1. CHAPTER 15 – FOOT AND ANKLE

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

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

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

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

6. ANATOMY - BONES SESAMOIDS Sesamoid bones sit in tendons
These are on ball on foot below big toe
Helps distribute weight

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

8. 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. ANKLE ANATOMY 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

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

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

12. LIGAMENTS LATERAL – 3 ligaments named for bones Anterior talofibular
(ATF)
Calcaneofibular
(CF)
Posterior talofibular
(PTF)

13. LIGAMENTS MEDIAL Deltoid Strong ligament
4 parts that form one ligament

14. LIGAMENTS TIBIOFIBULAR LIGAMENTS – holds tibia and fibula together
Anterior tibiofibular
Posterior tibiofibular

15. FOOT INJURIES 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 orthotics.

16. FOOT INJURIES RETROCALCANEAL BURSITIS ‘Pump bump’
Cause: Pressure from back of shoe
Signs/Symptoms: Swelling where the Achilles attaches to the calcaneus
Treatment: RICE, stretching, shoes with wider heel cups, donut pad.

17. FOOT INJURIES FRACTURES DISLOCATIONS SPRAINS STRAINS Toes Metatarsals
Interphalangeal Joints
SPRAINS
STRAINS

18. FOOT INJURIES 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

19. FOOT INJURIES 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?

20. FOOT INJURIES 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

21. FOOT INJURIES 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

22. 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

23. BIOMECHANICAL PROBLEMS
PRONATION
Cause of many, many leg, knee, back problems
What does it look like
Fallen arch with toes pointed outward
Looking at feet from behind, the Achilles will angle outward

24. ANKLE SPRAINS Review: 3 Degrees of Sprains
Abnormal (too much) motion causes ankle injuries
Named for motions that cause them
What are those motions?

25. TYPES OF 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

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

27. TYPES OF 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

28. TESTING ATF STABILITY Drawer Test Stablize lower leg with one hand
Pull heel forward (like opening a drawer)
Should not move forward if ligament is intact

29. TYPES OF 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

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

31. 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

32. Treatment of Ankle Sprains
Prevention – once you sprain an ankle it is easy to do again – tape and rehab
Rest – No activity for hours
Ice – 20 minutes on, 40 minutes off
Compression – ace wrap with horseshoe
Elevation – ankle above the heart
Support – crutches and aircast if needed

33. Ankle Rehab ABCs Circles Theraband exercises Single Leg Balance
Balance Board
Calf Raises
And so much more….

34. 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

35. The Lower Leg

36. ANATOMY
Bones
Tibia
Fibula

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

38. 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

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

41. LOWER LEG INJURIES Muscle Cramps
Sudden, violent contraction of the calf muscles
Causes:
Fatigue, overtraining, dehydration, poor nutrition, injury, poor flexibility
S/S: – sharp pain in the calf, toe is pointed
Tx: gentle stretch, ice, hydrate, can return to play if subsides and does not continue

42. LOWER LEG INJURIES STRESS FRACTURE
Cause: Repetitive pounding with training
S/S: Hurts more with and after activity, pain on one spot on bone
Tx: Requires x-ray, possibly a bone scan
If positive, no weight bearing for at least 2 weeks, no running for 4-6 weeks

43. LOWER LEG INJURIES 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

44. LOWER LEG INJURIES MEDIAL TIBIAL STRESS SYNDROME
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

45. LOWER LEG INJURIES 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

46. LOWER LEG INJURIES 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

47. LOWER LEG INJURIES ACUTE EXERTIONAL/CHRONIC COMPARTMENT SYNDROME
Cause: running and jumping activities
S/S: With activity, foot goes to sleep, crampy pain, and tingling. When activity stops, it goes away. Consistent as to when it comes on with activity
Tx: ice, activity modification, stretching, massage, and referral to the doctor (possible surgery)

48. INJURIES 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

49. INJURIES ACHILLES TENDINITIS TREATMENT
If there is crepitus, no running for 1-2 weeks
Stretch!
Heel lift in both shoes
Orthotics
Heat and/or ice

50. INJURIES ACHILLES TENDON RUPTURE Achilles in largest tendon in body
For Gastrocnemius 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?