chapter 16 KNES 315 b

midfoot

_____________ sprains often result form severe dorsiflexion, plantar flexion, or pronation; although the condition is seen in basketball and soccer players, it is more frequent in activities where the foot is unsupported, such as in gymnastics or dance in which slippers are typically worn, or in track athletes who wear running flats m 305

turf toe

_____________, a sprain of the plantar capsular ligament of the first MTP joint, results from forced hyperextension or hyperflexion of the great toe (i.e., jamming the toe into the end of the shoe); repetitive overload can also lead to injury, particularly when associated with a valgus stress tt 305

freiberg's disease

________________ is a painful avascular necrosis of the second, or rarely, third metatarsal head, often seen in active adolescents aged 14 to 18 years before closure of the epiphyses FD 311

conditions associated with heel pain in physical active young individuals

_________________ include: plantar fascitis heel fat pad syndrome achilles tendintiis/ strain retrocalcaneal bursiits calcaneal stress fractures calcaneal exostosis contusion infection tarsal coalition tarsal tunnel syndrome 312

plantar fascitis

_________________ is the most common hind foot problem in runners, affecting approximately 10% of runners; extrinsic factors that increase the incidence of the condition include training errors, improper footwear, and participating on unyielding surfaces; intrinsic factors include pes cavus or pes planus, decreased planter flexion strength, reduced flexibility of the plantar flexor muscles (e.g. Achilles tendon), excessive or prolonged pronation and torsional malalignment; these factors can overload the plantar fascia's origin on the anteromedial aspect of the calcaneus during weight-bearing activities pf 310

fractures

_________________- in the foot and lower leg region seldom result from a single traumatic episode; often, repetitive microtraumas lead to apophyseal or stress fractures; tensile forces associated with severe ankle sprains can lead to avulsion fractures of the fifth metatarsal, or severe twisting can lead to displaced and undisplaced fractures in the foot, ankle, or lower leg; a combination of forces can lead to a traumatic facture- dislocation; the management fr the conditions in this section is the same for each, unless otherwise noted; if a fracture is suspected, immediate referral to a physician is warranted; the application of cold and gentle compression to minimize pain adn swelling can be advantageous; crutches should be used if the individual is unable to bear weight 311

ankle sprains

__________________ are the most common injury in recreational and competitive sports; they are classified as Grade I (First degree), Grade II (second degree), and Grade III (third degree), based on the progression of anatomical structures damaged and the subsequent disability; in basketball, ankle sprains comprise more than 45% of all injuries, and in soccer, up to 31% of all injuries are _____________ 305

predisposing factors for tendinitis in the lower leg

___________________ include: TRAINING ERRORS that include: lack of flexibility in the gastrocnemius-soleus muscles poor training surface or sudden change from soft to hard surface or vice versa sudden changes in training intensity or program (e.g. adding hills, sprints, or distance) inadequate work-rest ratio that may lead to early muscle fatigue returning to participation too quickly following injury direct trauma infection from a penetrating wound into the tendon abnormal foot mechanics producing friction among shoe, tendon, and bony structure poor footwear that is not properly fitted to foot

medial tibial stress syndrome

_____________________ is a periostitis along the posteromedial tibial border, usually in the distal third, not associated with a stress fracture or compartment syndrome; although originally thought to be related to stress along the posterior tibialis muscle and tendon causing myositis, fascitis, and periositis, it is now believed to be related to periositis of the soleus insertion along the posterior medial tibial border; the soleus makes up the medial third of the heel cord as it inserts into the calcaneus; excessive pronation or prolonged pronation of the foot causes an eccentric contraction of the soleus, resulting in the periositis that produces the pain; other contributing factors include recent changes in running distance, speed, form, stretching, footwear, or running surface MTSS 310

exertional compartment syndrome

_____________________ is characterized by exercise induced pain and swelling that is relieved by rest; the compartments most frequently affected are the anterior (50 to 60%) and deep posterior (20 to 30%); the remaining 10 to 20% are divided evenly among the lateral, superficial posterior, and the fifth compartment around the tibalis posterior muscle; whereas acute ECS generally occurs in relatively sedentary people who undertake strenuous exercise, chronic ECS usually is seen in well-conditioned individuals younger than 40 ECS 331

