Unit 5:Understanding Athletic-Related Injuries to the Lower Extremity Foot and Ankle, Anatomy and Injuries Sports Medicine

The Foot and Ankle

The Foot (Bones) Bones = 26 14 phalanges 5 metatarsals 7 tarsals

Toes (Phalanges) Designed to give wider base for balance and propelling the body forward. 1st toe (Hallux) Two sesamoid bones located under the 1st MP joint.

Metatarsals 5 Bones 1st metatarsal is the largest and strongest and functions as the main body support during walking and running. Palpable at the ball of the foot. 5th metatarsal most common fractured.

Tarsals 7 bones Aids in the support of the body. Calcaneous = largest tarsal bone, supports talus and shapes heel, and provides attachment for achilles tendon.

Joints of the Foot Interphalangeal joint (IP) Flexion / Extension Metarsalphalangeal joint (MP) Abduction / Adduction

Bones of the Ankle Tibia Fibula Talus Main weight bearing bone of LOWER LEG Forms medial malleolus Fibula Non-weight bearing Mainly muscle and ligament attachment Forms lateral malleolus Talus Main weight bearing bone of the ANKLE

Lateral Ligaments of the Ankle Resist ankle inversion Anterior talofibular (ATF) Most commonly sprained Calcaneofibular (CF) Posterior talofibular (PTF)

Medial Ankle Ligaments Deltoid Resists ankle eversion Low rate of injury

Quiz Which bone in the lower leg is the most weight bearing? What does ATF stand for? Which ligaments resist inversion? Which ligaments resist eversion? What does MP stand for? How many tarsal bones are there? How many bones are in the foot?

Answers: Tibia Anterior Talofibular Anterior Talofibular, tibiofibular, calcaneofibular (lateral) Deltoid ligaments (medial) Metatarsalphalangeal 7 26

Muscles of the Foot and Ankle Anterior Muscles (3) Extensor Hallucis Longus/Brevis extension of great toe Extensor Digitorum Longus/Brevis extension of 2 – 5 phalanges

Muscles of the Foot and Ankle Anterior Muscles cont. (3) Tibialis anterior inversion and dorsiflexion of foot / ankle

Anterior Muscles

Muscles of the Foot and Ankle Medial Muscles (3) Tibialis Posterior Inversion and plantarflexion Flexor Hallucis Longus Flexor of great toe and plantarflexion of ankle Flexor Digitorum Longus Flexors of 2 – 5 toes and plantarflexion of ankle

Muscles of the Foot and Ankle

Muscles of the Foot and Ankle Posterior Muscles (2) Gastrocnemius plantarflexion of ankle Soleus

Muscles of the Foot and Ankle

Muscles of the Foot and Ankle Lateral Muscles (2) Peroneus Longus / Brevis eversion, plantar flexion of ankle

Quiz What is the primary function of the Extensor Hallucus Longus and Brevis? What is the primary function of the tibialis anterior? What two motions does the peroneus longus and brevis perform? What motion does the Gastrocnemius/ Soleus perform? What are the two main motions of the tibialis posterior muscle?

Answers Extension of great toe Inversion and dorsiflexion of foot Eversion and plantar flexion of the ankle Plantarflexion of ankle Inversion and plantarflexion

Arches of the Foot

Supinated Arches (High Arches)

Supinated Arches

Pronated Arches (Flat Feet)

Pronated Arches

Pronated Arches

Pronated Arches

Orthotics

Orthotics

Orthotics

Foot and Ankle Injuries

Ankle Sprain Cause: Excessive inversion or eversion of the ankle S/S: Point tenderness, swelling, discoloration, laxity, inability to walk or run properly (extent based on degree). TX: RICE, rehabilitation immediately (Grade III requires immobilization) Prevention: Strengthening exercises, proper shoes/ equipment

Lateral Ankle Sprain Mechanism (MX) ATF most common sprained 1st Degree Ankle Sprain Mechanism (MX) Inversion and/or plantarflexion ATF most common sprained Occurs during contact or non – contact.

