Chapter 18 (pp 487-496)

Injuries to the

Foot & Ankle

Objectives

Identify…• The bones of the foot & ankle• The ligaments of the foot & ankle• The muscles of the foot & ankle• The tendons of the foot & ankle• The blood vessels & nerves of the foot &

ankle• Other structures

The bones

• The foot contains 28 bones– Phalanges (16)

• Proximal (1-5)• Intermediate (2-5)• Distal (1-5)• Sesamoids (1)

The bones

• The foot contains 28 bones– Metatarsals (5)– Tarsal bones (7)

• Cuneiforms– Medial, intermediate,

lateral• Cuboid, Navicular• Talus, Calcaneous

The bones

• Tibia• Fibula

Phalanges

• There are 14 total phalanges– Great toe = 2– All other toes = 3

• Each toe has a proximal, intermediate, & distal phalange (except Great toe)

Phalanges

• Great toe has 2 sesamoid bones– Act like “mini patella”

to increase leverage and protect the joint

metatarsals

• Each toe has a corresponding metatarsal (MT)

• Important areas:– Head of the 1st MT– Base of the 5th MT– In-between the 2-3

MT heads

Tarsal bones

• The tarsal bones make up the mid- & rear-foot– Cuneiforms (E, F, G)

• Medial (G)• Intermediate (F)• Lateral (E)

– Cuboid (C)– Navicular (D)– Talus (B)– Calcaneous (A)

Bones of the leg

• Tibia and fibula extend past the talus bone

• Distal end is referred to as the malleolus– Medial = tibial– Lateral = fibular

Bones of the leg

• Tibia– Larger of the two

bones– Primary weight

bearing bone

Bones of the leg

• Fibula– Smaller bone, extends

more distally– Provides for muscle

attachments– ≤ 10% weight bearing

the ligaments

• Important ligaments in the foot:– Calcaneonavicular

ligament (spring ligament)

The ligaments

• Medial ankle:– Deltoid ligament

The ligaments

• Lateral ankle:– Anterior talofibular

(ATF)– Calcaneofibular

(CF)– Posterior talofibular

(PTF)• Not shown

The ligaments

• Lower leg:– Distal anterior

tibiofibular ligament– Distal posterior

tibiofibular ligament– Interosseous

membrane

articulations

• Interphalangeal (IP, PIP, DIP)

• Metatarsophalangeal (MP or MTP) joints

• Intermetatarsal joints• Tarsometatarsal (TMT)

joints • Subtalar joint• Talocrural joint

Subtalar joint

• Articulation of the talus & calcaneus

Talocrural joint

• Tibia, fibula, talus• Mortise & tenon

configuration• Talus is wedge-

shaped• Lateral malleolus

extends more distally than medial malleolus

Arches of the foot

• Support body weight• Absorb forces from

the ground• Provide space for

blood vessels, tendons, & muscles

Arches of the foot

• Metatarsal Arch – across metatarsal heads

• Transverse Arch – across metatarsal bases & cuneiforms

• Medial Longitudinal Arch – along the medial aspect

• Lateral Longitudinal Arch – along the lateral aspect

Arches of the foot

Plantar fascia

• Broad, thick tissue covering the bottom of the foot– Extends from the

calcaneus to the base of each metatarsal

– Supports the foot against downward forces

Muscles & tendons

• Intrinsic muscles of the foot:– Toe extensor– Toe flexors (3)– Great toe & 5th toe

abductors– Great toe adductor

Muscles & tendons

• Extrinsic muscles of the foot:– Divided by compartments

• Anterior• Lateral• Superficial posterior• Deep posterior

Muscles & tendons

• Anterior compartment– Tibialis anterior– Extensor hallucis

longus– Extensor digitorum

longus

• Dorsiflex the foot

Muscles & tendons

• Lateral compartment– Peroneus longus– Peroneus brevis

• Evert the foot

Muscles & Tendons

• Superficial posterior compartment– Gastrocnemius– Soleus– Plantaris

• Plantarflex the foot

Muscles & tendons

• Deep posterior compartment– Tibialis posterior– Flexor hallucis

longus– Flexor digitorum

longus

• Plantarflex & invert the foot

Neurological & Vascular

• Tibial nerve– Posterior leg &

plantar aspect of foot

• Common peroneal nerve– Anterior leg & foot

• Blood supply– Anterior tibial artery Dorsal pedal artery

– Posterior tibial artery

Distal pulse

34

OA 11.12

If an athlete came to you complaining of ankle pain, how would you address them?• What questions would you ask to

gather clues about what is going on?• What are some relevant observations

to make regarding their body?

