Injuries to the Lower Leg, Ankle, and Foot

Injuries to the Lower Leg, Ankle, and FootInjuries to the Lower Leg, Ankle, and FootFor an athlete to move well, there must be excellent functioning of the lower leg, ankle, and footThe foot must provide a stable base of support and as the same time be flexible and extremely mobileThis chapter discusses the skeletal and muscular anatomy of the foot and lower legWe will discuss:Ligaments of the ankle, compartments of the lower leg, muscular actions of each compartmentFractures as well as common sprains of ankle ligamentsInjuries to the Lower Leg, Ankle, and FootTreatment of ankle sprains and control of possible future sprains Recognition, care, and treatment of tendon injuries along with compartment problemsTreatment and care of athletes with shin splints and considers ways to enhance the performance of these athletesDiscuss foot disorders such as plantar fasciitis, heel spurs, Morton's neuroma, arch problems, bunions, blisters and calluses, providing guidelines for recognition, first aid treatment, and long term careAnd FINALLY ANKLE TAPING

Anatomy Review The lower leg, ankle, and foot work together to provide a stable base of support and a dynamic system of movementThe skeleton of the lower leg consist of the tibia and fibula

Anatomy Review Tibia is the larger and stronger of the two (commonly called the shin bone)Supports 98% of body wgtActs as an attachment for various muscles and helps to provide a mechanical advantage for some of them

Anatomy ReviewNormal foot contains 26 bones that are interconnected and supported by numerous ligamentsMany joints within the foot also assist with support and movement

Anatomy Review

Anatomy ReviewThe ankle joint (talocrural joint) is where the tibia, fibula, and talus joinProvides mainly plantar flexion and dorsiflexion of the footSubtalar joint is the articulation of the talus and the calcaneusResponsible for inversion and eversion of the footBoth joints are synovial, which means they are surrounded by a capsule and supported by ligaments

Anatomy Review The ankle joint is supported on the medial side by the large and strong deltoid ligamentOn the lateral side, the joint is supported by the anterior talofibular, the posterior talofibular, and the calcanefibular ligaments

Anatomy ReviewThese ligaments are not as large or strong as the deltoid ligamentAdditional lateral stability for the ankle joint is provided by the length of the fibula on the lateral side of the ankleThe ankle joint is strongest when placed in dorsiflexionThe talus fits much tighter between the tibia and fibula in this positionJoint is weakest when placed in plantar flexionAnatomy ReviewJoints, ligaments, and muscles help to create and maintain the two basic arches in the footLongitudinal arch has medial lateral divisionsTransverse arch runs from side to sideThese arches assist the foot as shock absorbers; also provide propulsion off surfaces during movement

Anatomy ReviewMuscles are divided into anterior (front), posterior (back), and lateral (side) compartmentsMuscles of the anterior compartment essentially produce dorsiflexion and extension of the toesTibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertiusVery compact area with little room for any extra tissue or fluid Anatomy ReviewPosterior compartment mainly functions to produce plantar flexion of the footReferred to as the calf musclesIs divided into two compartments, superficial section and deep sectionSuperficial sectionGastrochnemius, soleus, and plantar musclesGastrochnemius and soleus attach on the calcaneus via the achilles tendonPlantars muscle is small and insignificant in actionAnatomy ReviewDeep section of this compartment houses the tibialis posterior, flexor digitorum longus, flexor hallucis longus, and popliteus musclesBesides the popliteus these muscles course behind the medial mallelous of the tibia and along the bottom of the footThey help with the plantar flexion as well as flexion of the toesThe popliteus muscle is important in knee flexion

Anatomy ReviewLateral compartment of the lower leg contains the peroneus longus and peroneus brevis musclesMainly evertors (to turn the foot outward) of the foot but do assist with some plantar flexionBoth of these muscles course behind the lateral mallelous of the fibulaPeroneus longus courses under the lateral side of the foot and runs across the bottom to the first metatarsal and cuneiform bonesThe peroneus brevis attaches at the base of the 5th metatarsal and is subject to avulsion (forcible tearing away or separation)Compartments of the Leg

