1. CHAPTER 15 – FOOT, ANKLE AND LOWER LEG

2. FOOT ANATOMY

3. FOOT ANATOMY It is complex! 26 bones 33 joints
Over 100 muscles, tendons and ligaments

4. ANATOMY - BONES PHALANGES (Toes) – 14
Big toe has two phalanges, the rest of the toes have three
Proximal, middle, and distal

5. FOOT ANATOMY - BONES METATARSALS – 5
1ST one is medial and 5th one is lateral

6. FOOT ANATOMY – 26 BONES TARSAL BONES – 7 Calcaneus – heel bone
Talus – forms the ankle
Navicular – medial in respect to the talus
Cuboid - lateral
Cuneiforms (3)

7. FOOT ANATOMY PLANTAR FASCIA
Broad, flat tendonous structure that runs on the undersurface of the foot
Starts on the calcaneus and inserts onto the heads of the metatarsals
Supports the arch of the foot

9. FOOT ANATOMY - ARCHES Support body weight and absorb shock
There are four arches:
MEDIAL LONGITUDINAL ARCH
LATERAL LONGITUDINAL ARCH
METATARSAL ARCH
TRANSVERSE ARCH

10. FOOT - MOTIONS Toes Foot Flexion and Extension
Pronation – like fallen arch
Supination – high arch

11. ANKLE ANATOMY - BONES BONES Two bones in the lower leg Two tarsal bone
Tibia – medial, larger, weight bearing
Medial Malleolus
Fibula
Lateral Malleolus
Two tarsal bone
Talus
Calcaneus

12. ANKLE ANATOMY - JOINTS TRUE ANKLE JOINT Tibia, fibula and talus
Mortise
Definition: where the talus fits into the tibia and the fibula

13. ANKLE ANATOMY - JOINTS Subtalar joint
Between the Talus and the Calcaneus

14. ANKLE ANATOMY - LIGAMENTS
LATERAL –
3 ligaments named for bones
Anterior talofibular
(ATF)
Calcaneofibular
(CF)
Posterior talofibular
(PTF)

16. ANKLE ANATOMY - LIGAMENTS
MEDIAL
Deltoid
Strong ligament
4 parts that form one ligament

17. ANKLE ANATOMY - LIGAMENTS
TIBIOFIBULAR LIGAMENTS – holds tibia and fibula together
Anterior tibiofibular
Posterior tibiofibular

18. ANKLE MOTIONS
Dorsiflexion
Plantarflexion
Inversion
Eversion

19. LOWER LEG ANATOMY
Bones
Tibia
Fibula

20. LOWER LEG MUSCLES
The muscles are in four compartments with 2-4 muscles in each compartment
Compartments are held together by fascia

21. LOWER LEG MUSCLE COMPARTMENTS
LATERAL – everts the ankle
ANTERIOR – dorsiflexes the ankle
DEEP POSTERIOR – plantarflexes the ankle (the calf muscle)
POSTERIOR MEDIAL – inverts and plantarflexes the ankle

23. LOWER LEG - Major Muscles and Actions
Anterior Tibialis - dorsiflexor
Peroneals - evertors
Gastrocnemius – plantarflexor
Soleus – plantarflexor
Posterior Tibialis – invertor

24. PLANTAR FASCIITIS
Common with athletes who are on toes and/or have high arches
Causes: Not enough arch support in shoes, tight calf muscle
Signs/Symptoms: Pain occurs in the heel to mid-foot, especially with dorsiflexion
Hurts in the morning, feels better as they warm up
Treatment: Gentle stretches, roll on tennis ball or frozen can, arch taping or orthodics.

25. JONES FRACTURE Fracture of the base of the 5th metatarsal
Causes: overuse; inversion; rotational forces
S/S: Feels and hears a ‘pop’; pain in the lateral foot
Tx: immobilization (cast) 6-8 weeks or longer, often requires surgery

26. BUNIONS (HALLUX VALGUS)
Deformity of the head of the 1st metatarsal
Cause: extra bone is laid down on head of 1st metatarsal
Great toe becomes malaligned
S/S: Pain, swelling and deformity of big toe joint
Treatment: Proper shoes; doughnut pad over the bunion; surgery?

