Lower Leg, Ankle, and Foot
Conditions
Chapter 19
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Anatomy
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Anatomy
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Anatomy
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Anatomy (cont.)
• Hindfoot
– Calcaneus and talus
– Talocrural joint (ankle joint)
• Articulation of talus, tibia, and fibula
• Close-packed position—dorsiflexion
• Medial ligament—deltoid
• Lateral ligament—anterior talofibular;
posterior talofibular; calcaneofibular
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Anatomy (cont.)
• Tibiofibular joints
– Superior—proximal
– Inferior—distal
– Interosseous membrane
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Anatomy (cont.)
• Muscles
– Lateral and medial view
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Anatomy (cont.)
• Muscles
– Posterior view
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Anatomy (cont.)
• Nerves
– Sciatic nerve
• Tibial nerve
• Common peroneal nerve — deep and
superficial peroneal nerves
– Femoral — saphenous
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Anatomy (cont.)
• Blood supply
– Femoral artery
– Popliteal
– Anterior and posterior
tibial
– Anterior tibial
• Dorsal pedal
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Kinematics (cont.)
• Motions
– Ankle— dorsiflexion and plantarflexion
– Subtalar joint
• Inversion and eversion
• Pronation-combination of dorsiflexion,
eversion and abduction
• Supination-combination of plantar
flexion,inversion, and adduction
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Lower Leg Contusions
• Gastrocnemius contusion
– S&S
• Immediate pain and weakness
• Rapid hemorrhage and muscle spasm → palpable mass
– Management: cold with gentle stretch
• Tibial contusion (shin bruise)
– Vulnerable lack of padding
– Minor injury—caution: repeated blows → damage
periosteum
– Key: prevention
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Lower Leg Contusions (cont.)
• Acute compartment syndrome
– Lower leg includes 4 nonyielding compartments
– Mechanism: direct blow anterolateral aspect of the
tibia
– Consequence: rapid ↑ in tissue pressure →
neurovascular compromise
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Lower Leg Contusions (cont.)
– S&S
• History of trauma
• Increasingly severe pain—out of proportion to situation
• Firm and tight skin over anterior shin
• Loss of sensation between 1st and 2nd toes on dorsum
of foot
• Diminished pulse—dorsalis pedis artery
• Functional abnormalities within 30 minutes
– Management: cold; no compression or elevation;
immediate physician referral
– Irreversible damage can occur within 12–24 hours
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Ankle Sprains
• Inversion ankle sprain
– Mechanism: plantarflexion and
inversion
– Predisposing factors
• Lateral malleolus projects
farther downward
• Weakness in peroneals
• ↓ ROM in Achilles tendon
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Degree
Signs and Symptoms Inversion Sprain
Ankle Sprains
(Cont’d)
1st
Pain
and swelling on anterolateral aspect of lateral malleolus
Point tenderness over ATFL
No laxity with stress tests
2nd
Tearing or popping sensation felt on lateral aspect; pain and swelling on anterolateral and
inferior aspect of lateral malleolus
Painful palpation over ATFL and CFL
May also be tender over PTFL, deltoid ligament, and anterior capsule area
Positive anterior drawer and talar tilt test
3rd
Tearing or popping sensation felt on lateral aspect with diffuse swelling over entire lateral
aspect with or without anterior swelling
Can be very painful or absent of pain
Positive anterior drawer and talar tilt test
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Ankle Sprains (cont.)
• Eversion ankle sprain
–
Mechanism: excessive
dorsiflexion and eversion
–
Deltoid ligament
–
Potential
• Lateral malleolus fracture;
bimalleolar fracture
• Tear of anterior tibiofibular
ligament and interosseous
membrane
–
Predisposing factors
• Excessive pronation
• Hypomobile foot
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Ankle Sprains (cont.)
– S&S (eversion sprain)
• Mild to moderate injuries
 Often unable to recall the mechanism
 Some initial pain at time of injury, but often
subsides and individual continues to play
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Ankle Sprains (cont.)
 Swelling
• May not be as evident as a lateral sprain
• Between posterior aspect of lateral malleolus
and Achilles tendon
• Point tenderness in involved ligaments
• Severe injuries
 PROM pain-free in all motions except dorsiflexion
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Ankle Sprains (cont.)
• Syndesmosis sprain
– Spreading of space at distal tibiofibular joint
– Mechanism: dorsiflexion and external rotation
– Common: anterior inferior tibiofibular ligament
– Assessment based on:
• External rotation test
• Squeeze test
• Syndesmosis ligament palpation
• Passive dorsiflexion test
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Ankle Sprains (cont.)