Anatomy ReviewIncluded is also the peroneal nerve, a superficial nerve that is susceptible to injuryThe posterior tibial artery supplies blood to the peroneal muscles because there is no major artery in the lateral compartment

Common Sports InjuriesMany injuries occur to the lower leg, ankle, and footSome can be classified as traumatic, and others are chronic in natureTraumatic injuries typically involve skeletal structuresChronic injuries usually involve damage to soft tissues

Skeletal InjuriesFracturesDirect trauma through contact causes most fractures to the lower legMagnitude of contact necessary to fracture a bone such as the tibia or fibula can varyA fracture can be caused by being kicked by an opponent in a soccer match or by having a 300 pound lineman land on a leg http://www.youtube.com/watch?v=I-iEOoM1N-w

Skeletal InjuriesFracturesFractures to the foot can also occur from traumaHowever, violent trauma is not always required in fractures of the bones of the leg and footStress fractures can occur from overuse or microtrauma (microscopic lesion/injury)

Skeletal InjuriesfracturesIn running, for example, each time the foot strikes the ground it produces a small amount of trauma to the boneThis trauma damages a few bone cells, which the body must repair as quickly as possibleWhen the body cannot maintain the repair process and keep up with repeated microtrauma to a specific bone, a stress fracture resultsAdditionally, an avulsion fracture of the 5th metatarsal can occur in association with a lateral ankle sprainTherefore the possibility of such a fracture should be examined when an athlete sprains his/her ankleSkeletal InjuriesfracturesS&SSwelling and/or deformity at the location of the traumaDiscoloration at the site of the traumaPossible broken bone end projecting through the skinAthlete reports that a snap or a pop was heard or feltThe athlete may not be able to bear weight on the affected extremityIn the case of a stress fracture or a growth plate fracture that did not result from a traumatic event, the athlete complains of extreme point tenderness and pain at the site of suspected injury

Skeletal InjuriesfracturesTX:Watch and treat for shock if necessaryApply sterile dressings to any related wounds (ex open fx)Carefully immobilize the foot and leg using a splintArrange for transport to a medical facilityIn the event that bones are fractured, apply a castAthlete will be immobilized for a specified time

Skeletal InjuriesfracturesWhen the fracture has healed properly, the physician will release the athlete for rehabilitation, practice, and competition in that orderParticipation while a fracture is healing is NOT recommended because it may slow the healing processThere is a possibility of nonunion of a fracture, especially in the 5th metartasal of the foot, as a result of a diminished blood supply

Soft-Tissue Injuriesankle injuriesOne of the most common sports injuries to the lower leg and ankle is a sprained ankleAre abnormal stresses placed on ligamentous structures and cause various levels of damageSprains can occur to the lateral or medial ligaments of the ankle depending on which direction the foot moves when abnormal stress is placed on the ligaments and the foot rolls to one sideSoft-Tissue Injuriesankle injuriesThe noncontractile structures on the lateral aspect of the ankle are most susceptible to injuryThe formation of the bones of the ankle helps to stabilize it; the fibula extends inferiorly, approximating the lateral talus completelyThe ligaments on the lateral side, the anterior talofibular, the posterior talofibular, and the calcaneofibular ligaments are not as large or strong as the deltoid ligament on the medial side of the ankle jointSoft-Tissue Injuriesankle injuriesIt is estimated that 80% to 85% of ankle sprains occur to the lateral ligaments (Ryan et al., 1986)An interesting note is that authors are suggesting that serious ankle sprains in the adolescent athlete are unusual because the ligaments are typically stronger than the bones (Omey & Micheli, 1999)

