Transcript Foot, Ankle, Lower leg - James Island Charter High School

Foot, Ankle, Lower leg
Lesson 1 – bone and ligament
anatomy
Foot bones
 Foot bones
– 26 bones
 14 phalangeal
 5 metatarsals
 7 tarsals
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.
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
Tarsal bones
 Calcaneus
– Largest of tarsal bones
– Shapes the heel and sits below the talus
– Conveys body weight to the ground
– Attachment for achilles tendon and several
structures on plantar side
– Palpate on the posterior bottom of the foot
Tarsal bone cont…
 Talus
– Located above the calcaneus
– Fits between the lateral and medial malleoli
forming the talocural joint (a.k.a ankle joint) mortise
– Irregular shaped
 The bone is broader anterior than posterior
– Which gives the ankle more stability in
dorsiflexion as it makes a tight fit between the
malleoli (10 deg in DF vs. 23 deg in PF)
Tarsal bones cont.
 Navicular
– Located anterior of the talus on the medial aspect of the foot.
– Small tubercle may be palpated on the medial foot.
– Anteriorly articulates with the cuneiforms
 Cuboid
– Located on lateral aspect of foot. (palpate on lateral foot)
– Posterior articulates with the calcaneus and anterior with the 4th
and 5th metatarsals
 Cuneiforms
– Three bones located between the navicular and 3-5 metatarsals
– Palpate from mid foot to the medial side
Lower leg bones
 Tibia
–
–
–
–
Second longest bone in body
Principle weight bearing
Located on medial side of lower leg
The shaft has three sides – posterior, medial, lateral
 Lateral and posterior covered by muscle
– Triangle shaped on the top and round near the bottom
 Causes a anatomical weakness – bone more dense in this area
 Forms medial malleolus
Lower leg bones cont.
 Fibula
– Long slender bone located on lateral leg
– Non weight bearing
– Primary function is to provide attachment for
muscles
– Distal portion forms the lateral malleolus
 Malleolus extends further distally than medial to give
it more stability
Arches of the foot
 Medial longitudinal arch
– Runs along the medal side of the foot from the
calcaneus to distal head of the first metatarsal
– Bony support are the medial bones
– The soft tissue support is the plantar calcaneolnavicular
ligament (a.k.a spring ligament) and posterior tibialis
muscle
 Lateral Longitudinal arch
– Runs along lateral portion of the foot.
– Much lower and less flexible than the medial
Arches cont…
 Transverse arch
– Half dome over the anterior portion foot over the
tarsal bones, primarily the cuboid and internal
cuneiform
 Anterior metatarsal arch
– Shaped by the distal heads of the metatarsal
heads
Foot ligaments
 Spring ligament
– a.k.a plantar calcaneonavicular
ligament
– Located on medial side of foot
– Gives support to the medial
arch
– Helps with shock absorption
 Bifurcate ligament
– Located on lateral side of foot
 Located under fat pad on foot
– Connects cuboid to calcaneus
and calcaneus to the navicular
 Plantar fascia
– Lies on the bottom of
the foot from the
calcaneus to the head
of each metatarsal
head
– Helps support the foot
against downward
forces
Ankle/lower leg ligaments
 Interroseous membrane
– Connective tissue that
connects the tibia and fibula
– The membrane fills the
whole space between the
tibia and fibula in the lower
leg
– The membrane helps diffuse
forces placed on the lower
leg
Lateral ankle ligaments
 Anterior/Posterior
talofibular ligaments
– Both are located on lateral
ankle
– Helps prevent against
anterior/posterior torsion and
inversion of the ankle (talus
specifically)
 Calcaneofibular ligament
– Located laterally it traverses
inferiorly of the lateral
malleolus
– Protects against inversion of
the calcaneus
Lateral ankle ligaments cont…
 Calcaneofibular
ligament
– Located laterally it
traverses inferiorly of
the lateral malleolus
– Protects against
inversion of the
calcaneus
Ankle/lower leg ligaments
 Anterior/posterior
tibiofibular ligaments
– Sometimes called the
syndesmotic ligaments
– They connect the tibia
and fibula together at
the distal end of the
bones – forms the distal
portion of the
interroseous membrane
Medial ankle ligaments
 Deltoid ligaments
– Located medially on the
ankle
– Technically three ligaments
– treat as one
– Triangle shape that begins
on the medial malleolus and
ends on the medial talus,
calcaneus, and navicular
bone
– Protects against eversion,
pronation, and anterior
displacement of the ankle
(talus specifically)
Foot, ankle, and lower leg
Lesson 2 – muscles, movement
and other structures
Lateral muscles
 Peroneal brevis
– Origin or proximal attachment - lower 2/3 of outer
surface of fibula
– Insertion or distal attachment – base of 5th metatarsal
– Action – eversion of foot and plantar flexion
 Peroneal Longus
– Origin – upper 2/3 of fibula
– Insertion – undersurface of medial cuneiform and 1st
metatarsal
– Action – plantar flexion and eversion
Medial muscles
 Tibialis posterior
– Proximal attachment – posterior surface of tibia, fibula, and interroseous
membrane
– Distal attachment – undersurface of navicular, cuneiforms, and base of 2-4
metatarsals
– Action – inversion and plantar flexion of foot/ankle
 Flexor Hallicus Longus
– Proximal attachment – Lower 2/3 of posterior fibula
– Distal attachment – Undersurface of base of distal phalanx of the Big toe
(1st)
– Action – Plantar flexion of big toe and inversion and plantar flexion of
foot/ankle
 Flexor Digitorum longus
– Proximal attachment – Lower 2/3 of posterior tibia
– Distal attachment – Base of distal phalanx of toes 2-5
– Action – plantar flexion of toes 2-5 and plantar flexion and inversion of
ankle/foot
Anterior Muscles
 Anterior Tibialis
– Proximal attachment – Upper 2/3 of anterior tibia
– Distal attachment – inner surface medial cuneiform and 1st metatarsal
– Action – Dorsal flexion of ankle and inversion of foot
 Extensor Hallicus longus
– Proximal attachment – Anterior/inner surface of middle 2/3 of fibula
– Distal attachment – top of distal phalanx of big toe
– Action – dorsal flexion of ankle and big toe and foot inversion
 Extensor Digitorum longus
– Proximal attachment – Lateral condyle of Tibia, head of fibula, and upper
2/3 of fibula
– Distal attachment – top of middle and distal phalanx of toes 2-5
– Action – Dorsal flexion of ankle and toes 2-5, eversion of foot.
Posterior Muscles
 Gastrocnemius
– Proximal attachment – posterior surface of medial and lateral
condyles of femur
– Distal attachment – posterior surface of the calcaneus
– Action – plantar flexion of the ankle and flexion of the knee
 Soleus
– Proximal attachment – Upper 2/3 of posterior surface of tibia and
fibula
– Distal attachment – posterior surface of calcaneus
– Action – plantar flexion of the ankle
 Achilles tendon – formed from the gastrocnemius and
soleus
Other structures
 Anterior and Posterior tibial arteries
– Main blood supply for the ankle and foot
– Located in the anterior portion of the foot and behind medial malleolus
 Common peroneal nerve
– Located on lateral side
 Tibial nerve
– Located behind medial malleolus
 Retrocalcaneal bursa
– Located under the achilles tendon attachment
 Retinaculum
– Fascia that holds down ankle tendons as they curl from the lower leg into
the foot keeping them in place
 Joint capsule
– Fascia tissue that encompasses the ankle
Foot, ankle, and Lower leg
Lesson 3 – foot injuries
Heel Bruise
–
–
Contusion to the calcaneus
Etiology