• Management of ankle sprains
– Standard acute
– Assessment for additional damage (e.g., fracture)
– Use of appropriate immobilization
– Moderate/severe—physician referral
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Ankle Sprains (cont.)
• Subtalar dislocation
– Results from a fall from a height (as in basketball
or volleyball); foot lands in inversion
– disrupts interosseous talocalcaneal and
talonavicular ligaments
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Ankle Sprains (cont.)
– S&S
• Extreme pain and total loss of function is present
• Gross deformity may not be clearly visible
• Foot may appear pale and feel cold to the touch
• Individual may show signs of shock
– Concern: potential for peroneal tendon entrapment and
neurovascular damage
– Management: medical emergency; activate EMS; monitor
neurovascular function
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Strains of Foot and Lower Leg
• Tendinitis
– Common sites
• Achilles tendon just proximal to insertion on
calcaneus
• Tibialis posterior just behind medial malleolus
• Tibialis anterior on dorsum of foot just under
extensor retinaculum
• Peroneal tendons just behind lateral malleolus
and at distal attachment on base of 5th
metatarsal
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Strains of Foot and Lower Leg (cont.)
– Predisposing factors
• Training errors
• Direct trauma
• Infection from a penetrating wound into tendon
• Abnormal foot mechanics producing friction
between shoe, tendon, and bony structure
• Poor footwear that is not properly fitted to foot
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Strains of Foot and Lower Leg (cont.)
– S&S (tendinitis)
• History of morning stiffness
• Localized tenderness over tendon
• Swelling or thickness in tendon and peritendon tissues
• Pain with passive stretching and with active and resisted
motion
– Management
• Cryotherapy
• Address any mechanical problems
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Strains of Foot and Lower Leg (cont.)
• Peroneal tendon strain
– Mechanism
• Strong push-off a slightly pronated foot
• Forceful passive dorsiflexion
• Direct blow—posterior lateral malleolus
– Retinaculum tears, tendons slip forward over lateral
malleolus; simultaneous reduction
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Strains of Foot and Lower Leg (cont.)
– S&S
• Cracking sensation followed by intense pain and
inability to walk
• Swelling and point tenderness in posterior superior
lateral malleolus
• Extreme discomfort or apprehension during attempted
eversion against resistance
• Chronic—complains of “giving way” with little discomfort
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Strains of Foot and Lower Leg (cont.)
• Tibialis posterior tendon strain
– S&S
• Pain, mild swelling
• Weakness in plantarflexion and inversion
– Aids in supporting the MLA
– Could lead to collapse of midfoot; hyperpronation
may be visible
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Strains of Foot and Lower Leg (cont.)
• Gastrocnemius strain
– Medial head or musculotendinous junction
– Mechanism
• Forced dorsiflexion while knee is extended
• Forced knee extension while foot is dorsiflexed
• Muscular fatigue with fluid–electrolyte depletion and
cramping
– S&S
• Immediate pain, swelling, loss of function
– Management: standard acute; gentle stretching; heel
lifts
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Strains of Foot and Lower Leg (cont.)
• Achilles tendinitis
– Risk factors
• Tight heel cords
• Foot malalignment deformities
• Recent change in shoes or running surface
• Sudden increase in workload or change in exercise
environment
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Strains of Foot and Lower Leg (cont.)
– Acute S&S
• Aching or burning pain in posterior heel, ↑ with passive
dorsiflexion and resisted plantarflexion
• Point tenderness and crepitus at bony insertion
• Local nodules
– Chronic S&S
• Pain worse after exercise
• Thickened tendon
• Tightness in gastrocnemius–soleus
– Management: cryotherapy; NSAIDs; activity modification
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Strains of Foot and Lower Leg (cont.)
• Achilles tendon rupture
– Mechanism: push-off of forefoot while knee is
extending
– More common in athletes over age 30
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Strains of Foot and Lower Leg (cont.)
– S&S
• “Pop”
• Inability to stand on toes
• Visible defect
• Excessive passive dorsiflexion
• + Thompson’s test
– Management
• Compression wrap and splint; immediate physician
referral
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Overuse Conditions (cont.)
• Medial tibial stress syndrome
– Periostitis along posteromedial tibial border (distal third)
– Believed to be related to periostitis of the soleus insertion
along the posterior medial tibial border
• Excessive pronation causes an eccentric contraction of
soleus → periostitis
– Other contributing factors
• Recent changes in running distance, speed, footwear,
or running surface
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Overuse Conditions (cont.)