Soft-Tissue Injuriesankle injuriesCan occur in virtually any sport and can limit the abilities of the athlete in performance until resolution of the injury is completeAs the severity of the ankle sprain increases, so does the instability of the ankleIt is generally accepted that an eversion (move outward) ankle sprain is more severe, with greater instability, and should be cared for more conservatively (Ryan et al., 1986)However, an inversion (move inward) ankle sprain is more common, with the lateral ligaments being involved in 80% to 85% of all ankle sprainsSoft-Tissue Injuriesankle injuriesS&S of a lateral ankle sprain1st degree sprainpain, mild disability, point tenderness, little laxity, little or no swelling2nd degree sprainPain, mild-moderate disability, point tenderness, loss of function, some laxity (abnormal movement), swelling (moderate to severe)

Soft-Tissue Injuriesankle injuries3rd degree sprainPain and severe disability, point tenderness, loss of function, laxity (abnormal movement), swelling, (moderate to severe)Soft-Tissue Injuriesankle injuriesTX:Immediately apply ice, compression, and elevationA horse-shoe or doughnut shaped pad kept in place by an elastic bandage aids at this stage in the compression and reduction of fluid Have the athlete rest and use crutches to ambulate with a 3 or 4 point gait if a 2nd or 3rd degree sprain has occurredIf there is any hesitation about the severity, splint and refer for further evalSoft-Tissue Injuriesankle injuriesIt is important to recognize the possibility of a tibiofibular (tib/fib) syndesmosis sprain in conjunction with or masquerading as a lateral ankle sprainToo often a syndesmosis sprain is treated as a lateral ankle sprain, which is inappropriate and will not allow the athlete to progress in the healing process

Soft-Tissue Injuriesankle injuriesIt is important to know that there is a significant difference in the etiology of the injuryWith the lateral ankle sprain, there is an inversion mechanism, which includes supinationIn the tib-fib syndesmosis sprain, the mechanism is one of dorsiflexion followed by axial loading of the lower leg, with external rotation of the foot and internal rotation of the lower legTypically, athletes have their foot planted firmly with the foot in external rotation, and the lower leg twist medially, forcing the talus into the ankle mortiseThe axial load forces the tibia and fibula to separate slightly and sprain the syndesmosisSoft-Tissue Injuriesankle injuriesS&S of a tib/fib syndesmosis sprainMechanism of injury is different from a lateral ankle sprain; ankle dorsiflexion and foot external rotation are combined with internal rotation of the lower legTypical ankle sprain test may be positive but the athlete will c/o a great deal of pain and point tenderness in the area of the tib/fib syndesmosisSoft-Tissue Injuriesankle injuriesPerforming the squeeze test (squeezing the tibia and fibula together superior to the syndesmosis); elicits pain in the syndesmosis areaTXImmediately apply ice, compression, and elevation A horse-shoe or doughnut shaped pad kept in place by an elastic bandage aids Have the athlete rest and use crutches to ambulate for the first 72 hours, followed by use of a walking boot for a minimum of 3 days and preferably for 7 days following the initial injuryIf there is any question refer for further evaluationSoft-Tissue Injuriesankle injuriesIt is recognized that either taping or bracing can reduce the number of ankle sprains (Verhagen, van Mechelen, & de Vente, 2000)Some prefer to use the standard ankle-taping procedure as a prophylactic tx for ankles with no HX of an injuryOthers choose to augment the taping procedure to prevent future ankle sprains if one has occurred beforeIn published research studies, ankle taping as been demonstrated to help with the neuromuscular response of the muscles and to provide stability if done in a specific mannerBoth contribute to reduction of ankle sprainsSoft-Tissue Injuriesankle injuriesMost researchers agree that the best known method of ankle support, the prophylactic adhesive-taping procedure, supports the ankle for only a short period of time after exercise begins (Frankeny et al., 1993)Therefore, some researchers now maintain that bracing is better than taping for the prevention of ankle injuries, owing to the reduction in ROM, either at excessive points or within normal ranges (Cordova, Ingersoll, & LeBlanc, 2000)The combination of high-top shoes and taping or bracing can be helpful to athletes in reducing the number of ankle sprains they experienceSoft-Tissue Injuriesankle injuriesProprioception and the ankle is a very intense area of studyProper ankle proprioception is a critical element in reducing chronic ankle instability (Hintermann, 1999)Also be important part of both the preventative and rehabilitative aspects of ankle functioning (Hertel, 2000)

