Ankle Bones and Ligaments

Lateral Ankle ligaments

Medial Ankle Ligaments

Refresher Quiz

Medial view

Injuries of the Foot, Ankle, and Lower Leg

Acute Soft Tissue Injuries  Commonly occur as a result of direct contact and intrinsic and extrinsic forces acting on the foot, ankle, and leg.  Can include:  Contusions  Sprains  Strains

Contusions  Mechanism:  Contact with ground or opposing player  Kicking unyielding object  Be hit or stepped on  2 types: Bone and Soft Tissue  Bone:  Direct contact to the medial tibia can result in localized swelling (periostitis) and hematoma formation under the periosteum.  This swelling can take considerable time for the body to absorb.

Contusions  Soft Tissue:  Disability and loss of function are usually much worse with muscle contusions due to tenderness, swelling, and spasm within the muscle tissue.  Decrease ROM and strength also occur depending on the severity of the contusion.  Rarely result in serious injury.  Complications can arise from severe contusions and excessive bleeding within the enclosed anterior compartment.  Closely monitor any contusions that result in severe swelling of the compartment that result in neurovascular compromise.  Stone bruises can be particularly problematic because of the nature of the injury.  Can cause pain and point tenderness, making it difficult to bear weight.  Discoloration and swelling may vary depending on severity.

Sprains  Signs of inflammation  Pain  Heat  Swelling  Redness  Loss of function  1 st degree  Ligament is stretched, causing minor pain and inflammation  2 nd degree  Ligament is partially torn, causing considerable pain, and inflammation  3 rd degree  Ligament is completely ruptured, may not be as painful, but inflammation is obvious and function may be completely lost.

Lateral Ankle Sprains  Mechanism:  Inversion with or without plantar flexion.  Typical scenario involves a player landing on opponent’s foot or landing awkwardly on the outside of the foot.  Signs and Symptoms:  Immediate pain  May hear or feel a “pop”  Most sprains will follow general characteristics of 1 st -3 rd degrees.  Swelling may be a poor indicator of severity of injury because even minor sprains can result in considerable swelling.  2 nd and 3 rd degree sprains will commonly involve other structures due to compressive forces.

Lateral Ankle Sprains  Common Structures:  Almost always involves the ATFL  The CFL and PTFL may also be involved.  Dislocation of the ankle may result with 3 rd degree sprains  Associated fractures and avulsions are not uncommon

Medial Ankle Sprains  Much less common because of the structure of the ankle (Lateral Malleolus and Deltoid Ligament complex)  Mechanism:  Eversion  Signs and symptoms are consistent with 1 st -3 rd degree sprains.  Disability may be prolonged due to the function of the involved ligament structure.

Syndesmotic Sprains  Otherwise known as a “High Ankle Sprain”  Caused from disruption of Tibiofibular ligaments and the distal interosseous membrane.  Mechanism:  Forced Hyperdorsiflexion  Lateral rotation of the foot  Most often seen in contact sports like football. Also common in Skiing.

Foot Sprains  Any injury to a ligament inside the foot.  Can result from chronic stress on the foot or through acute injury.  Signs and symptoms include pain, point tenderness, swelling and difficulty with weight bearing activities.  A common foot sprain can include a Lasfranc injury that involves the 1 st and 2 nd tarsometatarsal joints.  The foot is dorsiflexed and everted, putting pressure on the 1 st metatarsal head.  Lisfranc sprains can cause a widening of the gap between the bones and result in pain that increases with weight bearing activity, and some joint instability.

Toe Sprains  Typically result from direct contact to the toes such as stubbing the toe.  Most problematic are sprains to the 1 st toe.  Commonly referred to as “Turf Toe”  Can result from extreme ranges of motion (flexion or extension)  May notice decreased range of motion with pain.  Incredibly painful when trying to push off.

Strains  Injury to a muscle or tendon  Typically result from either overstretching or muscular overload.  Most strains are of the acute variety, but there are some that are associated with chronic repetitive stress.  Signs and symptoms include the 5 signs of inflammation along with muscle spasm  2 nd and 3 rd degree strains may present a palpable defect in the muscle belly or tendon.  Cramping or prolonged spasm can lead to symptoms of a 1 st degree strain on the following day.

Rupture of the Achilles Tendon  Often results from sudden, violent plantar flexion during eccentric loading.  Hard contraction while the muscle is being lengthened.  Common mechanisms include quick changes of direction and rapid plantar flexion  The athlete will complain of immediate pain and disability.  They will often report feeling like they were kicked or shot in the back of the leg.  Considerable swelling and discoloration with a very obvious defect in the Achilles tendon.  The athlete will be unable to plantar flex the injured ankle.