achilles tendon rupture management

a compression wrap should be applied from the toes to the knee; the individual should be referred immediately to a physician; while this situation does not normally warrant summoning EMS, it can require immediate transport to an emergency care facility ATR 309

subtalar dislocation

a serious sprain that involves the subtalar joint results from a fall from a height (as in basketball or volleyball); the foot lands in inversion, disrupting the interosseous talocalcaneal and talonavicualr ligaments; if the foot lands in dorsiflexion and inversion, the CFL is also ruptured; when the dislocation occurs, the injury is better known as *basketball foot* SD307

achilles tendon rupture

acute rupture of the ________________ is probably the most severe acute musclar problem in the lower leg; it is more commonly seen in individuals 30 to 50 years old; the usual mechanism is a push-off the forefoot while the knee is extending, a common move in many propulsive activities; tendinous ruptures usually occur 1 to 2 inches proximal to the distal attachment of the tendon on the calcaneus ATR 309

subtalar dislocation management

because of the potential for peroneal tendon entrapment and neurovascular damage, leading to reduced blood supply to the foot, this dislocation is considered a medical emergency; the coach should activate the emergency action plan, including summoning of EMS; while waiting for EMS to arrive, the coach should monitor the individual for shock and treat as necessary SD 308

strains and tendinitis signs and symptoms

common signs and symptoms include a history of stiffness following a period of inactivity (e.g. morning stiffness), localized tenderness over the tendon, possible swelling or thickness in the tendon and peritendon tissues, pain with passive stretching, and pain with active and resisted motion ST 308

eversion ankle sprains

excessive pronation (i.e. abduction, eversion, and dorsiflexion) results when the plantar aspect of the foot is turned laterally, referred to as an _______________; __________________ i.e. medial) involve injury to the medial, deltoid-shaped talocrural ligaments (DI); although an isolated injury to the DI may result from forced dorsiflexion and eversion, such as landing from a long jump with the foot abducted or landing on another player's foot; these account for less than 10% of all injuries; most injuries in the DL are associated with a fibula fracture, syndesmotic injury, or severe lateral ankle sprains; *individuals with pronated or hypermovile feet tend to be at a greater risk for eversion injuries;* the talar dome is wider anteriorly than posteriorly; during dorsiflexion, the talus fits more firmly in the mortise suported by the distal anterior tibiofibular ligament; during excessive dorsiflexion and eversion, the talus is thrust laterally against the longer fibula, resulting in either a mild sprain to the DL or, if the force is great enough, a lateral malleolar fracture; if the force continues after the fracture occurs, the deltoid ligament may become ruptured, or may remain intact, avulsing a small bony fragment from the medial malleolus and leading to a bimalleolar fracture; in either case, the distal anterior tibiofibular ligament and interosseous membrane may be torn, producing total instability of the ankle joint and eventual degeneration EAS 307

inversion ankle sprain

excessive supination of the foot (i.e. adduction, inversion, and plantar flexion) results when the plantar aspect of the foot is turned inward toward the midline of the body, commonly referred to as an *inversion sprain;* acute inversion (i.e. lateral) sprains often occur while changing directions rapidly; interestingly, injury typically involves the unloaded foot and ankle (or, more accurately, just at the moment of loading) with a plantar flexion and inversion force; in plantar flexion, the ATFL is taut and the CFL is relatively loose, whereas in dorsiflexion, the opposite is true; the medial and lateral malleoli project downward over the talus to form a mortise-tension joint; the lateral malleolus projects further downward than the medial, thus limiting lateral talar shifts; as stress is initially applied to the ankle during plantar flexion and inversion, the ATFL first stretches; if the strain continues, the ankle loses ligamentous stability in its neutral position; the medial malleolus acts as a fulcrum to further the inversion, and stretches or ruptures the CFL IAS 306

subtalar dislocation signs and symptoms

extreme pain and total loss of function is present; gross deformity at the subtalar joint may not be clearly visible; the foot may appear pale and feel cold to the touch if neurovascular damage is present; the individual may show signs of shock SD 307

inversion ankle sprain signs and symptoms

in a grade I injury, the individual reports pain but can typically bear weight immediately after injury; in a grade II injury, the individual reports a pop suggesting the tearing of a ligament (i.e. the ATFL); rapid swelling and tenderness are localized over the ATFL and may extend over the CFL, and the individual can bear some weight, but definitely walks with a limp; a grade III injury mimics a grade II injury, except that the person is unable to bear weight as there is a functional instability IAS 306

