Injuries to the Lower Leg, Ankle, and Foot Chapter 16 Injuries to the Lower Leg, Ankle, and Foot

Anatomy Ankle/Foot Bones of Ankle & Foot Tibia Fibula Tarsals (7) Metatarsals (5) Phalanges (14)

Anatomy Ankle/Foot Foot Bones (medial view)

Anatomy Ankle/Foot Joints Ankle Distal Tibiofibular Subtalar Dorsiflexion/Plantarflexion Distal Tibiofibular Subtalar Inversion/Eversion Intertarsal Tarsometatarsal Metatarsophalangeal Interphalangeal

Ligaments The deltoid ligament is the primary stabilizer of the medial side of the talocrural (ankle) joint.

Ligaments Lateral ligaments The three primary ligaments are: Anterior talofibular Posterior talofibular Calcaneofibular Anterior/Posterior Tibiofibular

The Lateral Ankle These ligaments are NOT as large or strong as the deltoid. Additional lateral stability is provided by the length of the fibula on the lateral side of the ankle. The talocrural (ankle) joint is strongest in dorsiflexion and weakest in plantar flexion.

Muscular Compartments Three muscular compartments: Anterior Dorsiflexors and Extensors Lateral Evertors Superficial/Deep posterior. Plantarflexors and invertors. Achilles Tendon

Neurovascular supply The neurovascular supply of the three compartments: Anterior Deep peroneal nerve & artery Lateral Superficial peroneal nerve & artery Posterior Tibial nerve & artery

Common Sports Injuries Traumatic injuries typically involve skeletal and ligamentous structures. Fractures and sprains. Chronic injuries usually involve damage to soft tissues in the area but also include stress fractures. Some soft-tissue damage can result in severe complications.

Fractures Most often caused by direct trauma through contact. Contact causes most fractures to the lower leg and foot. Common fracture sites: Distal tibia and fibula. Metatarsal fractures from being kicked or stepped on. Non-union fracture to 5th is common if blood supply is disrupted. Avulsion fracture of 5th metatarsal can occur with a lateral ankle sprain. Repeated microtrauma can result in a stress fracture.

Fractures Signs and symptoms Swelling and/or deformity at the site of fracture. Possible broken bone end projecting through skin. Inability to bear weight on the affected leg. Discoloration at the site. Athlete reports a snap or pop was heard or felt. For a stress fracture or growth plate fracture that did not result from traumatic event, the athlete complains of extreme point tenderness and pain at the site of injury.

Fractures First Aid Carefully immobilize the foot and leg using a splint. Apply sterile dressing to any open wounds. Watch and treat for shock, if necessary. Arrange for transport to a medical facility. All fractures require immobilization. Many fractures will require surgery and extensive mobilization. Participation while a fracture is healing is not recommended.

Soft Tissue Injuries Ankle Injuries Ankle sprains can occur in virtually any sport and can limit the abilities of the athlete in performance. As the severity of the ankle sprain increases, so does the instability of the ankle . Lateral sprains are more common; 80% to 85% of all ankle sprains are to the lateral ligaments (inversion sprains). Eversion sprains, while less frequent, are often severe.

Ankle Sprains Signs and symptoms depend on degree of sprain. 1st degree: Pain, mild disability, point tenderness, little laxity, little or no swelling 2nd degree: Pain, mild to moderate disability, point tenderness, loss of function, some laxity, swelling (mild to moderate) 3rd degree: Pain and severe disability, point tenderness, loss of function, laxity, moderate to severe swelling

Courtesy of Brent Mangus Ankle Sprains First Aid Apply ice and compression. Elevate. Apply a horseshoe- or doughnut-shaped pad. Courtesy of Brent Mangus

Ankle Sprains First Aid Have athlete use crutches with three- or four-point gait if a second- or third- degree sprain has occurred. If there is any question regarding the severity of the sprain, refer athlete to a medical facility for physician’s evaluation. Allow time for ankle injury to heal properly.

