7/16/2014. Anatomy (bones) Chapter 18 & 19 Foot, Ankle, & Low Leg. Anatomy (bones) Lower leg anatomy. Lateral ligaments

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Anatomy (bones) Chapter 18 & 19 Foot, Ankle, & Low Leg Athletic Training

2 leg bones Tibia Fibula Anatomy (bones) 7 tarsal bones Talus Calcaneous

(intermediate) Third (lateral) Talus Navicular Lower leg anatomy Fibula

Condyle (proximal) Medial Malleolus (distal) Lateral ligaments Anterior

1 Anatomy (bones) Chapter 18 & 19 Foot, Ankle, & Low Leg Athletic Training Spring 2014 Jihong Park 26 foot bones 14 Phalanges 5 Metatarsals 7 Tarsal 2 leg bones Tibia Fibula Anatomy (bones) 7 tarsal bones Talus Calcaneous Cuboid cube Navicular neck 3 cuneiforms First (middle) Second (intermediate) Third (lateral) Talus Navicular Lower leg anatomy Fibula Lateral Malleolus (distal) Tibia Lateral Condyle (proximal) Medial Condyle (proximal) Medial Malleolus (distal) Lateral ligaments Anterior talofibular ligament ATF(L) Posterior talofibular ligament PTF(L) Calcaneofibular ligament CF(L) 1

Medial ligaments Deltoid ligaments Anterior

Arches Lateral Longitudinal Medial Longitudinal

fascia Thick white band of fibrous tissue Supports

and the first layer of the muscles Articulations

Intermetatarsal Tarsometatarsal Midtarsal Subtalar

Peroneus Longus Peroneus Brevis Tibialis Posterior*

on medial side Dorsiflexors Tibialis Anterior

2 Medial ligaments Deltoid ligaments Anterior talotibial Posterior talotibial Calcaneotibial Arches Lateral Longitudinal Medial Longitudinal Anterior transverse (metatarsal) Transverse Plantar fascia Thick white band of fibrous tissue Supports the foot against downward forces Between the skin and the first layer of the muscles Articulations Interphalangeal DIP PIP Metatarsophalangeal Intermetatarsal Tarsometatarsal Midtarsal Subtalar Plantarflexors Gastrocnemius Soleus Plantaris Peroneus Longus Peroneus Brevis Tibialis Posterior* Flexor Digitorum Longus* Flexor Hallicis Longus* * on medial side Dorsiflexors Tibialis Anterior Extensor Digitorum Longus Extensor Hallicus Longus Peroneus Tertius Extensor retinacula 2

Invertors Tibialis Anterior Tibialis Posterior Flexor digitorum

Flexor digitorum lonugs Tibial artery Tibial nerve Flexor hallucis

Extensor Digitorum Longus Peroneal retinacula Nerve and blood

Injuries can develop due to: Improper shoes Surface condition Poor

deviations due to abnormal alignment or excessive stress Talus fx

plantarflexion & external rotation of tibia Pain with weight

3 Invertors Tibialis Anterior Tibialis Posterior Flexor digitorum Longus Flexor hallicus lngus Tom, Dick, & Harry Tibialis posterior Flexor digitorum lonugs Tibial artery Tibial nerve Flexor hallucis longus Evertors Peroneus Longus Peroneus Brevis Peroneus Tertius Extensor Digitorum Longus Peroneal retinacula Nerve and blood supply Specific injuries Sport places excessive forces on the foot Injuries can develop due to: Improper shoes Surface condition Poor foot hygiene Improper techniques and/or body position Anatomical deviations due to abnormal alignment or excessive stress Talus fx Lateral fx: Inversion and dorsiflexion Medial fx: Inversion and plantarflexion & external rotation of tibia Pain with weight bearing and point tender talar dome RICE immediately, X-ray Immobilization with non-weight bearing 3

Fractured calcaneus Landing from a jump or fall Avulsion fx (calcaneonavicular lig.

