1. Foot, Ankle, and Lower Leg

2. Foot bones
Foot bones
26 bones
14 phalangeal
5 metatarsals
7 tarsals

3. Toes Each toe except for the big toe has three phalanges
Toes 2-5 are also known as digits
The big toe, a.k.a. hallux, has two.
The toes are designed to widen our base for balance and propelling our body.
Two sesamoid bones are located under the 1st metatarsalphalangeal joint (MTP joint)
These bones help increase the mechanical advantage of the flexor tendons that run under the big toe.

4. Metatarsals Five bones that lie between the toes and the tarsal bones
The first metatarsal is the biggest and the strongest.
This helps it function as the main weight bearing support during walking and running.
The fifth metatarsal protrudes on the lateral aspect of the foot.
Place where ligaments and muscle tendons attach

5. Ankle Bony Anatomy Talus (link between lower leg & foot) Tibia Fibula
Medial malleolus
Fibula
Lateral malleolus
Mortise
Tibial tuberosity
Tibial condyles

6. Bony Anatomy

7. Functional Anatomy Ankle is a stable hinge joint
Medial/lateral dislocation is prevented by malleoli
Square shape of talus adds stability of ankle
Most stable during dorsiflexion, least stable in plantar flexion

8. Ankle Motions Plantar Flexion Dorsiflexion Inversion Eversion
Pronation
Supination

9. Ankle Articulations Talar Joint (Talocrural joint)
Tibia & fibula with talus
Dome of talus articulates with mortise formed by tibia & fibula
Motions: dorsiflexion & plantar flexion
Subtalar Joint
Articulation of talus with calcaneus
Motions: inversion & eversion

11. Soft Tissue Gastrocnemius Soleus Tibialis posterior Tibialis anterior
Peroneus longus
Peroneus brevis
Plantaris
Plantar fascia
Anterior talofibular
Anterior tibiofibular
Calcaneofibular
Posterior talofibular
Deltoid ligament
Tibionavicular
Calcaneotibial
Anterior talotibial
Posterior talotibial
tibionavicular ligament, calcaneotibial ligament, anterior talotibial ligament, and the posterior talotibial ligament

12. Muscles of the Lower Leg
Anterior tibialis
Flexor digitorum longus
Flexor hallucis longus

13. Muscles of the Lower Leg
Peroneus tertius
Peroneus longus
Peroneus brevis

14. Muscles of the Lower Leg
Gastrocnemius
Soleus

15. Muscles of the Lower Leg

16. Muscles of the Lower Leg

17. Compartments of the Lower Leg
Anterior
Tibialias anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis muscles
Peroneal
Peroneus longus
Peroneus brevis
Deep Posterior
Popliteus
Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior
Superficial Posterior
Gastrocnemius
Soleus
Plantaris

18. Ligaments Lateral aspect Medial aspect Anterior talofibular (ATF)
Anterior tibiofibular
Calcaneofibular (CF)
Posterior talofibular
Medial aspect
Deltoid Ligament

19. Medial Ligaments of Ankle
Deltoid Ligament
rarely injured in sports
mechanism of injury typically eversion with dorsiflexion
longer time to heal than lateral ankle ligaments

20. Lateral Ligaments of Ankle
3 primary ligaments:
anterior talofibular
posterior talofibular
Calcaneofibular
NOT as large & strong as the deltoid.
Mechanism of injury is inversion associated with plantar flexion.

24. Pes Planus or Cavus Structural Deformities
Pes Planus = flat footed/ no arch
Pes Cavus = high arch

25. Feiss’ Line
The Feiss' line is a line that is made across a patient's foot that looks for navicular drop.  The patient is seated over the edge of a table.  A line is drawn from the medial malleolus to the plantar aspect of the 1st MTP joint while the patient is in a non=weight-bearing position.  The examiner marks the position of the navicular tubercle.  The patient is then instructed to stand up from a seated position.  While the patient is now weight bearing, the navicular is re-examined relative to the line that was originally drawn.  
If the navicular tubercle is above the Feiss' line, this is indicative of a supinated or pes cavus foot.   
If the navicular tubercle still intersects the Feiss' line, this is a neutral foot.  
If the navicular tubercle is below the Feiss' line, this is indicative of a pronated or pes planus foot. 

27. History Past Mechanism Changes in symptoms
Has this ever happened Before
Mechanism
What happened
How did it happen
When did it happen
What specific mvmt caused the injury?
Did you fall? How did you land?
Which direction did the body part move?
Changes in symptoms
Symptoms incr. or decr. since injury
Taking any meds?
Treating it on your own at all

28. History Pain Sounds or Sensations Where does it hurt?
Point with ONE finger
Rate the pain
Scale of 1-10
What makes it hurt?
Specific movements?
positioning
When does it hurt?
Can you describe the pain?
Sounds or Sensations
Did you feel any unusual sensations when it occurred?
Did you hear any unusual sounds when it occurred?

