Foot/Ankle Unit
SKELETAL ANATOMY
Lower Leg Bones
• Tibia
– Shin Bone
– Weight bearing bone in the lower leg
– Medial Malleolus:
• Distal end of tibia that forms the medial ankle bone
• Fibula
– Non-weight bearing bone
– Lateral Malleolus:
• Distal end of fibula that forms the lateral ankle bone
Foot Bones
• Tarsals (7)
–
–
–
–
Talus
Calcaneus
Cuboid
Cuneiforms
• (medial, middle, lateral)
– Navicular
• Metatarsals (5)
• Phalanges (14)
– Proximal
– Middle
– Distal
Joints
• Ankle:
– Distal Tibiofibular
– Talofibular
– Talocrural
• Foot:
– Intertarsal
– Tarsalmetatarsal
• Toes:
– Metatarsalphalangeal
– Proximal Interphalangeal
– Distal Interphalangeal
Ligaments
• Lateral
– Anterior Talofibular (ATF)
– Calcaneofibular (CF)
– Posterior Talofibular (PTF)
• Medial
– Deltoid
• High
– Anterior Tibiofibular
SOFT TISSUE ANATOMY
Terminology
• Plantarflexion (PF):
– Ankle movement in which foot moves toward ground and toes
are pointed to the ground
• Dorsiflexion (DF):
– Ankle movement in which toes/dorsum of foot moves upwards
towards knee
• Origin:
– Where muscle originates and attaches to bone
• Insertion:
– Where muscle attaches, usually distally, and where movement
occurs
Movements/Actions
• Foot/Ankle:
–
–
–
–
Inversion (inv)
Eversion (ev)
Plantarflexion (PF)
Dorsiflexion (DF)
• Toes:
–
–
–
–
Flexion (flex)
Extension (ext)
Abduction (abd)
Adduction (add)
Muscles
• The muscles for the foot and ankle are in
muscle groups on the lower leg.
• There are four main groups
– Anterior
– Posterior
– Medial
– Lateral
Posterior Muscles
Muscle
Origin
Insertion
Action
Gastrocnemius
Distal Femur
Calcaneus
PF and Knee Flexion
Soleus
Posterior tibia &
fibula
Calcaneus
PF
Posterior Muscle Diagram
Anterior Muscles
Muscle
Origin
Insertion
Function/Action
Tibialis Anterior
Tibia
Medial cuneiform & DF and slight
1st metatarsal
inversion
Extensor Hallicus
Longus
Fibula
Dorsal surface of
big toe
Extensor Digitorum
Longus
Tibia & Fibula
DF and inv of ankle,
extends 1st digit
DF and eversion,
extends toes 2-5
Anterior Muscles Diagram
Medial Muscles
Muscles
Origin
Insertion
Function/Action
Tibialis Posterior
Posterior Tibia
Navicular,
cuneiforms,
cuboid/metatarsals
2-4
PF and inversion
Flexor Digitorum
Longus
Posterior Tibia
Dorsal surface of
PF and inv, flexes
distal phalanges 2-5 toes 2-5
Flexor Hallicus
Longus
Fibula
Dorsal surface of 1st PF and inversion,
distal phalanx
flexes big toe
Medial & Lateral Diagram
Lateral Muscle Diagram
Lateral Muscles
Muscle
Origin
Insertion
Function/Action
Peroneus Longus
Fibula
Dorsal surface of 1st Eversion & PF
metatarsal and
medial cuneiform
Peroneus Brevis
Fibula
Proximal 5th
metatarsal
Eversion & PF
SPRAINS
Ankle Sprains
• Single most common injury in the physically active
caused by sudden inversion or eversion moments
• There are 3 types of Ankle Sprains:
– Inversion
• Also called a Lateral ankle sprain
• Most common and result in injury to the lateral ligaments
– Eversion
• Also called a Medial ankle sprain
• Least common due to anatomical structures, medial
malleolus
– Syndesmotic
• Also called a High ankle sprain
Ankle Sprains
The following chart shows the mechanism of injury or
MOI for each type of sprain according to the ligament
that is injured.