gastrocnemius muscle strain signs and symptoms

in an acute strain, the individual experiences a sudden, painful tearing sensation in the calf muscles, primarily at the musculotendinous junction between the muscles and Achilles tendon or in the medial head of the gastrocnemius muscle; immediate pain, swelling, loss of function, and stiffness are common; later, ecchymosis progresses down the leg into the foot and ankle GMS 309

strains and tendinitis management

in assessing these conditions, it should become apparent to the coach during the history component that the injury is overuse in nature and, as such, the coach should refrain form continuing assessment; rather, the coach should refer this individual to a physician for accurate diagnosis and treatment actions; the coach should not permit the individual to contue activity, as doing so could potentially exacerbate the condition; in addition, the coach could suggest the application of cold to the area to decrease pain and potential spasm ST 309

gastrocnemius muscle strain management

initial treatment should consist of standard acute care (i.e. cold, compression, elevation, and protected rest) and restricted activity; crutches should be used if the individual is unable to bear weight; if an apparently mild injury does not significantly improve in 3 to 4 days or if the injury is considered moderate to severe, immediate referral to a physician is necessary GMS 309

inversion ankle sprain management

initial treatment should consist of standard acute care (i.e. cold, compression, elevation, and protected rest) and restricted activity; crutches should be used if the individual is unable to bear weight; because lateral ankle sprains are common, there may be a tendency to view all injuries around the ankle as ankle sprains; *the coach should not simply dismiss an ankle injury as a sprain;* referral to a physician is warranted for accurate diagnosis and ongoing treatment; a moderate to severe sprain requires immediate referral to a physician IAS 306

syndesmosis sprain

injury to the distial tibiofibular syndesmosis (i.e. a high ankle sprain) often goes undetected, resulting in a longer recovery time and greater disability than the more frequent lateral ankle sprain; the incidence of injury is reported between 1 and 11% of all ankle injuries; the mechanism of injury differs from that of an inversion sprain; often, the foot is dorsiflexed and externally rotated; external rotation injures the structures of the syndesmosis by widening the ankle mortis SS 307

first degree ankle sprain (mild)

mechanism INVERSION AND PLANTAR FLEXION: anterior talofibular stretched INVERSION: calcaneofibular stretched DORSIFLEXION EVERSION: tibiofibular stretched, deltoid stretched, or an avulsion fracture of medial malleolus 305

strains and tendinitis

muscle strains seldom occur in the lower extremity, except in the gastrocnemius-soleus complex; instead, injury occurs to the musculotendinous junction or the tendon itself; most of the tendons in the lower leg have a synovial sheath surrounding the tendon, except the Achilles tendon, which has a peritendon sheath that is not synovial; several factors can predispose an individual to tendinittis; SEE BOX 16.2 2 slides BELOW common sites for tendon injuries include: the Achilles tendon just proximal to its insertion into the calcaneus the tibialis posterior just behind the medial malleolus the tibialis anterior on the dorsum of the foot just under the extensor retinaculum peroneal tendons just behind the lateral malleolus and at the distal attachment on the base of the fifth metatarsal ST 308

midfoot signs and symptoms

pain and swelling is deep on the medial aspect of the foot, and weight bearing may be painful m 305

MP and IP joints signs and symptoms

pain dysfunction, immediate swelling, and , if dislocated, gross deformity are evidend MPIP 305

overuse conditions

repetitive microscopic injury to tendinous structures can lead to chronic inflammation that overwhelms the tissue's ability to repair itself; other factors, such as faulty biomechanics, poor cushioning or stiff-soled shoes, or excessive downhill running, can also inflame the tendons; several overuse conditions are common in specific sports, such as plantar fascitis in running; medial tibial stress syndrome in football, dance, or running; and exertional compartment syndrome in soccer or distance running; many individuals complain of vague leg pain, but have no history of a specific injury that caused the pain, diffeerentiating these conditions from an acute muscle strain; a common complaint is pain caused by activity 319

eversion ankle sprains signs and symptoms

signs and symptoms of an isolated __________________ depend on the severity of injury; in mild to moderate injuries, the individual is often unable to recall the mechanism of injury; there may be some initial pain at the ankle when it was everted and dorsiflexed, but as the ankle returns to its normal anatomical position, pain often subsides and the individual contitnues to be active; in attempts to run or put pressure on the area, pain intensifies, but the individual may not make the connection between the pain and the earlier injury; swelling may not be as evident as a lateral strain because hemorrhage occurs deep in the leg and is not readily visible; swelling may occur just posterior to the lateral malleolus, between it and the achilles tendon; point tenderness can be elicited over the DL EAS 307

