unit 5:understanding athletic- related injuries to the lower extremity foot and ankle, anatomy and...

Unit 5:Understanding Athletic-Unit 5:Understanding Athletic-Related Injuries to the Lower Related Injuries to the Lower

ExtremityExtremity

Foot and Ankle, Anatomy and InjuriesFoot and Ankle, Anatomy and Injuries

Sports Medicine Sports Medicine

The Foot (Bones)The Foot (Bones)

Bones = 26Bones = 26 14 phalanges 14 phalanges 5 metatarsals5 metatarsals 7 tarsals7 tarsals

Toes (Phalanges)Toes (Phalanges) Designed to give Designed to give

wider base for wider base for balance and balance and propelling the body propelling the body forward.forward.

1st toe (Hallux)1st toe (Hallux) Two sesamoid Two sesamoid

bones located under bones located under the 1the 1stst MP joint. MP joint.

MetatarsalsMetatarsals 5 Bones5 Bones 11stst metatarsal is the metatarsal is the

largest and strongest largest and strongest and functions as the and functions as the main body support main body support during walking and during walking and running. running.

Palpable at the ball of Palpable at the ball of the foot.the foot.

55thth metatarsal most metatarsal most common fractured.common fractured.

TarsalsTarsals 7 bones7 bones Aids in the support of Aids in the support of

the body.the body. Calcaneous = largest Calcaneous = largest

tarsal bone, supports tarsal bone, supports talus and shapes talus and shapes heel, and provides heel, and provides attachment for attachment for achilles tendon.achilles tendon.

Joints of the FootJoints of the Foot Interphalangeal joint Interphalangeal joint

(IP)(IP) Flexion / ExtensionFlexion / Extension

Metarsalphalangeal Metarsalphalangeal joint (MP)joint (MP) Flexion / Extension Flexion / Extension Abduction / AdductionAbduction / Adduction

Bones of the AnkleBones of the Ankle TibiaTibia

Main weight bearing bone Main weight bearing bone of LOWER LEGof LOWER LEG

Forms medial malleolusForms medial malleolus

FibulaFibula Non-weight bearingNon-weight bearing Mainly muscle and Mainly muscle and

ligament attachmentligament attachment Forms lateral malleolusForms lateral malleolus

TalusTalus Main weight bearing bone Main weight bearing bone

of the ANKLEof the ANKLE

Lateral Ligaments of the Lateral Ligaments of the AnkleAnkle

Resist ankle inversionResist ankle inversion

Anterior talofibular (ATF)Anterior talofibular (ATF) Most commonly sprainedMost commonly sprained

Calcaneofibular (CF)Calcaneofibular (CF) Posterior talofibular (PTF)Posterior talofibular (PTF)

Medial Ankle LigamentsMedial Ankle Ligaments

DeltoidDeltoid

Resists ankle Resists ankle eversioneversion

Low rate of injuryLow rate of injury

QuizQuiz

1.1. Which bone in the lower leg is the most weight Which bone in the lower leg is the most weight bearing?bearing?

2.2. What does ATF stand for?What does ATF stand for?

3.3. Which ligaments resist inversion?Which ligaments resist inversion?

4.4. Which ligaments resist eversion?Which ligaments resist eversion?

5.5. What does MP stand for?What does MP stand for?

6.6. How many tarsal bones are there?How many tarsal bones are there?

7.7. How many bones are in the foot?How many bones are in the foot?

Answers:Answers:

1.1. TibiaTibia

2.2. Anterior TalofibularAnterior Talofibular

3.3. Anterior Talofibular, tibiofibular, calcaneofibular Anterior Talofibular, tibiofibular, calcaneofibular (lateral)(lateral)

4.4. Deltoid ligaments (medial)Deltoid ligaments (medial)

5.5. Metatarsalphalangeal Metatarsalphalangeal

6.6. 77

7.7. 2626

Muscles of the Foot and Muscles of the Foot and AnkleAnkle

Anterior Muscles (3)Anterior Muscles (3)

Extensor Hallucis Extensor Hallucis Longus/BrevisLongus/Brevis extension of great toeextension of great toe

Extensor Digitorum Extensor Digitorum Longus/BrevisLongus/Brevis extension of 2 – 5 extension of 2 – 5

phalangesphalanges

Muscles of the Foot and Muscles of the Foot and AnkleAnkle

Anterior Muscles Anterior Muscles cont. (3)cont. (3)

Tibialis anteriorTibialis anterior inversion and inversion and

dorsiflexion of foot / dorsiflexion of foot / ankleankle

Muscles of the Foot and Muscles of the Foot and AnkleAnkle

Medial Muscles (3)Medial Muscles (3)