–
Landing directly on the heel without or with limited protection
Signs and symptoms


–
Pain, pt tenderness, and swelling over calcaneus
Difficulty walking
Management




RICE immediately
Use of crutches for first few days
Use of donut pad when beginning walking
Use of other modalities; US, whirlpool, ect for help in healing.
Base of Fifth Tendonitis
–
Inflammation of Peroneal brevis at the insertion point at the base of the
fifth metatarsal.
Etiology
–

–
Overuse from running, poor support in shoes, complication of ankle sprain.
Signs and symptoms



–
Pain, point tenderness, and swelling over base of fifth.
Difficulty walking
Weakness and pain with eversion
Management



–
RICE
Other modalities – e-stim, ultrasound, WP
Walking boot if becomes to severe
Complications

If not treated and cured quickly can lead to avulsion of Peroneal tendon off
base of fifth (Jones fracture) – leads to surgery
Retrocalcaneal Bursitis
–
–
Bursa irritation over the Achilles/calcaneal
insertion
Etiology

–
Symptoms



–
Overuse – running, jumping
Pain and swelling on insertion
Strength loss minimum
Pain with passive dorsiflexion
Treatment

RICE – similar too Severs disease
Sesmoiditis
–
Irritation to sesmoid bones under 1st
metatarsal/phalangeal joint
Etiology
–

–
Running or jumping – excessive force on joint
Symptoms



–
Pain and swelling over joint
Pain with passive extension
Pain with active flexion
Treatment