Ankle Sprains Tibiofibular (tib-fib) Sprains – “High ankle” These injuries are often treated inappropriately as lateral ankle sprains, hindering recovery. The difference is the mechanism of injury. Tib-fib sprains involve dorsiflexion followed by axial loading with external rotation of the foot (Ant/Post Tibiofibular Ligs, IO Memb). Symptoms include a positive ext. rot. test, but athlete is also in great pain. “Squeeze test” elicits pain in syndesmosis area.

Tibiofibular Sprains – “High ankle” First Aid Immediately apply ice and compression, and elevate the leg. Apply a doughnut-shaped pad kept in place with an elastic bandage to provide compression. Have athlete rest and use crutches for first 72 hours, followed by wearing a walking boot for 3 to 7 days. Refer athlete to a medical facility for physician’s evaluation.

Preventing Ankle Injuries Taping or bracing will reduce the number of ankle injuries. Prophylactic adhesive taping supports the ankle only for a short time. Bracing may be better than taping. Bracing combined with some high-top shoes may be helpful. Address weaknesses in joint complex. Courtesy of McDavid

Chronic Ankle Instability Chronic Ankle Instability is when an athlete experiences repeated ankle sprains. Mechanical causes Use prophylactic bracing and taping. Functional causes Rehabilitate weakened structures. Restore ankle proprioception and neuromuscular control.

Tendon-Related Injuries Achilles tendon is commonly injured by long-distance runners, basketball players, and tennis players. Onset of tendonitis may be slow among runners, but more rapid among basketball and tennis players. Athletes who dramatically increase workout times or running distances, or who run on hard, uneven, or uphill surfaces are prone to Achilles tendonitis. The injury can be either acute or chronic. Acute injuries often associated with explosive jumping or blunt trauma.

Tendonitis Variety of tendons can be effected via acute or chronic mechanisms. Signs and symptoms Increased temperature in the immediate area. Tendon is painful on touch and movement and appears thickened. The pain associated with this condition is localized to a small area of the tendon and typically intensifies when movement is initiated after rest. First aid (Not necessary if chronic) Rest, Ice, Compression, Protection.

Achilles Tendon Rupture Signs and symptoms Swelling and deformity at site of injury. Athlete reports a pop or snap associated with the injury. Pain in lower leg that ranges from mild to extreme. Positive Thompson Test. Loss of function, mainly in plantar flexion. First Aid Immediately apply ice and compression. Immobilize with air cast or splint. Arrange for transport to nearest medical facility. Surgery is recommended.

Compartment Syndrome Compartment syndrome usually involves swelling of muscles inside lower leg compartments. Swelling puts pressure on vessels and nerves and can cause permanent damge. Acute trauma, such as being kicked in the leg, can result in swelling within the compartment. Very typical in the anterior compartment of the lower leg. Properly sized shin guards can protect lower leg in soccer. Chronic form is related to overuse of the compartment’s muscles.

Compartment Syndrome Signs and symptoms First Aid Pain and swelling in the lower leg. There may be loss of sensation or motor control to the lower leg and/or foot. Inability to use muscles in compartment (i.e., extend the big toe or dorsiflex the foot if anterior compartment). There can be loss of pulse in the foot. First Aid Apply ice & elevate. Do NOT apply compression. If there is numbness, loss of movement, or loss of pulse, seek medical advice immediately = medical emergency.

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Tibial Stress Syndrome “Shin Splints” “Shin splints” is a very common disorder of lower leg. Term describes exercise-induced leg pain. The types of activities that produce this problem and the manifestations of the injury vary depending on the athlete. The etiology and pathology of this disorder are unclear. May relate to biomechanics and neuromuscular characteristics or to training errors.

Shin Splints Signs and symptoms Lower leg pain either medially or posteromedially. Typically, the athlete reports a chronic problem that progressively worsens. Pain can be unilateral or bilateral. First Aid Apply ice and have the athlete rest. Use of NSAIDs may be helpful. Athlete may need to have his or her gait analyzed for biomechanical deficiencies. If problem worsens, athlete should seek medical advice.

Plantar Fasciitis The plantar fascia is a dense collection of tissues that traverses from the plantar aspect of the metatarsal heads to the calcaneal tuberosity. If this tissue becomes tight or inflamed by overuse or trauma, it can produce pain and disability. Typical symptom is extreme pain in the plantar aspect of the foot with the first steps taken after getting out of bed in the morning. Pain eases with subsequent steps. Athlete also has point tenderness in the region of the calcaneal tuberosity.

