Chapter 16

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 Common sites: -2nd metatarsal -Sesamoid bones -Navicular -Calcaneus -Tibia and fibula S&S: -Pain begins insidiously; ↑ with activity and ↓ with rest -Pain usually limited to fracture site

Peroneus longus

Lateral Eversion, plantar flexion

Displaced fractures and dislocations

MOI -Direct compression (e.g., falling from a height) -Compression & shearing (i.e., twisting mechanism) Potential neurovascular complications 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 -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

Midfoot

Navicular, cuboid, 3 cuneiforms; numerous joints Talocalcaneonavicular joint (TCN) -Talus moves simultaneously on calcaneus and navicular -Combined action of talonavicular and subtalar joint

Mallet toe

Neutral position at MTP and PIP joints, flexion at DIP joint

First Degree Ankle Sprain

Pain and swelling on anterolateral aspect of lateral malleolus Point tenderness over ATFL

Common Sites for Strainsand Tendinitis of the Foot and lower leg

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

Tibialis anterior

Anterior Dorsiflexion, inversion

Compartments of lower leg

Anterior Lateral Deep posterior Superficial posterior

Extensor digitorum longus

Anterior Toe extension, dorsiflexion

Freiberg's disease

Avascular necrosis of 2nd metatarsal head Active adolescents ages 14-18 S&S: diffuse pain in forefoot

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 Ligaments -Medial: deltoid -Lateral :anterior talofibular; posterior talofibular; calcaneofibular Subtalar joint -Behaves as a flexible structure -occurs here

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 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 Management: -Stop activity -Assessment by qualified health care practitioner

Subtalar dislocation concern and management

Concern: potential for peroneal tendon entrapment and neurovascular damage Management: medical emergency; activate EMS; monitor neurovascular function

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

Hallux rigidus

Degenerative arthritis in first MTP S&S: 1. Tender, enlarged first MTP joint 2. Loss of motion 3. Difficulty wearing shoes with an elevated heel 4. Hallmark sign—restricted toe extension

Management of tendinitis of lower leg

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

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) 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

Pes cavus

Excessively high arch that does not flatten during weight bearing Causes can vary - Might be hereditary, muscular, or neuro Rigid foot

Hammer toe

Extension of MTP joint, flexion at PIP joint, and hyperextended at the DIP joint

Plantar fasciitis

Extrinsic and intrinsic risk factors S&S: -Pain at plantar, medial heel -Pain with first steps in the morning, but diminshes 5-10 min ↑ pain with passive extension of great toe and ankle dorsiflexion -Pain relieved with activity, but recurs after rest MOI: training errors, poor strength and flexibility of Achilles tendon, excessive pronation Management: -Do not permit to continue activity until seen by a physician -Suggest application of cold to decrease pain and spasm

Blood supply of lower leg

Femoral artery Popliteal Anterior and posterior tibial Anterior tibial -Dorsal pedal

Pes planus

Flat foot; arch or instep of the foot collapsing & contacting the ground Typically, acquired deformity resulting from injury or trauma Mobile foot Rigid flat foot stays flat no matter what Flexible flat foot may be a candidate for an orthodic

Signs and Symptoms for Tendinitis of lower leg

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

Claw toe

Hyperextension of MTP joint and flexion of DIP and PIP joints

Foot and ankle motions

Inversion and eversion (subtalar) Pronation and supination- combination motions -Triplanar motions

Peroneus brevis

Lateral Eversion, plantar flexion

Acute compartment syndrome

Lower leg includes 4 nonyielding compartments MOI: direct blow anterolateral aspect of the tibia Rapid ↑ in tissue pressure → neurovascular compromise S&S -History of trauma -Increasingly severe pain—out of proportion to situation -Firm and tight skin over anterior shin -Loss of sensation between 1st and 2nd toes on dorsum of foot - Diminshed dorsalis pedis artery -Functional abnormalities within 30 minutes Management: -Cold -NO compression or elevation -Immediate referral to ER or summon EMS Irreversible damage can occur within 12-24 hours

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 S&S: -Foot displaced laterally at a gross angle to lower leg -Extreme pain -Can compromise the posterior tibial artery and nerve

Subtalar dislocation

MOI: fall from a height (as in basketball or volleyball); foot lands in inversion Disrupts interosseous talocalcaneal & talonavicular ligament 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