Tibialis PosteriorTibialis Posterior Inversion and Inversion and

plantarflexionplantarflexion

Flexor Hallucis LongusFlexor Hallucis Longus Flexor of great toe and Flexor of great toe and

plantarflexion of ankleplantarflexion of ankle

Flexor Digitorum LongusFlexor Digitorum Longus Flexors of 2 – 5 toes and Flexors of 2 – 5 toes and

plantarflexion of ankleplantarflexion of ankle

Muscles of the Foot and Muscles of the Foot and AnkleAnkle

Muscles of the Foot and AnkleMuscles of the Foot and Ankle

Posterior Muscles (2)Posterior Muscles (2)

GastrocnemiusGastrocnemius plantarflexion of ankleplantarflexion of ankle

SoleusSoleus plantarflexion of ankleplantarflexion of ankle

Muscles of the Foot and Muscles of the Foot and AnkleAnkle

Muscles of the Foot and Muscles of the Foot and AnkleAnkle

Lateral Muscles (2)Lateral Muscles (2)

Peroneus Longus / Peroneus Longus / BrevisBrevis eversion, plantar eversion, plantar

flexion of ankleflexion of ankle

Quiz Quiz

1.1. What is the primary function of the Extensor What is the primary function of the Extensor Hallucus Longus and Brevis?Hallucus Longus and Brevis?

2.2. What is the primary function of the tibialis What is the primary function of the tibialis anterior?anterior?

3.3. What two motions does the peroneus longus What two motions does the peroneus longus and brevis perform?and brevis perform?

4.4. What motion does the Gastrocnemius/ Soleus What motion does the Gastrocnemius/ Soleus perform?perform?

5.5. What are the two main motions of the tibialis What are the two main motions of the tibialis posterior muscle?posterior muscle?

AnswersAnswers

1.1. Extension of great toeExtension of great toe

2.2. Inversion and dorsiflexion of footInversion and dorsiflexion of foot

3.3. Eversion and plantar flexion of the ankleEversion and plantar flexion of the ankle

4.4. Plantarflexion of anklePlantarflexion of ankle

5.5. Inversion and plantarflexionInversion and plantarflexion

Arches of the FootArches of the Foot

Supinated Arches (High Supinated Arches (High Arches)Arches)

Supinated ArchesSupinated Arches

Pronated Arches (Flat Feet)Pronated Arches (Flat Feet)

Pronated ArchesPronated Arches

Pronated ArchesPronated Arches

Pronated ArchesPronated Arches

OrthoticsOrthotics

OrthoticsOrthotics

OrthoticsOrthotics

Foot and Ankle InjuriesFoot and Ankle Injuries

Ankle SprainAnkle Sprain Cause: Excessive inversion or

eversion of theankle

S/S: Point tenderness, swelling, discoloration,laxity, inability to walk or run properly (extentbased on degree).

TX: RICE, rehabilitation immediately (GradeIII requires immobilization)

Prevention: Strengthening exercises, propershoes/ equipment

11stst Degree Ankle Sprain Degree Ankle Sprain

Mechanism (MX)Mechanism (MX) Inversion and/or Inversion and/or

plantarflexionplantarflexion

ATF most common ATF most common sprainedsprained

Occurs during contact Occurs during contact or non – contact. or non – contact.

S/SS/S

11stst degree degree Mild painMild pain Pt – ATFPt – ATF Possible swellingPossible swelling Fast recovery to FWB Fast recovery to FWB

and ROMand ROM No joint laxityNo joint laxity

22ndnd Degree Ankle Sprain Degree Ankle Sprain

MXMX Same as 1Same as 1stst degree, more degree, more

severe.severe.

Involves the ATF, CFInvolves the ATF, CF Possible growth plate Possible growth plate

involvementinvolvement Most cases x-ray neededMost cases x-ray needed

S/SS/S

22ndnd degree degree Felt a popFelt a pop Localized severe painLocalized severe pain Pt – more then one Pt – more then one

ligamentligament Rapid swellingRapid swelling Decrease ROMDecrease ROM Laxity in jointLaxity in joint Unable to FWBUnable to FWB

33rdrd Degree Ankle Degree Ankle SprainSprain

Rupture of Rupture of ligaments (ATF, ligaments (ATF, CF, PTF)CF, PTF)

Consider a FXConsider a FX X-ray is X-ray is

mandatorymandatory

S/SS/S

33rdrd Degree Degree Felt or heard popFelt or heard pop Extreme painExtreme pain Extreme/rapid swellingExtreme/rapid swelling No ROMNo ROM Unable to FWBUnable to FWB

11stst Degree Degree Ankle SprainAnkle Sprain

22ndnd Degree Ankle Degree Ankle SprainSprain

33rdrd Degree Degree Ankle SprainAnkle Sprain

RICERICEReturn to Play Return to Play

(Toe raise, heel (Toe raise, heel walk, Full go w/ walk, Full go w/ full ROMfull ROMTape to PlayTape to PlayReevaluate Reevaluate 24hrs24hrs