Plantar Fasciitis Treatment is typically conservative and includes: Rest and Anti-inflammatories. Applying cold and heat alternatively to enhance healing. A heel pad and stretching the Achilles tendon complex can assist in recovery. Use of semirigid orthoses is also effective, but some athletes find it difficult to participate with such an orthotic in their shoes. Re-aggravating the injury increases the healing time.

Heel Spurs Heel spurs can be related to chronic plantar fasciitis. Chronic inflammation can result in ossification at the calcaneal tuberosity on bottom of heel. Heel spurs result in long-term disability for many athletes. Treatment of Heel Spurs Rest, ice, and changing footwear may help. Applying a doughnut-shaped pad beneath the heel spur may help. Athlete should consult a physician if spurs become incapacitating.

Morton’s Foot Morton’s foot typically involves either a shortened 1st metatarsal or an elongated 2nd metatarsal bone. This results in a weight shift to the 2nd metatarsal instead of along the 1st metatarsal. Results in pain throughout the foot during ambulation.

Morton’s Foot Morton’s foot may result in Morton’s neuroma. A neuroma is an abnormal growth on a nerve. The problem is usually with the nerve between the 3rd and 4th metatarsal heads. Pain radiates to 3rd and 4th toes. Tight-fitting shoes may be the cause. Going barefoot may help. This condition is best cared for by a physician.

Arch Problems There are two groups of arch problems Pes planus (flat feet) related to over-pronation. Excessive pronation can cause stress on navicular bone, soft tissue, and some of the joints around the ankle. Arch taping has limited effectiveness. Corrective arch orthoses or shoe selection in most beneficial. Pes cavas (high arches) associated with plantar fasciitis and clawing of the toes. Athlete may benefit from orthotic device.

Bunions Bunions may result from inflamed bursae or bone or joint deformities. Typical at 1st metatarsophalangeal joint, but 5th metatarsophalangeal can also be effected. Bunions are uncommon in high school and college athletes. Often caused by improperly fitting shoes. Chronic bunions should be evaluated by physician.

Blisters & Calluses Blisters and calluses are common formations, resulting from friction between layers of skin as a result of improperly fit or broken in shoes. Blisters When a blister forms, fluid collects between skin layers, occasionally the fluid will contain blood. Large blisters should be drained and the area padded to prevent further friction. Use sterile instruments and wear latex gloves or some other barrier to avoid contact with athlete’s body fluid. Calluses Form around bony areas. Buff to prevent growth.

National Safety Council Blisters National Safety Council First Aid Procedures Wash area with soap and warm water; sterilize area with rubbing alcohol. Use sterile needle to puncture the base of the blister and drain by applying light pressure. Process may need to be repeated during the first 24 hours. Do not remove the top of the blister. Apply antibiotic ointment to the top and cover with sterile dressing. Pad area with sterile bandages or foam. Check daily for signs of infection (redness or pus). After 3–7 days, remove the top of blister and apply antibiotic ointment and sterile dressing.

Turf Toe—Hyperextension of 1st MP Joint. Treat w/ ice/tape. Toe Injuries Turf Toe—Hyperextension of 1st MP Joint. Treat w/ ice/tape. Stone Bruise– Fat Pad bottom of heel is contused. Treat w/ doughnut pad and ice. Common injuries are torn-off nails or hematoma formation (blood) under the nail. Hematomas under nail needs to be released. Use commercially available nail bore to drill small hole in nail to release blood. Ingrown toenails may result from improperly fitting shoes. Soak affected toe in warm antibacterial solution. Elevate toenail by placing a small cotton roll under it and leave in place as nail grows. Have athlete obtain shoes that fit more comfortably.

Basic Ankle Taping 1. 2. 3. Anchors and Stirrups

Basic Ankle Taping 4. 5. 6. Stirrup Anchors and Medial Heel Lock

Basic Ankle Taping 7. 8. 9. Lateral Heel Lock

Basic Ankle Taping 10. 11. 12. Figure 8

Basic Ankle Taping 13. 14. 15. Figure 8 and closure strips (horseshoes)