The Foot & Ankle

Evaluation

Objectives

Identify…• Pertinent information to gather during a

foot & ankle evaluation• Important observations to make during

a foot & ankle evaluation

???

The Secondary Survey

• After ruling out life-threatening injuries, we begin the secondary survey– Treat for major injuries with acute on-field

care• Begins with an assessment of vital signs• Musculoskeletal Assessment

DOCUMENT EVERYTHING!

HOPS TECHNIQUE

The Evaluation Process

H.O.P.S.• History• Observation• Palpation

– Range of motion

• Special tests

H.I.P.S.• History• Inspection• Palpation

– Range of Motion

• Special tests

History

• What happened?– Gain information about the patient and the

injury– Most critical part of the evaluation!– Past medical history– History of the present condition

History

• Start with generic history questions– Chief complaint– Age– Occupation / sport / position etc.– General health

condition– Activity level– Medications

History

• History of previous injuries– What happened?– Who did you see?– What did they tell you?– How long were you out?– Has it fully resolved?

History

• Mechanism of injury– How did it happen?

Tension = sprain; fracture; strain

Torsion = sprain; fracture

Compression = contusion; fracture

Shear = fracture; sprain

Bending = fracture

HistoryAsk these questions regarding PAIN• P-rovocation – what causes it? what

makes it better?• Q-uality – what does it feel like?

neurological symptoms?• R-egion – where does it hurt? can you point

w/one finger?• S-everity – how bad does it hurt? (1-10)

• T-iming – when does it hurt? how long?

History

Type of Pain Structure

Cramping, dull, aching Muscle

Dull, aching Ligament, joint capsule

Sharp, bright, lightning-like, burning Nerve

Deep, nagging, dull Bone

Sharp, severe, intolerable Fracture

Throbbing, diffuse Vasculature

History

• Sounds & sensations– Did you hear any sounds? Did you hear

any pops, crackles, snaps, clicks?• What could this

indicate???

– Did you feelanything unusual?

History• Specific to the foot & ankle

– Previous history = chronic ankle instability– Mechanism of injury = ROM (Inversion,

Eversion, Plantarflexion, Dorsiflexion)– Location of pain – heel, foot, toes, arches,

lateral ankle, medial ankle, etc.• Determines what is injured

– Changes in activity,footwear, or training surfaces

Observation

• Athlete Moving?• Position of athlete?• Conscious?• Primary Survey• Inspect injury site• Secondary Survey

Observation

• When does this begin?• Compare each side bilaterally

to identify what is normal forthat person

• We look for:– Deformity, asymmetry,

edema, ecchymosis

Observation

We assess:• Gait• Gross motor function• Posture/position• Facial expression• Guarding

Observation

• Gait – how a person walks– Difficulty walking = antalgic gait

• Does the athlete favor one foot, limp, or is unable to bear weight?

• Does the athlete carry their weight on their toes or heel?

• Is the arch maintained while both weight-bearing and non-weight bearing

Observation

• Can the athlete move the limb on their own through normal function?

• Is the arch maintained while both weight-bearing and non-weight bearing

Critical thinking…

An athlete limps in to the ATR complaining of pain on the lateral aspect of his right ankle. He said he stepped off the curb funny and heard a pop in his foot. Now he is feeling sharp pain, and points to the lateral aspect of his ankle, just anterior to the lateral malleolus. You inspect the ankle and find edema beginning to form around the lateral malleolus.

Critical thinking…

An athlete limps in to the ATR complaining of pain on the lateral aspect of his right ankle. He said he stepped off the curb funny and heard a pop in his foot. Now he is feeling sharp pain, just anterior to the lateral malleolus. You inspect the ankle and find edema beginning to form around the lateral malleolus. He states the pain is a 6/10 and he can’t put all his weight on the ankle.

56

OA 11.13

• Identify 3 history questions to ask a soccer player who complains of discomfort in his dominant foot.

• List 5 anatomical areas you would observe.– What are you observing for?

Palpation

• Allows us to feel what is going on

• Compares normal to abnormal

• Utilizes touch to gather information

Palpation

• Bony Structures– Alignment– Crepitus – crackling

sound with movement– Joint alignment!

