Chapter 16 Foot, Ankle, and Lower Leg Conditions

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 16

Foot, Ankle, and Lower Leg Conditions

Chapter 16

Foot, Ankle, and Lower Leg Conditions


Anatomy Anatomy Skeletal features of the lower leg, ankle, and foot


Anatomy (cont’d)Anatomy (cont’d)

• Forefoot

– Metatarsals and phalanges; numerous joints

– Support and distribute body weight throughout the foot

– Toes

• Smooth the weight shift to the opposite foot during walking

• Help maintain stability during weight-bearing

– 1st digit – hallux or “great toe” – main body stabilizer during walking or running



• Midfoot

– Navicular, cuboid, 3 cuneiforms; numerous joints

– Talocalcaneonavicular joint (TCN)

• Talus moves simultaneously on calcaneus and navicular

• Combined action of talonavicular and subtalar joint



• Hindfoot

– Calcaneus and talus

– Talocrural joint (ankle joint)

• Hinge joint; plantarflexion and dorsiflexion

• Articulation of talus, tibia, and fibula

• Fibula extends farther distally than tibia – limits eversion

• Talar dome wider anteriorly – more stable in dorsiflexion



• Hindfoot (cont’d)

– Talocrural joint (ankle joint) (cont’d)

• Ligaments

• Medial: deltoid

• Lateral :anterior talofibular; posterior talofibular; calcaneofibular

– Subtalar joint

• Behaves as a flexible structure



• Ligaments supporting the midfoot and hindfoot region

Ligaments supporting the midfoot and hindfoot region, lateral and medial views



• Tibiofibular joints

– Superior—proximal

– Inferior—distal

– Interosseous membrane



• Plantar arches

– Support and distribute body weight

– Longitudinal arch—medial and lateral

– Transverse arch

– Ligaments

• Spring (calcaneonavicular)

• Long plantar

• Short plantar



Arches of the foot Medial longitudinal arch


Anatomy (cont’d)Anatomy (cont’d)• Plantar arches

– Plantar fascia

• Provides support for the longitudinal arch

Plantar fascia



• Nerves

– Sciatic nerve

• Tibial nerve

• Common peroneal nerve—deep and superficial peroneal nerves

– Femoral—saphenous



• Blood supply

– Femoral artery

– Popliteal

– Anterior and posterior tibial

– Anterior tibial

• Dorsal pedal

Blood supply to the leg, ankle, and foot region


Kinematics and Major Muscle ActionsKinematics and Major Muscle ActionsMuscles of the lower leg and foot. A. Lateral and medial view


Kinematics and Major Muscle Actions (cont’d)


Muscles of the lower leg and foot. B. Posterior view




Intrinsic muscles of the foot. A. Dorsal view




Intrinsic muscles of the foot. B. Plantar view




MUSCLE COMPARTMENT PRIMARY ACTION

Tibialis anterior Anterior Dorsiflexion, inversion

Extensor digitorum longus

Anterior Toe extension, dorsiflexion

Extensor hallucis longus

Anterior Extension of great toe

Peroneus tertius Anterior Eversion, dorsiflexion

Peroneus longus Lateral Eversion, plantar flexion

Peroneus brevis Lateral Eversion, plantar flexion




MUSCLE COMPARTMENT PRIMARY ACTION

Flexor digitorum longus

Posterior, deep Toe flexion, plantar flexion

Flexor hallucis longus Posterior, deep Flexion of he great toe, plantar flexion

Tibialis posterior Posterior, deep Inversion, plantar flexion

Gastrocnemius Posterior, superficial Plantar flexion, knee flexion

Soleus Posterior, superficial Plantar flexion

Plantaris Posterior, superficial Plantar flexion, knee flexion




• Gait cycle

– Consists of alternating periods of single-leg and double-leg support

– Requires a set of coordinated, sequential joint actions of the lower extremity

Gait




• Motions

– Toe—flexion and extension

– Ankle (subtalar)—dorsiflexion and plantarflexion

– Foot and ankle

• Inversion and eversion

• Pronation and supination




Motions of the foot and ankle. A. Dorsiflexion and plantar flexion. B. Eversion and inversion. C. Supination of the subtalar joint


Injury PreventionInjury Prevention

• Physical conditioning

– Strengthening

• Extrinsic muscles

• Intrinsic muscles

– Flexibility

• Achilles tendon


Injury Prevention (cont’d)Injury Prevention (cont’d)

