Bones = phalanges 5 metatarsals 7 tarsals

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Gabriella Garrison
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2 The Foot (Bones) Bones = phalanges 5 metatarsals 7 tarsals

3 Toes (Phalanges) Designed to give wider base for balance and propelling the body forward. 1st toe (Hallux) Two sesamoid bones located under the 1 st MP joint.

4 Metatarsals 5 Bones 1 st metatarsal is the largest and strongest and functions as the main body support during walking and running. Palpable at the ball of the foot. 5 th metatarsal most common fractured.

5 Tarsals 7 bones Aids in the support of the body. Calcaneous = largest tarsal bone, supports talus and shapes heel, and provides attachment for achilles tendon.

6 Joints of the Foot Interphalangeal joint (IP) Flexion / Extension Metarsalphalangeal joint (MP) Flexion / Extension Abduction / Adduction

7 Bones of the Ankle Tibia Main weight bearing bone of LOWER LEG Forms medial malleolus Fibula Non-weight bearing Mainly muscle and ligament attachment Forms lateral malleolus Talus Main weight bearing bone of the ANKLE

8 Lateral Ligaments of the Ankle Resist ankle inversion Anterior talofibular (ATF) Most commonly sprained Calcaneofibular (CF) Posterior talofibular (PTF)

9 Medial Ankle Ligaments Deltoid Resists ankle eversion Low rate of injury

11 Quiz 1. Which bone in the lower leg is the most weight bearing? 2. What does ATF stand for? 3. Which ligaments resist inversion? 4. Which ligaments resist eversion? 5. What does MP stand for? 6. How many tarsal bones are there? 7. How many bones are in the foot?

12 Answers: 1. Tibia 2. Anterior Talofibular 3. Anterior Talofibular, tibiofibular, calcaneofibular (lateral) 4. Deltoid ligaments (medial) 5. Metatarsalphalangeal

13 Muscles of the Foot and Anterior Muscles (3) Ankle Extensor Hallucis Longus/Brevis extension of great toe Extensor Digitorum Longus/Brevis extension of 2 5 phalanges

16 Muscles of the Foot and Ankle Anterior Muscles cont. (3) Tibialis anterior inversion and dorsiflexion of foot / ankle

17 Muscles of the Foot and Ankle Medial Muscles (3) Tibialis Posterior Inversion and plantarflexion Flexor Hallucis Longus Flexor of great toe and plantarflexion of ankle Flexor Digitorum Longus Flexors of 2 5 toes and plantarflexion of ankle

18 Muscles of the Foot and Ankle

19 Muscles of the Foot and Ankle Posterior Muscles (2) Gastrocnemius plantarflexion of ankle Soleus plantarflexion of ankle

20 Muscles of the Foot and Ankle

21 Muscles of the Foot and Ankle Lateral Muscles (2) Peroneus Longus / Brevis eversion, plantar flexion of ankle

22 Arches of the Foot

23 Supinated Arches (High Arches)

24 Supinated Arches

25 Pronated Arches (Flat Feet)

26 Pronated Arches

27 Pronated Arches

28 Pronated Arches

29 Foot and Ankle Injuries

Ankle Sprain Cause: Excessive inversion or eversion of the ankle S/S: Point tenderness, swelling, discoloration, laxity, inability to walk or run properly

30 Ankle Sprain Cause: Excessive inversion or eversion of the ankle S/S: Point tenderness, swelling, discoloration, laxity, inability to walk or run properly (extent based on degree). TX: RICE, rehabilitation immediately (Grade III requires immobilization) Prevention: Strengthening exercises, proper shoes/ equipment

31 1 st Degree Ankle Sprain Mechanism (MX) Inversion and/or plantarflexion ATF most common sprained Occurs during contact or non contact.