Lateral
Medial
High
ATF: PF and Inv
Deltoid: DF and Eversion
Ant. Tibiofibular: Excessive
DF or PF
CF: Inv
PTF: Severe inversion or
dislocation (rare)
Ankle Sprain Grades & Types
Ankle Sprain: S/S
• General S/S for all types of sprains:
– Swelling
– Pain with WB (weight bearing)
– Instability
– Ecchymosis (bruising/discoloration)
• Stress Test Positives:
– Anterior Drawer Test- ATF ligament
– Talar Tilt Test- CF and Deltoid ligaments
– Kleiger’s Test- Tib/fib ligament
Ankle Sprains: Rx
• General Acute Care:
– RICE with horseshoe
– NSAIDs
– Crutches?
• Usually for a grade 2 and up
– Referral
Toe Sprains
•Sprained Toes
– MOI:
• Generally caused by kicking non-yielding object
• Pushes joint beyond normal ROM or imparting a twisting motion
on the toe- disrupting ligaments and joint capsule
– S/S:
• Pain is immediate and intense but short lived
• Immediate swelling and discoloration occurring w/in 1-2 days
• Stiffness and residual pain will last several weeks
– Rx:
• RICE, buddy taping toes to immobilize
• Begin weight bearing as tolerable
Turf Toe
•Great Toe Hyperextension (Turf Toe)
– MOI:
• Hyperextension injury resulting in sprain of 1st
metatarsophalangeal joint
• May be the result of single or repetitive trauma
– S/S:
• Pain and swelling which increases during push off in walking,
running, and jumping
– Rx:
•
•
•
•
Increase rigidity of forefoot region in shoe
Taping the toe to prevent dorsiflexion
Ice and ultrasound
Rest and discourage activity until pain free
ACUTE INJURIES
Muscle Strains
• MOI:
– Due to violent contraction/twisting of foot
– Awkward landing
• S/S:
–
–
–
–
Pain with ROM or RROM
Possible pain with WB
Swelling or crepitus
May feel like being “hit in leg with a stick”
• Rx:
– RICE
– Taping/bracing
– Monitor for acute compartment syndrome
Achilles Tendon Rupture
• Occurs w/ sudden stop and go; forceful
plantar flexion w/ knee moving into full
extension
• Commonly seen in athletes > 30 years old
– Can be observed at any age
• Generally has history of chronic
inflammation
Achilles Tendon
Achilles Tendon Rupture
• S/S:
– Pain/inability to plantarflex
– Feels like they were “kicked in calf”
– Positive Thompson Test
– Deformity
• Rx:
– RICE
– Referral is rupture is suspected
Contusion
• MOI:
– Direct blow or crush of the muscle fibers
• S/S:
– Ecchymosis, bruise may develop
– Limited ROM; pain, weakness and partial loss of limb
function
– Palpation will reveal hard, rigid, inflexible area due to
internal hemorrhaging and muscle guarding
• Rx:
– Stretch to prevent spasm; apply cold compression and ice
– Wrap or tape will help to stabilize the area; padding to
protect the area
– Monitor for Acute Compartment Syndrome
Leg Cramps and Spasms
• Sudden, violent, involuntary contraction, either
clonic (intermittent) or tonic (sustained) in nature
• MOI:
– Difficult to determine; fatigue, loss of fluids, electrolyte
imbalance, inadequate reciprocal muscle coordination
• S/S:
– Cramping with pain and contraction of calf muscle
• Rx:
– Try to help patient relax to relieve cramp
– Firm grasp of cramping muscle with gentle stretching will
relieve acute spasm
– Ice will also aid in reducing spasm
– If recurrent may be fatigue or water/electrolyte imbalance
FRACTURES AND DISLOCATION
INJURIES
Dislocations
• Rare in ankle, but common in phalanges
• MOI:
•
Traction or twisting
• S/S:
•
•
•
Deformity
Possible fractures
Inability to move extremity
• Rx:
•
•
•
Immobilize
Cold
Referral for reduction or Emergency Action Plan (EAP)
Types of Acute Fx
• Avulsion Fractures
– Common for ATF Ligament to fracture lateral
malleolus (looks like 3rd Degree sprain)
– Jones Fracture- Peroneus brevis pulls off proximal
5th metatarsal with forced inversion
• Growth Plate (Epiphyseal) Fractures
– Distal plated in fibula and tibia may fracture with
inversion/eversion
Acute Fractures
• MOI:
•
•
•
Direct blows
Twisting
Associated with avulsions/dislocations
• S/S:
•
•
•
•
•
•
Localized Pain
Deformity?
