Injuries to the Foot, Injuries to the Foot, Ankle and Lower LegAnkle and Lower Leg

SPHS Sports MedicineSPHS Sports Medicine

John Hardin, InstructorJohn Hardin, Instructor

Bony AnatomyBony Anatomy

TibiaTibiaFibulaFibulaTarsalsTarsalsMetatarsalsMetatarsalsPhalangesPhalangesSesamoid BonesSesamoid Bones

TibiaTibia

Weight bearing boneWeight bearing boneArticulates with fibula both inferiorly Articulates with fibula both inferiorly

and superiorlyand superiorlyLandmarksLandmarks

Tibial tuberosity (proximal)Tibial tuberosity (proximal)Tibial PlateauTibial PlateauMedial MalleolusMedial MalleolusShaftShaft

FibulaFibula

Non-weight bearing boneNon-weight bearing boneExtends down past calcaneus Extends down past calcaneus

providing bony support to prevent providing bony support to prevent eversioneversion

Serves as site for muscle attachmentsServes as site for muscle attachmentsLandmarksLandmarks

Head of fibula (proximal)Head of fibula (proximal)Lateral malleolusLateral malleolus

TarsalsTarsals

Talus—articulates with the Talus—articulates with the tibia/fibulatibia/fibula

CalcaneusCalcaneusNavicularNavicularCuboidCuboidMedial, intermediate and lateral Medial, intermediate and lateral

cuneiformscuneiforms

JointsJoints

Tibiofibular joint--syndesmosisTibiofibular joint--syndesmosisAnkle joint (talocrural) Ankle mortiseAnkle joint (talocrural) Ankle mortiseSubtalar jointSubtalar jointMetatarsalphalangeal joints (MP)Metatarsalphalangeal joints (MP) Interphalangeal joints Interphalangeal joints

PIPPIPDIPDIP

ArchesArches

Transverse: proximal across tarsalsTransverse: proximal across tarsalsMedial longitudinal arch: from Medial longitudinal arch: from

calcaneus to 1calcaneus to 1stst metatarsal metatarsalStrengthened by spring ligament Strengthened by spring ligament (plantar (plantar

calcaneonavicular ligament)calcaneonavicular ligament)

Lateral longitudinal arch: from Lateral longitudinal arch: from calcaneus to 5calcaneus to 5thth metatarsal metatarsal

Metatarsal arch: shaped by distal Metatarsal arch: shaped by distal heads of metatarsalsheads of metatarsals

Muscles of lateral Muscles of lateral compartmentcompartment

Peroneus longusPeroneus longusPeroneus brevisPeroneus brevis

Both do eversionBoth do eversion

Muscles of the anterior Muscles of the anterior compartmentcompartment

Tibialis AnteriorTibialis AnteriorExtensor Digitorum LongusExtensor Digitorum LongusExtensor Hallicus LongusExtensor Hallicus Longus

All do dorsiflexion and some inversionAll do dorsiflexion and some inversionEDL—extension of toes 2-5EDL—extension of toes 2-5EHL—extension of great toeEHL—extension of great toe

**EDB—extends toes 2-4 (dorsum of **EDB—extends toes 2-4 (dorsum of foot)foot)

Muscles of Superficial Muscles of Superficial Posterior compartmentPosterior compartment

Tibialis Posterior (Tom)Tibialis Posterior (Tom)Flexor Digitorum Longus (Dick)Flexor Digitorum Longus (Dick)Flexor Hallicus Longus (Harry)Flexor Hallicus Longus (Harry)

All do Plantar Flexion and InversionAll do Plantar Flexion and InversionFDL– flexion of toes 2-5FDL– flexion of toes 2-5FHL—flexion of great toeFHL—flexion of great toe

Muscles of Deep Posterior Muscles of Deep Posterior CompartmentCompartment

Gastrocnemius—crosses knee and Gastrocnemius—crosses knee and ankle joint. Knee flexion/plantar flexionankle joint. Knee flexion/plantar flexion

Soleus---crosses ankle joint. Soleus---crosses ankle joint. PlantarflexionPlantarflexionJoin together at the Achilles tendonJoin together at the Achilles tendon

