Chapter 16 Kin 3114 (Foot, Ankle, and Lower Leg conditions)
Common sites for strains and tendonitis
- 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
Hindfoot
- Calcaneus and talus - Talocrural joint (ankle joint) - Subtalar joint
Management of acute compartment syndrome
- Cold - NO compression or elevation - immediate referral to ER or summon EMS
Footwear for injury prevention
- Demands of sport; wear shoe for its intended purpose - Proper fit
Management of medial tibial stress syndrome
- Do not permit to continue activity until seen by a physician - Suggest application of cold to decrease pain and spasm
Management of plantar fasciitis
- Do not permit to continue activity until seen by a physician - Suggest application of cold to decrease pain and spasm
Management of tendonitis
- 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
S&S of medial tibial stress syndrome
- 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.
Predisposing factors for eversion ankle sprain
- Excessive pronation - Hypomobile foot
Pes cavus
- Excessively high arch that does not flatten during weight bearing - Causes can vary - Rigid foot
S&S of exertional compartement syndrome
- 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
S&S of Ankle fracture-dislocation
- Foot displaced laterally at a gross angle to lower leg - Extreme pain - Can compromise the posterior tibial artery and nerve
Gastrocnemius strain mechanism of injury
- Forced dorsiflexion while knee is extended - Forced knee extension while foot is dorsiflexed - Muscular fatigue with fluid-electrolyte depletion & cramping
S&S of tibia-fibula fractures
- Gross deformity - Gross bone motion at the suspected fracture site - Immediate swelling, extreme pain, or pain with motion
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
S&S of tendonitis
- 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
Potential for what with an eversion ankle sprain
- Lateral malleolus fx; bimalleolar fx - Tear of anterior tibiofibular ligament &interosseous membrane
Predisposing factors of inversion ankle sprain
- Lateral malleolus projects farther downward - Least stable position of ankle is plantar flexion - Weakness in peroneals - ↓ ROM in Achilles tendon
Ligaments of Talocrural joint (ankle joint)
- Medial: deltoid (view slide with picture) - Lateral :anterior talofibular; posterior talofibular; calcaneofibular
Forefoot
- Metatarsals and phalanges; numerous joints - Support and distribute body weight throughout the foot - Toes - Hallux
S&S for mild to moderate eversion ankle sprain
- Often unable to recall the mechanism - Some initial pain at time of injury, but often subsides and individual continues to play
1st degree S&S for inversion ankle sprain
- Pain and swelling on anterolateral aspect of lateral malleolus - Point tenderness over ATFL
S&S of plantar fasciitis
- 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
S&S of stress fractures
- Pain begins insidiously; ↑ with activity and ↓ with rest - Pain usually limited to fracture site
S&S for turf toe
- Pain, point tenderness, and swelling on plantar aspect of MP joint - Extreme pain with extension
Medial tibial stress syndrome
- Periostitis along posteromedial tibial border (distal third) --- Soleus insertion --- Excessive pronation → eccentric contraction of soleus → periostitis
S&S for Syndesmosis sprain (High Ankle Sprain)
- Point tenderness over the anterolateral tibiofibular joint - Significant pain and swelling - Difficulty bearing weight
Common stress fractures
- Running and jumping, especially after significant ↑ training mileage; change in surface, intensity, or shoe type - Women w/ amenorrhea 6 months+ and oligomenorrhea
S&S of Heel contusion
- Severe pain in heel - Unable to bear weight
Function of the toes
- Smooth the weight shift to the opposite foot during walking - Help maintain stability during weight-bearing
Turf toe
- Sprain of the plantar capsular ligament of 1st MTP joint - valgus increases susceptibility
Management toe and foot sprains
- Standard acute - Physician referral
Management of ankle sprains
- Standard acute - Use of crutches if unable to walk without limp - Physician referral
Management of exertional compartment syndrome
- Stop activity - Assessment by qualified health care practitioner
Physical conditioning Injury Prevention for foot, ankle, and lower leg
- Strengthening --- Extrinsic muscles --- Intrinsic muscles - Flexibility --- Achilles tendon
Plantar arches (view slide with pics)
- Support and distribute body weight - Longitudinal arch—medial and lateral - Transverse arch - Ligaments --- Spring (calcaneonavicular) --- Long plantar --- Short plantar
Talocalcaneonavicular joint (TCN)
- Talus moves simultaneously on calcaneus and navicular - Combined action of talonavicular and subtalar joint
3rd degree S&S for inversion 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
2nd degree S&S for inversion 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
Hallux valgus (Toe deformities)
- Thickening of the medial capsule and bursa, resulting in severe valgus deformity - Asymptomatic or symptomatic
Predisposing factors for strains and tendonitis
- 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
Tibial contusion (shin bruise)
- Vulnerable lack of padding - Minor injury—caution: repeated blows → damage periosteum
MOI for turf toe
- forced hyperflexion or hyperextension of great toe - acute or repetitive overload
Management of Gastrocnemius strain
- standard acute; crutches if unable to walk w/out a limp - If symptoms persist > 2-3 days or mod-severe injury, physician referral
Compartments most frequently affected for exertional compartment syndrome
Compartments most frequently affected—anterior (50%-60%) & deep posterior (20-30%)
Management of Achilles tendon rupture
Compression wrap; immediate transport to emergency care facility or physician
How long may heel contusion persist
Condition may persist for months
How long could it take for irreversible damage to occur for acute compartment syndrome?