– S&S (MTSS)
• Dull pain begins at any point in the workout;
occasionally sharp and penetrating
• Pain along posteromedial border of tibia in distal
third
• Pain is relieved with rest, but may recur hours after
activity stops
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Overuse Conditions (cont.)
• Secondary to mechanical abnormalities:
 Increased Achilles tendon angle
 Greater Achilles tendon angle between heel
strike and maximal pronation
 Greater passive subtalar motion in inversion
and eversion
• ↑ pain with active plantarflexion
– Management: rest!!! cryotherapy; NSAIDs; refer to
Application Strategy 19.5
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Overuse Conditions (cont.)
• Exertional compartment syndrome
– Characterized by exercise-induced pain and
swelling that is relieved by rest
– Compartments most frequently affected—anterior
(50%–60%)
– Usually seen in well-conditioned individuals
younger than 40
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Overuse Conditions (cont.)
– S&S
• Aching leg pain and sense of fullness over involved
compartment
• Often affects both legs
• Symptoms relieved with cessation of exercise
• Activity-related pain begins at a predictable time
• Anterior compartment—mild foot drop; paresthesia on
dorsum of the foot
– Perform evaluation after exercise strenuous enough to
reproduce symptoms
– Management: assessing contributing factors
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Venous Disorders
• Deep vein thrombosis (DVT)
– Partial or complete blockage of a vein due to
accumulated blood products that form a clot
– Common—deep calf veins
• Embolism
– Obstruction or occlusion of a vessel by bacteria or
other foreign body
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Venous Disorders (cont.)
• DVT is typically asymptomatic and may not become apparent
until a pulmonary embolism occurs
• Most reliable signs
– Paresthesia in the area
– Chronic swelling and edema in the involved extremity,
engorged veins
– Ecchymosis formation with a blue hue
– + Homan’s sign
• Management: immediate physician referral
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Neurologic Conditions (cont.)
• Tarsal tunnel syndrome
– Posterior tibial nerve (or branch) constricted beneath
fibrous roof of foot flexor retinaculum
– Often linked to excessive pronation or excessive
valgus deformity
– S&S
• Pain at medial malleolus radiating into sole and
heel
• Paresthesia, dysesthesia, or hyperesthesia in
nerve distribution
• + Tinel’s sign
– Management: rest; NSAIDs; orthoses; gradual
return to activity
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Foot and Lower Leg Fractures
• Repetitive microtraumas → apophyseal or stress
fractures
• Tensile forces associated with severe ankle sprains →
avulsion fractures of 5th metatarsal
• Severe twisting → displaced and undisplaced fractures in
foot, ankle, or lower leg
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Foot and Lower Leg Fractures (cont.)
• Stress fractures
– Often seen in running and jumping, especially after
significant ↑ training mileage; change in surface,
intensity, or shoe type
– Common sites
• 2nd metatarsal
• Sesamoid bones
• Navicular
• Calcaneus
• Tibia and fibula
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Foot and Lower Leg Fractures (cont.)
– S&S
• Pain begins insidiously; ↑ with activity and ↓ with
rest
• Pain usually limited to fracture site
• Pain with percussion, tuning fork, or ultrasound
– Management: standard acute; physician referral
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Foot and Lower Leg Fractures (cont.)
• Avulsion fractures
–
Eversion sprain—deltoid ligament avulses portion of distal
medial malleolus
–
Inversion sprain—plantar aponeurosis or peroneus brevis
tendon avulses base of 5th metatarsal (type II)
–
Jones fracture
• Type I transverse fracture into the proximal shaft of 5th
metatarsal at junction of diaphysis and metaphysis
• Often overlooked in conjunction with a severe ankle sprain
• Complications: nonunions and delayed unions are common
–
Management: standard acute; physician referral
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Foot and Lower Leg Fractures (cont.)
• Osteochondral fracture
– Mechanism
• Compression of talus against medial malleolus
during medial ankle sprain; lateral malleolus
during lateral ankle sprain
• Anterolateral fracture: forceful inversion with
dorsiflexion
• Posteromedial fracture: forceful inversion with
plantarflexion
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Foot and Lower Leg Fractures (cont.)
