Foot, Ankle, and Lower Leg

Foot bones Foot bones 26 bones 14 phalangeal 5 metatarsals 7 tarsals

Toes Each toe except for the big toe has three phalanges Toes 2-5 are also known as digits The big toe, a.k.a. hallux, has two. The toes are designed to widen our base for balance and propelling our body. Two sesamoid bones are located under the 1st metatarsalphalangeal joint (MTP joint) These bones help increase the mechanical advantage of the flexor tendons that run under the big toe.

Metatarsals Five bones that lie between the toes and the tarsal bones The first metatarsal is the biggest and the strongest. This helps it function as the main weight bearing support during walking and running. The fifth metatarsal protrudes on the lateral aspect of the foot. Place where ligaments and muscle tendons attach

Ankle Bony Anatomy Talus (link between lower leg & foot) Tibia Fibula Medial malleolus Fibula Lateral malleolus Mortise Tibial tuberosity Tibial condyles

Bony Anatomy

Functional Anatomy Ankle is a stable hinge joint Medial/lateral dislocation is prevented by malleoli Square shape of talus adds stability of ankle Most stable during dorsiflexion, least stable in plantar flexion

Ankle Motions Plantar Flexion Dorsiflexion Inversion Eversion Pronation Supination

Ankle Articulations Talar Joint (Talocrural joint) Tibia & fibula with talus Dome of talus articulates with mortise formed by tibia & fibula Motions: dorsiflexion & plantar flexion Subtalar Joint Articulation of talus with calcaneus Motions: inversion & eversion

Soft Tissue Gastrocnemius Soleus Tibialis posterior Tibialis anterior Peroneus longus Peroneus brevis Plantaris Plantar fascia Anterior talofibular Anterior tibiofibular Calcaneofibular Posterior talofibular Deltoid ligament Tibionavicular Calcaneotibial Anterior talotibial Posterior talotibial tibionavicular ligament, calcaneotibial ligament, anterior talotibial ligament, and the posterior talotibial ligament

Muscles of the Lower Leg Anterior tibialis Flexor digitorum longus Flexor hallucis longus

Muscles of the Lower Leg Peroneus tertius Peroneus longus Peroneus brevis

Muscles of the Lower Leg Gastrocnemius Soleus

Muscles of the Lower Leg

Muscles of the Lower Leg

Compartments of the Lower Leg Anterior Tibialias anterior Extensor digitorum longus Peroneus tertius Extensor hallucis muscles Peroneal Peroneus longus Peroneus brevis Deep Posterior Popliteus Flexor digitorum longus Flexor hallucis longus Tibialis posterior Superficial Posterior Gastrocnemius Soleus Plantaris

Ligaments Lateral aspect Medial aspect Anterior talofibular (ATF) Anterior tibiofibular Calcaneofibular (CF) Posterior talofibular Medial aspect Deltoid Ligament

Medial Ligaments of Ankle Deltoid Ligament rarely injured in sports mechanism of injury typically eversion with dorsiflexion longer time to heal than lateral ankle ligaments

Lateral Ligaments of Ankle 3 primary ligaments: anterior talofibular posterior talofibular Calcaneofibular NOT as large & strong as the deltoid. Mechanism of injury is inversion associated with plantar flexion.

Pes Planus or Cavus Structural Deformities Pes Planus = flat footed/ no arch Pes Cavus = high arch

Feiss’ Line The Feiss' line is a line that is made across a patient's foot that looks for navicular drop.  The patient is seated over the edge of a table.  A line is drawn from the medial malleolus to the plantar aspect of the 1st MTP joint while the patient is in a non=weight-bearing position.  The examiner marks the position of the navicular tubercle.  The patient is then instructed to stand up from a seated position.  While the patient is now weight bearing, the navicular is re-examined relative to the line that was originally drawn.   If the navicular tubercle is above the Feiss' line, this is indicative of a supinated or pes cavus foot.    If the navicular tubercle still intersects the Feiss' line, this is a neutral foot.   If the navicular tubercle is below the Feiss' line, this is indicative of a pronated or pes planus foot. 

History Past Mechanism Changes in symptoms Has this ever happened Before Mechanism What happened How did it happen When did it happen What specific mvmt caused the injury? Did you fall? How did you land? Which direction did the body part move? Changes in symptoms Symptoms incr. or decr. since injury Taking any meds? Treating it on your own at all

History Pain Sounds or Sensations Where does it hurt? Point with ONE finger Rate the pain Scale of 1-10 What makes it hurt? Specific movements? positioning When does it hurt? Can you describe the pain? Sounds or Sensations Did you feel any unusual sensations when it occurred? Did you hear any unusual sounds when it occurred?