Rupture of the Plantaris muscle  Similar mechanism as Achilles Tendon Rupture, forced contraction while muscle is stretched.  Sudden sharp pain in the deep posterior leg that feels like being kicked or shot.  Due to the relatively insignificant function of the plantaris muscle, disability is usually minimal.

Rupture of the Peroneal Retinaculum  Peroneal retinaculum function to tether the Peroneus Longus and Peroneus Brevis behind the lateral malleolus.  Can be strained or ruptured by a direct blow, forceful eversion, or inversion ankle injury.  Damage can cause the peroneal tendons to sublux, or snap over the lateral malleolus.  Repetitive snapping of the tendons can result in peroneal tendon damage.

Chronic or Overuse Soft Tissue Injuries

Chronic Soft Tissue Injuries  Frequent complain in active individuals as a consequence of repeated microtrauma  The body is not allowed enough time to heal from normal wear and tear between workouts  This includes abnormal friction, traction, structural mechanics, or some combination of these.  Most problems stem from over pronation of the foot.  This can send excessive or abnormal stresses further up the body chain to the shins, knees, hips, and back.

Retrocalcaneal Bursitis  Affects the bursa that lies between the calcaneus and the distal insertion of the Achilles tendon.  Causes:  Repetitive overuse  Direct pressure  Friction from poorly fitted shoes  Signs/ Symptoms  Localized swelling  Redness  Point Tenderness  Pain with plantar flexion  May result in thickening of the bursa and eventual calcium formation if left untreated.

Plantar Fasciitis  Inflammation of the Plantar Fascia, which lies on the underside of the foot and stretches from the calcaneus to the metatarsal heads.  Typically an overuse injury but can be caused from being overweight, poor footwear or playing surface, or improper conditioning.  Athlete will complain of gradual onset of pain that gets better with exercise.  Pain will start out progressively worse and take longer before subsiding as condition worsens.  If the condition is prolonged, a heel spur may form.

Tendinitis  Inflammation of a tendon  Relatively common in the athletic population and typically results form overuse, friction, or tendon traction.  Signs and symptoms include pain, point tenderness, and crepitus over the inflamed tendon.  Crepitus is a grinding or grating sensation felt when moving the joint or muscle.  Pain may be evident with active or passive stretching.

Tenosynovitis  Inflammation of the synovial sheath that wraps around a tendon.  Characterized by snowball crepitus  Crepitus feels similar to the crunch of snow.  With both tendinitis and tenosynovitis, chronic thickening of the tendon or synovial sheath may occur with prolonged inflammation.

Calcaneal Apophysitis (Sever’s Disease)  Typically occurs in skeletally immature athletes.  The area around the insertion of the Achilles tendon becomes inflamed from repetitive stress.  Signs/ Symptoms  Posterior inferior heel pain  Point tenderness  Increased pain with weight bearing activity  Rapid growth and stretching of the Achilles tendon may be a predisposing factor.

Anterolateral Impingement  Chronic ankle pain that can result from synovitis and scar tissue thickening secondary to lateral ankle injuries.  Signs and symptoms:  Persistent pain in the anterolateral ankle  Pain may last for weeks or months after a lateral ankle sprain.

Medial Tibial Stress Syndrome (MTSS)  Commonly known as Shin Splints  Inflammation of the periosteum on the medial border of the tibia  Predisposing factors include:  Excessive pronation  Inflexibility of the posterior musculature  Dorsiflexor weakness or fatigue  High or low arches  Being overweight  Overuse  Condition can be brought on from changing footwear, running surfaces, or training intensity.  If left untreated, MTSS can lead to stress fractures, compartment syndrome, or bone tumors.

Traumatic Fractures

Tibial and Fibular Fractures  Can result from direct blow or indirect torsional stress  Fibula  Can result from direct blow or from severe eversion stress  Avulsion fractures are not uncommon in association with lateral ankle sprains.  Tibia  Requires much more force.  Can result from direct impact in sports like football.  Push off and avulsion fractures are relatively common as a result of severe inversion or eversion forces on the ankle.

Bimalleolar Fracture  Known as a Pott’s Fracture  Typically the result of excessive Eversion  Notice:  Avulsion fracture of medial malleolus  Shear fracture of the fibula

Foot Fractures  Typically the result of the same forces associated with foot sprains.  May also result from being stepped on, having heavy objects dropped on the foot, or from falling from a great hight.

Lisfranc Fractures  Notice:  Second metatarsal fracture  Tarsometatarsal joint dysfunction  Widened gap between cuneiforms  Displaced metatarsal bases

Jones Fracture  Occurs from indirect loading on the 5 th metatarsal with eversion and plantar flexion  Notice:  Obvious deformity at 5 th metatarsal base.

Calcaneal Fractures  Much less common  The most common cause happens when falling and landing on the heel from a great height.