CHAPTER 15 – FOOT AND ANKLE

FOOT ANATOMY It is complex! 26 bones 33 joints Over 100 muscles, tendons and ligaments

ANATOMY – 26 BONES TARSAL BONES – 7 Calcaneus – heel bone Talus – forms the ankle Navicular – medial in respect to the talus Cuboid - lateral Cuneiforms (3)

ANATOMY - BONES METATARSALS – 5 1ST one is medial and 5th one is lateral

ANATOMY - BONES PHALANGES (Toes) – 14 Big toe has two phalanges, the rest of the toes have three Proximal, middle, and distal

ANATOMY - BONES SESAMOIDS Sesamoid bones sit in tendons These are on ball on foot below big toe Helps distribute weight

ANATOMY - ARCHES Support body weight and absorb shock There are four arches: MEDIAL LONGITUDINAL ARCH LATERAL LONGITUDINAL ARCH METATARSAL ARCH TRANSVERSE ARCH

ANATOMY PLANTAR FASCIA Broad, flat tendonous structure that runs on the undersurface of the foot Starts on the calcaneus and inserts onto the heads of the metatarsals Supports the arch of the foot

ANKLE ANATOMY BONES Two bones in the lower leg Two tarsal bone Tibia – medial, larger, weight bearing Medial Malleolus Fibula Lateral Malleolus Two tarsal bone Talus Calcaneus

ANKLE ANATOMY TRUE ANKLE JOINT Tibia, fibula and talus Mortise Definition: where the talus fits into the tibia and the fibula

ANKLE ANATOMY TRUE ANKLE JOINT Tibia, fibula and talus Mortise Definition: where the talus fits into the tibia and the fibula

LIGAMENTS LATERAL – 3 ligaments named for bones Anterior talofibular (ATF) Calcaneofibular (CF) Posterior talofibular (PTF)

LIGAMENTS MEDIAL Deltoid Strong ligament 4 parts that form one ligament

LIGAMENTS TIBIOFIBULAR LIGAMENTS – holds tibia and fibula together Anterior tibiofibular Posterior tibiofibular

FOOT INJURIES PLANTAR FASCIITIS Common with athletes who are on toes and/or have high arches Causes: Not enough arch support in shoes, tight calf muscle Signs/Symptoms: Pain occurs in the heel to mid-foot, especially with dorsiflexion Hurts in the morning, feels better as they warm up Treatment: Gentle stretches, roll on tennis ball or frozen can, arch taping or orthotics.

FOOT INJURIES RETROCALCANEAL BURSITIS ‘Pump bump’ Cause: Pressure from back of shoe Signs/Symptoms: Swelling where the Achilles attaches to the calcaneus Treatment: RICE, stretching, shoes with wider heel cups, donut pad.

FOOT INJURIES FRACTURES DISLOCATIONS SPRAINS STRAINS Toes Metatarsals Interphalangeal Joints SPRAINS STRAINS

FOOT INJURIES JONES FRACTURE Fracture of the base of the 5th metatarsal Causes: overuse; inversion; rotational forces S/S: Feels and hears a ‘pop’; pain in the lateral foot Tx: immobilization (cast) 6-8 weeks or longer, often requires surgery

FOOT INJURIES BUNIONS (HALLUX VALGUS) Deformity of the head of the 1st metatarsal Cause: extra bone is laid down on head of 1st metatarsal Great toe becomes malaligned S/S: Pain, swelling and deformity of big toe joint Treatment: Proper shoes; doughnut pad over the bunion; surgery?

FOOT INJURIES TURF TOE Great Toe sprain Cause: Hyperextension of the big toe at the metatarsal phalangeal joint; kicking something Common on artificial turf b/c turf shoes allow more motion S/S: swelling and pain in the joint Tx: RICE, rigid insoles or toe boxes, taping to prevent hyperextension of toe

FOOT INJURIES INGROWN TOENAILS Cause: leading side of toenail grows into skin, usually results in infection and pain May trim nails too short or ill-fitting shoes S/S: Inflammed nail bed, may have drainage/pus Tx: May need to refer to doctor; soak in betadine bath; pack cotton under toenail

PUBLIC SERVICE ANNOUNCEMENT HIGH HEELS Loads 5 times your body weight onto your heel Overloads forefoot Deforms the arch Reduces shock absorption Plantar fasciitis Leads to inflamed nerves in your toes Morton’s Neuroma Shortens your calf Achilles tendinitis Changes your center of gravity – more forward Have to extend back to compensate

BIOMECHANICAL PROBLEMS PRONATION Cause of many, many leg, knee, back problems What does it look like Fallen arch with toes pointed outward Looking at feet from behind, the Achilles will angle outward

ANKLE SPRAINS Review: 3 Degrees of Sprains Abnormal (too much) motion causes ankle injuries Named for motions that cause them What are those motions?