stress fx Repetitive heel strike (distance runners) Pain with heel strike & bearing weight Pain continues after

activity can be returned gradually Calcaneal apophysitis (Sever s Disease) Traction injury of the Achilles tendon

activity RICES, stretching & NSAIDs Heel lift using a heel cup could relieve some stress/pain Retrocalcaneal

swelling around Achilles insertion RICE & NSAIDs Ultrasound Stretching Heel lifts and Donut Pad Shoe fit (larger

in long jumps Severe pain & unable to withstand weight bearing Warmth, redness, and swelling Reduce weight

sprain or plantar fasciitis Sign and Symptoms Displacement of cuboid causes pain along 4 th and 5 th metatarsals

4 Fractured calcaneus Landing from a jump or fall Avulsion fx (calcaneonavicular lig.) Immediate swelling Pain w/o deformity Unable to bear weight RICES and refer for X-rays Walking boot Calcaneal stress fx Repetitive heel strike (distance runners) Pain with heel strike & bearing weight Pain continues after exercise Rest and AROM (conservative) for 2-3 weeks Non-weight bearing exercise - pool running As pain subsides activity can be returned gradually Calcaneal apophysitis (Sever s Disease) Traction injury of the Achilles tendon attachment in young athletes (8-14 yrs) Pain at Achilles attachment Pain with activity and ceases following activity RICES, stretching & NSAIDs Heel lift using a heel cup could relieve some stress/pain Retrocalcaneal bursitis Result of pressure and rubbing of shoe heel counter Chronic inflammation and may develop exostoses Pain& swelling around Achilles insertion RICE & NSAIDs Ultrasound Stretching Heel lifts and Donut Pad Shoe fit (larger and wider heel) Heel contusion Cuboid subluxation Caused by sudden starts, stops or changes of direction Landing in long jumps Severe pain & unable to withstand weight bearing Warmth, redness, and swelling Reduce weight bearing & RICE/NSAIDs Heel cup Tape (temporary relief) Pronation and trauma Often confused with lateral ankle sprain or plantar fasciitis Sign and Symptoms Displacement of cuboid causes pain along 4 th and 5 th metatarsals and over the cuboid May refer pain to heel area and bearing weight increases pain Joint mobilisation & arch tape Orthotic can be used to maintain position of cuboid 4

Tarsal tunnel syndrome Any trauma to the area Space occupying Foot deformities Signs & symptoms Pain (sharp, achy) and paresthesia

Happens when foot hyper-plantarflexed with a simple twist and/or fall ligament sprain, fx, dislocation Signs & symptoms Pain and

planus (AKA: flat foot; fallen arch) Pes cavus (high arch) Medial longitudinal arch appears flat Deformity Tight Shoes Overweight

the foot If asymptomatic, no treatment Orthotics or taping Medial longitudinal arch is higher than normal Rigid foot General foot

fascia Plantar fasciitis Plantar fasciitis Plantar fascia Dense connective tissue on the bottom of foot Tension develops with toe

Limb length discrepancy, pronation, inflexible longitudinal arch, tight gastroc-soleus complex sings and symptoms Extreme pain

longitudinal arch Pain increases with ankle dorsiflexion and toe extension Soft orthotics with heel cup Vigorous heel cord

5 Tarsal tunnel syndrome Any trauma to the area Space occupying Foot deformities Signs & symptoms Pain (sharp, achy) and paresthesia Increased pain at night Muscle weakness NSAIDs & orthotics Surgery to relief stress Tarsometatarsal fx/dislocation (Lisfranc) Happens when foot hyper-plantarflexed with a simple twist and/or fall ligament sprain, fx, dislocation Signs & symptoms Pain and inability to bear weight Swelling & tenderness on dorsum of foot Generally requires ORIF Open reduction internal fixation Pes planus (AKA: flat foot; fallen arch) Pes cavus (high arch) Medial longitudinal arch appears flat Deformity Tight Shoes Overweight Excessive exercise Weakness of supporting muscle/ligament Calcaneal Eversion Weakness in Posterior Tibialis Pain in the bottom of the foot If asymptomatic, no treatment Orthotics or taping Medial longitudinal arch is higher than normal Rigid foot General foot pain Metatarsalgia May be with claw toes or hammer Toes If asymptomatic, no correction Orthotics Stretch Achilles and plantar fascia Plantar fasciitis Plantar fasciitis Plantar fascia Dense connective tissue on the bottom of foot Tension develops with toe extension Most common problem in long distance runners Poor running technique Excessive tightness of Achilles tendon Mal-alignment Limb length discrepancy, pronation, inflexible longitudinal arch, tight gastroc-soleus complex sings and symptoms Extreme pain with first step in the morning, loosens after first few hours Pain with weight bearing Anterior medial heel, along with medial longitudinal arch Pain increases with ankle dorsiflexion and toe extension Soft orthotics with heel cup Vigorous heel cord stretching and exercise Massage plantar surface of foot (tennis ball or rigid round surface) NSAIDs & occasionally steroid injection Strengthening intrinsic muscles 5

