Foot/Ankle Unit

SKELETAL ANATOMY

Lower Leg Bones Tibia – Shin Bone – Weight bearing bone in the lower leg – Medial Malleolus: Distal end of tibia that forms the medial ankle bone Fibula – Non-weight bearing bone – Lateral Malleolus: Distal end of fibula that forms the lateral ankle bone

Foot Bones Tarsals (7) – Talus – Calcaneus – Cuboid – Cuneiforms (medial, middle, lateral) – Navicular Metatarsals (5) Phalanges (14) – Proximal – Middle – Distal

Joints Ankle: – Distal Tibiofibular – Talofibular – Talocrural Foot: – Intertarsal – Tarsalmetatarsal Toes: – Metatarsalphalangeal – Proximal Interphalangeal – Distal Interphalangeal

Ligaments Lateral – Anterior Talofibular (ATF) – Calcaneofibular (CF) – Posterior Talofibular (PTF) Medial – Deltoid High – Anterior Tibiofibular

SOFT TISSUE ANATOMY

Terminology Plantarflexion (PF): – Ankle movement in which foot moves toward ground and toes are pointed to the ground Dorsiflexion (DF): – Ankle movement in which toes/dorsum of foot moves upwards towards knee Origin: – Where muscle originates and attaches to bone Insertion: – Where muscle attaches, usually distally, and where movement occurs

Movements/Actions Foot/Ankle: – Inversion (inv) – Eversion (ev) – Plantarflexion (PF) – Dorsiflexion (DF) Toes: – Flexion (flex) – Extension (ext) – Abduction (abd) – Adduction (add)

Muscles The muscles for the foot and ankle are in muscle groups on the lower leg. There are four main groups – Anterior – Posterior – Medial – Lateral

Posterior Muscles MuscleOriginInsertionAction GastrocnemiusDistal FemurCalcaneusPF and Knee Flexion SoleusPosterior tibia & fibula CalcaneusPF

Posterior Muscle Diagram

Anterior Muscles MuscleOriginInsertionFunction/Action Tibialis AnteriorTibiaMedial cuneiform & 1 st metatarsal DF and slight inversion Extensor Hallicus Longus FibulaDorsal surface of big toe DF and inv of ankle, extends 1 st digit Extensor Digitorum Longus Tibia & FibulaDF and eversion, extends toes 2-5

Anterior Muscles Diagram

Medial Muscles MusclesOriginInsertionFunction/Action Tibialis PosteriorPosterior TibiaNavicular, cuneiforms, cuboid/metatarsals 2-4 PF and inversion Flexor Digitorum Longus Posterior TibiaDorsal surface of distal phalanges 2-5 PF and inv, flexes toes 2-5 Flexor Hallicus Longus FibulaDorsal surface of 1 st distal phalanx PF and inversion, flexes big toe

Medial & Lateral Diagram

Lateral Muscle Diagram

Lateral Muscles MuscleOriginInsertionFunction/Action Peroneus LongusFibulaDorsal surface of 1 st metatarsal and medial cuneiform Eversion & PF Peroneus BrevisFibulaProximal 5 th metatarsal Eversion & PF

SPRAINS

Ankle Sprains Single most common injury in the physically active caused by sudden inversion or eversion moments There are 3 types of Ankle Sprains: – Inversion Also called a Lateral ankle sprain Most common and result in injury to the lateral ligaments – Eversion Also called a Medial ankle sprain Least common due to anatomical structures, medial malleolus – Syndesmotic Also called a High ankle sprain

Ankle Sprains LateralMedialHigh ATF: PF and InvDeltoid: DF and EversionAnt. Tibiofibular: Excessive DF or PF CF: Inv PTF: Severe inversion or dislocation (rare) The following chart shows the mechanism of injury or MOI for each type of sprain according to the ligament that is injured.

Ankle Sprain Grades & Types

Ankle Sprain: S/S General S/S for all types of sprains: – Swelling – Pain with WB (weight bearing) – Instability – Ecchymosis (bruising/discoloration) Stress Test Positives: – Anterior Drawer Test- ATF ligament – Talar Tilt Test- CF and Deltoid ligaments – Kleiger’s Test- Tib/fib ligament

Ankle Sprains: Rx General Acute Care: – RICE with horseshoe – NSAIDs – Crutches? Usually for a grade 2 and up – Referral

Toe Sprains Sprained Toes – MOI: Generally caused by kicking non-yielding object Pushes joint beyond normal ROM or imparting a twisting motion on the toe- disrupting ligaments and joint capsule – S/S: Pain is immediate and intense but short lived Immediate swelling and discoloration occurring w/in 1-2 days Stiffness and residual pain will last several weeks – Rx: RICE, buddy taping toes to immobilize Begin weight bearing as tolerable

