Chapter Six Foot, Ankle & Lower Leg

Anatomy The foot is the site of some of the most debilitating conditions suffered by athletes. Include: Blisters Calluses Athletes foot Turf toe Ligament Sprains Ingrown toe nails Heel bruises Arch strains Fractures

Anatomy The foot has stresses that exceed the demands placed on any other area of the body. Stabilizes & Supports During: Standing Walking Running Jumping The foot absorbs up to 3 times the body weight!

Anatomy Individually, the parts of the foot (bones, muscles, ligaments) are weak. Collectively, they can withstand most of the demands placed on them in athletics.

Anatomy The key to proper function of the foot is a set of four arches. Help absorb the impact of walking, running, & jumping. The arches are: Metatarsal Transverse Medial Longitudinal (inner) Lateral Longitudinal (outer)

Anatomy The foot contains ¼ of the total number of bones in the body. 7 Tarsal bones 5 Metatarsal bones 14 Phalanges There are also 38 joints!

Anatomy Tarsal Bones: Talus Calcaneus Navicular Cuboid Medial, Intermediate, & Lateral Cuniform Bones (that’s 3 of them) Mid-foot region has 5 Metatarsal Bones The toes (AKA Phalanges) have 14 Bones

Anatomy METATARSAL

Anatomy The ankle joint (Talocrural Joint) The most commonly injured joint in athletics. Most injuries are either ligament sprains or muscle strains.

Anatomy The ankle joint has 2 joints: Talocrural Joint Subtalar Note: Bones: Tibia, Fibula, & Talus Subtalar Bones: Talus & Calcaneus (2 largest Bones of the foot) Note: Large boney Prominences on either side of the foot are the Medial Malleoli (tibia) & Lateral Malleoli (fibula)

Anatomy Tibia Transmits the weight or force placed on the lower leg to the talus. Mounted directly on top of the talus & extends over the medial side forming the medial malleolis Fibula On the lateral side forming the lateral malleolis helps to stabilize the ankle joint

Range of Motion Talocrural Joint a hinge joint. Dorsiflexion “toes to the nose” Plantar Flexion extension “Point the Toes”

Range of Motion Subtalar Joint triplanar movement with around the oblique axis. Most stable when placed in dorsiflexion

Range of Motion Talus Moves Anteriorly (forward) & Posteriorly (Backward) Talus sit on top of the calcaneous The ankle joint despite # of injuries in the area is still very strong. Stresses in athletics is the cause of ankle injuries

Anatomy After bony structure strong ligaments make up the first line of defense against ankle sprains. Most ligaments involved in supporting the ankle are attached to the rough edges of the malleoli.

Anatomy / Ligaments Ligaments are named for the bones they connect. Most commonly injured are on the Lateral side (outside) of the ankle. Anterior talofibular (ATF) Anterior tibiofibular Calcaneofibular Posterior talofibular Ligaments on the Medial side (inside) of the ankle (fyi, sprain to medial ligaments often associated with a fx) Deltiod

Anatomy / Muscles 13 Major Muscle that support the ankle joint 2 of the most important: Achilles Tendon Peroneus Muscle Group

Anatomy / Muscles Achilles Tendon The attachment of the Gastronemius and Soleus Muscles (Calf Muscles) Attach to the Calcaneus Tightness of Achilles Tendon is often the cause of recurrent ankle sprains.

Anatomy / Muscles Peroneal Muscle Group of muscles along the Lateral side of the leg & foot The Peroneal Brevis attach to several areas of the foot The Peroneal Longus runs across the plantar surface of the foot When the Peroneal group contracts it everts the foot This helps to prevent Lateral ankle sprains.

Anatomy / Shin 2 Bones of the Leg: Tibia Fibula Shin – is the area in the front of the leg Interosseous Membrane – associated with anterior (front) shin pain (Shin Splints) Dermatome – A sensory distribution of a nerve root. Produces sensation in the corresponding area Myotome – a single nerve root Produces movement of anatomical structures

Bones Tibia Fibula Talus Calcaneus Navicular Cuniforms (1-3) Cuboid Metatarsals (1 – 5) Phalanges (1 – 5)

Ligaments / Muscles Anterior Talofibular Ligament Posterior Talofibular Ligament Deltoid Ligament Gastrocnemius – Plantar Flexes the foot & Flexes the lower leg. Soleus - Plantar Flexes the foot Peroneus Longus – everts & abducts foot, Plantar Flexes foot Peroneus Brevis – everts & abducts foot, Plantar Flexes foot Popliteus – Knee Flexon, medial rotation of tibia

Arches Metatarsal Transverse Medial Longitudinal (inner) Lateral Longitudinal (outer)

Range of Motion Dorsiflexion – the act of drawing the toe or foot toward the dorsal aspect of the proximally conjoined body segment. Toes to the nose Plantar Flexion – the act drawing the toe or of the proximally conjoined body segment. Point the toe

Range of Motion Inversion – turning the sole of the foot inward Eversion – turning the sole of the foot outward Flexion (toes) – decreasing the angle between the toes and the sole of the foot Extension (toes) – Increasing the angle between the toes and the sole of the foot

Range of Motion Pronation – combined motions of calcaneal eversion, foot abduction and dorsiflexion. Supination - combined motions of calcaneal inversion, foot adduction and plantar flexion. Abduction – movement of body segments away from the midline Adduction - movement of body segments towards from the midline

Evaluation The first purpose of an evaluation is to determine if a serious injury has occurred. Always suspect a fx till proven otherwise Signs of Fracture Direct or indirect pain Deformity Grating sound Loss of function

Evaluation Note: some fractures are not accompanied by swelling or pain. If a Fracture is suspected the extremity should be splinted & the athlete transported for medical evaluation.

