THE FOOT, ANKLE AND LOWER LEG Unit 12

The foot has one of the highest incidences of sports injuries. Because of this and the complicated nature of the anatomical structures, injuries to the foot represent a MAJOR challenge to the athletic trainer.

- TRANSMISSION OF STRESS - COORDINATED MOVEMENT FOOT ANATOMY The foot is basically designed for: - STRENGTH - FLEXIBILITY - TRANSMISSION OF STRESS - COORDINATED MOVEMENT

FOOT ANATOMY The 28 bones are divided into: 14 Phalangeal Bones 5 Metatarsal Bones 7 Tarsal Bones 2 Sesamoid Bones

FOOT ANATOMY 14 Phalangeal Bones (Toes): - Designed to give a wider base both for balance and for propelling the body forward.-

numbered 1-5 Phalanges (Toes) Big toe = #1 Little toe = #5 AKA hallux 2 phalangeal bones Little toe = #5 Toes 2-5 have 3 phalangeal bones Proximal=close to metatarsals (blue) Middle (green) Distal = away from metatarsals

5 Metatarsal Bones (Foot): - Lie between and articulate (form a joint) with the tarsals and the phalanges.

Are numbered according to the phalanges they articulate with There is little movement permitted the ligamentous arrangement gives elasticity to the foot in weight bearing.

7 Tarsal Bones: These bones are important for support of the body and its locomotion. Calcaneus (Orange) and Talus (purple) permit inversion and eversion to take place.

Sesamoids Cuboid

FOUR - ARCHES of the FOOT: The arches assist the foot by: - Supporting the body weight. - Absorbing the shock of weight bearing. - Providing a space (plantar aspect) for blood vessels, nerves & muscles.

FYI – not in notes * Medial (inside) * Lateral (outside) * Transverse (back) * Metatarsal (ball of the foot)

Arches of the Foot Medial Longitudinal Arch: - Runs from the calcaneus to the head of the first metatarsal. - Main supporting ligament is the Spring Ligament - acts as a “spring” by returning the arch to its normal position.

Arches of the Foot 2. Lateral Longitudinal Arch: (orange) Runs from the calcaneus to the head of the fifth metatarsal This arch is much lower and less flexible than the medial longitudinal arch.

Arches of the Foot 3. Metatarsal Arch: - This arch runs along the heads of the metatarsals (the ball of the foot). Metatarsal red, transverse blue

Arches of the Foot 4. Transverse Arch: - Is located in front of the heel - This arch gives protection to soft tissue and increases the foot’s mobility.

Movements of theFoot ~ Inversion- the sole of the foot turns in ~ Eversion- the sole of the foot turns out.

FOOT CONDITIONS

1. Heel Contusion: stop and go FOOT CONDITIONS Contusions (bruises) Two types: cause the athlete a great deal of discomfort and disability. 1. Heel Contusion: stop and go 2. Instep Contusion: stepped on or hit (ML arch)

Fractures and Dislocations The foot has high susceptibility to trauma in sports. Kicking an object, being stepped on, or abnormal stresses are the most common mechanisms.

Jones’ Fracture - Fracture of the 5th metatarsal – commonly caused by sharp inversion and plantar flexion of the foot.

Stress Fracture - common on the 2nd and 3rd metatarsal - associated with Morton’s toe.

Morton‘s Toe An abnormally short 1st metatarsal bone - transfer the stress from the big toe the 2nd and 3rd toes. Prone to stress fractures and Interdigital Neuroma. Beware of photo on next page

Interdigital Neuroma - An inflammation of the nerves between the 3rd and 4th metatarsals

- A sprain to the metatarsophalangeal joint Turf Toe - A sprain to the metatarsophalangeal joint - Usually affects the great toe Caused by excessive force applied to toe - Kicking - Hyperextension, pushing off - FB Linemen prone to it due to position stance - More common to occur on artificial turf (harder surface, not as forgiving as grass)

Turf Toe Signs and Symptoms - Point tender; swelling; discoloration (ecchymosis); pain during toe-off when walking, therefore abnormal gait Care - P-R-I-C-E (protect, rest, ice, compression, elevation) Tape toe to limit extension Place a hard, non-yielding insole in the shoe to prevent extension

- Fallen Medial Longitudinal Arch Pes Planus - Fallen Medial Longitudinal Arch - Flat foot Condition is typically congenital (born with it) Causes of injury: bad/old shoes, overweight, weak arches, severe pounding on hard surface

Pes Cavus - Clawfoot - Hollow Foot - High Arch Can lead to chronic pain Treatment: Wear supportive devices (orthotics).

Take off your shoes and socks You will be analyzing your partners arch. Have them stand on a sheet of paper. Best if slightly weight bearing. What type of arch do you think they have? Outline their foot – only part touching the ground (the best you can)

What type of footprint did you leave?

