ATC 222

CHAPTER 18 & 19: THE FOOT, ANKLE, AND LOWER LEG

Bones

Foot & Ankle -14 Phalanges -5 Metatarsals -7 Tarsals -2 Sesamoids

Bones

Leg -Tibia -Fibula

Joints

Talocrual (ankle joint)“Ankle Mortise”

-dorsiflexion & plantarflexion

Joints

Subtalar -pronation and supination

Ligamentous Support

Lateral Ligaments -anterior talofibular (atf) -posterior talofibular (ptf) -calcaneofibular (cf)

Ligamentous Support

Medial -deltoid

Ligamentous Support of the Leg

Anterior and Posterior Tibiofibular -interroseus membrane

Injuries of the Foot

Acute Conditions

Heel Bruise

Etiology -sudden stop or go -change in direction

Heel Bruise

Signs & Symptoms -focal pain in the heel

Management -Ice soaks, rest NSAID -heel cup or doughnut pad

Longitudinal Arch Strain

Etiology -forceful contact with playing surface -unaccustomed, severe exercise early in

the season

Longitudinal Arch Strain

Signs & Symptoms -pain just below the medial malleolus -swelling & tenderness medially

Management -ice soaks, arch taping for support,

reduce weight bearing

Plantar Fascia (Aponeurosis) Strain

Etiology -depressed longitudinal arch or mild pes

cavus -excessive running early coupled with

poor calf flexibility

Plantar Fascia Strain

Signs & Symptoms -sudden pain in the arch relieved with

non-weight bearing -pain when getting out of bed in the AM -point tenderness over calcaneal

epicondyle

Jones Fracture

Etiology -inversion and plantarflexion of the foot

Signs & Symptoms severe pain & tenderness over base of

5th

Jones Fracture

Management cast 3-6 weeks

Metatarsal Fracture

Conditions of the Forefoot & Toe

Bunion (hallux valgus)

EtiologySigns & Symptoms

-swelling, ruber, & tenderness at the MP joint

Bunion

Management -wide toe box -doughnut pad -tape splint with wedge

Bunionettes (tailor’s bunion)

Sesamoiditis

Metatarsalgia

Etiology -poor calf flexibility, pes cavus -fallen metatarsal arch due to pronation

& splayed foot

Metatarsalgia

Signs & Symptoms -flattened transverse arch

Metatarsalgia

Management -metatarsal pad or bar -aggressive static stretching,

strengthening of flexors -Thomas heel to relieve pronation

Interdigital Neuroma

Etiology -splayed toes & pronated foot

Signs & Symptoms -swelling -severe, intermittent & radiating pain

with weight bearing

Interdigital Neuroma

Management -wide toe box -metatarsal bar -steroid injection

Morton’s Toe

Sever’s Disease (Calcaneal Apophysitis)

Etiology intense activity

Signs & Symptoms -pain @ posterior heel with activity

Sever’s Disease

Management -restricting DF by elevating heel will resolve when apophysis closes modification of activity level walking boot 6-8 weeks

Retrocalcaneal Bursitis

Etiology -excessive rubbing due to increased

pressure

Signs & Symptoms -ruber, swelling

Plantar Fasciitis (Heel Spur Syndrome)

Etiology -excessive pronation @ subtalar joint -leg length discrepancy -tight calf, etc

Plantar Fasciitis

Signs & Symptoms -anterior/medial heel pain -intense pain in the AM -pain with DF of toes

Plantar Fasciitis

Management -longitudinal arch support -friction massage -aggressive stretching of calf & DF of

great toe -shoe with firm arch support

Metatarsal Stress Fracture

Etiology -training errors -morton’s toe or other atypical

conditions of foot

Metatarsal Stress Fracture

Signs & Symptoms -gradual increase in pain

Management -rest, walking boot x-ray vs. walking boot

Conditions of Lower Leg & Ankle

Lateral Ankle Sprain (inversion)