Lateral Ankle Sprain S/S 1st degree Mild pain Pt – ATF Possible swelling Fast recovery to FWB and ROM No joint laxity

Lateral Ankle Sprain 2nd Degree Ankle Sprain MX Involves the ATF, CF Same as 1st degree, more severe. Involves the ATF, CF Possible growth plate involvement Most cases x-ray needed

Lateral Ankle Sprain S/S 2nd degree Felt a pop Localized severe pain Pt – more then one ligament Rapid swelling Decrease ROM Laxity in joint Unable to FWB

Lateral Ankle Sprain 3rd Degree Ankle Sprain Rupture of ligaments (ATF, CF, PTF) Consider a FX X-ray is mandatory

Lateral Ankle Sprain S/S 3rd Degree Felt or heard pop Extreme pain Extreme/rapid swelling No ROM Unable to FWB

Lateral Ankle Sprain Treatment 1st Degree Ankle Sprain 2nd Degree Ankle Sprain 3rd Degree Ankle Sprain RICE Return to Play (Toe raise, heel walk, Full go w/ full ROM Tape to Play Reevaluate 24hrs (Horseshoe w/ compression wrap) Crutches 24 hours Reevaluate 24hrs Refer to Dr. X-rays RICE (Horseshoe w/ compression wrap) Crutches Posterior Splint

Ankle Special Tests Anterior Drawer Test Tests for ligament instability Mainly tests ATF integrity but can also test the CF and PTF depending on severity Ankle must be relaxed Ankle in slight plantar flexion

Ankle Special Tests Talar Tilt Test for lateral ankle instability Positive test indicates tear in ATF, and CF

Ankle Special Tests Thompson Test Test for achilles tendon rupture

Ankle Dislocation Mx: S/S: Anterior – Heel strikes ground forcefully Posterior – blow to anterior lower leg S/S: PN deformity, inability to move foot, rapid swelling, refusal to allow moving or touching foot TX: Splint, ICE, 911 or transport to hospital

Turf Toe Sprain of the 1st MP joint Mx: S/S Hyperextension/ hyperflexion of great toe Common on artificial surface Flexible types of footwear can contribute S/S Pain over the first MP joint

Achilles Tendonitis MX: S/S: TX: Prevention: Repetitive motions such as running and jumping that cause tendon breakdown S/S: Swelling, crepitus, pn with palpation, pn with dorsiflexion, weak with plantarflexion TX: RICE Limiting or restricting the activity that caused the irritation Aggressive stretching of heel cord Crepitus (crackling and grinding) may mean it is too late Prevention: Achilles and gastroc/solues stretching, proper acclimization to activity.

Achilles Tendon Rupture MX: Sudden, forceful plantar flexion of the ankle with a chronically tight tendon. S/S: Feel or hear a pop. Feel as if they’ve been kicked in the leg. Inability to plantar flex foot. TX: Surgery or a cast Prevention: Stretching and proper care of any tendonitis

Longitudinal Arch Strain Mx – Downward force to the foot causing depression of the arch Most common with overuse (running) S/S Sharp pain with weight bearing Painful during dorsiflexion

Lower Leg Problems “Shin Splints”: MX: S/S: TX: catch all term related to lower leg pain. MX: constant pounding associated with running S/S: sharp pain in lower leg around medial/lateral aspect of lower leg and connective tissue between tibia and fibula TX: RICE (cold whirlpool), heal lift, arch support, shoes, change running surface

Compartment Syndrome MX: S/S: TX: Prevention: Increased pressure within one of four compartments of lower leg causes compression of the structures in the leg. S/S: Deep aching pain, tightness, and swelling. Pain with stretching. TX: Acute~ immediate surgery Chronic~ activity modification & ice and some times surgery Prevention: Stretching (Hard to prevent)

Toe Abnormalities Hammer Toes MX: TX: Poor shoe choices Middle joint (PIP) flexed, other joints (MP, DIP) hyperextended TX: Refer, orthotics or surgery

Bunion / Hallux Valgus MX: S/S: TX: Prevention: Bony enlargement of the head of the 1st metatarsal caused from wearing improperly fitting shoes S/S: Obvious deformity, tenderness, and swelling TX: Proper shoe selection, protection devices, surgery may be necessary Prevention: Properly fitting shoes

Ingrown Toenail MX: S/S: TX: Prevention: Improper shoe fitting and nail cutting S/S: Increased pain, swelling, redness around the nail bed TX: Hot, soapy water, antibiotics, raise nail up Prevention: Proper shoes, proper nail trimming