MP and IP joints

sprains and dislocations to the _________________ of the toes may occur by tripping or stubbing the toe; varus and valgus forces more commonly affect the first and fifth toes, rather than the middle three MPIP 305

foot and ankle sprain

sprains to the foot and ankle region are common in sports, particularly for those individuals who play on badly maintained fields; in many sports, cleated shoes become fixed to the ground, while the limb continues to rotate around it; in addition, the very nature of changing directions places an inordinate amount of strain on the ankle region; other methods of injury include stepping in a hole, stepping off a curb, stepping on an opponent's foot, or rolling the foot off the surface 304

gastrocnemius muscle strain

strains to the medial head of the gastrocnemius are often seen in tennis players over 40, hence the nickname *tennis leg*; common mechanisms are forced dorsiflexion, while the knee is extended; forced knee extension, while the foot is dorsiflexed; and muscular fatigue with fluid-electrolyte depletion and muscle cramping if related to muscle cramping, the strain is commonly attributed to dehydration (particulalry in the heat), electrolyte imbalance, or *prolonged muscle fatigue that stimulates cramping followed by an actual tear in the muscle fibers* GMS 309

tendinopathies of the foot and lower leg

tendinopathies of the foot and lower leg are relatively common and encompass a wide spectrum of conditions ranging from tendinitis to tenosynovistis to partial and complete ruptures; the tendons *most often involved in the foot and ankle include the Achilles, posterior tibialis, peroneal brevis, and peroneal longus tendons*; in contrast to acute traumatic tendinous injury, these injuries *most involve repetitive submaximal loading of the tissues, resulting in repetitive microtrauma* 308

syndesmosis sprain signs and symptoms

the area of maximum point tenderness is usually over the anterolateral tibiofibular joint; the degree of pain and swelling can be significant; the individual will have difficulty bearing weight on the injured ankle; the most commonly injured ligament, and a source of anterolateral ankle impingement, is the anterior inferior tibiofibular ligament; the least injured ligament is the posterior inferior tibiofibular ligament, although the interosseous ligament may also be variably injured SS 307

medial tibial stress syndrome management

the coach should refer this individual to a physician for accurate diagnosis and treatment options; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition; in addition, the coach could suggest the application of cold to the area to decrease pain and potential spasm MTSS 311

plantar fascitis management

the coach should refer this individual to a physician for accurate diagnosis and treatment options; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition; in addition, the coach could suggest the application of cold to the area to decrease pain and potential spasm PF 310

freiberg's disease signs and symptoms

the condition can lead to diffuse pain in the forefoot region FD 311

exertional compartment syndrome management

the immediate management involves ceasing activity; ultimately, the individual needs to be assessed by a qualified healthcare practitioner; assessment should include both extrinstic factors (e.g. training patterns, technique, shoe design, and training surface) and intrinsic factors (E.g. foot alignment, especially hindfoot pronation, muscle imbalance, and flexibility) ECS 311

turf toe signs and symptoms

the individual has pain, tenderness, and swelling on the plantar aspect of the MTP joint of the great toe; extension of the great toe is extremely painful; this condition has the potential to persist for weeks or months; because the sesamoid bones are located in the tendons of the flexor hallucis brevis, this condition sometimes is associated with tearing of the flexor tendons, fracture of the sesamoid bones, bone bruises, and osteochondral fractures in the metatarsal head tt 305

achilles tendon rupture signs and symptoms

the individual hears and feels a characteristic pop in the posterior ankle and reports a feeling of being shot or kicked in the heel; clinical signs and symptoms include a visible defect in the tendon, inability to stand on the tiptoes or even balance on the affected leg, swelling and bruising around the malleoli, and excessive passive dorsiflexion; because the personeal longus, peroneal brevis, and muscles in the deep posterior compartment are still intact, the individual may limp or walk with the foot and leg externally rotated, since this does not require push-off with the superficial calf muscles ATR 309