• Soft Tissues– Swelling– Painful areas– Muscle/tendon deficit

Range of motion

• Definition:– Range of motion refers to the distance

and direction a joint can move between the flexed position and the extended position

– In true clinical settings,we use a goniometerto measure ROM

Range of motion

• Types– Active range of motion (AROM)– Passive range of motion (PROM)– Resistive range of motion (RROM)

Range of motion

• AROM– The patient’s ability to move a joint under

their own strength• PROM

– The joint’s ability to be moved through a range of motion

• RROM– Measurement of the muscle strength of a

joint through the ROM

Range of motion

• Performed bilaterally on the uninjured side first– Why??

Allows us to get a look at what is normal for that athlete!

Range of motion

• For the foot…– ROM occurs at

each joint– Only the MTP &

IP joints of the toes are assessed

Range of motion

• For the ankle…– ROM occurs at

the subtalar and talocrural joints

– Both are assessed as one unit

Movements

• The foot & ankle act together during movement

• The toes are assessed together

Movements

Ankle Movements• Dorsiflexion• Plantar Flexion

• Inversion• Eversion

Toe Movements• Flexion• Extension

• Adduction• Abduction

– Only for Great & 5th toe

Ankle movements

• Dorsiflexion (DF) – elevating the toes above the ankle joint

• Aka: walking on your heels

• Normal: 20o

Ankle movements

• Plantarflexion (PF) – depressing the toes below the ankle joint

• Aka: walking on your toes, pushing a gas pedal

• Normal: 50o

Ankle movements

• Inversion (INV) – bringing the sole of the foot medial

• Aka: walking on the outside of the foot

• Normal: 20o

Ankle movements

• Eversion (EV) – bringing the sole of the foot lateral

• Aka: walking on the arch/inside of the foot

• Normal: 5o

Toe movements

• Flexion (FLEX) – decreasing the joint angle by bringing the bones together

• Aka: curling the toes• Normal: 45-90o

Toe movements

• Extension (EXT) – increasing joint angle by separating the bones

• Aka: straightening the toes

• Normal: 70o at the MTP joints

Toe Movements

• Abduction (ABD) & Adduction (ADD) (Great & 5th toe):–Simply known as

splaying or squeezing the toes

• Normal: ??

Assessing ROM

• When assessing, make note of:– Differences in AROM– Pain during PROM– Decreased strength during RROM

Assessing AROM

• Have the patient move their ankle through the 4 movements– Toes up like walking on heels– Point toes like pushing on gas pedal– Bring big toe in and down– Bring little toe out and up

Assessing AROM

• Have the patient flex & extend, ABD & ADD the toes– Curl your toes– Straighten them– Splay the toes– Squeeze the toes

Assessing PROM

• The examiner will move the ankle through the ROMs to the extreme end – why??– I am going to move your foot/ankle for you.

Just try to relax and let me know if you feel discomfort, pain, or anything unusual.

Assessing RROM

• The athlete will move through each ROM as the examiner places resistance against the movement– DF – pull the dorsal foot downward– PF – resist the sole of the foot– INV – push against the 1st MTP joint– EV – push against the 5th MTP joint

Assessing RROM

• The athlete will move through each ROM as the examiner places resistance against the movement– Toe FLEX – resist the curling of the toes– Toe EXT – resist the straightening of the

toes

Resistive range of motion

• Each motion is caused by certain muscles or muscle groups

• DF: tibialis anterior• PF: gastrocnemius &

soleus (calf muscles)• INV: tibialis posterior• EV: peroneal muscle

group

Grading ROM

• AROM & PROM are graded as within normal limits (WNL) or decreased/limited & why– AROM: R = WNL, L = decreased DF due to

pn

Grading ROM

• RROM is graded on a 0-5 scale

0. Absent – no muscle contraction 1. Trace – contraction without movement 2. Poor – full ROM without gravity 3. Fair – full ROM against gravity 4. Good – 3 + some resistance 5. Normal – 3 + full resistance

Documenting ROM

• When documenting ROM, each movement must be listed & assessed.