• Protective equipment

– Braces; orthotics

• Footwear

– Demands of sport; wear shoe for its intended purpose

– Proper fit


Toe and Foot ConditionsToe and Foot Conditions

• Toe deformities

– Hallux rigidus

• Degenerative arthritis in first MTP

• S&S

• Tender, enlarged first MTP joint

• Loss of motion

• Difficulty wearing shoes with an elevated heel

• Hallmark sign—restricted toe extension


Toe and Foot Conditions (cont’d)Toe and Foot Conditions (cont’d)

• Toe deformities

– Hallux valgus

• Thickening of the medial capsule and bursa, resulting in severe valgus deformity

• Asymptomatic or symptomatic

• Treatment—symptomatic



Hallux valgus



• Hammer toe

– Extension of MTP joint, flexion at PIP joint, and hyperextended at the DIP joint

• Claw toe

– Hyperextension of MTP joint and flexion of DIP and PIP joints

• Mallet toe

– Neutral position at MTP and PIP joints, flexion at DIP joint



• S&S: painful callus formation on dorsumIP joints

Toe deformities



• Pes cavus

– Excessively high arch that does not flatten during weight bearing

– Causes can vary

– Rigid foot



• Pes planus

– Flat foot; arch or instep of the foot collapsing & contacting the ground

– Typically, acquired deformity resulting from injury or trauma

– Mobile foot



• Both conditions can be asymptomatic, but associated with common injuries

Common foot deformities


Contusions Contusions

• Heel contusion

– Thick padding of adipose tissue—does not always suffice

– Stress in running, jumping, changing directions

– S&S

• Severe pain in heel

• Unable to bear weight


Contusions (cont’d)Contusions (cont’d)

• Heel contusion (cont’d)

– Management: cold; heel cup or doughnut pad; referral

– Condition may persist for months



• Gastrocnemius contusion

– S&S

• Immediate pain and weakness

• Rapid hemorrhage and muscle spasm → palpable mass

– Management:

• Cold with gentle stretch

• If symptoms persist > 2-3 days, physician referral



• Tibial contusion (shin bruise)

– Vulnerable lack of padding

– Minor injury—caution: repeated blows → damage periosteum

– Management: standard acute

– Key: prevention


Lower Leg Contusions Lower Leg Contusions

• Acute compartment syndrome

– Lower leg includes 4 nonyielding compartments

– MOI: direct blow anterolateral aspect of the tibia

– Rapid ↑ in tissue pressure → neurovascular compromise


Lower Leg Contusions (cont’d)Lower Leg Contusions (cont’d)

• Acute compartment syndrome (cont’d)

– S&S

• History of trauma

• Increasingly severe pain—out of proportion to situation

• Firm and tight skin over anterior shin




– S&S (cont’d)

• 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 referral to ER or summon EMS

– Irreversible damage can occur within 12–24 hours


Toe and Foot SprainsToe and Foot Sprains

• IP & MP joints

– MOI: tripping or stubbing the toe

– S&S

• Pain, dysfunction, immediate swelling

• Dislocation—gross deformity


Toe and Foot Sprains (cont’d)Toe and Foot Sprains (cont’d)

• Midfoot sprains

– MOI: severe dorsiflexion, plantarflexion, or pronation

– More frequent in activities in which foot is unsupported

– S&S

• Pain and swelling is deep on medial aspect of foot

• Weight bearing may be too painful



• Turf toe

– Sprain of the plantar capsular ligament of 1st MTP joint

– MOI: forced hyperflexion or hyperextension of great toe

– Acute or repetitive overload

– Valgus ↑ susceptibility



• Turf toe (cont’d)

– S&S (cont’d)

• Pain, point tenderness, and swelling on plantar aspect of MP joint

• Extreme pain with extension

– Potential for tear in flexor tendons or fracture of sesamoid bones



• Management toe and foot sprains

– Standard acute

– Physician referral


Ankle SprainsAnkle Sprains

• Inversion ankle sprain

– MOI: plantarflexion and inversion

– Predisposing factors

• Lateral malleolus projects farther downward

• Least stable position of ankle is plantar flexion

• Weakness in peroneals

• ↓ ROM in Achilles tendon


Ankle Sprains (cont’d)Ankle Sprains (cont’d)Inversion ankle sprain


Ankle Sprains (cont’d)Ankle Sprains (cont’d)