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

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 Management: -Compression wrap; immediate transport to emergency care facility or physician

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

IP & MP joints Sprains

MOI: tripping or stubbing the toe S&S: -Pain, dysfunction, immediate swelling -Dislocation—gross deformity

Eversion ankle sprain

Mechanism: excessive dorsiflexion and eversion Deltoid ligament Potential: -Lateral malleolus fx; bimalleolar fx -Tear of anterior tibiofibular ligament &interosseous membrane -excessive pronation -hypomobile foot 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 -Swelling -May not be as evident as a lateral sprain -Between posterior aspect of lateral malleolus and Achilles tendon -Point tenderness in involved ligaments S&S Severe Injuires: -PROM pain-free in all motions except dorsiflexion

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 - Sports w/ quick start and stops - 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

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

Fracture management

Mild -Standard acute with physician referral Serious conditions -Activate emergency plan, including summoning EMS -Assess and treat for shock

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 S&S: -Gross deformity -Gross bone motion at the suspected fracture site -Immediate swelling, extreme pain, or pain with motion

Coach and Onsite Assessment

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 Abnormal sensation, or absent or weak pulse Gross joint instability Any unexplained pain that affects normal function

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 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 -Pain with resisted plantar flexion or standing on tiptoe -Often an associated varus alignment of the lower extremity, including a greater Achilles tendon angle. Management: -Do not permit to continue activity until seen by a physician -Suggest application of cold to decrease pain and spasm

Ligaments supporting the midfoot and hindfoot region

Posterior talo fibular calcaneofibular anterior talofibular plantar calcaneonavicular

Flexor hallucis longus

Posterior, deep Flexion of he great toe, plantar flexion

Tibialis posterior

Posterior, deep Inversion, plantar flexion

Flexor digitorum longus

Posterior, deep Toe flexion, plantar flexion

Soleus

Posterior, superficial Plantar flexion

Gastrocnemius

Posterior, superficial Plantar flexion, knee flexion

Plantaris

Posterior, superficial Plantar flexion, knee flexion

Injury prevention

Protective equipment -Braces; orthotics Footwear -Demands of sport; wear shoe for its intended purpose -Proper fit

Plantar fascia

Provides support for the longitudinal arch

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

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

s&S of toe deformities

S&S: painful callus formation on dorsumIP joints

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 S&S: -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

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

Management toe and foot sprains

Standard acute Physician referral Taping to prevent hyperextension or hyperflexion

Management of Ankle SPrain

Standard acute Use of crutches if unable to walk without limp Physician referral

Injury prevention: Physical conditioning

Strengthening -Extrinsic muscles -Intrinsic muscles Flexibility -Achilles tendon

Tibiofibular joints

Superior—proximal Inferior—distal -Anterior tibiofibular -Posterior tibiofubular Interosseous membrane - Between tibia and fibula

Plantar arches

Support and distribute body weight longitudinal arch Transverse arch- medial to lateral Ligaments Spring (calcaneonavicular) - Long plantar - Short plantar

Third Degree Ankle Sprain

Tearing or popping sensation felt on lateral aspect Diffuse swelling over entire lateral aspect with or without anterior swelling Can be very painful or absent of pain

Second degree ankle sprain

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

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 -Surfaces (hard and soft) Management: cold; heel cup or doughnut pad; referral Condition may persist for months

Hallux valgus

Thickening of the medial capsule and bursa, resulting in severe valgus deformity Asymptomatic or symptomatic Treatment—symptomatic Causes: - Over pronating - Rheumatoid arthritis

Sciatic nerve

Tibial nerve (posterior to medial malleolus) Common peroneal nerve—deep and superficial peroneal nerves (antero-lateral leg)

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

Tibial contusion (shin bruise)

Vulnerable lack of padding Minor injury—caution: repeated blows → damage periosteum Management: standard acute Key: prevention

Extensor hallicus longus

anterior extension of great toe

pronation

dorsiflexion, eversion and abduction

Peroneus tertius

anterior eversion and dorsiflexion

Ankle (subtalar) motions

dorsiflexion and plantarflexion

Toe Motions

flexion and extension

supination

inversion, plantar flexion and adduction

Femoral

saphenous

Thompson test

squeeze calf for plantar flexion