The Ankle

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					The Ankle,
Foot, and
Lower Leg
Evaluation and Common Injuries
                  HOPS
• Remember HOPS allows you to be a
  detective and determine what is wrong.

•   History
•   Observation
•   Palpation
•   Stress
                   History
• Is their a previous injury (weakness)?
• How did the injury occur? If possible have
  the athlete demonstrate.
  – Very important in ankle sprains
     3 Common Ankle Sprains
      Plantarflexion or
          Inversion
      – Lateral sprain
•   In this injury the foot
    is turned downward
    and inward,
    stretching the
    lateral ligaments.
    Almost 90 percent
    of all ankle injuries
    are of this type.
      3 Common Ankle Sprains
       Eversion – Medial
           sprain
•   In this injury the foot is
    turned outward,
    stretching the medial
    ligaments. Only 5
    percent of all ankle
    injuries are of this type.
    *Although this injury is
    not very common, it is
    usually more serious
    and is frequently
    accompanied by a
    fracture.
     3 Common Ankle Sprains
      Dorsiflexion – Tibiofibular joint sprain –
         also known as Syndesmosis sprain
         or High Ankle Sprain
•   In this injury the foot is forced upwards
    toward the shin, stretching the ligaments
    of the tibiofibular joint. Once believed
    that only 5 percent of all ankle injuries
    are of this kind, but new research
    believes this may be more.
                Sounds

•   Did you hear any sounds? Snap – crack
    - pop
•   These may indicate a fracture or a
    ligament rupture.
               Observation
• Compare to uninjured side.
  – Swelling
  – Deformity (fracture/dislocation may be
    present)
  – Discoloration (tissue tearing or
    contusion/bruise)
Observation
Observation
              Observation
• Watch the athlete walk if possible
  – Limp
  – Not putting down heel
  – Not putting down toe
  – Dragging foot
  – ???
              Palpation
–   Where is the area of pain? Bone, ligament,
    muscle
–   How painful is the injured area?
–   Is there a specific area of tenderness?
                Special Tests
–       Check Range of Motion.
    •     Active - Plantarflexion, Dorsiflexion, Inversion,
          Eversion with both extremities at same time.
    •     Passive
        Special Tests
–Percussion
 Test –
 Tests for
 fracture.
 Concuss, or
 tap bottom of
 foot.
        Special Tests
–Compression
 Test –
 Tests for
 fracture.
 Compress tibia
 and fibula
 together.
          Special Tests

– Eversion Stress Test – Evaluates
  injury to the medial ligaments.

– Inversion Stress Test – Evaluates
  injury to the lateral ligaments.
                 Special Tests
– Anterior Drawer Test – The
  examiner places one hand
  in front where the instep is,
  while the other is place
  behind the calcaneus. He
  then attempts to displace
  the foot forward on the
  ankle by exerting the
  anterior force, while
  stabilizing the tibia. A
  positive anterior drawer
  sign can be demonstrated
  if there is significant
  damage to the anterior
  talofibular ligament.
           Special Tests
– Thompson Test
  Tests the
  Achilles tendon.
  Done by
  squeezing the
  calf muscle with
  the athlete lying
  in a prone
  position.
         Special Tests
–Talar Tilt –
 tests the extent
 of eversion
 and inversion
 injuries.
              Special Tests
– Kleiger’s Test – used
  to determine an injury
  to the deltoid ligament.
  Foot is rotated
  laterally. Pain over
  deltoid determines
  issues with that
  structure. Pain over
  the lateral malleolus
  indicates injury to the
  syndesmosis (tibfib
  joint).
                 Referral
When should the athlete see their Physician
   or Doctor?
  –   When a first time ankle injury of some
      severity has occurred. There is a high
      incidence of avulsion fracture with this
      injury.
  –   If an eversion injury has occurred. There is
      a great risk of fracture with this injury.
                Referral
–   If there is chronic or disabling pain. This
    may indicate a more serious problem than
    a sprain.
–   If the athlete tells you he heard or felt a
    snap, or crack when the injury happened.
    This may indicate a ligament tear or
    fracture.
–   If the athlete is an adolescent and he has
    had a serious ankle injury. In this age
    group there is a risk of injury to the growth
    plate.
             Specific Injuries
• Ankle Sprains – see descriptions already given
  – Plantarflexion/Inversion – Lateral sprain
  – Dorsiflexion – Tibiofibular joint sprain – also
    known as a Syndesmosis sprain.
Ankle Sprains – see descriptions already given

        Plantarflexion/Inversion – Lateral sprain
Ankle Sprains – see descriptions already given

                Eversion – Medial sprain
                Ankle Fracture
• Ankle Fracture
• Avulsion – When a
  person sprains their ankle
  and pulls a chip of bone
  off with the ligament.
• Complete – fracture all
  the way through the
  bone.
• Stress Fracture – typically
  more in the leg – will talk
  more about it then.
Ankle Dislocation