Bracing – tape - donut
Ice and other modalities
Plantarfascitis
–
Irritation of fascia that lays on the plantar foot – especially around
½” from base of calcaneus
Etiology
–



–
Overuse – arch taking to much pressure. Not enough padding on
heel of shoes
Running on toes instead of heel to toe
Poor support of arch
Symptoms

–
Pain around calcaneus ½” from origin. Hurts immensely first thing in
the morning.
Treatment





Arch taping
Getting proper shoes
Ice massage
Stretching
Takes along time to heal
Turf Toe
–
–
Hyperextension or hyperflexion of 1st metatarsal
Etiology


–
Forceful flex or over extension of big toe while running
Stubbing toe
Symptoms

–
Swelling and pain over joint
Treatment



RICE
Tape
Modalities
Bifurcate sprain
–
Sprain of ligament that holds talus, cuboid and navicular together

–
Located around fat pad on lateral side of foot
Etiology

–
Inversion of foot
symptoms



–
similar to ankle
swelling and pain over fat pad in foot and lateral foot
pain and mild weakness with eversion
Treatment




Similar to ankle
RICE
Foot strengthening
Heals faster than regular ankle sprain
Medial and Lateral arch
–
Etiology

–
Signs and symptoms


–
Poor shoes, overweight, postural anomalies,
weakened support structures
Soreness, tiredness around arch
Pain when running
Management


Tape
Strengthening of surrounding structures
Fallen Metatarsal heads
–
Etiology

–
Weakened surrounding structures due to undue stress being
placed on toes 2-5 causing them to splay apart.
Signs and symptoms


–
Transverse arch becomes flattened and may see one or two
head of metatarsals depress
Pain when walking
Management


Place small pad behind fallen metatarsal head helping push
back up
Strengthen surrounding structures
Fractures

Dome of Talus
–
–
–
etiology
 severe inversion or forceful dorsiflexion
signs and symptoms
 pain located in center of ankle in mortise area
management
 RICE
 refer to doctor
Fractures
–
Navicular

Etiology
–
–

signs and symptoms
–
–

high arches
poor shoes
pain when running and jumping around Navicular
point tender over tubercle
management
–
–
–
RICE
x-rays
walking boot
Fractures

March fracture
–
–
–
–
fracture of metatarsal – usually 2nd or 3rd
etiology
 overuse on running or marching
 people with atypical conditions more disposed to
injury
 short first metatarsal, hallix valgus, flat foot
signs and symptoms
 pain, swelling and pt tender over specified metatarsal
management
 RICE
 x-rays
 crutches and walking boot
Fractures
–
Jones fracture


Fracture of base of
fifth
etiology
–

signs and symptoms
–
–

forceful inversion
pain and swelling
over base of fifth
weakness with
eversion
management
–
–
RICE
x-rays - crutch
Foot, Ankle, Lower Leg
Lesson 4 – ankle injuries
Lateral ankle sprain
–
Injury to one or more the lateral ligaments (Ant
TaloFib, PTF, CalcFib)
Etiology
–

–
Due to inversion or plantarflexion and inversion of the ankle.
Landing wrong or stepping on someone’s foot or object are
main occurrences
Sign and symptoms


Pain, point tenderness, redness, swelling in the area of lateral
malleolus. ROM and strength limited. Possible abnormal
joint motion
Severity graded on a scale of 3 depending on severity of
above symptoms
Three degrees of Lateral ankle
sprains
Lateral ankle sprains
– Special tests
 Anterior drawer – tests anterior talofibular ligament
 Posterior drawer – tests posterior talofibular ligament
 Calcaneal tilt – (dorsiflexion – inversion) – calcaneal fibular
– Management
 RICE with acute injuries
– Goal is to reduce swelling quickly as possible and allow the 1st
stage and 2nd stage of healing to take effect.
– Use of walking boot may be needed if 2nd degree or higher
 Next goal is to regain full ROM and strength
 Regain normal running and agilities
 Anything over grade 2 with adolescence should consider x-rays
Special tests
 Anterior drawer test
– Patient positions foot in slight plantar flexion
– Brace anterior shin with left hand
– Pull heel anteriorly with right hand
– Positive test findings
 Laxity and poor endpoint on forward translation
Special test
 Talar tilt (calcaneal tilt)
– Brace heel with left hand
– Invert foot with right hand
– Compare to opposite side
Medial ankle sprains
–
–
Injury to the deltoid ligament
Etiology

–
Eversion stress placed on the ankle from landing wrong or
stepping on someone’s foot
Sign and symptoms