Swelling
Ecchymosis
Crepitis
Pain with WB
Acute Fractures
• Stress Tests:
– Tap Test (Percussion)- tibia, fibula, talus or
calcaneus
– Calf Squeeze (Compression)- tibia or fibula
• Rx:
– RICE
– X-ray, reduction, casting up to 6 weeks depending
on the extent of injury
– Be prepared to activate Emergency Action Plan
(EAP) if open fracture or signs of shock
Types of Stress Fx
• March Fracture
– Stress Fracture to the metatarsals due to
repetitive activity
• Most commonly the 2nd metatarsal
• Tibial or fibula Stress Fracture
– Common overuse condition, particularly in those
with structural and biomechanical insufficiencies
– Runners tends to develop in lower third of lower
leg (dancers middle third)
Stress Fractures
• Extremely common due to repetitive action
• General Management:
– S/S:
• point tenderness; especially in WB position
– Rx:
• NWB (non-weight bearing) > week or more
• Walking boot or cast possible
• Out of activity 3-4 weeks
• Gradual resumption of activity
OTHER INJURIES
Compartment Syndrome
• A painful and dangerous condition caused by pressure
buildup from internal bleeding or swelling of tissues.
– The pressure decreases blood flow, depriving muscles and
nerves of needed nourishment.
• Acute compartment syndrome
– Occurs secondary to direct trauma
– Medical emergency
• Acute exertional compartment syndrome
– Evolves with minimal to moderate activity
• Chronic compartment syndrome
– Symptoms arise consistently at certain point during activity
Compartment Syndrome
Acute Compartment Syndrome
• MOI: direct blow or tearing of muscle fibers
causing swelling
• S/S:
– Pain becoming worse; eventually numbness
– Loss of foot ROM
– Leg swelling
• Rx: Medical Emergency! Refer Immediately
– Apply cold and elevate
– Surgical intervention is probably necessary
Plantar Fasciitis
• MOI:
–
–
–
–
–
–
Shoes
Overweight
Activity on hard surfaces
Overuse
Poor mechanics
Fatigue
• S/S:
– Morning pain
– Swelling
– Pain with WB
– Crepitus
• Rx:
–
–
–
–
–
Good shoes/orthotics
Stretching
Ice
Taping
Referral?
Arches
•Pes Planus Foot (Flatfoot)
– MOI:
• Associated with excessive pronation, forefoot varus, wearing tight
shoes (weakening supportive structures) being overweight,
excessive exercise placing undo stress on arch
•Pes Cavus (High Arch Foot)
– MOI:
• Higher arch than normal; associated with excessive supination,
accentuated high medial longitudinal arch
Morton’s Toe Vs Neuroma
•Morton’s Toe
– Etiology
• Abnormally short 1st metatarsal, making 2nd toe look longer
• More weight bearing occurs on 2nd toe as a result and can impact gait
• Stress fracture could develop
•Morton’s Neuroma
– Etiology
• Thickening of nerve sheath (common plantar nerve) at point where
nerve divides into digital branches
• Commonly occurs between 3rd and 4th met heads; medial and lateral
plantar nerves come together
• Irritated by collapse of transverse arch of foot, putting transverse
metatarsal ligaments under stretch, compressing digital nerves and
vessels
Shin-Splints
• Shin-splints is a catch-all term for tendonitis,
chronic compartment syndrome or a stress
fracture
• Medial Tibial Stress Syndrome (MTSS) is the
more appropriate term for shin-splint-type
pain
Shin-Splints
• MOI:
– Pes planus (flat feet)
– Overweight
– Poor conditioning
– Poor shoes
– Activity on hard surfaces
– Overuse/Muscle weakness
– Poor running technique
– Genetics
Shin-Splints
• S/S:
– Pain is usually found on medial side of leg
– Pain with activity that gets progressively worse over
time
• Rx:
–
–
–
–
–
RICE before/after
Check shoes, running shoes are only good for 500 miles
Stretch, Strengthen, Cross Train
NSAIDs
Refer for fracture or compartment syndrome
EVALUATIONS
Evaluation: The Why
• The athlete’s well-being WILL depend on the
accuracy and thoroughness of your Soap!