Soft-Tissue Injuriesankle injuriesWhatever the choice of the coach or athlete, many factors must be considered in preventing ankle sprainsThese include:Type of activity, compliance of the athlete in wearing braces or prophylactic taping, cost to the school or athlete, effectiveness of the brace as reported in research studiesThere are some consequences of using adhesive tape, including:Blisters, tape cuts, and loss of circulation

Tendon-related InjuriesThe achilles tendon is commonly injured by long distance runners, basketball players, and tennis playersThe onset of tendinitis may be slow among runners, but much more rapid among basketball or tennis players Great many of short-burst movements requiring jumping or rapid motion from side to side

Tendon-related injuriesSome controversy exsist about the actual injury that constitutes Achilles tendinitisThe Achilles tendon itself, which attaches the gastrocnemius and soleus muscles to the calcaneus, can become inflamedHowever, either tendon sheath or the subcutaneous bursa dorsal to the tendon can become inflammed

Tendon-related injuriesMost agree that athletes who dramatically increase their running distance or workout times and who do so running on hard, uneven, or uphill surfaces are prone to Achilles tendinitis (Omey & Micheli, 1999)It is estimated that 11% of runners and up to 52% of former elite runners experience an Achilles tendinopathy (tiny tears (microtears) in the tissue in and around the tendon caused by overuse)http://www.youtube.com/watch?v=F2e6LmQsJps

Tendon-related injuriesSuperficially, Achilles tendinitis can produce an increased temperature in the immediate area; moreover, the tendon is painful on touch and movement and appears thickenedThis pain associated with this condition is localized to a small area of the tendon and typically intensifies when movement is initiated after restCan be seen over an extended period of time (days to weeks)Or over a shorter period of time (days)

Tendon-related injuriesTX for chronic Achilles tendinitis:Immediate rest until the swelling subsidsNSAIDS, small heel lift assist the reduction of swelling and the return to practice and competitionStretching has also been shown to be beneficial to athletes with Achilles Tendinitis (Taylor et al., 1990)Controlled stretching on a slant board or against a wall each day will aid in a return to participationAdditionally, if an athlete must exercise or run, it is advised this be done in a controlled environment (swimming pool)Tendon-related injuriesControlled gradual stressing exercises using the eccentric contraction of the Achilles assist the athlete in returning to activityAn athletes activity level and type of exercise must be closely monitored during the healing phaseWithout the proper amount of rest, the body has a hard time repairing injury, thereby increasing the amount of time the athlete experiences difficulty with the condition

Tendon-related injuriesExplosive jumping or direct trauma from some type of impact can cause traumatic injuries to the Achilles tendon by tearing or rupturing the tendonCan occur in many different sports

Tendon-related injuriesS&SSwelling and deformity at the site of injuryReports a pop or snap associated with the injuryPain in the lower leg, which may range from mild to extremeLoss of function, mainly in plantar flexionTX:Immediately apply rice and compression to the areaImmobilize the foot by an air cast or splintArrange for transportation to the nearest medical facilityTendon-related issuesDuring the acute phase of the healing process, minimize dorsiflexion and eliminate forced dorsiflexion This movement can produce more damage and inflammation to the areaThe long term effects of a ruptured Achilles tendon depend on the severity or completeness of the ruptureIf surgery is necessary, the athlete will most likely be out of commission for the rest of the seasonThe athlete will need to be careful and aware of the value of stretching and warming up