Prevent & Treat Chapter 16

Subtalar joint

- lies beneath the talus, where facets of the talus articulate with the sustentaculum tali on the superior calcaneus -no muscles attach to the talus; the stability of joint is derived from several small ligaments -behaves as a flexible structure, with motion occurring only through stretching of ligaments during weight bearing; motion at the subtalar joint involves "male" ovoid bone surfaces sliding over reciprocally shaped "female" ovoid bone surfaces

S & S Achilles tendon rupture

-"Pop" -Inability to stand on toes -Visible defect -Excessive passive dorsiflexion

Displaced fractures and dislocations (Metatarsals)

-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

Hallux

-1st toe/great toe: main body stabilizer during walking or running

Common sites for stress fractures

-2nd metatarsal -Sesamoid bones -Navicular -Calcaneus -Tibia and fibula

Plantar fascia

-A specialized, thick, interconnected band of fascia that covers the plantar surface of the foot -Provides support for the longitudinal arch *- during the weight-bearing phase of the gait cycle, the plantar fascia stretches on the order of 9% to 12% of resting length, functioning like a spring to store mechanical energy that is then released to help the foot push off from the surface

Common sites for strains and tendinitis

-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

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 1. begins with a period of single-leg support in which body weight is supported by one leg while the other leg swings forward 2. swing phase can be divided into the initial swing, midswing, and terminal swing 3. period of double support begins with the contact of the swing leg with the ground or floor; body weight transfers from the support leg to the swing leg, the swing leg undergoes a loading response and becomes the new support leg; a new period of single support then begins as the swing leg loses ground contact 4. midstance—time through which body weight is balanced over the support 5. as the body's center of gravity shifts forward, the terminal stance phase of the support leg coincides with the terminal swing phase of the opposite leg

Displaced fractures and dislocations

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

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 (overuse conditions)

-Do not permit to continue activity until seen by a physician -Suggest application of cold to decrease pain and 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.

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) -May occur at the site of any ligamentous or tendinous attachment

Predisposing factors for an eversion ankle sprain

-Excessive pronation -Hypermobile foot

Pes Cavus (toe/foot condition)

-Excessively high arch that does not flatten during weight bearing -Causes can vary -Rigid foot

S & S of Exertional compartment 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 a Subtalar ankle dislocation

-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 -Concern: potential for peroneal tendon entrapment and neurovascular damage

S & S of a Tibia-fibula fracture

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

S & S of Sever's Disease

-Heel pain with activity -Decreased heel cord flexibility -Pain with standing on tiptoes

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

Gastrocnemius strain

-If related to muscle cramping, the strain is commonly attributed to dehydration (particularly in the heat), electrolyte imbalance, or prolonged muscle fatigue that stimulates cramping followed by an actual tear in the muscle fibers -Medial head or musculotendinous junction -"Tennis Leg" -Mechanism -Forced dorsiflexion while knee is extended -Forced knee extension while foot is dorsiflexed -Muscular fatigue with fluid-electrolyte depletion & cramping

Hindfoot

-Includes the calcaneus and talas -Talocrural joint (ankle joint) -Hinge joint; plantarflexion and dorsiflexion -Articulation of talus, tibia, and fibula

What is turf toe?

-Is a sprain of the MTP joint of the great toe -Results in extreme pain with extension of the great toe -Can result from an acute trauma or repetitive overload

Ankle fracture-dislocation

-Landing from a height with foot in excessive eversion or inversion -Being kicked from behind while the foot is firmly planted

Acute compartment syndrome

-Lower leg includes 4 nonyielding compartments -MOI: direct blow anterolateral aspect of the tibia -Rapid ↑ in tissue pressure → neurovascular compromise -Swelling in nonyielding anatomic space leads to increased local venous pressure and obstructs the neurovascular structure

Subtalar ankle dislocation

-MOI: fall from a height (as in basketball or volleyball); foot lands in inversion -Foot lands in inversion, disrupting the interosseous talocalcaneal and talonavicular ligaments

Achilles tendon rupture

-MOI: push-off of forefoot while knee is extending -More common in individuals over age 30

Plantar fasciitis can be a result of which of the following?

-Training errors -Excessive overpronation -Excessive oversupination -Poor strength or flexibility of the Achilles tendo

Predisposing factors for strains and tendinitis

-Training errors (5) -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

Pes Planus (toe/foot condition)

-an acquired deformity result from injury or trauma involving the soft tissues structures that maintain the normal integrity of the arch -Flat foot; arch or instep of the foot collapsing & contacting the ground -mobile foot

Tibial contusion

-common in soccer, field hockey, baseball, softball, or football, where the lower leg is often subjected to high-impact forces -shin is particularly void of natural subcutaneous fat -although painful, the condition can be managed effectively with ice, compression, elevation, and rest -management- standard acute

Eversion ankle sprain

-forced dorsiflexion and eversion (e.g., landing from a long jump with the foot abducted; landing on another player's foot) -deltoid ligament -potential causes: -Lateral malleolus fx; bimalleolar fx -Tear of Anterior Tibiofibular ligament &interosseous membrane

S & S of a IP and MP joint (toe/foot sprain)