Plantaris—cross ankle and knee joints. Plantaris—cross ankle and knee joints. Knee flexion/plantar flexionKnee flexion/plantar flexionTendon run parallel to the Achilles tendon Tendon run parallel to the Achilles tendon

mediallymedially

MiscellaneousMiscellaneous

Plantar FasciaPlantar FasciaFrom calcaneus to heads of metatarsals.From calcaneus to heads of metatarsals.Maintain stability of foot and supports Maintain stability of foot and supports

medial longitudinal archmedial longitudinal arch Interosseus MembraneInterosseus Membrane

Thick connective tissue runs length of Thick connective tissue runs length of tib/fib and holds them togethertib/fib and holds them together

Plantar fasicaPlantar fasica

Medial LigamentsMedial Ligaments

Deltoid ligamentDeltoid ligament 4 parts4 parts Very strongVery strong Not injured as oftenNot injured as often

Lateral ligamentsLateral ligaments

Anterior talofibularAnterior talofibular Posterior talofibularPosterior talofibular Calcaneofibular Calcaneofibular

Other ligamentsOther ligaments

Anterior inferior Anterior inferior tibiofibular tibiofibular ligamentligament

Posterior inferior Posterior inferior tibiofibular tibiofibular ligamentligament

Prevention of InjuriesPrevention of Injuries

Wear properly fitting shoesWear properly fitting shoesAnkle supportAnkle supportProtective equipmentProtective equipmentMaintain adequate strength and Maintain adequate strength and

flexibilityflexibilityHeel cord stretchingHeel cord stretchingStrengthening in inversion, eversion, Strengthening in inversion, eversion,

plantar and dorsiflexionplantar and dorsiflexionProprioception (balance training)Proprioception (balance training)

Heel Bruise Heel Bruise (Stone Bruise)(Stone Bruise)

Mxn: Landing on heels, hitting heel on Mxn: Landing on heels, hitting heel on something hard—causing a contusion to something hard—causing a contusion to the bottom of calcaneusthe bottom of calcaneus

S/S: Severe pain in heel, difficulty weight S/S: Severe pain in heel, difficulty weight bearing, POTbearing, POT

TX: ice, rest/non weight bearing til pain TX: ice, rest/non weight bearing til pain subsides, heel cup or doughnut when subsides, heel cup or doughnut when returningreturning

Complication: inflammation of Complication: inflammation of periosteumperiosteum

Plantar FasciitisPlantar Fasciitis

Mxn: tight heel cord, inflexibility of Mxn: tight heel cord, inflexibility of longitudinal arch, improper footwear, longitudinal arch, improper footwear, leg length discrepancy, rapid leg length discrepancy, rapid increase/change in trainingincrease/change in training

S/S: POT over the anteriomedial S/S: POT over the anteriomedial calcaneus and plantar fascia, calcaneus and plantar fascia, stiffness and pain in AM or after stiffness and pain in AM or after prolonged sitting, pain with passive prolonged sitting, pain with passive extension of toes combined with extension of toes combined with dorsiflexiondorsiflexion

TX: long term—8-12 weeksTX: long term—8-12 weeks

vigorous heel cord stretching, ice vigorous heel cord stretching, ice massage, heel cup, taping, ultrasound, massage, heel cup, taping, ultrasound, NSAIDS, NSAIDS,

Last resort: surgery to cut the fasciaLast resort: surgery to cut the fascia

Complications: can develop a bone spur Complications: can develop a bone spur if not cared for—surgery to remove itif not cared for—surgery to remove it

Metatarsal FractureMetatarsal Fracture

Mxn: direct force or twisting/torsion Mxn: direct force or twisting/torsion force or overuseforce or overuse

Most common is the Jone’s fracture—Most common is the Jone’s fracture—near base of 5near base of 5thth, avulsion (at the , avulsion (at the base), midshaft base), midshaft

S/S: POT over metatarsal, swelling, S/S: POT over metatarsal, swelling, pain, “pop” or “crack”, possible pain, “pop” or “crack”, possible deformitydeformity

Tx: Ice, Compression wrap, crutches, Tx: Ice, Compression wrap, crutches, send to Dr. for x-ray.send to Dr. for x-ray.