Jones fx Fracture of metatarsal by inversion and PF, direct force (stepped on) or repetitive episodes Most

rate and course of healing is unpredictable Crutches with no immobilisation, gradually progressing WB

Overuse Change in shoes or training surface Dull ache during exercise, progressing to pain at rest Pain with

gradual and orthotics for pronation Bunion (Hallux valgus deformity) Bunion (Hallux valgus deformity)

and causing lateral mal-aignment of great toe Tight shoes Maligned flexor and extensor tendons Obvious

Pad between toes Tape/splint Exercises Both flexors & extensors Surgery Bunionectomy Morton s neuroma

Between 3 rd & 4 th metatarsal head: medial and lateral plantar nerves come together Irritated or collapse

removal of shoes Hyperextension of the toes on WB symptoms Shoes with narrow toe box or high heels symptoms

6 Jones fx Fracture of metatarsal by inversion and PF, direct force (stepped on) or repetitive episodes Most common = base of fifth metatarsal Forceful contraction with jumping Point tenderness/swelling High nonunion rate and course of healing is unpredictable Crutches with no immobilisation, gradually progressing WB Nonunion occurs, internal fixation may be required Bone stimulators have also been suggested Stress fx Overuse Change in shoes or training surface Dull ache during exercise, progressing to pain at rest Pain with compression and WB Bone scan 3-4 days PWB followed by 2 weeks rest (no running) Return to running should be gradual and orthotics for pronation Bunion (Hallux valgus deformity) Bunion (Hallux valgus deformity) Inflamed bursa becomes thickened Exostosis deformity Bursae becomes inflamed and thickens, enlarging joint, and causing lateral mal-aignment of great toe Tight shoes Maligned flexor and extensor tendons Obvious deformity, pain, inflammation, point tenderness Take off shoes when sitting at desk Wide toe shoes Orthotic Pad between toes Tape/splint Exercises Both flexors & extensors Surgery Bunionectomy Morton s neuroma Thickening of nerve sheath (common plantar nerves) at point where nerve divides into digital branches Between 3 rd & 4 th metatarsal head: medial and lateral plantar nerves come together Irritated or collapse of the transverse arch Excessive pronation Sharp, burning paresthesia with compression Relief with NWB or removal of shoes Hyperextension of the toes on WB symptoms Shoes with narrow toe box or high heels symptoms Morton s neuroma Bone scan to r/o stress fx MRI Wide toe box shoes Metatarsal pad (teardrop) in between toes Surgery Cut deep transverse metatarsal ligament 6

Toe sprains & fx Kicking a non-yielding object Crushing sings and symptms Immediate intense pain, popping sound Swelling, discoloration & possible deformity Pain may last for several weeks RICES,

swelling of MTP joint Increased pain with extension/flexion of the toe Prevent extension/flexion of toe/s Taping & orthotics Ice & ultrasound Subungual hematoma Direct pressure, dropping an

RICE immediately to reduce pain and swelling Relieve pressure within 12-24 hours (lance or drill nail): must be streile Ankle joint: functional anatomy Ankle is a stable hinge joint ROM from 20