HISTORY Mechanism of Injury Location of Pain Sensation experienced How did it happen? Location of Pain Where does it hurt? Sensation experienced Did you hear a “pop” or a “snap”? Previous History Have you injured this area before?

Observation Look for signs of trauma: Compare involves vs. Uninvolved Bleeding Deformity Swelling Discoloration Scars

Palpation Palpate above & below injury site. Work your way down to injury. Gain confidence of athlete Involve the athlete as much as possible Compare Areas to check: Neurological (motor/sensory) Circulation Anatomical Structures Fracture Test (palpation, compression, distraction)

Special Test Testing instability, disability, & pain. Before you start, can you make it worse? Only a NATABOC certified athletic trainer is considered competent to perform these test and give a proper evaluation (other medical professional as well) Test performed to assess the following: 1. Joint Stability 2. Muscles / Tendons 3. Accessory Anatomical Structures 4. Inflammation 5. ROM (active, assistive, passive, resistive) 6. Pain / weakness

Special Test Assessment Test: Bony Integrity Ligament Stability Heel Tap Test: Check the Tibia, Fibula, & Talus Squeeze Test: Check the Tibia & Fibula Ligament Stability Anterior Drawer Test: Test anterior talofibular and calcaneofibular ligaments Talar Tilt: Calcaneofibular, anterior talofibular, but also the (medial) deltoid ligaments

Special Test Muscle Function Thompson Test: Test the Achilles tendon

Refer When There is: Gross Deformity Significant Pain Increase swelling Circulation or Neurological Issues Joint Instability Suspected Fracture Abnormal Sensations (clicking, popping, grating, or weakness) Any doubts!

Injuries Ankle Sprains Most common injury to the ankle Usually caused by excessive plantar flexion with inversion “stepping in a hole”

Injuries (Ankle Sprain) 3 Categories 1. First Degree – (mild) 1 or more supporting ligaments are stretched Minor discomfort, point tenderness, swelling. No instability 2. Second Degree – (moderate) a portion 1 or more ligaments are torn There is pain, point tenderness, swelling, disability, & loss of function There is some abnormal movement in the joint 3. Third Degree – (Severe) 1 or more ligaments are completely torn Joint is unstable Pain can be extreme to very little (torn nerve endings), loss of function, point tenderness, rapid swelling Usually associated with a fracture

Injuries (Arch Sprain) Arches are designed to act as “shock absorbers” Most common injuries occur to the metatarsal or the inner longitudinal arches Any of the 4 arches can sprain a ligament Causes: Flat feet Overuse Overweight Fatigue Training on hard surfaces Wearing non supportive, worn, or shoes that do not FIT!

Injuries (Great Toe Sprain) “Turf Toe” A sprain given to the First Metatarsophalangeal Joint. Mechanism of injury – hyperextension of the great toe.

Injuries (Medial Tibia Stress Syndrome) Shin Splints Thought to be an inflammation of the interosseous membrane, strain to the soleus muscle, or other chronic lower leg condition. Cause: muscle weakness or imbalance, lack of proper conditioning, improper or incomplete warm-up, poor flexibility, lack of stretching, running on hard surfaces, improper running form or habits, improper running shoe, or poor anatomical structures.

Injuries (Plantar Fasciitis) The plantar fascia is a wide, non – elastic ligamentous tissue that extends from the anterior portion of the calcaneus to the heads of the metatarsals. Supply support to the longitudinal arch of the foot. Can strain tissue from overuse, unsupportive footwear, a tight Achilles tendon, or running o hard surfaces.

Injuries (Heel Spur) A bony growth on the calcaneus that causes painful inflammation of the accompanying soft tissue and is aggravated by exercise.

Injuries (Anterior Compartment Syndrome) 4 Compartments Once suspected, anterior compartment syndrome should be treated as a medical emergency

Injuries (Anterior Compartment Syndrome) Cause: Direct trauma or excessive exercise can result in hemorrhage & swelling inside the compartment. Swelling will increase the pressure on the peroneal nerve, the veins, and finally, the arteries inside the compartment. Without arterial circulation, muscle cells will become necrotic and die.

Injuries (Anterior Compartment Syndrome) Signs: Pain even after icing down Firmness of the muscle Numbness of the foot Pain with passive ROM Lack of strength

Injuries (Achilles Tendon Strain) Achilles Tendon is the strongest in the body Injuries range from a minor strain to a complete tear. Minor strains should be treated conservatively because many strains will lead to complete tear Remember Thomson Test for eval.

Injuries (Stress Fracture) If exercise is too severe, or too long in a duration, a negative change in bone structures will occur and cause stress fracture.

Injuries (muscle cramps) A cramp is a sudden, involuntary contraction of a muscle. Cause: unknown Can be because of several factors: Fatigue Fractures Dehaydration Poor Flexibility Previous injury, rehab not completed Improper fitted equipment.