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.