Irreversible damage can occur within 12-24 hours
Gastrocnemius strain locations (see slide pic)
Medial head or musculotendinous junction
Inversion
More common for ankle rolls, ankle rolls outward. Medial part of the foot rolls toward the lateral part of the foot. Medial part raises and lateral part toward the ground.
An Achilles tendon rupture is more common in individuals of what age?
More common in individuals over age 30
S&S of Achilles tendon rupture
- "Pop" - Inability to stand on toes - Visible defect - Excessive passive dorsiflexion
Common sites of stress fractures
- 2nd metatarsal - Sesamoid bones - Navicular - Calcaneus - Tibia and fibula
Fracture management for severe conditions
- Activate emergency plan, including summoning EMS - Assess and treat for shock
S&S of (Acute compartment syndrome)
- 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 - Diminished pulse—dorsalis pedis artery - Functional abnormalities within 30 minutes
Motions of foot and ankle
- Inversion and eversion - Pronation and supination
MOI of Ankle fracture-dislocation
- Landing from a height with foot in excessive eversion or inversion - Being kicked from behind while the foot is firmly planted
Midfoot
- Navicular, cuboid, 3 cuneiforms; numerous joints - Talocalcaneonavicular joint (TCN)
S &S that require immediate physician referral (potential for EMS) for coach 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
Lower leg includes how many nonyielding compartments? (Acute compartment syndrome)
4
Subtalar joint
Behaves as a flexible structure
Pes cavus and planus symptomatic or no?
Both conditions can be asymptomatic, but associated with common injuries
Protective equipment injury prevention
Braces; orthotics
Exertional compartment syndrome
Characterized by exercise-induced pain and swelling that is relieved by rest
Main ligament involved for eversion ankle sprain
Deltoid ligament
Hammer toe
Extension of MTP joint, flexion at PIP joint, and hyperextended at the DIP joint - Somewhat bent at knuckle of toe, not raised too high (view pic)
Claw toe
Hyperextension of MTP joint and flexion of DIP and PIP joints - highly raised at knuckle of toe. Goes way up and then the end of the toe points down again
S&S of Gastrocnemius strain
Immediate pain, swelling, loss of function
Tibia-fibula fractures frequency
Nearly 60% of tibial fractures involve the middle and lower third of the tibia.
Mallet toe
Neutral position at MTP and PIP joints, flexion at DIP joint - Toes is straight until the last joint and then points down a little bit
S&S for severe eversion ankle sprain
PROM pain-free in all motions except dorsiflexion
Plantarflexion
Pointing the toes down
Other contributing factors for medial tibial stress syndrome
Recent changes in running distance, speed, footwear, or running surface
Syndesmosis sprain (High Ankle Sprain)
Spreading of space at distal tibiofibular joint
Fracture management for mild conditions
Standard acute with physician referral
Another main S&S for mild to moderate eversion ankle sprain
Swelling: - May not be as evident as a lateral sprain - Between posterior aspect of lateral malleolus and -Achilles tendon - Point tenderness in involved ligaments
Treatment for hallux valgus (view pic)
Treatment—symptomatic
Cause of Pes planus
Typically, acquired deformity resulting from injury or trauma
Where is exertional compartment syndrome usually seen?
Usually seen in well-conditioned individuals <40 yrs old
What is common with Syndesmosis sprain (High Ankle Sprain)?
anterior inferior tibiofibular ligament
Management of Heel contusion
cold; heel cup or doughnut pad; referral
Mechanism of injury for Eversion ankle sprain
excessive dorsiflexion and eversion
Motions of toe
flexion and extension
1st Digit called
hallux or "great toe"
Function of the 1st digit
main body stabilizer during walking or running
S&S of toe deformities
painful callus formation on dorsumIP joints
MOI of Inversion ankle sprain
plantarflexion and inversion
MOI of Achilles tendon rupture
push-off of forefoot while knee is extending
Eversion
Internal rotation, Ankle rolling to the inside to where the lateral part of the foot raises while the medial part goes toward the ground
Plantar fasciitis has what kind of risk factors?
Extrinsic and intrinsic risk factors
Pes planus
Flat foot; arch or instep of the foot collapsing & contacting the ground Mobile foot
Management and key to tibial contusion
Management: standard acute Key: prevention
Dorsiflexion
Pointing the toes up, lifting the front of the foot
More serious possible S&S for turf toe
Potential for tear in flexor tendons or fracture of sesamoid bones
Plantar fascia (Plantar arches)
Provides support for the longitudinal arch
Is there a rapid increase of decrease in tissue pressure and what does that lead to? (Acute compartment syndrome)
Rapid ↑ in tissue pressure → neurovascular compromise
MOI for Acute compartment syndrome
direct blow anterolateral aspect of the tibia
MOI for Syndesmosis sprain (High Ankle Sprain)
dorsiflexion and external rotation
Motions of ankle (subtalar)
dorsiflexion and plantarflexion
MOI of tibia-fibula fractures
torsional force, resulting in either a spiral or oblique fracture of the lower third of the tibia.