Possibly on crutches for 6-8 weeks, Possibly on crutches for 6-8 weeks, non-weight bearing to allow for non-weight bearing to allow for healinghealing

Complication: Non union fracture. Complication: Non union fracture. May require surgery to fixMay require surgery to fix

Longitudinal Arch StrainLongitudinal Arch Strain

Mxn: Unaccustomed stresses/forces Mxn: Unaccustomed stresses/forces placed on foot when in contact with a placed on foot when in contact with a hard playing surface.hard playing surface.Flattening of the foot (arch) when in Flattening of the foot (arch) when in

midsupport phasemidsupport phaseMay occur suddenly or over a longer May occur suddenly or over a longer

period of timeperiod of time

S/S: Pain felt just distal to the medial S/S: Pain felt just distal to the medial malleolus when running malleolus when running Swelling and POT along the Swelling and POT along the

calcaneonavicular ligament (spring calcaneonavicular ligament (spring ligament) and the first cuneiformligament) and the first cuneiform

POT over the FHL tendon as a result of POT over the FHL tendon as a result of compensation for stress on ligamentcompensation for stress on ligament

TX: Rest, ice, reduction of weight TX: Rest, ice, reduction of weight bearing until relatively pain freebearing until relatively pain freeUltrasoundUltrasoundArch tapingArch taping

Turf ToeTurf Toe

Sprain of the MP joint of the great toSprain of the MP joint of the great toMxn: Hyperextension of great toe—Mxn: Hyperextension of great toe—

trauma or overusetrauma or overuseUsually occurs on an unyielding surface Usually occurs on an unyielding surface

such as turfsuch as turfKicking an unyielding objectKicking an unyielding object

S/S: POT over MP joint of great toeS/S: POT over MP joint of great toeSwellingSwellingDiscolorationDiscolorationPain with movement especially pushing Pain with movement especially pushing

off big toe when taking a stepoff big toe when taking a step

TX: Rest, ice, compressionTX: Rest, ice, compressionInsert a hard insole into shoe to prevent Insert a hard insole into shoe to prevent

hyperextension of MP jointhyperextension of MP jointTape for hyperextensionTape for hyperextension

Subungual HematomaSubungual Hematoma

Mxn: being stepped on or something Mxn: being stepped on or something being dropped onto the toebeing dropped onto the toeToes being jammed into the end of the Toes being jammed into the end of the

shoe while runningshoe while running

S/S: Bleeding into the nail bed S/S: Bleeding into the nail bed (under nail)(under nail)Throbbing painThrobbing painPressure against nail exacerbates the Pressure against nail exacerbates the

problemproblem

TX: drain the blood from the nailTX: drain the blood from the nailUse a drill bitUse a drill bitHeat a paperclip and burn through nailHeat a paperclip and burn through nailUse a scalpel to make hole in nailUse a scalpel to make hole in nail

BlistersBlisters

Mxn: shearing force on the skin that Mxn: shearing force on the skin that causes fluid to accumulate below top causes fluid to accumulate below top layer of skinlayer of skinMay be clear, bloody or become infectedMay be clear, bloody or become infected

S/S: area of fluid under skinS/S: area of fluid under skinCan be painfulCan be painfulMay break openMay break openMay become infected—redness, heat, May become infected—redness, heat,

puspus

TX: cover with skin lube, bandage, TX: cover with skin lube, bandage, foam or felt doughnut around it.foam or felt doughnut around it.If large, then drain, but clean it and treat If large, then drain, but clean it and treat

as open woundas open woundCover prior to practices/competitionsCover prior to practices/competitions

Ankle SprainsAnkle Sprains

InversionInversionEversionEversionHigh Ankle SprainHigh Ankle Sprain

Inversion Ankle SprainInversion Ankle SprainMost common, resulting in injury to Most common, resulting in injury to

the lateral ligamentsthe lateral ligamentsATF ligament is the weakest of the 3ATF ligament is the weakest of the 3