Turf Toe Great Toe Hyperextension (Turf Toe) – MOI: Hyperextension injury resulting in sprain of 1st metatarsophalangeal joint May be the result of single or repetitive trauma – S/S: Pain and swelling which increases during push off in walking, running, and jumping – Rx: Increase rigidity of forefoot region in shoe Taping the toe to prevent dorsiflexion Ice and ultrasound Rest and discourage activity until pain free

ACUTE INJURIES

Muscle Strains MOI: – Due to violent contraction/twisting of foot – Awkward landing S/S: – Pain with ROM or RROM – Possible pain with WB – Swelling or crepitus – May feel like being “hit in leg with a stick” Rx: – RICE – Taping/bracing – Monitor for acute compartment syndrome

Achilles Tendon Rupture Occurs w/ sudden stop and go; forceful plantar flexion w/ knee moving into full extension Commonly seen in athletes > 30 years old –Can be observed at any age Generally has history of chronic inflammation

Achilles Tendon

Achilles Tendon Rupture S/S: – Pain/inability to plantarflex – Feels like they were “kicked in calf” – Positive Thompson Test – Deformity Rx: – RICE – Referral is rupture is suspected

Contusion MOI: – Direct blow or crush of the muscle fibers S/S: – Ecchymosis, bruise may develop – Limited ROM; pain, weakness and partial loss of limb function – Palpation will reveal hard, rigid, inflexible area due to internal hemorrhaging and muscle guarding Rx: – Stretch to prevent spasm; apply cold compression and ice – Wrap or tape will help to stabilize the area; padding to protect the area – Monitor for Acute Compartment Syndrome

Leg Cramps and Spasms Sudden, violent, involuntary contraction, either clonic (intermittent) or tonic (sustained) in nature MOI: – Difficult to determine; fatigue, loss of fluids, electrolyte imbalance, inadequate reciprocal muscle coordination S/S: – Cramping with pain and contraction of calf muscle Rx: – Try to help patient relax to relieve cramp – Firm grasp of cramping muscle with gentle stretching will relieve acute spasm – Ice will also aid in reducing spasm – If recurrent may be fatigue or water/electrolyte imbalance

FRACTURES AND DISLOCATION INJURIES

Dislocations Rare in ankle, but common in phalanges MOI: Traction or twisting S/S: Deformity Possible fractures Inability to move extremity Rx: Immobilize Cold Referral for reduction or Emergency Action Plan (EAP)

Types of Acute Fx Avulsion Fractures – Common for ATF Ligament to fracture lateral malleolus (looks like 3 rd Degree sprain) – Jones Fracture- Peroneus brevis pulls off proximal 5 th metatarsal with forced inversion Growth Plate (Epiphyseal) Fractures – Distal plated in fibula and tibia may fracture with inversion/eversion

Acute Fractures MOI: Direct blows Twisting Associated with avulsions/dislocations S/S: Localized Pain Deformity? Swelling Ecchymosis Crepitis Pain with WB

Acute Fractures Stress Tests: – Tap Test (Percussion)- tibia, fibula, talus or calcaneus – Calf Squeeze (Compression)- tibia or fibula Rx: – RICE – X-ray, reduction, casting up to 6 weeks depending on the extent of injury – Be prepared to activate Emergency Action Plan (EAP) if open fracture or signs of shock

Types of Stress Fx March Fracture – Stress Fracture to the metatarsals due to repetitive activity Most commonly the 2 nd metatarsal Tibial or fibula Stress Fracture – Common overuse condition, particularly in those with structural and biomechanical insufficiencies – Runners tends to develop in lower third of lower leg (dancers middle third)

Stress Fractures Extremely common due to repetitive action General Management: – S/S: point tenderness; especially in WB position – Rx: NWB (non-weight bearing) > week or more Walking boot or cast possible Out of activity 3-4 weeks Gradual resumption of activity

OTHER INJURIES

Compartment Syndrome A painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues. – The pressure decreases blood flow, depriving muscles and nerves of needed nourishment. Acute compartment syndrome – Occurs secondary to direct trauma – Medical emergency Acute exertional compartment syndrome – Evolves with minimal to moderate activity Chronic compartment syndrome – Symptoms arise consistently at certain point during activity

Compartment Syndrome

Acute Compartment Syndrome MOI: direct blow or tearing of muscle fibers causing swelling S/S: – Pain becoming worse; eventually numbness – Loss of foot ROM – Leg swelling Rx: Medical Emergency! Refer Immediately – Apply cold and elevate – Surgical intervention is probably necessary

Plantar Fasciitis MOI: – Shoes – Overweight – Activity on hard surfaces – Overuse – Poor mechanics – Fatigue S/S: – Morning pain – Swelling – Pain with WB – Crepitus Rx: – Good shoes/orthotics – Stretching – Ice – Taping – Referral?