AROM: R = WNL, L = WNL

PROM: R = WNL, L = WNL with Pn

RROM: R = 5/5DF, 5/5PF, 5/5INV, 5/5EV; L = 5/5DF, 3/5PF due to Pn, 3/5INV due to Pn, 2/5EV due to Pn

So far…

• Gathered clues by taking a history• Observed for signs of injury• Palpated the structures for

abnormalities• Tested ROM to find differences

Differential Diagnosis

• By now the choices of injury should be narrowed down to a handful of options…

• A list of possible injuries is known as a Differential Diagnosis (DDx)

Rule Them Out

• In order to determine the injury, we must rule out the DDx

• To do this we use special tests

Special Tests

• Ligamentous• Joint play• Neurological• Vascular

88

OA 11.14

• What does HOPS stand for?• Which part is most important?• A list of possible injuries is known as

a…

SPECIAL TESTS FOR FRACTURES

Long Bone Compression Test

• Patient: supine• Examiner: standing in front of patient’s

feet• Action: grasp one MT by the head and

apply an axial force down the length of the bone.

Long bone compression test

Long Bone Compression Test

• Positive: pain along the MT shaft• Pathology: MT fracture

Tap test

• Patient: supine• Examiner: standing in front of patient’s

feet• Action: tap on the end of the phalange

Tap test

• Positive: pain along the phalange• Pathology: phalangeal fracture

Squeeze test

• Patient: supine• Examiner: adjacent to injured leg, hands

cupped behind tibia/fibula• Action: gently squeeze the tibia/fibula,

progress towards site of pain

Squeeze test

Squeeze test

• Positive: pain; crepitus• Pathology: fibular fracture; syndesmosis

sprain

Bump test

• Patient: supine• Examiner: standing in front of involved

heel• Action: Dorsiflex the ankle and bump

the calcaneus

Bump test

Bump test

• Positive: pain• Pathology: stress fracture of talus or leg

SPECIAL TESTS FOR SPRAINS

Anterior drawer test• Patient: Sitting over edge of table with knee

flexed• Examiner: Sitting in front of patient

– Hand 1 stabilizing leg above malleoli– Hand 2 cups calcaneus with foot on forearm

• Action: Calcaneus and talus drawn forward while stabilizing leg

Anterior drawer test

Anterior drawer test• Positive: Increased translation of talus; lack

of end feel; pain• Pathology: ATF ligament sprain

Talar tilt test (INVersion)

• Patient: Supine or Sitting over edge of table with knee flexed

• Examiner: In front of patient– Hand 1 grasps calcaneus– Hand 2 stabilizes leg above malleoli

• Action: Hand 1 provides inversion stress

Talar tilt test (Inversion)

Talar tilt test (INVersion)

• Positive: Increased tilt of talus or gap; lack of end feel; pain

• Pathology: CF ligament sprain & possible ATF sprain

Talar tilt test (EVersion)

• Patient: Supine or Sitting over edge of table with knee flexed

• Examiner: In front of patient– Hand 1 grasps calcaneus– Hand 2 stabilizes leg above malleoli

• Action: Hand 1 provides eversion stress

Talar tilt test (Eversion)

Talar tilt test (EVersion)

• Positive: Increased tilt of talus or gap; pain

• Pathology: Deltoid ligament sprain

SPECIAL TESTS FORTENDON RUPTURES

Thompson’s test

• Patient: Prone with feet off edge of table• Examiner: Side of patient

– Hand 1 over gastroc muscle• Action: Squeeze gastroc while

observing plantar flexion of foot

Thompson’s test

Thompson’s test

• Positive: No plantar flexion• Pathology: Achilles tendon rupture

INJURIES

objectives

• Identify pathologies that occur in the foot & ankle, differentiating their signs & symptoms–Bony pathologies–Ligamentous pathologies–Musculotendinous pathologies–Other structural/functional pathologies

STRUCTURAL DEFORMITIESOf the foot

Foot malalignments

• Pes Planus (flat foot)– Rigid or flexible– Trauma/weakness to supporting structures

of the arch• Pes Cavus (hollow foot)

– Congenital– Less effective at absorbing ground forces

than pes planus

Pes planus and pes cavus

Foot malalignments

• Mallet toe – DIP flexion

• Hammer toe – PIP flexion

SKELETAL PATHOLOGIESOf the foot

fractures

• Can occur to any bone in the foot/ankle• Some are more typical than others• All may have general Sx/Sy:

– Deformity– Limited ROM– Crepitus– Localized pain– Radiating pain– Swelling– Inability to bear weight

Jones vs. base of 5th fracture

Jones Fx• Proximal base of

the 5th metatarsal – 1 cm from styloid process

Base of 5th Fx• Attachment of

peroneus brevis muscle

• Often avulsion fx from countering INV mechanism

Jones vs. base of 5th fracture

Metatarsal stress fracture

• Known as aMarch Fx

• Stress fx of metatarsal 2-4 (typically)–Very localized pain–Dull pain–Worsens with activity

What is the diagnosis?