Mxn: “rolling” the ankle, landing on Mxn: “rolling” the ankle, landing on another athlete’s foot, stepping in a another athlete’s foot, stepping in a hole, etc. hole, etc. Inversion/plantar flexion Inversion/plantar flexion

The inversion mxnThe inversion mxn

Structures injuredStructures injured

ATF lig. injured with the plantar ATF lig. injured with the plantar flexion/inversion mxnflexion/inversion mxn

Calcaneofibular lig. and posterior Calcaneofibular lig. and posterior talofibular lig. injured when then talofibular lig. injured when then inversion force is increasedinversion force is increased

33rdrd degree Lateral Ankle degree Lateral Ankle sprain sprain

S/S: Pain, Swelling, discoloration, S/S: Pain, Swelling, discoloration, POT over the sinus tarsi, the distal POT over the sinus tarsi, the distal end of the lateral malleolus and end of the lateral malleolus and posterior of the lateral malleolus, posterior of the lateral malleolus, joint instability, joint stiffness, joint instability, joint stiffness, decreased ROM, “+” anterior drawer decreased ROM, “+” anterior drawer testtest

Will vary with the degree of the Will vary with the degree of the injuryinjury

Tx: RICE, “horseshoe” shaped Tx: RICE, “horseshoe” shaped felt/foam pad fit around the lateral felt/foam pad fit around the lateral malleolusmalleolusTreat for shockTreat for shockcrutches if necessarycrutches if necessaryMedical attention if severe or possibility Medical attention if severe or possibility

of fractureof fracture

ComplicationsComplications

Avulsion fracture of lateral malleolusAvulsion fracture of lateral malleolusAvulsion fracture of base of 5Avulsion fracture of base of 5thth

metatarsalmetatarsalPush-off fracture of medial malleolusPush-off fracture of medial malleolus

Eversion Ankle SprainEversion Ankle Sprain

Less common due to bony structure Less common due to bony structure of ankleof ankle

Deltoid ligament damage (any or all Deltoid ligament damage (any or all 4 portions4 portions

Mxn: ankle everts due Mxn: ankle everts due to----someone/something landing on to----someone/something landing on the lateral aspect of leg during weight the lateral aspect of leg during weight bearing or---bearing or---

S/S: Pain, swelling, discoloration, joint S/S: Pain, swelling, discoloration, joint instability, joint stiffness, decreased instability, joint stiffness, decreased ROM, POT over medial malleolus and ROM, POT over medial malleolus and deltoid ligamentdeltoid ligament

Will vary depending on severityWill vary depending on severity

Tx: RICE, “horseshoe” shaped Tx: RICE, “horseshoe” shaped felt/foam pad, felt/foam pad, crutches if necessarycrutches if necessaryTreat for shockTreat for shockMedical attention with severe sprain of if Medical attention with severe sprain of if

fracture is suspectedfracture is suspected

ComplicationsComplications

Avulsion fracture of medial malleolusAvulsion fracture of medial malleolusContused deltoid ligament due to Contused deltoid ligament due to

impingement between medial impingement between medial malleolus and calcaneusmalleolus and calcaneus

Fracture of lateral malleolusFracture of lateral malleolus

““High” Ankle SprainHigh” Ankle Sprain

Also called syndesmoticAlso called syndesmoticAnterior and posterior tibiofibular Anterior and posterior tibiofibular

ligaments damageligaments damage

Mxn: forced dorsiflexion or extreme Mxn: forced dorsiflexion or extreme plantar flexion/inversionplantar flexion/inversion

Someone landing on the back of the Someone landing on the back of the leg with the foot in contact with the leg with the foot in contact with the ground (dorsiflexion)ground (dorsiflexion)

S/S: may be swelling or not, may S/S: may be swelling or not, may have discoloration or not have discoloration or not

painpainPOT over ATF and proximal to that at POT over ATF and proximal to that at

the junction of the tibia and fibulathe junction of the tibia and fibulapainful to bear weight, unable to go painful to bear weight, unable to go

up on toesup on toes

Tx: RICE, Crutches, medical Tx: RICE, Crutches, medical attention if unable to bear weight or attention if unable to bear weight or if significant swelling occursif significant swelling occurs

Treat for shockTreat for shockHard to treat and can take weeks to Hard to treat and can take weeks to

healheal

ComplicationsComplications

Fracture to the dome of the talusFracture to the dome of the talusTear of the interosseus membraneTear of the interosseus membrane

Ankle Fractures and Ankle Fractures and DislocationsDislocations

Mxn: similar to those of the ankle Mxn: similar to those of the ankle sprains but generally more force is sprains but generally more force is appliedapplied

Can be open or closedCan be open or closed

What do these injuries look What do these injuries look like?like?

