelling and discoloration Obvious deformity with dislocation

27. © 2007 McGraw-Hill Higher Education. All rights reserved. Fractures and Dislocations of the Phalanges - Cont  Care Dislocations should be reduced by a physician ________________________________________ ________________________________________ Buddy taping is generally sufficient Shoe with larger toe box may be necessary

28. © 2007 McGraw-Hill Higher Education. All rights reserved. Bunion (Hallux Valgus Deformity)  Cause of Injury Exostosis of 1st metatarsal head; associated with forefoot varus; shoes that are too narrow, pointed or short Bursa becomes inflamed and thickens, enlarging joint, and causing lateral malalignment of great toe  Sign of Injury ________________________________________ ___________________________ As inflammation continues, angulation increases causing painful ambulation

29. © 2007 McGraw-Hill Higher Education. All rights reserved. Care  _______________ _______________ _______________ _______________ _______________ _______________ ______  Surgery may be required during later stages of condition

30. © 2007 McGraw-Hill Higher Education. All rights reserved. Morton’s Neuroma  Cause of Condition Thickening of nerve sheath (common plantar nerve) at point where nerve divides into digital branches Commonly occurs between __________ met heads where medial and lateral plantar nerves come together  Signs of Condition Burning paresthesia and severe intermittent pain in forefoot _________________________________

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32. Care  Teardrop pad can be placed between met heads to increase space, decreasing pressure on neuroma  __________________ __________________ ________________

33. © 2007 McGraw-Hill Higher Education. All rights reserved. Turf Toe  Cause of Injury Hyperextension injury resulting in sprain of 1st metatarsophalangeal joint May be the result of single or repetitive trauma  Signs and Symptoms Pain and swelling which increases during push off in walking, running, and jumping  Care Increase rigidity of forefoot region in shoe Taping the toe to prevent dorsiflexion Rest and discourage activity until pain free  3-4 weeks may be required for pain to subside

34. © 2007 McGraw-Hill Higher Education. All rights reserved. Calluses  Cause of Condition Develop from friction – may be painful as fatty layer loses elasticity and cushioning effect May be vulnerable to tears and cracks and possible blister development underneath  Care ________________________________ Massaging with small amounts of lotion may be helpful Sanding or pumicing – care must be exercised Can be prevented  ________________________________________  ________________________________

35. © 2007 McGraw-Hill Higher Education. All rights reserved. Blisters  Cause of Injury Shearing forces on skin – results in development of fluid accumulation between layers of skin Wearing appropriate footwear (socks and shoes) and applying lubricants may help to reduce friction  Care Take action to reduce friction (apply lubricants, cover with tape/band aid/donut pad) Avoid puncturing in order to prevent infection Puncturing may be necessary if pressure build- up is to great and is causing excessive pain

36. © 2007 McGraw-Hill Higher Education. All rights reserved. Ingrown Toenails  Cause of Condition _____________________________________ ________________________________  Care Shoes should be appropriate width and length ____________________________________ _____________________________________________ _____________________________________________ Should be cut short enough that it is not irritated by shoes or socks Treatment may require soaking and packing toenail with cotton in order to lift nail away from soft tissue Cutting a “V” notch toward the infected side will allow the nail to grow towards the middle

37. © 2007 McGraw-Hill Higher Education. All rights reserved. Subungual Hematoma  Cause of Injury Direct pressure, dropping an object on toe, kicking another object Repetitive shear forces on toenail  Signs of Injury ___________________________________ _____________________________________ _________________________________  Care RICE immediately to reduce pain and swelling Relieve pressure within 12-24 hours (lance or drill nail) – must be sterile to prevent infection

38. © 2007 McGraw-Hill Higher Education. All rights reserved. Preventing Injury in the Lower Leg and Ankle Achilles Tendon Stretching  A tight heel cord may limit dorsiflexion and may predispose athlete to ankle injury  Should routinely stretch before and after practice  Stretching should be performed with knee extended and flexed 15-30 degrees – See next slide Strength Training  __________________________________________ _________________________________________  Develop a balance in strength throughout the range

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40. Balance Control Training  Can be enhanced by training in controlled activities on uneven surfaces or a balance board Footwear  Can be an important factor in reducing injury  Shoes should not be used in activities they were not made for Preventive Taping and Orthoses  Tape can provide some prophylactic protection  However, improperly applied tape can disrupt normal biomechanical function and cause injury  Lace-up braces have even been found to be effective in controlling ankle motion

41. © 2007 McGraw-Hill Higher Education. All rights reserved. Assessing the Lower Leg and Ankle History  Past history  Mechanism of injury  When does it hurt?  Type of, quality of, duration of pain?  Sounds or feelings?  Swelling?  Previous treatments?

42. © 2007 McGraw-Hill Higher Education. All rights reserved. Observations  Postural deviations?  Is there difficulty with walking?  Deformities, asymmetries or swelling?  Color and texture of skin, heat, redness?  Patient in obvious pain?  Is range of motion normal? Palpation  Begin with bony landmarks and progress to soft tissue  Attempt to locate areas of deformity, swelling and localized tenderness

43. © 2007 McGraw-Hill Higher Education. All rights reserved. Special Test - Lower Leg  Percussion/bump and Compression tests Used when fracture is suspected Percussion test is a blow to the tibia, fibula or heel to create vibratory force that resonates w/in fracture causing pain Compression test involves compression of tibia and fibula either above or below site of concern

44. © 2007 McGraw-Hill Higher Education. All rights reserved. Ankle Stability Tests  Anterior drawer test Used to determine damage to anterior talofibular ligament primarily A positive test occurs when foot slides forward and/or makes a clunking sensation as it reaches the end point – Laxity=+sign  Talar tilt test Performed to determine extent of inversion or eversion injuries With foot at 90 degrees calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament – Laxity=+sign If the calcaneus is everted, the deltoid ligament is tested – Laxity=+sign

45. © 2007 McGraw-Hill Higher Education. All rights reserved. Anterior Drawer Test Talar Tilt TestBump Test

46. © 2007 McGraw-Hill Higher Education. All rights reserved. Functional Tests  While weight bearing the following should be performed Walk on toes (plantar flexion) Walk on heels (dorsiflexion) Hops on injured ankle Start and stop running Change direction rapidly Run figure eights