-pain. dysfunction, immediate swelling -dislocation- gross deformity

Talus

-saddle-shaped -serves as the critical link between the foot and ankle -has several functional articulations (including the talocrural joint and the subtalar joint)

Management of Exertional compartment syndrome

-stop activity -assessment by qualified health care practitioner

IP and MP joint (toe/foot sprain)

-tripping or stubbing the toe

Talocrural (ankle) joint

-uniaxial, modified synovial hinge joint -formed by the talus, the tibia, and the lateral malleolus of the fibula; concave end of the weight-bearing tibia mates with the convex superior surface of the talus to form the roof and medial border of the ankle mortise -lateral malleolus extends farther distally than the medial malleolus; eversion is more seriously limited than inversion -dome of the talus is wider anteriorly than posteriorly --- results is that dorsiflexion is more stable position than plantarflexion

Which of the following muscles are located in the deep posterior compartment of the lower leg?

Flexor hallucis longus Tibialis posterior Flexor digitorum longus

Syndesmosis Ankle Sprain

"The Dreaded High Ankle Sprain" -Spreading of space at distal tibiofibular joint -MOI: dorsiflexion and external rotation -Common: anterior inferior tibiofibular ligament

Reverse turf toe (soccer toe)

-Because of forced hyperflexion of the MTP joint while kicking an instep ball strike, soccer players often irritate the dorsal capsular structures of the first MTP joint -The condition can be acute or chronic and demonstrates similar signs and symptoms as the traditional turf toe, except pain is noted dorsally over the joint and passive flexion of the toe is painful

S & S of a Ankle fracture-dislocation

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

Which of the following describes Sever's disease?

-It is an apophysitis of the calcaneus -It can be attributed to decreased heel cord and hamstring flexibility -Pain tends to be worse during and after activity, but improves with rest

Midfoot sprains

-MOI: severe dorsiflexion, plantarflexion, or pronation -More frequent in activities in which foot is unsupported

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

S & S of an eversion sprain

-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 sprai -Between posterior aspect of lateral malleolus and Achilles tendon -Point tenderness in involved ligaments -Sever injuries -PROM pain-free in all motions except dorsiflexion

Midfoot

-Navicular, cuboid, -3 cuneiforms (Medial, Middle, Lateral) -Numerous joints -Talocalcaneonavicular joint (TCN)

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

Stress fractures are common in who?

-Often seen in running and jumping, particularly after a significant increase in training mileage, or a change in surface, intensity, or shoe type -Neck of the 2nd metatarsal is the most common location for a stress fracture, although it is also seen on the 4th and 5th metatarsals. -Women w/ amenorrhea 6 months+ and oligomenorrhea

S & S of a midfoot sprains

-Pain and swelling is deep on medial aspect of foot -Weight bearing may be too painful

1st degree ankle sprain

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

S & S of Plantar fasciitis (overuse conditions)

-Pain at plantar, medial heel -Pain with first steps in the morning, but diminshes 5-10 min -Increased pain with passive extension of great toe and ankle dorsiflexion -Pain relieved with activity, but recurs after rest -Pain and stiffness are related to muscle spasm and splinting of the fascia secondary to inflammation -Normal muscle length is not easily attained, and it leads to additional pain and irritation

S & S of a stress fracture

-Pain begins insidiously; increases with activity and decreases with rest -Pain usually limited to fracture site

S &S of turf toe

-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

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 of a Syndesmosis Ankle Sprain

-Point tenderness over the anterolateral tibiofibular joint -Significant pain and swelling Difficulty bearing weight -Typically takes longer to heal than an inversion or eversion sprain. Sports participation may be delayed for up to 3 months after the initial treatment begins

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

S & S of a heel contusion

-Severe pain in heel -Unable to bear weight

Hallux Rigidus (toe/foot deformity)

-Sports that involve running and jumping may predispose an individual to this condition -Degenerative arthritis in first MTP

Ligaments

-Spring (calcaneonavicular) -Long plantar -Short plantar

Tibiofibular joints

-Superior—proximal: - plantar synovial joint, tightly reinforced with anterior and posterior ligaments -Inferior—distal: a syndesmosis, where dense fibrous tissue binds the bones together -Interosseous membrane: structural arrangement allows for some rotation and slight abduction (spreading), while still maintaining joint integrity

3rd 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

2nd 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 -Excessive body weight, age, poorly cushioned or worn-out running shoes, increases in training, and hard, uneven training surfaces can predispose an individual to this condition

Halux Valgus (toe/foot deformity)

-Thickening of the medial capsule and bursa, resulting in severe valgus deformity

Sever's Disease

-associated with growth spurts, tight heel cords, poor hamstring flexibility, and other biomechanical abnormalities contributing to poor shock absorption -because the apophyseal plate is vertically oriented, it is particularly susceptible to shearing stresses from the gastrocnemius -Traction-type injury of calcaneal apophysis -Seen in ages 7-10

Joint fractures

-because of low vascularization and high stresses at this site, associated with a poor outcome; nonunions and delayed unions are common -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