Arches Pes Planus Foot (Flatfoot) – MOI: Associated with excessive pronation, forefoot varus, wearing tight shoes (weakening supportive structures) being overweight, excessive exercise placing undo stress on arch Pes Cavus (High Arch Foot) – MOI: Higher arch than normal; associated with excessive supination, accentuated high medial longitudinal arch

Morton’s Toe Vs Neuroma Morton’s Toe – Etiology Abnormally short 1st metatarsal, making 2nd toe look longer More weight bearing occurs on 2nd toe as a result and can impact gait Stress fracture could develop Morton’s Neuroma – Etiology Thickening of nerve sheath (common plantar nerve) at point where nerve divides into digital branches Commonly occurs between 3rd and 4th met heads; medial and lateral plantar nerves come together Irritated by collapse of transverse arch of foot, putting transverse metatarsal ligaments under stretch, compressing digital nerves and vessels

Shin-Splints Shin-splints is a catch-all term for tendonitis, chronic compartment syndrome or a stress fracture Medial Tibial Stress Syndrome (MTSS) is the more appropriate term for shin-splint-type pain

Shin-Splints MOI: – Pes planus (flat feet) – Overweight – Poor conditioning – Poor shoes – Activity on hard surfaces – Overuse/Muscle weakness – Poor running technique – Genetics

Shin-Splints S/S: – Pain is usually found on medial side of leg – Pain with activity that gets progressively worse over time Rx: – RICE before/after – Check shoes, running shoes are only good for 500 miles – Stretch, Strengthen, Cross Train – NSAIDs – Refer for fracture or compartment syndrome

EVALUATIONS

Evaluation: The Why The athlete’s well-being WILL depend on the accuracy and thoroughness of your Soap! Ask probing questions and record accurately The aim of the examination process is to provide an efficient and effective exchange, and to develop a rapport between the clinician and patient The information gathered is used to provide the athlete with the best care and to provide a record of what has been done, for medical and legal purposes.

HOPS H istory: – A series of questions asked to determine nature and location of injury O bservation: – A visual examination of the injury P alpation: – A hands-on approach where examiner feels for deformity or other abnormal findings S tress tests: – A series of tests to check range of motion and degree of function of tissues at a joint

SOAP Note Format Subjective: – Detailed information about the history of injury and athlete; chief complaints, sign, and symptoms Objective: – Information that is a record of test measurements; the data gained from inspection Assessment: – Identification of the problem; identify the injury and the severity of it Plan of Action: – What are you going to do; the immediate treatment, rehab, or referral

Active Listening Skills The following skills should be used during a evaluation to help you gather information and gain the athletes trust: 1.Face the speaker; lean slightly forward 2.Maintain eye contact 3.Minimize external/internal distractions 4.Respond appropriately 5.Focus solely on what the speaker is saying 6.Keep an open mind 7.Avoid giving advice until you have completely evaluated injury 8.Don’t interrupt 9.Stay engaged in the interview

Subjective: Oral/Verbal Info General Questioning Prompts: – Was there a previous injury? – How did it happen? – When did it happen? – What did you feel? – How do you feel? – What is the type of pain? – Where does it hurt? – Did it make a sound? * Ask for a witness if the person is incapable of answering

Objective: Visual Inspection Look for the following: – Swelling – Deformity: protrusions – Ecchymosis: Discoloration – Symmetry – Gait: Walk – Scars – Facial expressions – Bleeding – Depressions – ROM

Objective: Hands-On Format Perform Palpation Check anatomical structures to determine points of pain Check for abnormalities Preform special test or stress tests to assess severity – Stress Tests: Anterior Drawer Test – ATF Ligament Talar Tilt Test – CF Ligament Kleiger’s Test - Thompson Test – Achilles Tendon Rupture Tap (Percussion) Test – Fracture test Calf Squeeze (Compression) Test – Fracture Test – Manual Muscle testing (RROM) Dorsiflexors/Plantarflexors Toe flexors/extensors Inverters/Everters

RETURN TO PLAY

Terminology Therapeutic: – Healing action

Phase I: Pain Management The time immediately following the injury or surgery, in which movement is limited to ease pain Areas of Importance: – Pain control – Decrease inflammation – RICE

Phase II: ROM Time when therapeutic action initiated includes; joint range-of-motion, mobility and flexibility exercises Areas of Importance: – PROM: passive rom AAROM: active assisted rom AROM: active rom Flexibility

Phase III: Balance PROPRIOCEPTION (Balance) –The body relearning the ability to sense the position of its limbs during movement; includes balance Areas of Importance: – Balance exercises – Coordination exercises

Phase IV: Strength To increase muscular strength Areas of Importance: – Emphasize the injured area, but maintain whole body strength

Phase V: Endurance For both the cardiovascular and muscle systems to perform work over a period of time Areas of Importance: – High amount of repetitions with low weight – Full-body cardiovascular endurance

Phase VI: Sport Specific Where the athlete mimics specific sport-like or functional activity. This leads to full resumption of activity. Areas of Importance: Gradual resumption of activity Limited or restrictive moving towards full resumption