Foot and ankle Common injuries

Squeamish? Roll/twisted ankle: Breaking ankle: http://www.youtube.com/watch?v=lgNttdd7UIc Breaking ankle: http://www.youtube.com/watch?v=vA5BU045gi4 Kevin Ware https://www.youtube.com/watch?v=6PSV0AV1BI0 Luis Garrido https://www.youtube.com/watch?v=EZi4MhKS9Lk

Bones injuries S&S Pain Decreased ROM Swelling Bruising NWB Obvious deformity

Any bone Epiphyseal Fx Jones Fx Acute fx Stress fx Avulsion fx How many types of acute fx do we have? ___ Stress fx Avulsion fx Epiphyseal Fx Fx to the growth plate (typically tib/fib) MOI: Plantarflexion and inversion Serious – potential to stunt growth Jones Fx Avulsion fx of the styloid process of the 5th MT Forceful muscle contraction w/ ankle inversion Union vs. non-union

Non-Union

Knock-off Fx Stress Fx Fx to lateral malleolus Forced dorsiflexion & inversion Stress Fx Most commonly tib/fib and MT Repetitive stress (usually from running) Pain becomes more intense at night and following activity Usually Dx w/ bone scan (Dexa-Scan) or MRI

Knock-off fx Bi-malleolar fx

Bone Scan

Grading system Ligament: bone to bone Tendon: muscle to bone 1+/-: stretched, but no tearing/fraying of fibers 2+/-: tearing, but incomplete 3: complete tear

Soft Tissue Injury S&S: Pain Swelling Decreased ROM Increased temp of skin Bruising NWB + laxity test

Ligament/tendon injuries ATFL– Most commonly sprained MOI – “rolling ankle”, stepping in hole Accounts for 85% Deltoid Ligament Keep ankle from evertion; stronger than ATF MOI – Stepping in hole High Ankle Sprain – Syndesmotic Sprain MOI - Dorsiflexion and evertion Accounts for 15% Achilles Tendon Tendinitis/Rupture More commonly torn with age MOI – Forced Dorsiflexion with knee bent

https://www.youtube.com/watch?v=CdbJmKB0buk

Great-Toe Sprain Arch Sprain Plantar Faciitis MOI - Forced Flexion/Extension “Turf Toe” Arch Sprain Repetitive stress, running on hard surface, or improper footwear Pain with running and swelling over affected arch Plantar Faciitis Inflammation of the thick connective tissue

Muscle Injuries Strain Common muscles affected: Grade 1, 2, 3 Peroneals Gastrocnemius/Soleus complex Tibialis Anterior

“shin Splints” If left un-treated can cause: Caused by: Medial tibial stress syndrome (MTSS) Irritated and swollen muscles, often from overuse, ramping up workout intensity, changing the surface, improper/old footwear Caused by: Over-pronation or ''flat feet" -- when the impact of a step makes your foot's arch collapses If left un-treated can cause: Stress fractures, which are tiny breaks in the lower leg bones

Tx: Rest your body. It needs time to heal. Ice your shin to ease pain and swelling. Do it for 20’ every 3 to 4 hours for 2 to 3 days, or until the pain is gone. Anti-inflammatory painkillers. NSAIDs Arch supports for your shoes. Orthotics -- which can be custom-made or bought off the shelf -- may help with flat feet. Range-of-motion exercises Neoprene sleeve for support. Physical therapy to strengthen the muscles in your shins.

You know it’s healed when.. Your injured leg is as flexible as your other leg. Your injured leg feels as strong as your other leg. Your can jog, sprint, and jump without pain. Your X-rays are normal or show healed stress fx. There's no way to say exactly when your shin splints will go away. It depends on what's causing them. People also heal at different rates; 3 to 6 months is not unusual.

Misc Injuries Ankle dislocation Force applied to joint stronger than joint could withstand Reduction: https://www.youtube.com/watch?v=ANA2b-g3qaw

Contusion – broken blood vessels leaking into soft tissue. MOI – Blunt force trauma

Toe Abnormalities Hammertoe Middle Phalanyx flexed while Distal and Proximal are hyperextended MOI- Rupture of Extensor Digitorum Longus due to BFT

Ingrown Toenail Nail grows into surrounding soft tissue often result of poor trimming May need to be surgically excised

Diagnosis Process HOPS: History Observation Palpation – Provides a reference for the comparison of bilateral symmetry of bones, alignment, tissue temperature, or other deformity as well as the presence of increased tenderness Joint and Muscle Functional Assessment – impairment due to ROM, Strength, P with movement Joint Stability Tests – reference for laxity, gapping, hypo/hypermobility, end-feel Special Test

Manual Muscle Testing Patient position: Muscle tested must be against gravity Examiner position: stabilize proximal to the joint being tested and provide resistance to the distal joint “Break test” Positive test: weakness and/or pain compared contralateral

Grading 5/5 Normal: can resist max pressure with no pain 4/5 Good: can resist moderate pressure 3/5 Fair: Can move body part against gravity thru full ROM 2/5 poor: Can move body part in gravity-eliminated position thru full ROM 1/5 Trace: cannot produce movement, but muscle contraction is palpable 0/5 Zero: No contraction is felt

End-Feel (Normal) Soft: soft tissue approximation (ex: knee flexion) Firm: Muscular stretch/Capsular Stretch/Ligamentous Stretch (ex: MCP extension) Hard: bone to bone ex: Elbow ext

End-feel (pathological) Soft: occurs sooner or later in ROM than normal in a joint that normally has a firm or hard end-feel ex: edema/synovitis Firm: occurs sooner or later in ROM than normal in a joint that normally has soft or hard end-feel ex: Capsular/muscular/ligamentous shortening Hard: occurs sooner or later in ROM than normal in a joint that normally has soft or firm end-feel; feels like a bony block ex: Loose bodies in joint/myositis ossificans/fx Spasm: Joint motion is stopped involuntarily or voluntary muscle spasm ex: inflammation/strain/joint instability Empty: no end-feel bc end of ROM is never reached; no resistance felt (except for patient’s protective muscle splinting or muscle spams called “muscle guarding”)