–
Similar to lateral ankle sprain
Special test

–
Eversion stress
Management


Same as lateral ankle
Grade 2 or above consider x-rays to rule out avulsion fracture
Anterior Tibiofibular sprain
–
A.K.A. high ankle sprain. Sprain of ligament that holds tibia and
fibular together in lower 1/3 of lower leg
Etiology
–

–
Severe external rotation of ankle. Foot usually in dorsiflexion when
occurs
Signs and symptoms



–
Severe pain over area of anterior Tibiofibular region.
Usually NO or minimal swelling evident
Loss of function
Management




Takes along time to heal
RICE
Walking boot
Tape in slight plantar flexion
Foot, Ankle, Lower leg
Lesson 5 – lower leg injuries
Anterior compartment syndrome
–
Severe contusion, bruising of lower leg, swelling accumulates in compartments
does not flow out

–
Usually in anterior compartment
etiology

–
blow to the area. Kicked, hit by bat or ball, tackled, fall on area
symptoms

extreme swelling of lower leg
–


–
looks wood like - shiny
weakness in dorsiflexion and eversion
numbness on dorsal foot
Treatment






Elevate leg
Check pulse – dorsal pedis and tibial arteries
Refer to emergency room immediately
24-48 hrs necrosis sets in
Surgery – fasciactomy
Prevention most important
–
never wrap a bruised lower leg
–
elevate with ice as soon as possible
Chronic compartment syndrome
–
–
Exercise induced – not emergency like ACS –
fascia too tight
Etiology

–
Symptoms


–
Running, muscles to big and/or fascia too tight
numbness during running in toes
Similar symptoms as ACS but disappear after
finish workout.
Treatment

Refer to Doctor
“Shin Splints”
–
Five types; muscle strain, stress fracture, chronic
compartment syndrome, irritation to periosteum, strain
to interosseus membrane
Muscle strain
–

Etiology
–

Symptoms
–
–
–

muscle strain to anterior tibialis, overuse running, poor support
from shoes
pain with dorsiflexion
pain while running
palpation – hurts in large area along muscle
Treatment
–
–
–
reduction of pain
strengthen muscle TA and stretch gastroc
look for better support in shoe
“Shin Splints”
–
Stress Fracture

Etiology
–
–

Symptoms
–
–
–
–
–

overuse on running, changes in workout
poor support in shoes with high arches
pain in one spot
continually gets worse
may ache at night or during day or pain does not disappear
shortly after workout
Pain on Tibia
radiates through leg when running
Treatment
–
–
–
referral to doctor
rest
return three weeks after all pain has disappeared
“Shin Splints”

irritation to periosteum
–
–
–
–

Interosseus strain
–
–
–

usually low
similar to muscle strain except hurts directly on bone
usually located lower 1/3 of tibia
Treatment
 takes longer to heal then muscle strain
 modalities
Last option
Takes long time to heal
Deep pain
Chronic compartment syndrome
–
See #2
Gastrocnemius strain
–
–
Strain at the gastroc-soleus junction or at
medial head near origin
Etiology

–
Symptoms


–
Forceful action – running or jumping
Pain and muscle weakness in area
Swelling if severe enough
Treatment


RICE
Modalities
Achilles strain, tendonitis, and
rupture
–
Etiology

–
Overuse on running or jumping, or acute contusion or forceful movement
Symptoms

–
Pain, swelling, weakness with plantar flexion
Treatment




RICE
Modalities
Strengthening
Must be careful – chronic tendonitis my lead to rupture
–
–
–
–
–
feel deformity in Achilles
injured feels like they got shot
totally disabled
immediate swelling
Positive Thompson test

Injured lay prone feet hang over edge

Squeeze calf –

negative sign – foot plantar flexes

positive sign – foot does not move
Thrombosis
–
–
Blood clot
Etiology

–
Blow to the area
Symptoms


Deep pain in calf
Positive sign on Homan’s sign
–
–
–
–
Athlete lay supine
Raise leg and passively put foot in dorsiflexion
Feels pain in specific spot deep in calf, may feel bump if clot big
enough
Treatment

Referral to Dr.
Severs Disease
–
–
Similar to Osgood Schlatter’s of the knee
Etiology


–
Overuse – running and jumping in adolescence 12-18 yrs old
Degeneration of the area just below where the Achilles inserts to the
calcaneus
Signs and symptoms



Pain, swelling, and redness in the area where Achilles inserts to the
calcaneus
Pain and weakness with plantar flexion
Hurts during activity
–
–
rest helps alleviate pain
management



RICE with acute symptoms
Heel cup – which will restrict dorsiflexion for activity
When apophysis closes (around age 18) problem ceases
Accessory Bones
– Os Trigodom
– Located on back of calcaneus
– Irritation from overuse plantarflexion