• Ask probing questions and record accurately
• The aim of the examination process is to provide
an efficient and effective exchange, and to
develop a rapport between the clinician and
patient
• The information gathered is used to provide the
athlete with the best care and to provide a record
of what has been done, for medical and legal
purposes.
HOPS
• History:
– A series of questions asked to determine nature and
location of injury
• Observation:
– A visual examination of the injury
• Palpation:
– A hands-on approach where examiner feels for deformity or
other abnormal findings
• Stress tests:
– A series of tests to check range of motion and degree of
function of tissues at a joint
SOAP Note Format
• Subjective:
– Detailed information about the history of injury and
athlete; chief complaints, sign, and symptoms
• Objective:
– Information that is a record of test measurements; the
data gained from inspection
• Assessment:
– Identification of the problem; identify the injury and the
severity of it
• Plan of Action:
– What are you going to do; the immediate treatment,
rehab, or referral
Active Listening Skills
The following skills should be used during a evaluation to
help you gather information and gain the athletes trust:
1.
2.
3.
4.
5.
6.
7.
Face the speaker; lean slightly forward
Maintain eye contact
Minimize external/internal distractions
Respond appropriately
Focus solely on what the speaker is saying
Keep an open mind
Avoid giving advice until you have completely evaluated
injury
8. Don’t interrupt
9. Stay engaged in the interview
Subjective: Oral/Verbal Info
• General Questioning Prompts:
–
–
–
–
–
–
–
–
Was there a previous injury?
How did it happen?
When did it happen?
What did you feel?
How do you feel?
What is the type of pain?
Where does it hurt?
Did it make a sound?
* Ask for a witness if the person is incapable of
answering
Objective: Visual Inspection
• Look for the following:
– Swelling
– Deformity:
• protrusions
– Ecchymosis:
• Discoloration
– Symmetry
– Gait:
• Walk
–
–
–
–
–
Scars
Facial expressions
Bleeding
Depressions
ROM
Objective: Hands-On Format
•
•
•
•
Perform Palpation
Check anatomical structures to determine points of pain
Check for abnormalities
Preform special test or stress tests to assess severity
– Stress Tests:
•
•
•
•
•
•
Anterior Drawer Test – ATF Ligament
Talar Tilt Test – CF Ligament
Kleiger’s Test Thompson Test – Achilles Tendon Rupture
Tap (Percussion) Test – Fracture test
Calf Squeeze (Compression) Test – Fracture Test
– Manual Muscle testing (RROM)
• Dorsiflexors/Plantarflexors
• Toe flexors/extensors
• Inverters/Everters
RETURN TO PLAY
Terminology
• Therapeutic:
– Healing action
Phase I: Pain Management
• The time immediately following the injury or
surgery, in which movement is limited to ease
pain
• Areas of Importance:
–Pain control
–Decrease inflammation
–RICE
Phase II: ROM
• Time when therapeutic action initiated includes;
joint range-of-motion, mobility and flexibility
exercises
• Areas of Importance:
–PROM:
•passive rom
•AAROM:
•active assisted rom
•AROM:
•active rom
•Flexibility
Phase III: Balance
• PROPRIOCEPTION (Balance)
– The body relearning the ability to sense the
position of its limbs during movement;
includes balance
• Areas of Importance:
– Balance exercises
– Coordination exercises
Phase IV: Strength
• To increase muscular strength
• Areas of Importance:
– Emphasize the injured area, but maintain whole
body strength
Phase V: Endurance
• For both the cardiovascular and muscle
systems to perform work over a period of
time
• Areas of Importance:
– High amount of repetitions with low weight
– Full-body cardiovascular endurance
Phase VI: Sport Specific
• Where the athlete mimics specific sport-like
or functional activity. This leads to full
resumption of activity.
• Areas of Importance:
•Gradual resumption of activity
•Limited or restrictive moving towards full resumption