SIGNS AND SYMPTOMS

1st Pain and swelling on anterolateral aspect of lateral malleolusPoint tenderness over ATFL

2nd Tearing or popping sensation felt on lateral aspectPain and swelling on anterolateral and inferior aspect of lateral malleolusPainful palpation over ATFL and CFLMay also be tender over PTFL, deltoid ligament, and anterior capsule area

3rd Tearing or popping sensation felt on lateral aspectDiffuse swelling over entire lateral aspect with or without anterior swellingCan be very painful or absent of pain



• Eversion ankle sprain

– Mechanism: excessive dorsiflexion and eversion

– Deltoid ligament

– Potential

• Lateral malleolus fx; bimalleolar fx

• Tear of anterior tibiofibular ligament &interosseous membrane



• Eversion ankle sprain (cont’d)


• Excessive pronation

• Hypomobile foot



• Eversion Sprain (cont’d)

– S&S

• 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



• Eversion sprain (cont’d)

– S&S (eversion sprain)

• Mild to moderate injuries

• Swelling

• May not be as evident as a lateral sprain

• Between posterior aspect of lateral malleolus and Achilles tendon

• Point tenderness in involved ligaments



• Eversion Sprain (cont’d)

– S&S

• Severe injuries

• PROM pain-free in all motions except dorsiflexion



• Syndesmosis sprain (High Ankle Sprain)

– Spreading of space at distal tibiofibular joint

– MOI: dorsiflexion and external rotation

– Common: anterior inferior tibiofibular ligament

– S&S

• Point tenderness over the anterolateral tibiofibular joint

• Significant pain and swelling

• Difficulty bearing weight



• Management of ankle sprains

– Standard acute

– Use of crutches if unable to walk without limp

– Physician referral



• Subtalar dislocation

– MOI: fall from a height (as in basketball or volleyball); foot lands in inversion

– Disrupts interosseous talocalcaneal & talonavicular ligament



• Subtalar dislocation (cont’d)

– 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



• Subtalar dislocation

– Concern: potential for peroneal tendon entrapment and neurovascular damage

– Management: medical emergency; activate EMS; monitor neurovascular function


Tendinopathies of the Foot & Lower LegTendinopathies of the Foot & Lower Leg

• Strains & 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


Tendinopathies of the Foot & Lower Leg (cont’d)


• Strains & Tendinitis


• 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




– 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

• Do not permit to continue activity until seen by a physician

• Suggest the application of cold to the area to decrease pain and potential spasm


Tendiopathies of the Foot & Lower Leg (cont’d)

Tendiopathies of the Foot & Lower Leg (cont’d)

• 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 & cramping




• Gastrocnemius strain (cont’d)

– S&S

• Immediate pain, swelling, loss of function

– Management:

• standard acute; crutches if unable to walk w/out a limp

• If symptoms persist > 2-3 days or mod-severe injury, physician referral




Gastrocnemius muscle strain




• Achilles tendon rupture

– MOI: push-off of forefoot while knee is extending

– More common in individuals over age 30

– S&S

• “Pop”

• Inability to stand on toes

• Visible defect

• Excessive passive dorsiflexion




• Achilles tendon rupture (cont’d)

– Management

• Compression wrap; immediate transport to emergency care facility or physician




• Achilles tendon rupture


Overuse ConditionsOveruse Conditions

• Plantar fasciitis

– Extrinsic and intrinsic risk factors

– S&S

• Pain at plantar, medial heel

• Pain with first steps in the morning, but diminshes 5-10 min

• ↑ pain with passive extension of great toe and ankle dorsiflexion

• Pain relieved with activity, but recurs after rest


Overuse Conditions (cont’d)Overuse Conditions (cont’d)

• Plantar fasciitis (cont’d)

– Management:


• Suggest application of cold to decrease pain and spasm



• Medial tibial stress syndrome

– Periostitis along posteromedial tibial border (distal third)

• Soleus insertion

• Excessive pronation → eccentric contraction of soleus → periostitis

– Other contributing factors

• Recent changes in running distance, speed, footwear, or running surface



• Medial tibial stress syndrome (cont’d)

– S&S

• 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



– S&S (MTSS) (cont’d)

• Pain with resisted plantar flexion or standing on tiptoe

• Often an associated varus alignment of the lower extremity, including a greater Achilles tendon angle.