TYPES OF ANKLE SPRAINS Inversion Most common type of ankle sprain Accounts for 80% of all sprains AKA ‘a lateral ankle sprain’ First degree sprain Only involves the anterior talofibular ligament Mild pain, tenderness, and swelling No instability

TYPES OF ANKLE SPRAINS Inversion Second degree sprain Anterior talofibular ligament is torn and calcaneofibular ligament is injured as well Most painful Moderate swelling Mild Instability

TYPES OF ANKLE SPRAINS Inversion Third degree sprain Complete tear of all three lateral ligaments Uncommon Lots of pain, but it can subside Very unstable Usually requires surgery

TESTING ATF STABILITY Drawer Test Stablize lower leg with one hand Pull heel forward (like opening a drawer) Should not move forward if ligament is intact

TYPES OF ANKLE SPRAINS Eversion Not as common Can occur more on tartan surfaces and artificial turf Everything is worse (pain, swelling, etc) when compared to an inversion injury If the deltoid tears, the tibiofibular ligaments may tear also

High Ankle Sprain Involves Anterior Inferior Tibiofibular (AITFL) Ligament Injury allows tibia and fibula to separate

High Ankle Sprain Cause: Inversion with rotation; rotation of foot S/S: pain with external rotation of foot; tender over AITFL Treatment: RICE, may need to be immobilized; possible surgery if severe enough

Treatment of Ankle Sprains Prevention – once you sprain an ankle it is easy to do again – tape and rehab Rest – No activity for 24-48 hours Ice – 20 minutes on, 40 minutes off Compression – ace wrap with horseshoe Elevation – ankle above the heart Support – crutches and aircast if needed

Ankle Rehab ABCs Circles Theraband exercises Single Leg Balance Balance Board Calf Raises And so much more….

Ankle Fractures Always need to suspect a fracture when evaluating a potential sprained ankle Cause: Too much motion S/S: immediate swelling, point tender over the bone, does not want to weight bear Treatment: splint, ice, x-ray Cast 6-8 weeks

The Lower Leg

ANATOMY Bones Tibia Fibula

MUSCLES The muscles are in four compartments with 2-4 muscles in each compartment Compartments are held together by fascia

MUSCLE COMPARTMENTS LATERAL – everts the ankle ANTERIOR – dorsiflexes the ankle DEEP POSTERIOR – plantarflexes the ankle (the calf muscle) POSTERIOR MEDIAL – inverts and plantarflexes the ankle

Major Muscles and Actions Anterior Tibialis - dorsiflexor Peroneals - evertors Gastrocnemius – plantarflexor Soleus – plantarflexor Posterior Tibialis – invertor

LOWER LEG INJURIES Muscle Cramps Sudden, violent contraction of the calf muscles Causes: Fatigue, overtraining, dehydration, poor nutrition, injury, poor flexibility S/S: – sharp pain in the calf, toe is pointed Tx: gentle stretch, ice, hydrate, can return to play if subsides and does not continue

LOWER LEG INJURIES STRESS FRACTURE Cause: Repetitive pounding with training S/S: Hurts more with and after activity, pain on one spot on bone Tx: Requires x-ray, possibly a bone scan If positive, no weight bearing for at least 2 weeks, no running for 4-6 weeks

LOWER LEG INJURIES MEDIAL TIBIAL STRESS SYNDROME ‘SHIN SPLINTS’ Occurs in distal 2/3 of posterior/medial tibia Causes: pronation, lack of flexibility in the lower legs, hard surfaces, hills, muscle weakness, poor shoes, increasing running distance too quickly

LOWER LEG INJURIES MEDIAL TIBIAL STRESS SYNDROME S/S: resisted plantar flexion and inversion should hurt, pain is just off the tibia Treatment : prevention (shoes, arch support), strengthening, stretching, ice massage, contrast bath, tape arches Refer to MD if no improvement to rule out stress fracture

LOWER LEG INJURIES COMPARTMENT SYNDROME Occurs when pressure increases in compartment and shuts off blood and nerve supply to the foot Most often occurs in the anterior and deep posterior compartment THREE TYPES Acute Acute Exertional Chronic

LOWER LEG INJURIES ACUTE COMPARTMENT SYNDROME Medical emergency Causes: direct blow to the lower leg Usually in the anterior lower leg Symptoms come about several hours later S/S: compartment is tense, warm, red and shiny; complains of (c/o) deep aching pain; circulation and sensory problems in foot Tx: ice, elevation – refer to ER immediately

LOWER LEG INJURIES ACUTE EXERTIONAL/CHRONIC COMPARTMENT SYNDROME Cause: running and jumping activities S/S: With activity, foot goes to sleep, crampy pain, and tingling. When activity stops, it goes away. Consistent as to when it comes on with activity Tx: ice, activity modification, stretching, massage, and referral to the doctor (possible surgery)

INJURIES ACHILLES TENDINITIS Chronic, overuse condition that comes about gradually Causes: running and jumping, repetitive stress, running up hills, poor flexibility S/S: achy type pain, Achilles is tender on palpation, pain with standing plantarflexion, may have crepitus, hurts to warm up and to cool down

INJURIES ACHILLES TENDINITIS TREATMENT If there is crepitus, no running for 1-2 weeks Stretch! Heel lift in both shoes Orthotics Heat and/or ice

INJURIES ACHILLES TENDON RUPTURE Achilles in largest tendon in body For Gastrocnemius and Soleus muscles Most common tearing spot is 1” above its insertion on the calcaneus Causes: Sudden, forceful plantar flexion and extension of the knee, age, previous tendinitis S/S: Feel and hear a snap, “kicked in the leg”, very weak plantarflexion, no Achilles observed Tx: Immobilization to ER, surgery?