32 S/S 1 st degree Mild pain Pt ATF Possible swelling Fast recovery to FWB and ROM No joint laxity

33 2 nd Degree Ankle Sprain MX Same as 1 st degree, more severe. Involves the ATF, CF Possible growth plate involvement Most cases x-ray needed

35 S/S 2 nd degree Felt a pop Localized severe pain Pt more then one ligament Rapid swelling Decrease ROM Laxity in joint Unable to FWB

36 3 rd Degree Ankle Sprain Rupture of ligaments (ATF, CF, PTF) Consider a FX X-ray is mandatory

37 S/S 3 rd Degree Felt or heard pop Extreme pain Extreme/rapid swelling No ROM Unable to FWB

38 1 st Degree Ankle Sprain RICE Return to Play (Toe raise, heel walk, Full go w/ full ROM Tape to Play Reevaluate 24hrs 2 nd Degree Ankle Sprain RICE (Horseshoe w/ compression wrap) Crutches 24 hours Reevaluate 24hrs Refer to Dr. X-rays 3 rd Degree Ankle Sprain RICE (Horseshoe w/ compression wrap) Crutches Walking Boot Refer to Dr. X-rays

39 Syndesmotic Injury High Ankle Sprain of ligaments between tibia and fibula Associated with rotational injury Pushed back on planted foot Interosseus Ligament Anterior-Inferior Tibiofibular Ligament Posterior-Inferior Tibiofibular Ligament

Physical Exam: Syndesmotic Injury Pain with External Rotation Test Separates tibia from fibula Tenderness between tibia and fibula Positive Squeeze

40 Physical Exam: Syndesmotic Injury Pain with External Rotation Test Separates tibia from fibula Tenderness between tibia and fibula Positive Squeeze test Limited dorsiflexion Pain with weight bearing and rising up on their toes Imaging: X-Ray Possible widening of the space between tibia and fibula

41 Treatment of High Ankle Sprain Boot as needed if severe pain Functional Rehab Strengthening, early ROM Similar to ankle sprain Takes twice as long to recover as compared to ankle sprain Widening with fracture may require Ortho referral for surgical repair

42 Anterior Drawer Test Tests for ligament instability Mainly tests ATF integrity but can also test the CF and PTF depending on severity Ankle must be relaxed Ankle in slight plantar flexion

43 Talar Tilt Test for lateral ankle instability Positive test indicates tear in ATF, and CF Kleigers Test Test for High Ankle Sprain. Dorsiflexion and external rotation

44 Squeeze Test Compression of the mid tibia and fibula with reproduction of pain in the ankle Indicates High Ankle Sprain pain from syndesmotic injury

45 Ankle Dislocation Mx: Heel strikes ground forcefully; blow to anterior lower leg S/S: Deformity, inability to move foot, rapid swelling, refusal to allow moving or touching foot TX: Splint, ICE, 911 or transport to hospital HJUl

47 Turf Toe Sprain of the 1 st MP joint Mx: S/S Hyperextension/ hyperflexion of great toe Common on artificial surface Flexible types of footwear can contribute Pain over the first MP joint

49 Achilles Tendonitis MX: Repetitive motions such as running and jumping that cause tendon breakdown S/S: Swelling, crepitus, pn with palpation, pn with dorsiflexion, weak with plantarflexion TX: RICE Limiting or restricting the activity that caused the irritation Aggressive stretching of heel cord Crepitus (crackling and grinding) may mean it is too late Prevention: Achilles and gastroc/solues stretching, proper acclimization to activity.

51 Achilles Tendon Rupture MX: Sudden, forceful dorsiflexion of the ankle with a chronically tight tendon. S/S: Feel or hear a pop. Feel as if they ve been kicked in the leg. Inability to plantar flex foot. TX: Surgery or a cast Prevention: Stretching and proper care of any tendonitis

52 Thompson Test Test for achilles tendon rupture

54 Longitudinal Arch Strain Mx Downward force to the foot causing depression of the arch Most common with overuse (running) S/S Sharp pain with weight bearing Painful during dorsiflexion

55 Lower Leg Problems Shin Splints : catch all term related to lower leg pain. MX: constant pounding associated with running S/S: sharp pain in lower leg around medial/lateral aspect of lower leg and connective tissue between tibia and fibula TX: RICE (cold whirlpool), heal lift, arch support, shoes, change running surface

57 MX: Compartment Syndrome Increased pressure within one of four compartments of lower leg causes compression of the structures in the leg. S/S: Deep aching pain, tightness, and swelling. Pain with stretching. TX: Acute~ immediate surgery Chronic~ activity modification & ice and some times surgery Prevention: Stretching (Hard to prevent)

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5 th Metatarsal Fractures Jones Fracture: The Don t Miss Fracture See in sprinters, jumpers Watershed Region/Poor blood flow = Poor healing, risk of nonunion Treatment: Referral to Orthopedics or