– Management:


• Suggest application of cold to decrease pain and spasm



• Exertional compartment syndrome

– Characterized by exercise-induced pain and swelling that is relieved by rest

– Compartments most frequently affected—anterior (50%–60%) & deep posterior (20-30%)

– Usually seen in well-conditioned individuals <40 yrs old




– S&S

• Exercise-induced pain that is often described as a tight, cramplike, or squeezing ache and a sense of fullness

• Often affects both legs

• Relieved with rest, only to recur if exercise resumes

• Anterior compartment—mild foot drop; paresthesia dorsum of foot




– Management:

• Stop activity

• Assessment by qualified health care practitioner


Foot and Lower Leg FracturesFoot 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


Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)

• Freiberg's disease

– Avascular necrosis of 2nd metatarsal head

– Active adolescents ages 14–18

– S&S: diffuse pain in forefoot



• Sever's disease

– Traction-type injury of calcaneal apophysis

– Seen in ages 7–10

– S&S

• Heel pain with activity

• Decreased heel cord flexibility

• Pain with standing on tiptoes



• Stress fractures

– Common:

• Running and jumping, especially after significant ↑ training mileage; change in surface, intensity, or shoe type

• Women w/ amenorrhea 6 months+ and oligomenorrhea



• Stress fractures (cont’d)

– Common sites

• 2nd metatarsal

• Sesamoid bones

• Navicular

• Calcaneus

• Tibia and fibula



• Stress fracture (cont’d)

– S&S

• Pain begins insidiously; ↑ with activity and ↓ with rest

• Pain usually limited to fracture site



• Avulsion fractures

– Eversion sprain—deltoid lig. avulses distal medial malleolus

– Inversion sprain—plantar aponeurosis or peroneus brevis tendon avulses base of 5th metatarsal (type II)



• Avulsion fractures

– 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



Avulsion fractures



• Displaced fractures and dislocations

– MOI

• Direct compression (e.g., falling from a height)

• Compression & shearing (i.e., twisting mechanism)

– Potential neurovascular complications



• Displaced fractures and dislocations (cont’d)

• Phalanges

– MOI: axial load (e.g. jamming toe) or direct trauma (e.g., crushing)

– Swelling; ecchymosis; pain; able to walk

• Metatarsals

– Swelling; pain

– Pain increases with weight bearing

– Potential for displacement



• Displaced fractures and dislocations (cont’d)

– Metatarsals (cont’d)

• 1st metatarsal dislocated from 1st cuneiform; other 4 metatarsals are displaced laterally, usually in combination with fracture at base of 2nd metatarsal

• History of severe midfoot pain, paresthesia, or swelling in midfoot region with variable flattening of arch or forefoot abduction



• Tibia-fibula fractures

– Nearly 60% of tibial fractures involve the middle and lower third of the tibia.

– MOI: torsional force, resulting in either a spiral or oblique fracture of the lower third of the tibia.



• Tibia-fibula fractures (cont’d)

– S&S

• Gross deformity

• Gross bone motion at the suspected fracture site

• Immediate swelling, extreme pain, or pain with motion



• Ankle fracture–dislocation

– MOI

• Landing from a height with foot in excessive eversion or inversion

• Being kicked from behind while the foot is firmly planted



• Ankle fracture–dislocation (cont’d)

– S&S

• Foot displaced laterally at a gross angle to lower leg

• Extreme pain

• Can compromise the posterior tibial artery and nerve



• Fracture management

– Mild

• Standard acute with physician referral

– Serious conditions

• Activate emergency plan, including summoning EMS

• Assess and treat for shock


Coach and Onsite AssessmentCoach and Onsite Assessment

• S &S that require immediate physician referral (potential for EMS)

– Obvious deformity suggesting a dislocation, fracture, or ruptured Achilles tendon

– Significant loss of motion or muscle weakness

– Excessive joint swelling

– Possible epiphyseal or apophyseal injuries


Coach and Onsite Assessment (cont’d)Coach and Onsite Assessment (cont’d)

• S &S that require immediate physician referral (potential for EMS) (cont’d)

– Abnormal sensation, or absent or weak pulse

– Gross joint instability

– Any unexplained pain that affects normal function

• Refer to Application Strategy 16.2

Chapter 16 Foot, Ankle, and Lower Leg Conditions

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