After the mxnAfter the mxnSee the placement of the See the placement of the foot?foot?

Sliding into baseSliding into base He’s there!He’s there!

Getting helpGetting help

And the open ones?And the open ones?

Open Fx/dislocationOpen Fx/dislocation Open fractureOpen fracture

And some x-raysAnd some x-rays

S/S: Immediate swelling S/S: Immediate swelling immense pain immense pain possible deformity and/or open possible deformity and/or open

woundwoundPOT over the bonePOT over the bone+ compression and percussion tests+ compression and percussion tests

Tx: Splint in the position you find itTx: Splint in the position you find itCare for open wound if necessaryCare for open wound if necessaryTreat for shockTreat for shockCall 911 if the injury is severe/openCall 911 if the injury is severe/openER visitER visit

TendonitisTendonitis

Tendons most often affectedTendons most often affectedTibialis posteriorTibialis posteriorTibialis anteriorTibialis anteriorPeronealsPeronealsAchilles Achilles

Mxn: faulty foot biomechanicsMxn: faulty foot biomechanicsInappropriate or poor/worn footwearInappropriate or poor/worn footwearAcute trauma to tendonAcute trauma to tendonTightness of heel cordTightness of heel cordTraining errorsTraining errorsExcessive running, jumping, hillsExcessive running, jumping, hills

S/S: pain with active movements S/S: pain with active movements and passive stretchingand passive stretchingPOT over insertion of tendonPOT over insertion of tendonwarmthwarmthCrepitusCrepitusThickening of tendon (achilles)Thickening of tendon (achilles)Stiffnes and pain following periods of Stiffnes and pain following periods of

inactivityinactivity

Tx: RestTx: RestModalities: ice, heat, ultrasoundModalities: ice, heat, ultrasoundNSAIDSNSAIDSExercise to strengthen muscle(s) Exercise to strengthen muscle(s)

involvedinvolvedStretchingStretchingOrthotics or taping to relieve stress on Orthotics or taping to relieve stress on

tendontendon

Tib/Fib fractureTib/Fib fracture

Tibia is most commonly fractured Tibia is most commonly fractured long bone in the bodylong bone in the body

Mxn: direct trauma to the tibia/fibula Mxn: direct trauma to the tibia/fibula or bothor both

Indirect trauma such as combination Indirect trauma such as combination rotation/compressive forcerotation/compressive force

S/S: Immediate painS/S: Immediate painSwellingSwellingPossible deformityPossible deformityMay be open or closedMay be open or closed

Tx: Splint in the position you find itTx: Splint in the position you find itTreat for shockTreat for shockCall 911 if necessaryCall 911 if necessaryER visitER visit

Stress FracturesStress Fractures

Tibial (mid shaft)Tibial (mid shaft)Fibular (distal third)Fibular (distal third)Metatarsal (2Metatarsal (2ndnd is most common) is most common)

Mxn: repetitive loading during Mxn: repetitive loading during training and conditioning and training and conditioning and jumpingjumpingFaulty biomechanics combined with Faulty biomechanics combined with

excessive/change in trainingexcessive/change in training

S/S: pain with activityS/S: pain with activityIncrease in pain when activity is finishedIncrease in pain when activity is finishedGradually gets worseGradually gets worsePOT on one specific point on the bonePOT on one specific point on the boneCan limit ability to participateCan limit ability to participate

Tx: stop activity (2-4 weeks)Tx: stop activity (2-4 weeks)Alternate conditioning—non weight Alternate conditioning—non weight

bearingbearingIceIceCrutches/protective footwearCrutches/protective footwearMedical referralMedical referral

XraysXraysBone scanBone scan

Medial Tibial Stress Medial Tibial Stress SyndromeSyndrome

Shin splints Shin splints

Mxn: strain of tibialis posterior Mxn: strain of tibialis posterior tendon and its fascial sheath at tendon and its fascial sheath at attachment to periosteum of distal attachment to periosteum of distal tibia due to running/etc. tibia due to running/etc.