– S&S
• Unresolved chronic pain after ankle sprain
• Deep/aching activity-related pain
• Swelling, catching, crepitus, weakness, and
chronic instability
• Palpable crepitus or loose fragments
• ↑ pain on palpation of corners of talus during
extreme plantarflexion
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Foot and Lower Leg Fractures (cont.)
• Osteochondral fractures
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Foot and Lower Leg Fractures (cont.)
– Lateral process of talus
• Due to traumatic ankle sprain
• Persistent ankle pain; inability to walk for long periods
– Posterior fracture to talus
• Forced plantarflexion
• Pain with running, jumping; resisted plantarflexion and
great toe flexion
– Neck of talus
• Forced dorsiflexion
• May compromise blood supply to talus
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Foot and Lower Leg Fractures (cont.)
• Tibia-fibula fractures
– Fracture medial malleolus
• Inversion sprain
– Fracture lateral malleolus
• Eversion and dorsiflexion
• Bimalleolar fracture
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Foot and Lower Leg Fractures (cont.)
– Maisonneuve fracture
• External rotation of foot
• Associated fracture of proximal third of fibula
• S&S: tenderness over deltoid and fracture site
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Foot and Lower Leg Fractures (cont.)
• Ankle fracture–dislocation
– Mechanism
• Landing from a height with foot in excessive eversion or
inversion
• Being kicked from behind while the foot is firmly
planted
• Foot displaced laterally at a gross angle to lower leg;
extreme pain
• Can compromise the posterior tibial artery and nerve
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Foot and Lower Leg Fractures (cont.)
• Fracture management
– Remove shoe and sock to expose injured area
– Assess neurovascular integrity
– Mild
• Standard with physician referral
– Serious conditions
• Assess and treat for shock
• Activate EMS
– Refer to Application Strategy 19.6
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Assessment
• History
• Observation/inspection
• Palpation
• Physical examination tests
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Assessing the Lower Leg and Ankle
• History
– Past history
– Mechanism of injury
– When does it hurt?
– Type of, quality of, duration of pain?
– Sounds or feelings?
– How long were you disabled?
– Swelling?
– Previous treatments?
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• Observations
–
Postural deviations?
–
Genu valgum or varum?
–
Is there difficulty with walking?
–
Deformities, asymmetries or swelling?
–
Color and texture of skin, heat, redness?
–
Patient in obvious pain?
–
Is range of motion normal?
• Palpation
–
Begin with bony landmarks and progress to soft tissue
–
Attempt to locate areas of deformity, swelling and localized
tenderness
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Neutral Talar Position
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Range of Motion (ROM)
• AROM
– Ankle dorsiflexion (20°)
– Ankle plantarflexion (30–50°)
– Pronation (15–30°)
– Supination (45–60°)
• PROM
– Normal end feel
• Dorsiflexion, plantarflexion, pronation, supination,
toe flexion and extension—tissue stretch
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ROM (cont.)
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ROM (cont.)
• RROM
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Stress Tests
• Anterior drawer test
• Talar tilt
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• Ankle Stability Tests
– Anterior drawer test
• Used to assess
anterior talofibular
ligament primarily
and other lateral
ligament secondarily
• A positive test
occurs when foot
slides forward and/or
makes a clunking
sound as it reaches
the end point
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– Talar tilt test
• Performed to determine
extent of inversion or
eversion injuries
• Calcaneus is inverted
and excessive motion
indicates injury to
calcaneofibular ligament
and possibly the
anterior and posterior
talofibular ligaments
• If the calcaneus is
everted, the deltoid
ligament is tested
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Stress Tests (cont.)
• External rotation (Kleiger’s) test
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Special Tests
• Thompson’s test
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Neurological dysfunction
• Tinel’s sign
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• Functional Tests
– While weight bearing the following should be
performed
• Walk on toes (plantar flexion)
• Walk on heels (dorsiflexion)
• Hops on injured ankle
• Start and stop running
• Change direction rapidly
• Run figure eights
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Neurologic Tests
• Myotomes
– Knee extension—L3
– Ankle dorsiflexion—L4
– Toe extension—L5
– Ankle plantarflexion, foot eversion, or hip
extension—S1
– Knee flexion—S2
• Reflexes
– Patella—L3, L4
– Achilles tendon—S1
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Neurologic Tests (cont.)
• Dermatomes
• Peripheral nerve distribution
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Rehabilitation
• Restoration of motion
• Restoration of proprioception and balance
– Closed-chain exercises
• Muscular strength, endurance, and power
– Open-chain exercises
– PNF-resisted exercises
• Cardiovascular fitness
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