Injuries to the Foot, Ankle and Lower Leg Original Author: Sabino Sports Medicine Connie Rauser, Instructor Injuries to the Foot, Ankle and Lower Leg

Bony Anatomy Tibia Fibula Tarsals Metatarsals Phalanges Sesamoid Bones

Tibia Weight bearing bone Articulates with fibula both inferiorly and superiorly Landmarks Tibial tuberosity (proximal) Tibial Plateau Medial Malleolus Shaft

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

Tarsals Talus—articulates with the tibia/fibula Calcaneus Navicular Cuboid Medial, intermediate and lateral cuneiforms

Joints Tibiofibular joint--syndesmosis Ankle joint (talocrural) Ankle mortise Subtalar joint Metatarsalphalangeal joints (MP) Interphalangeal joints PIP DIP

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

Muscles of lateral compartment Peroneus longus Peroneus brevis Both do eversion

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)

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

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

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

Plantar fasica

Medial Ligaments Deltoid ligament 4 parts Very strong Not injured as often

Lateral ligaments Anterior talofibular Posterior talofibular Calcaneofibular

Other ligaments Anterior inferior tibiofibular ligament Posterior inferior tibiofibular ligament

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)

Injuries to the Foot, Ankle and Lower Leg

Heel Bruise (Stone Bruise) MOI: 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

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

S/S: Pt tender 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

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

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

S/S: Pt. tenderover metatarsal, swelling, pain, “pop” or “crack”, possible deformity

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

Longitudinal Arch Strain MOI: 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

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

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

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

S/S: Pt. tenderover MP joint of great toe Swelling Discoloration Pain with movement especially pushing off big toe when taking a step

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

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

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

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

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

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

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

Ankle Sprains Inversion Eversion High Ankle Sprain

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

The inversion MOI

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

3rd degree Lateral Ankle sprain

S/S: Pain, Swelling, discoloration, Pt S/S: Pain, Swelling, discoloration, Pt. tender 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 Anterior Drawer Test – Tests ATF Talar Tilt – Calcaneofib and Deltoid Ligaments Kleiger Test – High Ankle Calcaneus (Bump) Test – Calcaneus Fx

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

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

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

MOI: 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, Pt. tenderover medial malleolus and deltoid ligament Will vary depending on severity Tests: Talar Tilt

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

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

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

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

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

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

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

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

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

Sliding into base He’s there!

Getting help

And the open ones? Open Fx/dislocation Open fracture

And some x-rays

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

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

Tendonitis Tendons most often affected Tibialis posterior Tibialis anterior Peroneals Achilles

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

S/S: pain with active movements and passive stretching Pt. tender over insertion of tendon warmth Crepitus Thickening of tendon (achilles) Stiffness and pain following periods of inactivity

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

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

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

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

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

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

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

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

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

Medial Tibial Stress Syndrome Shin splints What is it? Theories Fascia pulling off of the bone (Soleus) Bone Reaction (bone not being able to keep up between osteoclasts and osteoblasts) Posterior tibialis pulling off of the medial surface of the bone

MOI: 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

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

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

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

Anterior compartment syndrome MOI: 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

Tx: initially ice to reduce swelling If circulation/sensory changes occur—MEDICAL EMERGENCY Fasciotomy Return to activity 2-4 months post surgery

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

S/S: felt/heard a “pop” at back of leg (sounds like a twig snap or gun shot) 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

Achilles tendon defect

Thompson Test

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

Open achilles tendon rupture

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

And other weird things

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

Ankle Taping Procedures Apply Tuf-Skin Heel and Lace Pads Pre-wrap from midfoot to 2 finger widths below calf belly 2 anchor strips

Begin 3 Stirrups In between each stirrup is a horseshoe/C strip ALWAYS GO MEDIAL TO LATERAL….unless

Once 3 stirrups and C strips are in place 4 heel locks 2 medial 2 lateral 2 figure 8s

Once all parts are on the ankle Close out Make it Pretty

All Together Spray Heel and Lace Pads Pre-Wrap 2 Anchors 3 Stirrups 3 C Strips 4 Heel locks 2 medial 2 lateral 2 Figure 8s Close Out