1. Chapter Six
Foot, Ankle & Lower Leg

2. Anatomy
The foot is the site of some of the most debilitating conditions suffered by athletes.
Include:
Blisters
Calluses
Athletes foot
Turf toe
Ligament Sprains
Ingrown toe nails
Heel bruises
Arch strains
Fractures

3. Anatomy
The foot has stresses that exceed the demands placed on any other area of the body.
Stabilizes & Supports During:
Standing
Walking
Running
Jumping
The foot absorbs up to 3 times the body weight!

4. Anatomy
Individually, the parts of the foot (bones, muscles, ligaments) are weak.
Collectively, they can withstand most of the demands placed on them in athletics.

5. Anatomy
The key to proper function of the foot is a set of four arches.
Help absorb the impact of walking, running, & jumping.
The arches are:
Metatarsal
Transverse
Medial Longitudinal (inner)
Lateral Longitudinal (outer)

6. Anatomy The foot contains ¼ of the total number of bones in the body.
7 Tarsal bones
5 Metatarsal bones
14 Phalanges
There are also 38 joints!

7. Anatomy Tarsal Bones: Talus Calcaneus Navicular Cuboid
Medial, Intermediate, & Lateral Cuniform Bones (that’s 3 of them)
Mid-foot region has 5 Metatarsal Bones
The toes (AKA Phalanges) have 14 Bones

8. Anatomy
METATARSAL

9. Anatomy The ankle joint (Talocrural Joint)
The most commonly injured joint in athletics.
Most injuries are either ligament sprains or muscle strains.

10. Anatomy The ankle joint has 2 joints: Talocrural Joint Subtalar Note:
Bones: Tibia, Fibula, & Talus
Subtalar
Bones: Talus & Calcaneus (2 largest Bones of the foot)
Note:
Large boney Prominences on either side of the foot are the Medial Malleoli (tibia) & Lateral Malleoli (fibula)

11. Anatomy
Tibia
Transmits the weight or force placed on the lower leg to the talus.
Mounted directly on top of the talus & extends over the medial side forming the medial malleolis
Fibula
On the lateral side forming the lateral malleolis helps to stabilize the ankle joint

12. Range of Motion Talocrural Joint a hinge joint.
Dorsiflexion “toes to the nose”
Plantar Flexion extension “Point the Toes”

13. Range of Motion Subtalar Joint
triplanar movement with around the oblique axis.
Most stable when placed in dorsiflexion

14. Range of Motion
Talus
Moves Anteriorly (forward) & Posteriorly (Backward)
Talus sit on top of the calcaneous
The ankle joint despite # of injuries in the area is still very strong.
Stresses in athletics is the cause of ankle injuries

15. Anatomy
After bony structure strong ligaments make up the first line of defense against ankle sprains.
Most ligaments involved in supporting the ankle are attached to the rough edges of the malleoli.

16. Anatomy / Ligaments Ligaments are named for the bones they connect.
Most commonly injured are on the Lateral side (outside) of the ankle.
Anterior talofibular (ATF)
Anterior tibiofibular
Calcaneofibular
Posterior talofibular
Ligaments on the Medial side (inside) of the ankle (fyi, sprain to medial ligaments often associated with a fx)
Deltiod

17. Anatomy / Muscles 13 Major Muscle that support the ankle joint
2 of the most important:
Achilles Tendon
Peroneus Muscle Group

18. Anatomy / Muscles Achilles Tendon
The attachment of the Gastronemius and Soleus Muscles (Calf Muscles)
Attach to the Calcaneus
Tightness of Achilles Tendon is often the cause of recurrent ankle sprains.

19. Anatomy / Muscles Peroneal Muscle
Group of muscles along the Lateral side of the leg & foot
The Peroneal Brevis attach to several areas of the foot
The Peroneal Longus runs across the plantar surface of the foot
When the Peroneal group contracts it everts the foot
This helps to prevent Lateral ankle sprains.

20. Anatomy / Shin 2 Bones of the Leg: Tibia Fibula
Shin – is the area in the front of the leg
Interosseous Membrane – associated with anterior (front) shin pain (Shin Splints)
Dermatome – A sensory distribution of a nerve root.
Produces sensation in the corresponding area
Myotome – a single nerve root
Produces movement of anatomical structures

21. Bones Tibia Fibula Talus Calcaneus Navicular Cuniforms (1-3) Cuboid
Metatarsals (1 – 5)
Phalanges (1 – 5)

22. Ligaments / Muscles Anterior Talofibular Ligament
Posterior Talofibular Ligament
Deltoid Ligament
Gastrocnemius – Plantar Flexes the foot &
Flexes the lower leg.
Soleus - Plantar Flexes the foot
Peroneus Longus – everts & abducts foot,
Plantar Flexes foot
Peroneus Brevis – everts & abducts foot, Plantar
Flexes foot
Popliteus – Knee Flexon, medial rotation of tibia

23. Arches Metatarsal Transverse Medial Longitudinal (inner)
Lateral Longitudinal (outer)

24. Range of Motion Dorsiflexion – the act of drawing the toe or
foot toward the dorsal aspect
of the proximally conjoined
body segment.
Toes to the nose
Plantar Flexion – the act drawing the toe or
of the proximally conjoined body
segment.
Point the toe

25. Range of Motion Inversion – turning the sole of the foot inward
Eversion – turning the sole of the foot outward
Flexion (toes) – decreasing the angle between
the toes and the sole of the
foot
Extension (toes) – Increasing the angle
between the toes and the sole of
the foot

26. Range of Motion Pronation – combined motions of calcaneal
eversion, foot abduction and
dorsiflexion.
Supination - combined motions of calcaneal
inversion, foot adduction and
plantar flexion.
Abduction – movement of body segments
away from the midline
Adduction - movement of body segments
towards from the midline

27. Evaluation
The first purpose of an evaluation is to determine if a serious injury has occurred.
Always suspect a fx till proven otherwise
Signs of Fracture
Direct or indirect pain
Deformity
Grating sound
Loss of function

28. Evaluation
Note: some fractures are not accompanied by swelling or pain.
If a Fracture is suspected the extremity should be splinted & the athlete transported for medical evaluation.

