Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Lower Leg, Ankle, and Foot...

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Lower Leg, Ankle, and Foot Conditions

Lower Leg, Ankle, and Foot Conditions

Chapter 19


AnatomyAnatomy


Anatomy


Anatomy (cont.)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



• Tibiofibular joints

– Superior—proximal

– Inferior—distal

– Interosseous membrane



• Muscles

– Lateral and medial view


Anatomy (cont.)Anatomy (cont.)• Muscles

– Posterior view



• 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


Kinematics (cont.)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


Lower Leg ContusionsLower 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


Lower Leg Contusions (cont.)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


Lower Leg Contusions (cont.)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


Ankle SprainsAnkle Sprains

• Inversion ankle sprain

– Mechanism: plantarflexion and inversion

– Predisposing factors

• Lateral malleolus projects farther downward

• Weakness in peroneals

• ↓ ROM in Achilles tendon


Ankle Sprains (Cont’d)Ankle Sprains (Cont’d)

Degree Signs and Symptoms Inversion Sprain

1st Pain and swelling on anterolateral aspect of lateral malleolusPoint tenderness over ATFLNo 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 CFLMay also be tender over PTFL, deltoid ligament, and anterior capsule areaPositive 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 painPositive anterior drawer and talar tilt test


Ankle Sprains (cont.)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


Ankle Sprains (cont.)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



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



• 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


Ankle Sprains (cont.)Ankle Sprains (cont.)• Management of ankle sprains

– Standard acute

– Assessment for additional damage (e.g., fracture)

– Use of appropriate immobilization

– Moderate/severe—physician referral



• Subtalar dislocation

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

– disrupts interosseous talocalcaneal and talonavicular ligaments



– 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


Strains of Foot and Lower Leg 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


Strains of Foot and Lower Leg (cont.)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



– 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



• 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



– 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



• 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


Strains of Foot and Lower Leg (cont.)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



• 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


Strains of Foot and Lower Leg (cont.)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



• Achilles tendon rupture

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

– More common in athletes over age 30



– S&S

• “Pop”

• Inability to stand on toes

• Visible defect

• Excessive passive dorsiflexion

• + Thompson’s test

– Management

• Compression wrap and splint; immediate physician referral


Overuse Conditions (cont.)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


Overuse Conditions (cont.)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


Overuse Conditions (cont.)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


Overuse Conditions (cont.)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


Overuse Conditions (cont.)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


Venous DisordersVenous 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


Venous Disorders (cont.)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


Neurologic Conditions (cont.)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


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.)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



– 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


Foot and Lower Leg Fractures (cont.)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


Foot and Lower Leg Fractures (cont.)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



– 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



• Osteochondral fractures



– 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



• Tibia-fibula fractures– Fracture medial malleolus

• Inversion sprain– Fracture lateral malleolus

• Eversion and dorsiflexion• Bimalleolar fracture


Foot and Lower Leg Fractures (cont.)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



• 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


Foot and Lower Leg Fractures (cont.)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


AssessmentAssessment

• History

• Observation/inspection

• Palpation

• Physical examination tests


Assessing the Lower Leg and AnkleAssessing 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?


• 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


Neutral Talar PositionNeutral Talar Position


Range of Motion (ROM)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


ROM (cont.)ROM (cont.)


ROM (cont.)ROM (cont.)• RROM


Stress TestsStress Tests

• Anterior drawer test

• Talar tilt


• 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


– 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


Stress Tests (cont.)Stress Tests (cont.)

• External rotation (Kleiger’s) test


Special TestsSpecial Tests

• Thompson’s test


Neurological dysfunctionNeurological dysfunction

• Tinel’s sign


• 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


Neurologic TestsNeurologic 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


Neurologic Tests (cont.)Neurologic Tests (cont.)

• Dermatomes

• Peripheral nerve distribution


RehabilitationRehabilitation• Restoration of motion

• Restoration of proprioception and balance

– Closed-chain exercises

• Muscular strength, endurance, and power

– Open-chain exercises

– PNF-resisted exercises

• Cardiovascular fitness

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Lower Leg, Ankle, and Foot...

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Transcript of Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Lower Leg, Ankle, and Foot...