Arch Sprain Often caused by running on a hard surface, improper footwear, or repetitive stress Signs and Symptoms - Pain in the arch especially when walking or running - Swelling and point tenderness on plantar surface

Treatment - P-R-I-C-E - Arch pad - Exercise foot muscles and stretch Achilles tendon

Bunions Hallux Valgus - Great Toe - structural or friction Tailor’s Bunions - affects the 5th metatarsophalangeal joint - friction.

Plantar Fasciitis A chronic problem associated with a resistance to stretch of the Achilles tendon. Common to distance runners. Increased pain in the morning.

THE ANKLE Unit 12 b

- Ankle injuries, especially to the ligamentous tissue, are the most frequent injuries in sports. - Understanding the complex nature of ankle injuries should be a major goal.

THE ANKLE - The ankle is considered a hinge joint. Anatomy - The ankle is considered a hinge joint. - The strongest aspect of the ankle joint is its bony arrangement - provides most of the stability.

Only two movements occur at the ankle joint - Plantar Flexion - Dorsiflexion.

ANKLE ANATOMY Four bones make up the ankle joint: Tibia Fibula Talus Calcaneus

TIBIA: - Is the largest bone in the lower leg. - It‘s main function is to support the body’s weight. - The distal end forms the MEDIAL MALLEOLUS.

FIBULA: - Is located on the lateral side of the leg. - Its main function is to provide an attachment for ligaments and muscles. - The distal end forms the LATERAL MALLEOULUS.

TALUS: - Is the main weight-bearing bone of the articulation TALUS: - Is the main weight-bearing bone of the articulation. - It rests on the calcaneus. CALCANEUS: - Also known as the Heel Bone

THE ANKLE LIGAMENTS: - The ligamentous support of the ankle reinforces the bony arrangement. - This support consists of the CAPSULE and - Five ligaments on the lateral aspect - One ligament on the medial aspect.

LIGAMENTS LATERAL LIGAMENTS: Are usually injured when a person rolls an ankle Anterior Talofibular Lig. (ATF) - the ligament most commonly sprained - most athletes sprain the ATF ligament at some point of their career Calcaneofibular Lig. Posterior Talofibular Lig. ATF red, calcaneo fib blue,post. TF yellow

LIGAMENTS When a person suffers a high ankle sprain, he usually injures the... - Posterior Tibiofibular Lig. or - Anterior Tibiofibular Lig. Post.tibfib green, ant tibfib purple

LIGAMENTS MEDIAL LIGAMENTS: Deltoid Ligament - very strong and therefore less frequently injured Deltoid red

THE ANKLE Muscles and Movements: The muscular arrangement is the WEAKEST aspect of ankle stability - The muscles are located in the lower leg and long tendons have to cross the joint.

ANKLE MUSCLES Lateral Aspect: Peroneal Family Posterior Aspect: - 3 muscles: Longus, Brevis, and Tertius) Posterior Aspect: Gastrocnemius Soleus Achilles Tendon

ANKLE MUSCLES Anterior Aspect Medial Aspect Tibialis Anterior Dorsiflexion, Inversion Medial Aspect Tibia Bone – no muscles

Movements of the Ankle Plantar flexion- toes move away from lower leg (down) - The pushing-off movement when you walk or jump Dorsiflexion- pulling the toes and foot upward toward the leg. End lecture

Ankle and Lower Leg Injuries and Conditions

INJURY PREVENTION Stretching - Achilles Tendon Strengthening - Key Muscles Proprioceptive Training Wearing Proper Footwear Taping or Bracing

A sprain is a stretching or tearing of ligaments LIGAMENT INJURIES A sprain is a stretching or tearing of ligaments Usually occurs as a result of trauma to a joint that is forced to an extreme range of its motion

MECHANISMS of INJURY Injuries are generally caused by a sudden lateral or medial twists. Inversion sprains are the most common. Most sprains are a vertically loaded rather than a horizontally load.

MECHANISMS of INJURY Usually a lateral sprain will involve 1 or 2 ligaments - this depends on the mechanism of injury. Tight Achilles Tendon increases the chance of a sprain.

ANKLE SPRAIN Because of their frequency and the disability that results, ankle sprains present a major problem to the athletic trainer. Can occur on the lateral or medial aspect of the ankle

ANKLE SPRAIN Most sprained ankle injuries are rushed back to activity before healing has taken place.

Incompletely healed, the ankle becomes chronically inflamed and unstable, eventually causing a major problem for the athlete.