29. HISTORY Mechanism of Injury Location of Pain Sensation experienced
How did it happen?
Location of Pain
Where does it hurt?
Sensation experienced
Did you hear a “pop” or a “snap”?
Previous History
Have you injured this area before?

30. Observation Look for signs of trauma: Compare involves vs. Uninvolved
Bleeding
Deformity
Swelling
Discoloration
Scars

31. Palpation Palpate above & below injury site.
Work your way down to injury.
Gain confidence of athlete
Involve the athlete as much as possible
Compare
Areas to check:
Neurological (motor/sensory)
Circulation
Anatomical Structures
Fracture Test (palpation, compression, distraction)

32. Special Test Testing instability, disability, & pain.
Before you start, can you make it worse?
Only a NATABOC certified athletic trainer is considered competent to perform these test and give a proper evaluation (other medical professional as well)
Test performed to assess the following:
1. Joint Stability Muscles / Tendons
3. Accessory Anatomical Structures
4. Inflammation ROM (active, assistive, passive, resistive)
6. Pain / weakness

33. Special Test Assessment Test: Bony Integrity Ligament Stability
Heel Tap Test: Check the Tibia, Fibula, & Talus
Squeeze Test: Check the Tibia & Fibula
Ligament Stability
Anterior Drawer Test: Test anterior talofibular and
calcaneofibular ligaments
Talar Tilt: Calcaneofibular, anterior talofibular, but
also the (medial) deltoid ligaments

34. Special Test
Muscle Function
Thompson Test: Test the Achilles tendon

35. Refer When There is: Gross Deformity Significant Pain
Increase swelling
Circulation or Neurological Issues
Joint Instability
Suspected Fracture
Abnormal Sensations (clicking, popping, grating, or
weakness)
Any doubts!

36. Injuries Ankle Sprains Most common injury to the ankle
Usually caused by excessive plantar flexion with inversion
“stepping in a hole”

37. Injuries (Ankle Sprain)
3 Categories
1. First Degree – (mild) 1 or more supporting ligaments
are stretched
Minor discomfort, point tenderness, swelling.
No instability
2. Second Degree – (moderate) a portion 1 or more
ligaments are torn
There is pain, point tenderness, swelling, disability, & loss of function
There is some abnormal movement in the joint
3. Third Degree – (Severe) 1 or more ligaments are
completely torn
Joint is unstable
Pain can be extreme to very little (torn nerve endings), loss of function, point tenderness, rapid swelling
Usually associated with a fracture

38. Injuries (Arch Sprain)
Arches are designed to act as “shock absorbers”
Most common injuries occur to the metatarsal or the inner longitudinal arches
Any of the 4 arches can sprain a ligament
Causes:
Flat feet
Overuse
Overweight
Fatigue
Training on hard surfaces
Wearing non supportive, worn, or shoes that do not FIT!

39. Injuries (Great Toe Sprain) “Turf Toe”
A sprain given to the First Metatarsophalangeal Joint.
Mechanism of injury – hyperextension of the
great toe.

40. Injuries (Medial Tibia Stress Syndrome) Shin Splints
Thought to be an inflammation of the interosseous membrane, strain to the soleus muscle, or other chronic lower leg condition.
Cause: muscle weakness or imbalance, lack of proper conditioning, improper or incomplete warm-up, poor flexibility, lack of stretching, running on hard surfaces, improper running form or habits, improper running shoe, or poor anatomical structures.

41. Injuries (Plantar Fasciitis)
The plantar fascia is a wide, non – elastic ligamentous tissue that extends from the anterior portion of the calcaneus to the heads of the metatarsals.
Supply support to the longitudinal arch of the foot.
Can strain tissue from overuse, unsupportive footwear, a tight Achilles tendon, or running o hard surfaces.

42. Injuries (Heel Spur)
A bony growth on the calcaneus that causes painful inflammation of the accompanying soft tissue and is aggravated by exercise.

43. Injuries (Anterior Compartment Syndrome) 4 Compartments
Once suspected, anterior compartment syndrome should be treated as a medical emergency

44. Injuries (Anterior Compartment Syndrome)
Cause:
Direct trauma or excessive exercise can result in hemorrhage & swelling inside the compartment.
Swelling will increase the pressure on the peroneal nerve, the veins, and finally, the arteries inside the compartment.
Without arterial circulation, muscle cells will become necrotic and die.

45. Injuries (Anterior Compartment Syndrome)
Signs:
Pain even after icing down
Firmness of the muscle
Numbness of the foot
Pain with passive ROM
Lack of strength

46. Injuries (Achilles Tendon Strain)
Achilles Tendon is the strongest in the body
Injuries range from a minor strain to a complete tear.
Minor strains should be treated conservatively because many strains will lead to complete tear
Remember Thomson Test for eval.

47. Injuries (Stress Fracture)
If exercise is too severe, or too long in a duration, a negative change in bone structures will occur and cause stress fracture.

48. Injuries (muscle cramps)
A cramp is a sudden, involuntary contraction of a muscle.
Cause: unknown
Can be because of several factors:
Fatigue
Fractures
Dehaydration
Poor Flexibility
Previous injury, rehab not completed
Improper fitted equipment.