Talocrural joint: DF & PF Subtalar joint: inversion & eversion Lateral ankle sprains Plantar flexion Inversion Internal rotation Talus on the tibia The hegits of malleoli More plantar flexion

disability WB is minimally impaired No or minimal laxity Tx RICE, NSAIDs, taping 7-10 days to return Grade II (ATF & CF) Feel or hear pop Moderate pain with difficulty WB X-ray to rule out fx;

7 Toe sprains & fx Kicking a non-yielding object Crushing sings and symptms Immediate intense pain, popping sound Swelling, discoloration & possible deformity Pain may last for several weeks RICES, X-rays, buddy taping toes to immobilise Begin WB as tolerable Turf toe The 1 st MTP joint sprain due to hyperextension/flexion/valgus force of Hallux Usually on artificial turf Significant pain & swelling of MTP joint Increased pain with extension/flexion of the toe Prevent extension/flexion of toe/s Taping & orthotics Ice & ultrasound Subungual hematoma Direct pressure, dropping an object on toe, or kicking another object Repetitive shear forces on toenail Signs of Injury Accumulation of blood underneath toenail Likely to produce extreme pain and ultimately loss of nail RICE immediately to reduce pain and swelling Relieve pressure within hours (lance or drill nail): must be streile Ankle joint: functional anatomy Ankle is a stable hinge joint ROM from 20 of DF to 50 of PF Medial & lateral displacement is prevented by the malleoli Ligament arrangement limits inversion and eversion at the subtalar joint Most stable during DF, least stable in PF Talocrural joint: DF & PF Subtalar joint: inversion & eversion Lateral ankle sprains Plantar flexion Inversion Internal rotation Talus on the tibia The hegits of malleoli More plantar flexion increases likelihood of a sprain ATF most common (>85%) Lateral ankle sprains Severity of injury is classified according to grades Swelling is not an indication Grade I (ATF) Mild pain and disability WB is minimally impaired No or minimal laxity Tx RICE, NSAIDs, taping 7-10 days to return Grade II (ATF & CF) Feel or hear pop Moderate pain with difficulty WB X-ray to rule out fx; crutches Grade III (ATF, CF, and PTF possibly tibiofibular lig.) Severe pain/swelling/discolouration Unable to WB X-ray; crutches & immobilisation (isometric in cast) May require surgery due to laxity and instability 7

Afferent Signals 7/16/2014 Medial ankle sprains (5-10% ankle sprains)) Everted foot/feet, uneven surface Foot pronation Can be from inversion

ankle sprains Syndesmotic ankle sprains Injury to the distal tibiofemoral joint Anterior/posterior tibiofibular ligament DF with ER (w/ inversion

ankle sprains Ankle sprains (Fallet 1998) Chronic ankle instability Most common clinical presentations ATFL + CFL = 34% ATFL + CFL + PTFL = 31%

3% Syndesmotic sprain = 1% Other = 15% Longstanding symptoms including epidodes of giving way and recurrent sprains after initial sprain Develops

Subjective feeling that the ankle is unstable Proprioceptive and/or neuromuscular deficits Rehabilitation should focus on a combination of ankle

Achilles tendon strain/rupture Ligaments CNS JOINT STABILITY Bony Stability Muscles & Tendons Efferent Signals Sudden stop and go Forceful PF