SPRAINED ANKLE LATERAL and MEDIAL Signs, Symptoms and First Aid: - First Degree - Second Degree - Third Degree

Ankle Sprain Signs and Symptoms - pain - swelling - discoloration - athlete may have heard or felt a pop or snap - usually inability to function normal

First Degree Ankle Sprain 0-20% of the ligaments are torn - a thorough evaluation is neccessary to rule out a fracture and to determine the degree of injury

If a fracture can be ruled out and the athlete can run without limping he or she might return to competition after being taped for support

Second Degree Sprain With a second degree sprain, swelling is rapid and usually in form of a grapefruit 20% to 70% of the ligamentous fibers are torn, which means the joint is now somewhat unstable The athlete experiences moderate to severe pain

With a third degree ankle sprain, swelling may be rapid or delayed Third Degree Sprain With a third degree ankle sprain, swelling may be rapid or delayed It affects the entire ankle and foot

70% to 100% of the ligamentous fibers are torn, which leaves the joint extremely unstable The athlete usualy experiences extreme pain for a few seconds, then moderate or no pain

Treatment First aid treatment consists of - P-R-I-C-E for the first 48 to 72 hours - Crutches If the condition has not improved after 72 hours the athlete should be sent to the team physician for x-rays to eliminate the possibility of a fracture

Special Test Kleiger’s Deltoid ligament Also high ankle sprains Anterior Tibiofibular and Posterior Tibiofibular Patient: seated with knee flexed, feet over end of table. Examiner: one hand stabilize lower leg, other holds medial aspect of foot, rotate laterally Positive: pain on deltoid or lateral malleolus

Special Test Talar Tilt (inversion stress) Inversion / Eversion Sprains ATF, PTF, CF Patient: seated with knee flexed, feet over end of table, relaxed. Examiner: one hand stabilize lower leg, other hand moves ankle to 90 degrees of flexion, invert calcaneus Positive: excessive movement of talus To test deltiod; evert calcaneus

Special Test Anterior Drawer ATF ligament and capsule Patient – sits over edge of table leg relaxed Examiner – cups heel with one hand, grasps lower leg just above ankle mortise with heel of other hand Pull heel anteriorly while stabilizing tibia and fibula Positive – movement forward occurs or “clunk” sounds Modification – can be done with foot stabilized on table

ANKLE FRACTURES or DISLOCATIONS Forced Inversion Forced Eversion Forced Rotation Avulsion Fractures - Ligaments and / or Muscles Signs, Symptoms and First Aid:

Ankle Dislocation Signs and Symptoms - Severe pain - Obvious deformity Can occur anterior or posterior Signs and Symptoms - Severe pain - Obvious deformity - Loss of function - Rapid swelling

Treatment - A dislocated ankle is a medical emergency!!! - Call 911 immediately - Splint lower leg and ankle in the position you find it in - DO NOT MOVE the athlete - Treat athlete for possible shock

Special Test Compression Lower leg Fx Patient: seated with legs straight, feet over end of table, relaxed. AT: with heel of both hands compress tibia and fibula together just inferior to knee. Repeat in one inch intervals inferiorly Positive: Increases pain

Special Test Percussion Lower leg Fx Patient: seated with legs straight, feet over end of table, relaxed. AT: One hand stabilizes lower leg (gently), with heel of other hand apply force upward on calcaneus. Repeat with increasing force. Positive: Increases pain in lower leg

ACHILLES TENDON INJURIES STRAIN Are not uncommon in sport and can result after an ankle injury due to strength imbalance. Tendency to become chronic.

TENDINITIS Can develop from a strain, jerking movements, friction or an increase in activity.

ACHILLES TENDON INJURIES BURSITIS - occurs from pressure on, or overstretching of the Achilles Tendon. - Inflammation of the Bursa Sac.

ACHILLES TENDON INJURIES FIRST AID: Ice Both heels should be elevated. Taping - helps reduce the stress. Stretching of the Achilles Tendon.

ACHILLES TENDON INJURIES RUPTURE - Common in sports that require stop and go movements. - Can occur to anyone but more common in athletes over the age of 30. - A history of chronic inflammation predisposes an athlete.

Often a loud SNAP can be heard. Heel raises are IMPOSSIBLE. Classic Signs & Symptoms: Athlete will state that someone KICKED them in the calf or stepped on the back of their shoe. Often a loud SNAP can be heard. Heel raises are IMPOSSIBLE. A POSITIVE THOMPSON TEST.

Special Test Thompson’s Test Achilles Tendon Rupture Patient: lays prone on table with feet suspended over edge AT: squeeze belly of calf and observe foot Positive: foot will not move when calf is squeezed

PERONEAL TENDON SUBLUXATION Caused by a second or third degree sprain. The result is a tearing of the capsule that holds the peroneal tendons in place. “Popping” or “Snapping”

Tibial Stress Syndrome Commonly called “shin splints” Can be medial or lateral Accounts for 10-15% of all running injuries Symptoms and signs 4 grades 1 – pain after activity only 2 – pain before and after 3 – pain before, during and after 4 – pain so severe cannot participate in activity Treatment X-rays/bone scan recommended to rule out fx Ice massage and flexibility training

ANKLE EVALUATION Understand the mechanism of injury -What happened Evaluate - Bones (rule out fracture) - Ligaments (extend of damage) - Muscles ( check for strength)