Unit 3: Lower leg, foot, ankle

Lower leg/ankle

Anatomy Tibia Fibula Talus Calcaneus Weight bearing bone of lower leg Heel bone

Articulations Inferior tibiofibular joint Talocrural joint (ankle joint) Subtalar joint

Ligaments Lateral ligaments Medial Anterior talofibular Posterior talofibular Calcaneofibular Medial Deltoid

Muscles (4 compartments) Anterior Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peroneal (fibularis) tertius Lateral Peroneal (fibularis) longus Peroneal (fibularis) brevis Superficial posterior Gastroc Soleus Plantaris Deep posterior Popliteus Flexor hallucis longus Flexor digitorum longus Tibialis posterior

Anterior Muscle Action Tibialis anterior Dorisflex and inverts foot Extensor hallicus longus Dorsiflex and inverts foot; extends great toe Extensor digitorum longus Dorsiflex and everts foot; extends the toes Peroneus (fibularis) teritus Dorsiflex and everts foot

Lateral Muscles Actions Peroneus (fibularis) longus Plantar flexes and everts foot Peroneus (fibularis) brevis Plantar flexes and everts the foot

Superficial posterior Muscles Actions Gastrocnemius Flexes the leg and plantarflexes the foot Soleus Plantarflexes the foot Plantaris Flexes the leg; plantarflexes the foot

Deep posterior Muscles Actions Popliteus Flexes and rotates the leg medially Flexor hallicus longus Plantar flexes and inverts the foot; flexes great toe Flexor digitorum longus Plantarflexes and inverts the foot; flexes the toes Tibialis posterior Plantarflexes and inverts the foot

Evaluation-History Distinguish between overuse vs. acute Acute- sudden onset Overuse- develops over time What irritates it more? Intensity, activity, sport, terrain What kind of surface do they play on? How long has it been bothering them and how did it happen?

Evaluation- Observation Gait analysis – how they walk Foot type Arches, forefoot position, rearfoot position Weight bearing vs. non-weight bearing alignment

Evaluation- Palpation Bony landmarks Tibia, fibula, malleolus’, calcaneus, talus, navicular, cuboid, cuneiforms, metatarsals, styloid process of the 5th, metatarsal heads Plantar fascia Ligaments- ATF, CF, PTF, deltoid Muscles – anterior tibialis, gastroc, soleus, peroneals, extensor tendons, Achilles tendon

Evaluation- Special Tests Muscle testing Extensor digitorm longus Extensor hallicus longus Flexor digitorum longus Flexor hallicus longus Tibialis anterior Tibialis posterior Peroneals Gastrocnemius Soleus

Evaluation- Special tests What it tests for… Video Anterior drawer ATF https://www.youtube.com/watch?v=dprnjn_OTzo Posterior drawer PTF https://www.youtube.com/watch?v=4ameXWlUQb4 Compression test Fracture https://www.youtube.com/watch?v=409QcILpZe0 Bump test https://www.youtube.com/watch?v=e3YjkuJYwP4 Thompson test Achilles https://www.youtube.com/watch?v=8PvgvUV8N8U Talar tilt (inversion) CF (eversion) deltoid https://www.youtube.com/watch?v=2qF_DOe2jPE

Ankle injuries Lateral ankle sprain Medial ankle sprain Syndesmotic (high) ankle sprain Achilles tendinitis Medial tibial stress syndrome Compartment syndrome

Ankle injuries Lateral ankle sprain Ligaments involved: CF, ATF, PTF MOI: Inversion Signs and symptoms: Painful pop on lateral side of ankle Bruising Instability Swelling Weakness Treatment: RICE/crutches if unable to walk Rehab

Ankle injuries Medial ankle sprain Ligaments involved: deltoid MOI: eversion Signs and symptoms: Painful pop on medial side of ankle Bruising Instability Swelling Weakness Treatment: RICE/crutches if unable to walk Rehab

Ankle injuries Sydesmotic Sprain (high) MOI: forced dorsiflexion Typically happen in conjunction with lateral or medial ankle sprain Signs and symptoms: Severe pain Loss of function Pain with passive ER and dorsiflexion Treatment: Take longer to heal Immobilization RICE rehab

Ankle injuries Achilles tendinitis Inflammation of the Achilles tendon MOI: repetitive weight-bearing activities; duration and intensity of activity is increased too quickly with insufficient recovery time; overuse injury Signs and symptoms: Generalized pain and stiffness in Achilles Uphill running and hill workouts Crepitus in tendon Treatment: Proper shoe ware Decrease activity and proper training Modalities Massage

Ankle injuries Medial tibial stress syndrome (MTSS) Shin splints MOI: repetitive microtrauma due to running and jumping activities Weakness of leg muscles Shoes Training errors (on hard surfaces) Signs and symptoms: pain in medial leg Treatment: stretching, strengthening program, change in shoes and training, ice, modalities

Ankle injuries Compartment syndrome MOI: increased pressure within one of the compartments of the lower leg and causes compression in the muscles and neurovascular structures Signs and symptoms: Deep aching pain Tightness and swelling Pain with passive stretching Reduced circulation and sensory changes Treatment: Ice and elevation, stretching Refer to doctor

Rehab

Foot

Anatomy Toes (phalanges) First toe- hallux Metatarsals – 5 bones between the phalanges and tarsal bones Tarsal bones Calcaneus (heel bone) Talus Cuboid Navicular Cuneiforms – first, second, and third

Arches of the foot Metatarsal arch Transverse arch Medial longitudinal arch Lateral longitudinal arch Plantar fascia- band of fibrous tissue along the bottom of the foot

Articulations Interphalangeal (IP) joint Metatarsophalangeal (MTP) joint Intermetatarsal joint Tarsometatarsal Joint (Lizfranc) Subtalar joint Midtarsal joint

Muscles and movements Dorsiflexion Plantarflexion Tibialis anterior Extensor digitorum longus Extensor hallicus longus Peroneus teritus Plantarflexion Gastrocnemius Soleus Plantaris Peroneus longus and brevis Tibialis posterior FHL FDL

Muscles and movements Inversion, adduction, and supination “Tom, Dick, and Harry” Tibialis posterior Flexor digitorum longus Flexor hallicus longus Eversion, abduction, and pronation Peroneus longus Peroneus brevis Peroneus tertius EDL

Evaluation- History

Evaluation- Observation

Evaluation- Palpation

Evaluation- Special Tests

Foot injuries Jone’s Fracture March fracture Calcaneus fracture Metatarsalgia Turf toe Lizfranc injury

Foot deformities/injuries Pes planus – flat foot Pes cavus – high arch Plantar fascitis Jones fracture – fx at base of 5th metatarsal Turf toe (great toe hyperextension)

Rehab In small groups come up with a 3 day ankle/lower leg rehab program Show progression through the program Pick one of these injuries: Shin splints Ankle sprain Turf toe Achilles tendinitis

Rehab Examples of beneficial exercises for lower leg/ankle/foot… Balance on dynadisc/foam pads SL hops Calf raises 4 way ankle exercises Towel scrunches Heel walks Toe walks

So how does walking work?

Gait cycle

Let’s walk it out… Looking for… Pronation Supination Toe out/in