Lisfranc injury

• Acute injury• Mechanism of Injury (MOI)

– Rotation of the TMT joints– Forced hyper-plantarflexion– Forced toe extension & DF

• Displacement of the metatarsals• Severe pain & swelling; “pop” or

“tear”• Most require surgery

SOFT TISSUE PATHOLOGIESOf the foot

sprains

• Can occur to any ligament in the foot/ankle

• General Sx/Sy– Limited ROM– Localized pain– Swelling - edema– Inability to bear weight– (+) special test for that ligament

Arch sprain

• Caused by increased stress on arch• Flattening of the foot• Acute or chronic• Sx/Sy:

– Pain with weight bearing activities– swelling

Plantar fasciitis

• MOI: acute or insidious

• Sx/Sy:– Pain at origin &

plantar fascia after non-weight bearing (NWB)

– Pain w/ DF & toe extension

– Tight gastrocs, old age, ↓ ankle mobility

Hallux Valgus

• Great toe deformity• Degeneration of 1st MTP joint• Often leads to bunions

1st MTP Joint sprain

• “Turf toe”• MOI: planted foot w/

DF ankle–Hyperextension of the

MTP joint–Pain with push-off,

joint ROM, quick stops

Retrocalcaneal bursitis

• “Pump bump”• Inflammation of

the Achilles bursa

SKELETAL PATHOLOGIESOf the ankle

Tibial/fibular fracture

• MOI: Direct blow, or INV/EV stress

• May have:– gross deformity– audible “pop”– inability to bear weight

• Sx/Sy:– Localized pain, radiating pain– Crepitus & swelling

Talus fracture

• MOI: forced dorsiflexion with inversion• May mimic an ankle sprain• Avascular necrosis may develop• Often missed in

x-rays – CT/MRI to confirm

• Surgical fix

Stress fracture

• MOI: chronic microtraumatic forces• Sx/Sy:

– Gradual onset– Localized pain over shaft of bone

(“aching” pain)– Pain ↑ w/ activity & ↓ w/ rest– Often missed on x-rays– May mimic MTSS

Stress fracture

Medial tibial stress syndrome

• AKA: “Shin splints”• MOI: chronic pulling of the periosteum

surrounding the tibia by the posterior tibialis muscle

Medial tibial stress syndrome

• Sx/Sy:– Gradual onset from overuse, muscle

fatigue, biomechanics– Pain during activity, relieved with rest– Diffuse pain along the medial tibia– Pain with palpation– Pain during RROM for INV

Medial Tibial Stress Syndrome

• Medial Tibial Stress Syndrome

SOFT TISSUE PATHOLOGIESOf the ankle

Lateral ankle sprains

• Inversion with plantarflexion mechanism

• Most common injury to the body– Why?? – anatomically– Stronger deltoid

ligament, lateral malleoli extends further

Lateral ankle sprains

Lateral ankle sprains

• Area of pain = ligament involved

• Anterior talofibular = sinus tarsi

• Calcaneofibular = distal to lateral malleolus

• Posterior fibular = posterior to lateral malleolus

• Graded on a 1-3 scale

Lateral ankle sprains

Deltoid sprain

• Eversion or rotation mechanism

• Rare injury (5%) – most occur as avulsion fracture

• Sx/Sy:– General ligament

sprain sx/sy

Deltoid sprain

Syndesmosis sprain

• AKA “High ankle sprain”• MOI: Forced DF and/or eversion; rotation• Slow to heal

Syndesmosis sprain

• Sx/Sy:– Pain around & above ankle mortise– Inability to bear weight– Decreased ROM

• Anterior tibiofibular ligament• Interosseous membrane

Syndesmosis sprain

Achilles tendinitis

• Inflammation of the tendon due to overuse

• Sx/Sy:– Visibly enlarged Achilles tendon from

posterior aspect– ↓ strength & ROM– Altered gait or physical performance– Localized pain (“burning”)– Crepitus

Achilles tendinitis

Compartment syndrome

• Caused by direct blow or injury within fascial compartment– Typically anterior or deep posterior

compartments

Compartment syndrome

• Sx/Sy:– Severe pain – “ache”, “dull”, “sharp”– Muscle tightness, weakness, cramping; ↓

strength & ROM– Feeling of numbness & tingling in area– Sensation of hot/cold

• Medical emergency

Compartment syndrome

Compartment Syndrome