Observation/Inspection Movement How do they move? How did he walk in? What mannerisms did he use during the history? Facial expressions Asymmetries/ Deformity Do both sides look the same? Obvious deformity Swelling - Lumps Markings - Redness/ Discoloration Sounds

Palpation Used to confirm or deny assessments. Start away from the injury and move toward the site of pain (about 2-3 inches when appropriate) Palpate Bilaterally (both sides) Start w/ light pressure then move to deeper palpation

Palpation Notice Point Tenderness Trigger Points Crepitus Specific site of pain Trigger Points Crepitus Grinding, crunching, or crackling sensation with the rubbing of tissues Tissue Density Increased Spasm Scarring Decreased Swelling Hemorrhage Symmetry Are both sides equal Temperature

Common Injuries to the Ankle & Lower Leg

Contusions Occur most often on tibia Can be painful and disabling Complication compartment syndrome

Muscle Strains Most common in calf Result from: Result from: violent contraction Overstretching Continued overuse Result from: Repetitive overuse Single violent contraction Acute strain to Achilles have tendency to become chronic

Cramps A sudden, involuntary contraction of a muscle Contributing factors include: Fatigue Fractures Dehydration Lack of nutrients in diet Poor flexibility Improperly fitted equipment

Cramps—Treatment Passive stretching Fluid replacement Water Sports drink Massage Rest Ice

Achilles Tendonitis Inflammation of Achilles tendon Tearing of tendon tissues caused by excessive stress Occurs at point where tendon attaches to heel

Achilles Tendonitis Symptoms develop gradually Repeated or continued overstress increases inflammation Pain, crepitus, redness Treatment Prevention Stretching Ice/Rest NSAIDs Heel lift/Achilles taping

Achilles Tendon Rupture Rupture occurs w/in tendon, approx 1-2” proximal to insertion Eccentric force applied to dorsiflexed foot Poor conditioning Overexertion Direct trauma Surgically repaired Rehab = 1yr + Thompson test

Erik Karlsson achilles injury Chauncy Billups Thompson Test

Medial Tibial Stress Syndrome aka shin splints term for pain that occurs below knee Anterior shin Medial shin Result of doing too much too soon Associated with: repetitive activity on hard surface forcible excessive use of leg muscles (running, jumping) tightness of gastroc and/or soleus muscles improper footwear running biomechanics

MTSS Treatment Ice Reduce activity level Gentle stretching Biomechanical assessment Orthotics NSAIDs Strengthening and flexibility program

Stress Fractures Incomplete crack in bone Microscopic fractures in bone that will eventually lead to full fracture if left untreated Repeated stress placed on bone greater than body’s ability to heal it

Stress Fractures—S/Sxs “hot spot” of sharp, intense pain upon palpation Shin-splint Pain more generalized Pain worse in am Stress Fx Pain worse in pm

Compartment Syndrome Swelling within one or more of the compartments of the lower leg Caused by: Contusion Fracture Crush injury Localized infection Excessive exercise Overstretching

Ankle Sprains MOI: combo of excessive inversion and PF aka lateral ankle sprain Anterior Talofibular Ligament (ATF) Calcaneofibular (CF) Posterior talofibular (PTF) Eversion (medial) ankle sprain less common Deltoid ligament

Ankle Sprains Injury to ligamentous and capsular tissue Traumatic joint twist that results in stretching of total tearing of the stabilizing connective tissue One of most common & disabling sports injuries General Symptoms: Joint swelling Local temperature increase Pain Point tenderness Skin discoloration

Ankle Sprains

Inversion Eversion Syndesmotic Anterior Talofibular Calcaneofibular Posterior Talofibular Eversion Deltoid Ligament Syndesmotic High ankle sprain

Ankle Sprain—S/SXS Grade 1 Grade 2 Grade 3 Some pain Severe sprain Minimum LOF Mild point tenderness Little or no swelling No abnormal motion Grade 2 Pain Moderate LOF Swelling Slight to moderate instability Grade 3 Severe sprain Extremely painful initially LOF Severe instability Tenderness Swelling May represent subluxation that reduced spontaneously

Ankle Sprain—Treatment R.I.C.E. Crutches Boot Splint, tape, brace Compressive wrap Horseshoe

Fractures Mechanism Signs/symptoms: most often caused by direct trauma to the tibia, fibula or bone(s) of the foot repeated “microtrauma” can result in a stress fracture growth plate injures can occur in the adolescent -- known as “Salter-Harris” fractures Signs/symptoms: swelling/deformity, discoloration broken bone end protruding athlete reports a snap/pop inability to bear weight stress fractures often become more painful at night

Fractures First Aid: treat for shock apply sterile dressing to any open wounds carefully immobilize using appropriate splinting technique contact EMS and arrange for transport Hudson Fracture Kevin Ware Injury

Special Tests & Rehabilitation

Anterior Drawer Talar Tilt Tests integrity of anterior talofibular ligament Tests integrity of calcaneofibular ligament

Squeeze Test Bump Test/Tap Test Squeezing the tibia and fibula together Can indicate fracture or high ankle sprain Bump calcaneus Indicate fracture to tibia/fibula Indicate high ankle sprain Tap mallelous Indicate fracture of particular bone

Ankle Rehab 4-way TheraBand® Heel walks/Toe walks 3-way heel raises Unilateral Balance 3-way Tramp throw