8 Afferent Signals 7/16/2014 Medial ankle sprains (5-10% ankle sprains)) Everted foot/feet, uneven surface Foot pronation Can be from inversion sprains Deltoid can be impinged and contused Pain/swelling/discolouration Unable to bear weight Possible avulsion fx : similar to the lateral ankle sprains Syndesmotic ankle sprains Injury to the distal tibiofemoral joint Anterior/posterior tibiofibular ligament DF with ER (w/ inversion or eversion) Severe inversion sings and symptms Severe pain (usually anteriorly located) Loss of function WB difficult : similar to the other ankle sprains Ankle sprains (Fallet 1998) Chronic ankle instability Most common clinical presentations ATFL + CFL = 34% ATFL + CFL + PTFL = 31% ATFL only = 16% PTFL only = 2% CFL only = 1% Other = 14% Most common primary diagnoses Grade 1 sprain = 71% Grade 2 sprain = 10% Grade 3 sprain = 3% Syndesmotic sprain = 1% Other = 15% Longstanding symptoms including epidodes of giving way and recurrent sprains after initial sprain Develops following 1/3 of all initial ankle sprains Mechanical Laxity that physically allows for movement beyond the physiologic limit of ROM Functional Subjective feeling that the ankle is unstable Proprioceptive and/or neuromuscular deficits Rehabilitation should focus on a combination of ankle strengthening and improving proprioception What makes a stable joint? Achilles tendon strain/rupture Ligaments CNS JOINT STABILITY Bony Stability Muscles & Tendons Efferent Signals Sudden stop and go Forceful PF Eccentric contraction (landing from a jump) sings and symptms: 1º & 2º same as typical muscle strain 3rd degree (achilles rupture) = deformity, pop, cannot do toe raise RICE, NSAIDs/analgesics 1º & 2º tape for activity Heel lift (more for 2º) 3º surgery 8

Peroneal (fibularis) tendon subluxation Fibularis tendon strain Inversion ankle sprain resulting in tearing of fibularis retinaculum Direct blow to the area sings and symptms Deformity with DF/PF

supination Stress on peroneal tendon Sings and symptoms Pain on the fibularis tendon during push-off RICE, NSAIDs, appropriate warm-up and flexibility exercise Orthotics and elastic taping Posterior

9 Peroneal (fibularis) tendon subluxation Fibularis tendon strain Inversion ankle sprain resulting in tearing of fibularis retinaculum Direct blow to the area sings and symptms Deformity with DF/PF (Snapping/popping) Ecchymosis, swelling, tenderness, and crepitus RICES, NSAIDs/analgesics Reinforce compression pad Surgery if conservative plan fails Patients with pes cavus due to excessive supination Stress on peroneal tendon Sings and symptoms Pain on the fibularis tendon during push-off RICE, NSAIDs, appropriate warm-up and flexibility exercise Orthotics and elastic taping Posterior tibialis strain Common overuse condition in runners with foot hypermobility or over pronation Repetitive microtrauma Sings and symptoms Pain/swelling, tenderness Pain with resistive inversion/pf Initially RICE, NSAIDs/analgesics NWB cast with foot in inversion may help Correct problem of over pronation Taping Orthotics Gastrocnemius/soleus strain Quick start or stop, jumping May feel like being hit in leg with a stick Pain/swelling, tenderness, and muscle dysfunction Similar to other strains Use heel wedge to reduce calf stretching Compression slip may help Medial tibial stress syndrome (shin splints) Repetitive trauma Weak muscles, improper footwear, training errors, varus foot, tight heel cord, pronated feet Pain over the anterior portion of shin Catch all for stress fx, muscle strains, chronic anterior compartment syndrome Pain w activity Pain before & after activity but affecting performance Pain before, during and after activity, affecting performance Pain so severe, performance is impossible 9

Medial tibial stress syndrome (shin splints) Physician referral for X-rays and bone scan Activity modification Correction of

surae) Arch taping and/or orthotics Compartment syndrome Traumatic: activate EMS Direct trauma Pain, achy, sharp, muscle

of fascia Post exercise fluid retention due to decreased venous return Compartment syndrome (management) Acute Requires

10 Medial tibial stress syndrome (shin splints) Physician referral for X-rays and bone scan Activity modification Correction of abnormal biomechanics Ice massage to reduce pain and inflammation Flexibility programme for gastroc-soleus complex (triceps surae) Arch taping and/or orthotics Compartment syndrome Traumatic: activate EMS Direct trauma Pain, achy, sharp, muscle weakness/tightness, cramping, swelling, numbness Exertional (acute or chronic) Symptoms occur during/after exercise thickness of fascia Post exercise fluid retention due to decreased venous return Compartment syndrome (management) Acute Requires emergency surgery Reduce pressure or release fascia Fasciotomy Exertional RICE, NSAIDs/analgesics Modify activity Recurrent may require surgery 10

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

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