61 5 th Metatarsal Fractures Jones Fracture: The Don t Miss Fracture See in sprinters, jumpers Watershed Region/Poor blood flow = Poor healing, risk of nonunion Treatment: Referral to Orthopedics or Podiatry Splint in ER and make Non-weight bearing Non-weight bearing with cast for 4-6 weeks followed by 4-6 weeks in walking boot ~ 75% heal with non-operative treatment If athlete, often orthopedic pinning required 30-50% will re-fracture

62 Jones Fracture X-Ray

63 Lisfranc Injury Lisfranc Ligament: Base of 2 nd Metatarsal Medial Cuneiform -Injury causes separation of the base of the 1 st and 2 nd metatarsals leading to forefoot instability

64 Lisfranc Injury Injury is referred to as a Lisfranc if there is any disruption of the tarsometatarsal joint complex Injury can range from sprain of the Lisfranc ligament to dislocation (due to ligament tear) to fracture Why is this area of the foot prone to injury? Transverse ligaments connect the bases of the four lateral metatarsals No transverse ligament exists between the 1 st and 2 nd metatarsal bases Minimal support = increased risk of injury

$metatarsal Look for fracture at base of 2 nd metatarsal XR findings very subtle. If have midfoot pain and negative XR, still possibly a Lisfranc and needs follow up http://orthoinfo.aaos.org/topic.$

65 Imaging X-Ray Weight-bearing: AP and lateral, +/- oblique -Tell radiology what diagnosis you are concerned about Lisfranc Injury XR Evaluation: Look for widening of space between 1 st and 2 nd metatarsal Look for fracture at base of 2 nd metatarsal XR findings very subtle. If have midfoot pain and negative XR, still possibly a Lisfranc and needs follow up

66 Toe Abnormalities Hammer Toes MX: TX: Poor shoe choices Middle joint (PIP) flexed, other joints (MP, DIP) hyperextended Refer, orthotics or surgery

67 Bunion / Hallux Valgus MX: Bony enlargement of the head of the 1st metatarsal caused from wearing improperly fitting shoes S/S: Obvious deformity, tenderness, and swelling TX: Proper shoe selection, protection devices, surgery may be necessary Prevention: Properly fitting shoes

70 MX: Ingrown Toenail Improper shoe fitting and nail cutting S/S: Increased pain, swelling, redness around the nail bed TX: Hot, soapy water, antibiotics, raise nail up Prevention: Proper shoes, proper nail trimming

72 Foot & Ankle Rehab Begin rehab with modalities. E-Stim, Thermotherapy, Massage, Etc. **Remember the 3 components that need to be done sequentially** 1) Flexibility and ROM 2) Strength and Muscle Endurance 3) Proprioception, Coordination, and Agility

73 Flexibility & ROM 1. Plantar Flexor Stretch 2. Seating Soleus Stretch 3. Seated Calf Stretch 4. Standing Calf Stretch 1. 3x30 seconds

74 Strength- Toe Marble Pick-Ups x3 Towel Scrunch Increase difficulty with weight x3 Manual/T-Band Toe Flexion/Extension 3x12

75 Strength- Ankle 4 Way Isometrics 3x12

76 Strength- Ankle Heel Walks Toe Walks 3x20 feet Calf Raises Single/Double Leg Straight/Bent Knee Lunges- FWD/LAT Change surface for increase difficulty

77 Strength- Ankle 4- way Ankle Can be done with Theraband, cuff weights, or manually. ABC s

78 Proprioception- Ankle Weight Shifts Done very early Single Leg Balance Hard surface Eyes Closed Surface Change Ball Toss Clocks

79 Agilities- Ankle t Hops Single/Double Leg FWD/BKW, S/S, CW, CCW Dot drills Single/Double Leg Hops

80 Agilities- Ankle Slide Board Very difficult. Should only be done when close to return Box Jumps S/S, FWD, Jump Over, etc

81 Foot & Ankle Rehab End rehab session with: Cryotherapy, E-Stim, Stretching, Massage

Prevention and Treatment of Injuries. Anatomy. Anatomy. Tibia: the second longest bone in the body

Prevention and Treatment of Injuries The Ankle and Lower Leg Westfield High School Houston, Texas Anatomy Tibia: the second longest bone in the body Serves as the principle weight-bearing bone of the leg.