29. Observation/Inspection
Movement
How do they move?
How did he walk in?
What mannerisms did he use during the history?
Facial expressions
Asymmetries/ Deformity
Do both sides look the same?
Obvious deformity
Swelling Lumps
Markings Redness/ Discoloration
Sounds

30. Palpation Used to confirm or deny assessments.
Start away from the injury and move toward the site of pain (about 2-3 inches when appropriate)
Palpate Bilaterally (both sides)
Start w/ light pressure then move to deeper palpation

31. Palpation Notice Point Tenderness Trigger Points Crepitus
Specific site of pain
Trigger Points
Crepitus
Grinding, crunching, or crackling sensation with the rubbing of tissues
Tissue Density
Increased
Spasm
Scarring
Decreased
Swelling
Hemorrhage
Symmetry
Are both sides equal
Temperature

32. Common Injuries to the Ankle & Lower Leg

33. Contusions Occur most often on tibia Can be painful and disabling
Complication
compartment syndrome

34. Muscle Strains Most common in calf Result from: Result from:
violent contraction
Overstretching
Continued overuse
Result from:
Repetitive overuse
Single violent contraction
Acute strain to Achilles have tendency to become chronic

35. Cramps A sudden, involuntary contraction of a muscle
Contributing factors include:
Fatigue
Fractures
Dehydration
Lack of nutrients in diet
Poor flexibility
Improperly fitted equipment

36. Cramps—Treatment Passive stretching Fluid replacement Water
Sports drink
Massage
Rest
Ice

37. Achilles Tendonitis Inflammation of Achilles tendon
Tearing of tendon tissues caused by excessive stress
Occurs at point where tendon attaches to heel

38. Achilles Tendonitis Symptoms develop gradually
Repeated or continued overstress increases inflammation
Pain, crepitus, redness
Treatment
Prevention
Stretching
Ice/Rest
NSAIDs
Heel lift/Achilles taping

39. Achilles Tendon Rupture
Rupture occurs w/in tendon, approx 1-2” proximal to insertion
Eccentric force applied to dorsiflexed foot
Poor conditioning
Overexertion
Direct trauma
Surgically repaired
Rehab = 1yr +
Thompson test

42. Erik Karlsson achilles injury
Chauncy Billups
Thompson Test

43. Medial Tibial Stress Syndrome
aka shin splints
term for pain that occurs below knee
Anterior shin
Medial shin
Result of doing too much too soon
Associated with:
repetitive activity on hard surface
forcible excessive use of leg muscles (running, jumping)
tightness of gastroc and/or soleus muscles
improper footwear
running biomechanics

44. MTSS Treatment Ice Reduce activity level Gentle stretching
Biomechanical assessment
Orthotics
NSAIDs
Strengthening and flexibility program

45. Stress Fractures Incomplete crack in bone
Microscopic fractures in bone that will eventually lead to full fracture if left untreated
Repeated stress placed on bone greater than body’s ability to heal it

46. Stress Fractures—S/Sxs
“hot spot” of sharp, intense pain upon palpation
Shin-splint
Pain more generalized
Pain worse in am
Stress Fx
Pain worse in pm

47. Compartment Syndrome
Swelling within one or more of the compartments of the lower leg
Caused by:
Contusion
Fracture
Crush injury
Localized infection
Excessive exercise
Overstretching

48. Ankle Sprains MOI: combo of excessive inversion and PF
aka lateral ankle sprain
Anterior Talofibular Ligament (ATF)
Calcaneofibular (CF)
Posterior talofibular (PTF)
Eversion (medial) ankle sprain less common
Deltoid ligament

49. Ankle Sprains Injury to ligamentous and capsular tissue
Traumatic joint twist that results in stretching of total tearing of the stabilizing connective tissue
One of most common & disabling sports injuries
General Symptoms:
Joint swelling
Local temperature increase
Pain
Point tenderness
Skin discoloration

50. Ankle Sprains

51. Inversion Eversion Syndesmotic Anterior Talofibular Calcaneofibular
Posterior Talofibular
Eversion
Deltoid Ligament
Syndesmotic
High ankle sprain

52. Ankle Sprain—S/SXS Grade 1 Grade 2 Grade 3 Some pain Severe sprain
Minimum LOF
Mild point tenderness
Little or no swelling
No abnormal motion
Grade 2
Pain
Moderate LOF
Swelling
Slight to moderate instability
Grade 3
Severe sprain
Extremely painful initially
LOF
Severe instability
Tenderness
Swelling
May represent subluxation that reduced spontaneously

53. Ankle Sprain—Treatment
R.I.C.E.
Crutches
Boot
Splint, tape, brace
Compressive wrap
Horseshoe

54. Fractures Mechanism Signs/symptoms:
most often caused by direct trauma to the tibia, fibula or bone(s) of the foot
repeated “microtrauma” can result in a stress fracture
growth plate injures can occur in the adolescent -- known as “Salter-Harris” fractures
Signs/symptoms:
swelling/deformity, discoloration
broken bone end protruding
athlete reports a snap/pop
inability to bear weight
stress fractures often become more painful at night

55. Fractures First Aid: treat for shock
apply sterile dressing to any open wounds
carefully immobilize using appropriate splinting technique
contact EMS and arrange for transport
Hudson Fracture
Kevin Ware Injury

57. Special Tests & Rehabilitation

58. Anterior Drawer
Talar Tilt
Tests integrity of anterior talofibular ligament
Tests integrity of calcaneofibular ligament

59. Squeeze Test Bump Test/Tap Test
Squeezing the tibia and fibula together
Can indicate fracture or high ankle sprain
Bump calcaneus
Indicate fracture to tibia/fibula
Indicate high ankle sprain
Tap mallelous
Indicate fracture of particular bone

60. Ankle Rehab 4-way TheraBand® Heel walks/Toe walks 3-way heel raises
Unilateral Balance
3-way Tramp throw