plantar fascitis signs and symptoms

the individual reports pain on the plantar, medial heel that is relieved with activity, but recurs after rest; pain increases with weight-bearing; it is particularly severe with the first few steps in the morning, particularly in the proximal, plantar, medial heel, but diminishes with 5 to 10 minutes; pain and stiffness are related to muscle spasm and splinting of the fascia secondary to inflammation; pain can radiate up the medial side of the heel, and occasionally across the lateral side of the foot; normal muscle length is not easily attained, and it leads to additional pain and irritation; point tenderness is elicited over or just distal to the medial tubercle of the calcaneus, and increaes with passive toe extension; passive extension of the great toe and dorsiflexion of the ankle will increase pain and discomfort PF 310

eversion ankle sprains management

the management is the same as for an inversion ankle sprain 307 initial treatment should consist of standard acute care (i.e. cold, compression, elevation, and protected rest) and restricted activity; crutches should be used if the individual is unable to bear weight; because lateral ankle sprains are common, there may be a tendency to view all injuries around the ankle as ankle sprains; the coach should not simply dismiss an ankle injury as a sprain; referral to a physician is warranted for accurate diagnosis and ongoing treatment; a moderate to severe sprain requires immediate referral to a physician EAS 306

syndesmosis sprain management

the management is the same as for an inversion ankle sprain; this sprain typically takes longer to heal than an inversion or eversion sprain; participation and sports and physical activity may be delayed for up to 3 months after the initial treatment begins SS 307 initial treatment should consist of standard acute care (i.e. cold, compression, elevation, and protected rest) and restricted activity; crutches should be used if the individual is unable to bear weight; because lateral ankle sprains are common, there may be a tendency to view all injuries around the ankle as ankle sprains; the coach should not simply dismiss an ankle injury as a sprain; referral to a physician is warranted for accurate diagnosis and ongoing treatment; a moderate to severe sprain requires immediate referral to a physician

toe and foot sprains and dislocations

the toes and feet can be common sites for sprains particularly during an activity in which there is minimal support for the foot; the management for these conditions involves standard acute care as well as referral to a qualified healthcare practitioner for an accurate diagnosis and treatment options 304

exertional compartment syndrome signs and symptoms

the typical history of chronic ECS is exercise-induced pain that is often described as a tight, cramp-like, or squeezing ache and a sense of fullness, both over the invovled compartment; *the condition often affects both legs;* symptoms are almost always relieved with rest, usually within 20 minutes of exercise, only to recur if exercise is resumed; activity- related pain begins at a predictable time after starting exercise or after reaching a certain level of intensity and increases if the training persists; many individuals with anterior compartment involvement describe mild foot drop or paresthesia (or both) on the dorsum of the foot, and demonstrate fascial defects or hernias, usually in the distal third of the leg over the intramuscular septum ECS 311

medial tibial stress syndrome signs and symptoms

typically seen in runners or jumpers, the pain can occur at any point during a workout and is typically characterized as a dull ache, although it occasionally can be sharp and penetrating; as activity progresses, pain diminishes only to recur hours after activity has ceased; in later stages, pain is present before, during, and after activity, and may restrict performance; point tenderness is elicited in a 3 to 6 cm area along the distal posteromedial tibial border; pain is aggravated by resisted plantar flexion or standing on tiptoe; there is often an associated varus alignment of the lower extremity, including a greater Achilles tendon angle MTSS 311

second degree ankle sprain (moderate)

INVERSION AND PLANTAR FLEXION: partial tear of anterior talofibular, with calcaneofibular stretched INVERSION: calcaneofibular torn, and anterior talofibular stretched DORSIFLEXION EVERSION: partial tear of tibiofibular, partial tear of deltoid and tibiofibular 305

third degree ankle sprain (severe)

INVERSION AND PLANTAR FLEXION: rupture of anterior talofibular and calcaneofibular, with posterior talofibular and tibiofibular torn INVERSION: rupture of calcaneofibular, and anterior talofibular with posterior talofibular stretched DORSIFLEXION EVERSION: rupture of tibiofibular, rupture of deltoid, and interosseous membrane with possible fibular fracture above syndesmosis 305