Phalangeal fracture

-caused by an axial load (e.g., jamming the toe into an immovable object) or direct trauma (e.g., crushing injury) -minor injuries with exception of a fracture to the great toe -swelling, ecchymosis, and pain are present; the individual is able to walk, but may have problems with footwear; tenderness resolves in 3-4 weeks -MOI: axial load (e.g. jamming toe) or direct trauma (e.g., crushing) -Swelling; ecchymosis; pain; able to walk

Metatarsal fracture

-classified according to their anatomic location (i.e., neck, shaft, or base) -single fracture tends to be minimally displaced because of the restraining forces of the intermetatarsal ligaments -swelling and pain are localized over the fracture site; pain increases with weight bearing -Swelling; pain -Pain increases with weight bearing -Potential for displacement

Management of acute compartment syndrome

-cold -NO compression (lead to deterioration) or elevation -immediate referral to ER or summon EMS -irreversible damage can occur within 12-24 hours

Management of a heel contusion

-cold; heel cup or doughnut pad; referral Condition may persist for months

Plantar arche

-function to support and distribute body weight from the talus through the foot

Exertional compartment syndrome

-generally occurs in relatively sedentary people who undertake strenuous exercise; chronic ECS is usually seen in well-conditioned individuals younger than 40 -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

Gastrocnemius contusion

-hemorrhage and muscle spasm quickly lead to a tender, firm mass that is easily palpable -immediate pain and weakness

Longitudinal arche

-higher medial than lateral -runs from the anterior, inferior calcaneus to the metatarsal heads

Turf toe

-hyperextension or hyperflexion of the great toe (i.e., jamming the toe into the end of the shoe) -Sprain of the plantar capsular ligament of 1st MTP joint -MOI: forced hyperflexion or hyperextension of great toe -Acute or repetitive overload -Valgus ↑ susceptibility

Management of a gastrocnemius contusion

-if the condition does not improve in 2 to 3 days, ultrasound may be used under the direction of a physician to assist in breaking up the hematoma -cold with gentle stretch

Plantar fasciitis (overuse conditions)

-most common hind foot problem in runners, affecting approximately 10% of runners -extrinsic factors: training errors, improper footwear, and participating on unyielding surfaces -intrinsic factors: pes cavus or pes planus, decreased plantarflexion strength, reduced flexibility of the plantarflexor muscles (e.g., Achilles tendon), excessive or prolonged pronation, and torsional malalignments

Inversion ankle sprain

-often occur while changing directions rapidly -injury typically involves the unloaded foot and ankle (or, more accurately, just at the moment of loading) with a plantarflexion and inversion force Predisposing factors: -lateral malleolus projects farther downward -least stable position of ankle is plantar flexion -weakness in peroneals -decrease in ROM in Achilles tendon

Transverse arche

-runs across the anterior tarsals and metatarsals

After receiving a blow to the anterior lower leg, an athlete has a diminished dorsalis pedis pulse and paresthesia between the great and second toe. What conditions might the athlete be experiencing?

Acute compartment syndrome

Which of the following ligaments provide stability to the lateral aspect of the ankle joint?

Anterior talofibular Posterior talofibular Calcaneofibular

4 compartments of the leg

Anterior, Posterior Superficial, Posterior Deep, Lateral

Protection equipment for injury prevention

Braces; orthotics Footwear: Demands of sport; wear shoe for its intended purpose, proper fit

Supination id the combination of the movements of?

Calcaneal inversion, foot adduction, plantar flexion

Management of an Achilles tendon rupture

Compression wrap; immediate transport to emergency care facility or physician

The muscles in the anterior compartment of the lower leg perform which of the following motions?

Dorsiflexion Inversion Eversion Toe extension

Motion of the ankle

Dorsiflexion and plantarflexion

Because the fibula extends farther distally than the tibia, the motion of inversion is limited.

False

Inversion ankle sprains are far more common than eversion ankle sprains in the adolescent age group. However, in the adult population , inversion and eversion ankle sprains are sustained at virtually equal rates?

False

Motion of the toe

Flexion and Extension

S & S of a Gastrocnemius strain

Immediate pain, swelling, loss of function

Motion of the foot and ankle

Inversion and eversion Pronation and supination

A transverse fracture of the proximal shaft of the fifth metatarsal at the junction of the diaphysis and metaphysis is referred to as?

Jones fracture An avulsion fracture

Hindfoot ligaments

Medial: Deltoid Lateral: Anterior Talofibular; Posterior talofibular; Calcaneofibular

Management of a Subtalar ankle dislocation

Medical emergency; activate EMS; monitor neurovascular function

The ankle is capable of which of the following movements?

Plantar flexion Dorsiflexion

The common mechanism of injury for Achilles tendon rupture is?

Push-off of the forefoot with the knee extended

Management of toe and foot sprains

Standard acute Physician referral

Management of a 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

Medial tibial stress syndrome pain is aggravated by?

Standing on tiptoe

Physical condition for a foot/ankle injury

Strengthening: extrinsic muscles, intrinsic muscles Flexibility: Achilles tendon

What joint is considered the true ankle joint?

Talocrural

The distal aspect of the tibia is referred to as?

The medial malleolus

The great toe is the main body stabilizer during walking or running.

True