RICE RICE

(Horseshoe w/ (Horseshoe w/ compression wrap)compression wrap)Crutches 24 hoursCrutches 24 hoursReevaluate 24hrsReevaluate 24hrsRefer to Dr.Refer to Dr.X-raysX-rays

RICE RICE (Horseshoe w/ (Horseshoe w/ compression compression wrap)wrap)CrutchesCrutchesPosterior Posterior SplintSplintRefer to Dr.Refer to Dr.X-raysX-rays

Anterior Drawer Anterior Drawer TestTest Tests for ligament Tests for ligament

instabilityinstability Mainly tests ATF Mainly tests ATF

integrity but can also integrity but can also test the CF and PTF test the CF and PTF depending on severitydepending on severity

Ankle must be relaxedAnkle must be relaxed Ankle in slight plantar Ankle in slight plantar

flexionflexion

Talar TiltTalar Tilt Test for lateral ankle Test for lateral ankle

instabilityinstability Positive test indicates Positive test indicates

tear in ATF, and CFtear in ATF, and CF

Thompson TestThompson Test Test for achilles Test for achilles

tendon rupturetendon rupture

Ankle DislocationAnkle Dislocation

Mx: Anterior – Heel strikes ground forcefully Posterior – blow to anterior lower leg

S/S: PN deformity, inability to move foot, rapid

swelling, refusal to allow moving or touching foot

TX: Splint, ICE, 911 or transport to hospital

Sprain of the 1Sprain of the 1stst MP joint MP joint Mx:Mx:

Hyperextension/ Hyperextension/ hyperflexion of great toehyperflexion of great toe

Common on artificial Common on artificial surfacesurface

Flexible types of footwear Flexible types of footwear can contributecan contribute

S/SS/S Pain over the first MP jointPain over the first MP joint

Turf ToeTurf Toe

Achilles Tendonitis MX:

Repetitive motions such as running and jumping that cause tendon breakdown

S/S: Swelling, crepitus, pn with palpation, pn with dorsiflexion, weak

with plantarflexion TX:

RICE Limiting or restricting the activity that caused the irritation Aggressive stretching of heel cord

• Crepitus (crackling and grinding) may mean it is too late Prevention:

Achilles and gastroc/solues stretching, proper acclimization to activity.

Achilles Tendon Rupture

MX: Sudden, forceful plantar flexion of the ankle with a

chronically tight tendon. S/S:

Feel or hear a pop. Feel as if they’ve been kicked in the leg. Inability to plantar flex foot.

TX: Surgery or a cast

Prevention: Stretching and proper care of any tendonitis

Mx – Mx – Downward force to the Downward force to the

foot causing foot causing depression of the archdepression of the arch

Most common with Most common with overuse (running)overuse (running)

S/SS/S Sharp pain with weight Sharp pain with weight

bearingbearing Painful during Painful during

dorsiflexiondorsiflexion

Longitudinal Arch StrainLongitudinal Arch Strain

““Shin Splints”:Shin Splints”: catch all term related to lower catch all term related to lower

leg pain.leg pain. MX:MX:

constant pounding associated constant pounding associated with runningwith running

S/S:S/S: sharp pain in lower leg sharp pain in lower leg

around medial/lateral aspect around medial/lateral aspect of lower leg and connective of lower leg and connective tissue between tibia and tissue between tibia and fibulafibula

TX: TX: RICE (cold whirlpool), heal RICE (cold whirlpool), heal

lift, arch support, shoes, lift, arch support, shoes, change running surfacechange running surface

Lower Leg Problems

Compartment Syndrome MX:

Increased pressure within one of four compartments of lower leg causes compression of the structures in the leg.

S/S: Deep aching pain, tightness, and swelling. Pain with

stretching. TX:

Acute~ immediate surgery Chronic~ activity modification & ice and some times

surgery Prevention:

Stretching (Hard to prevent)

Toe Abnormalities

Hammer Toes MX:

Poor shoe choices Middle joint (PIP)

flexed, other joints (MP, DIP) hyperextended

TX: Refer, orthotics or

surgery

Bunion / Hallux Valgus

MX: Bony enlargement of the head of the 1st metatarsal

caused from wearing improperly fitting shoes S/S:

Obvious deformity, tenderness, and swelling TX:

Proper shoe selection, protection devices, surgery may be necessary

Prevention: Properly fitting shoes

Ingrown Toenail

MX: Improper shoe fitting and nail cutting

S/S: Increased pain, swelling, redness around the

nail bed TX:

Hot, soapy water, antibiotics, raise nail up Prevention:

Proper shoes, proper nail trimming