Etiology -inversion, plantar flexion, adduction

Signs & Symptoms Grade I, II, III

Management

Signs & Symptoms

Grade I

-mild stretching of the ATF-mild pain, weight bearing is not

impaired

Grade II

-complete tear of ATF & stretch or tear of CF

-”pop” or tear felt-moderate pain, weight bearing is

difficult-tenderness, effusion, & ecchymosis

Grade III

-very rare, usually associated with talar subluxation

-ATF, CF, PTF & joint capsule affected-severe pain noted laterallydiffuse effusion, ecchymosis, major

loss of function

Management

Grade I

-RICE-horseshoe & wrapgraduated exercises ROM, strength,

proprioception

Grade II

-RICE-x-ray-crutches prn

Grade III

-possible cast for 3 weeks

Eversion Ankle Sprains

etiology -eversion, abduction, dorsiflexion pes planus

Syndesmotic Ankle Spain

Etiology -inversion=AITF -eversion=PITF

Syndesmotic Ankle Sprain

Signs & Symptoms -talus moves 5 degrees -passive DF causes pain in the ankle

mortise

Ankle Fracture

Etiology -forcible abduction and adduction of the

foot -a planted foot with forcible IR of the leg -avulsion fx with 2nd or 3rd degree

sprain

Ankle Fracture

Signs & Symptoms -extreme pain and possible deformity

Acute Achilles Tendon Injuries

Achilles Tendon Strain

Etiology -sudden excessive DF

Signs & Symptoms -pain & weakness with PF

Achilles Tendon Strain

Management -ICE -compressive wrap -heel lift

Achilles Tendon Rupture

Etiology sudden stop-&-go -30+ -chronic inflammation

Achilles Tendon Rupture

Signs & Symptoms -immediate pain & snap -indentation & soft achilles -+Thompson

Achilles Tendon Rupture

Management-surgery vs. repair-cast with foot in PF = 4 weeks

Chronic Ankle Tendon Injuries

Achilles Tendinitis

Etiology -training errors, tight calf, pes cavus,

tight hamstringsSigns & Symptoms

-crepitus, point tenderness, weakness, decreased ROM

Achilles Tendinitis

Management -gentle stretching, ice soaks, NSAIDS -heel lift

Retocalcaneal Bursitis

Etiology -undue pressure on achilles tendon

Management

Anterior/Posterior Tibial Tendinitis

Etiology -anterior=excessive downhill running posterior=hyperpronated foot

Anterior/Posterior Tibial Tendinitis

Signs & Symptoms -pain over the muscle or tendon

Management -anterior=avoid hills & decrease

mileage -correct pronation -ice and aggressive stretching

Acute Leg Injuries

Acute Compartment Syndrome

Etiology -direct blow to the leg

Signs & Symptoms -weakness with DF & toe extension -paresthesia of dorsum of foot or

between1st & 2nd toe

Acute Compartment Syndrome

Management -medical emergency -decompress fascia -NEVER apply a compressive wrap

Leg Fractures

fibula=middle thirdtibia=lower thirdEtiology

-direct vs. indirect

Leg Fractures

Signs & Symptoms -deformity, crepitus, -leg is hard & swollen from internal

hemorrhaging -volkmann’s contracture

Overuse Leg Injuries

Medial Tibial Stress Syndrome

Etiology -pes planus, overuse, lack of reciprocal

muscle coordination

Medial Tibial Stress Syndrome

Signs & Symptoms -Grade I: pain during exercise -Grade II: before & after -Grade III: before, during, & after -Grade IV: no pain

Medial Tibial Stress Syndrome

Management -NSAIDS -ice massage -aggressive stretching before & after

Stress Fracture of the Tibia & Fibula

Etiology -pronated foot= fibula -pes cavus= tibia -overuse

Stress Fracture of the Tibia & Fibula

Signs & Symptoms -intense pain after practice -focal tenderness -+ percussion