27. MORTON’S NEUROMA Neuroma is a mass about the nerve sheath
S/S: burning, cramping, numb feeling in space between third and fourth toes.
Cause: Hyperextension of toes and wearing shoes with narrow toe boxes can increase symptoms
Tx: teardrop pad under the metatarsal heads, good shoe selection, possible surgery

28. TURF TOE Great Toe sprain
Cause: Hyperextension of the big toe at the metatarsal phalangeal joint; kicking something
Common on artificial turf b/c turf shoes allow more motion
S/S: swelling and pain in the joint
Tx: RICE, rigid insoles or toe boxes, taping to prevent hyperextension of toe

29. INGROWN TOENAILS
Cause: leading side of toenail grows into skin, usually results in infection and pain
May trim nails too short or ill-fitting shoes
S/S: Inflammed nail bed, may have drainage/pus
Tx: May need to refer to doctor; soak in betadine bath; pack cotton under toenail

30. PUBLIC SERVICE ANNOUNCEMENT
HIGH HEELS
Loads 5 times your body weight onto your heel
Overloads forefoot
Deforms the arch
Reduces shock absorption
Plantar fasciitis
Leads to inflamed nerves in your toes
Morton’s Neuroma
Shortens your calf
Achilles tendinitis
Changes your center of gravity – more forward
Have to extend back to compensate

31. ANKLE SPRAINS Inversion Most common type of ankle sprain
Accounts for 80% of all sprains
AKA ‘a lateral ankle sprain’
First degree sprain
Only involves the anterior talofibular ligament
Mild pain, tenderness, and swelling
No instability

32. ANKLE SPRAINS Inversion Second degree sprain
Anterior talofibular ligament is torn and calcaneofibular ligament is injured as well
Most painful
Moderate swelling
Mild Instability

33. ANKLE SPRAINS Inversion Third degree sprain
Complete tear of all three lateral ligaments
Uncommon
Lots of pain, but it can subside
Very unstable
Usually requires surgery

34. ANKLE SPRAINS Eversion Not as common
Can occur more on tartan surfaces and artificial turf
Everything is worse (pain, swelling, etc) when compared to an inversion injury
If the deltoid tears, the tibiofibular ligaments may tear also

35. High Ankle Sprain
Involves Anterior Inferior Tibiofibular (AITFL) Ligament
Injury allows tibia and fibula to separate

36. High Ankle Sprain Cause: Inversion with rotation; rotation of foot
S/S: pain with external rotation of foot; tender over AITFL
Treatment: RICE, may need to be immobilized; possible surgery if severe enough

37. Ankle Fractures
Always need to suspect a fracture when evaluating a potential sprained ankle
Cause: Too much motion
S/S: immediate swelling, point tender over the bone, does not want to weight bear
Treatment: splint, ice, x-ray Cast 6-8 weeks

38. MEDIAL TIBIAL STRESS SYNDROME
‘SHIN SPLINTS’
Occurs in distal 2/3 of posterior/medial tibia
Causes: pronation, lack of flexibility in the lower legs, hard surfaces, hills, muscle weakness, poor shoes, increasing running distance too quickly
S/S: resisted plantar flexion and inversion should hurt, pain is just off the tibia
Treatment : prevention (shoes, arch support), strengthening, stretching, ice massage, contrast bath, tape arches
Refer to MD if no improvement to rule out stress fracture

39. COMPARTMENT SYNDROME
Occurs when pressure increases in compartment and shuts off blood and nerve supply to the foot
Most often occurs in the anterior and deep posterior compartment
THREE TYPES
Acute
Acute Exertional
Chronic

40. ACUTE COMPARTMENT SYNDROME
Medical emergency
Causes: direct blow to the lower leg
Usually in the anterior lower leg
Symptoms come about several hours later
S/S: compartment is tense, warm, red and shiny; complains of (c/o) deep aching pain; circulation and sensory problems in foot
Tx: ice, elevation – refer to ER immediately

41. ACHILLES TENDINITIS
Chronic, overuse condition that comes about gradually
Causes: running and jumping, repetitive stress, running up hills, poor flexibility
S/S: achy type pain, Achilles is tender on palpation, pain with standing plantarflexion, may have crepitus, hurts to warm up and to cool down
TREATMENT
If there is crepitus, no running for 1-2 weeks
Stretch!
Heel lift in both shoes
Orthodics
Heat and/or ice

42. ACHILLES TENDON RUPTURE
Achilles in largest tendon in body
For Gastronemius and Soleus muscles
Most common tearing spot is 1” above its insertion on the calcaneus
Causes: Sudden, forceful plantar flexion and extension of the knee, age, previous tendinitis
S/S: Feel and hear a snap, “kicked in the leg”, very weak plantarflexion, no Achilles observed
Tx: Immobilization to ER, surgery?