Faulty biomechanicsFaulty biomechanics Improper footwearImproper footwearTight heel cord/achilles tendonTight heel cord/achilles tendonTraining errorsTraining errors

S/S: diffuse pain along the distal S/S: diffuse pain along the distal tibia (2/3) mediallytibia (2/3) medially

POT in the same areaPOT in the same areaPain after activity—then before/afterPain after activity—then before/after

—then all the time—then all the time

Tx: Modify activityTx: Modify activityCorrect foot biomechanics (orthotics)Correct foot biomechanics (orthotics)Heel cord stretchingHeel cord stretchingStrengthening of muscles in Posterior Strengthening of muscles in Posterior

compartmentcompartment Ice massageIce massageFriction massageFriction massageTaping—arch support/ankleTaping—arch support/ankle

Compartment SyndromesCompartment Syndromes Increased pressure in the Increased pressure in the

compartment(s) of the legcompartment(s) of the legCauses compression of the muscles & Causes compression of the muscles &

neurovascular structures neurovascular structures Anterior, lateral, deep posterior Anterior, lateral, deep posterior

commoncommon3 types3 types

Acute Acute Acute exertionalAcute exertionalChronic Chronic

Anterior compartment Anterior compartment syndromesyndrome

Mxn: direct blow to the anterior Mxn: direct blow to the anterior compartmentcompartment

S/S: deep aching painS/S: deep aching painTightness & swellingTightness & swellingPain with passive stretchingPain with passive stretchingReduced circulation/sensory changes in Reduced circulation/sensory changes in

footfootMay have LOMMay have LOM

Tx: initially ice to reduce swellingTx: initially ice to reduce swellingIf circulation/sensory changes occur—If circulation/sensory changes occur—

emergency room visitemergency room visitFasciotomyFasciotomyReturn to activity 2-4 months post Return to activity 2-4 months post

surgerysurgery

Achille Tendon RuptureAchille Tendon Rupture

Largest tendon in bodyLargest tendon in bodyMost common in athletes over 30 yrsMost common in athletes over 30 yrsSeen in sports with ballistic Seen in sports with ballistic

movements—tennis, raquetball, movements—tennis, raquetball, basketball, etc.basketball, etc.

Mxn: sudden forceful plantar flexion Mxn: sudden forceful plantar flexion of ankleof ankle

S/S: felt/heard a “pop” at back of legS/S: felt/heard a “pop” at back of legFelt as is someone hit them with a rockFelt as is someone hit them with a rockPain with plantar flexion/dorsiflexionPain with plantar flexion/dorsiflexionInability to plantar flexInability to plantar flexPalpable/visible defect at the achilles Palpable/visible defect at the achilles

tendontendon+ Thompson test+ Thompson test

Achilles tendon defectAchilles tendon defect

Thompson TestThompson Test

Tx: immobilizeTx: immobilizeiceiceSend to ERSend to ERRequires surgery w/ 6-8 weeks Requires surgery w/ 6-8 weeks

immobilizationimmobilizationRehab to regain full ROM/StrengthRehab to regain full ROM/Strength

Open achilles tendon ruptureOpen achilles tendon rupture

ContusionsContusions

Mxn: direct trauma to areaMxn: direct trauma to area

S/S: pain, swelling, increased S/S: pain, swelling, increased warmth, hematomawarmth, hematoma

Tx: RICE, protective padding, modify Tx: RICE, protective padding, modify activity if necessaryactivity if necessary

And other weird thingsAnd other weird things

Another viewAnother view

Treatment for this?Treatment for this?

Immoblize objectImmoblize objectCut object at each end to allow for Cut object at each end to allow for

transporttransportTreat for shockTreat for shockSurgery to remove impaled objectSurgery to remove impaled object