          • Bone moves out of
            correct alignment.
            Very painful.
         Achilles Tendonitis
• Inflammation of the Achilles or its tendon
  sheath causing pain. Can cause a
  thickening of the Achilles. Of ten hard to
  treat.
            Achilles Rupture
• Complete tear of the
  Achilles.
  Peroneal Tendon Subluxation
• Sheath around
  Tendon tears allowing
  peroneals to move
  out of the groove
  behind the lateral
  malleolus.
              Functional Tests
– While weight bearing the following should be
  performed
   •   Walk on toes (plantar flexion)
   •   Walk on heels (dorsiflexion)
   •   Walk on lateral borders of feet (inversion)
   •   Walk on medial borders of feet (eversion)
   •   Hops on injured ankle
   •   Passive, active and resistive movements should be manually
       applied to determine joint integrity and muscle function
– If the patient has difficulty with bearing weight these
  tests should not be utilized.
• This can happen
  when an athlete has a
  stress fracture but
  then continues to run.
  Leg can just break in
  two.
              Ankle Injury Videos
• Soccer Broken Leg
• http://www.youtube.com/watch?v=NJj90YxWt1U

• Ankle Dislocation Video
• http://www.youtube.com/watch?v=pEeOknjrK1w

• Soccer Broken Leg
• http://www.youtube.com/watch?v=KdzyeYNVGMY

• Football Greatest Injuries- Joe Theismann
  http://www.youtube.com/watch?v=PQ1iVRRu6w0&feature=related

• Football Leg Injury
                   Foot Injuries
Athlete Foot
• Fungal Infection
• Signs and Symptoms
  – Extreme itching on
    soles of feet, between
    and on top of toes
  – Appears as dry scaling
    patch
• Treatment
  – Topical antifungal and
    hygiene
                        Foot Injuries




• Calluses
   – Build up of skin

   – Treated with lotion
                 Foot Injuries
• Bursitis/Pump Bump
  – Inflammation of the bursa beneath the Achilles
  – Result of shoe rubbing on heel
  – Treated with stretching of Achilles, padding of
    heel/bump and heel lift
                     Foot Injuries
• Flat Feet (Pes Planus)
   – Cause
      • Heredity, overuse, shoes,
        etc.
   – Sign and Symptoms
      • May or may not have pain.
      • Look for “abnormal” foot
   – Treatment – only if have
     pain
      • Strengthening/Stretching
      • Orthotics
      • Taping
                    Foot Injuries
• High Arch – Pes Cavus
   – Rigid Foot = poor shock
     absorption
   – Sign and Symptoms
      • Possible foot pain
      • Achilles & Plantar Fascia
        pain
      • Callus development on
        ball and heel of foot
   – Management
      • If no pain – do nothing
      • Orthotics
      • Stretching
Foot Injuries
   • Black Toe Nails
      – Cause
          • Direct pressure, dropping an
            object on toe, kicking another
            object or repetitive forces on
            toenail
      – Signs and Symptoms
          • Accumulation of blood underneath
            toenail
          • Likely to produce extreme pain
            and ultimately loss of nail
      – Management
          • RICE immediately to reduce pain
            and swelling
          • Relieve pressure within 12-24
            hours (lance or drill nail) – must be
            sterile to prevent infection
                    Foot Injuries
• Plantar Fasciitis
   – Causes
      • Change from rigid supportive footwear to flexible footwear
      • Poor running technique
      • Leg length discrepancy, excessive pronation, inflexible
        longitudinal arch, tight gastroc-soleus complex
      • Running on soft surfaces, shoes with poor support
   – Sign and Symptoms
      • Pain in anterior medial heel, along medial longitudinal arch
      • Increased pain in morning, loosens after first few steps
      • Increased pain with forefoot dorsiflexion
                 Foot Injuries
• Plantar Fasciitis
  – Management
     • Extended treatment (8-12 weeks)
     • Orthotic therapy is very useful (soft orthotic with
       deep heel cup)
     • Simple arch taping, use of a night splint to stretch
     • Vigorous heel cord stretching and exercises that
       increase great toe dorsiflexion
     • NSAID’s and occasionally steroidal injection
               Foot Injuries
•   Foot Fractures
•   Foot Stress Fractures
•   Foot Strains
•   Foot Sprains
                     Foot Injuries
• Great Toe Hyperextension (Turf Toe)
  – Cause
     • Hyperextension injury resulting in sprain of Big Toe
     • May be the result of single or repetitive trauma
  – Signs and Symptoms
     • Pain and swelling which increases during push off
  – Management
     •   Increase rigidity of forefoot region in shoe
     •   Taping the toe to prevent dorsiflexion
     •   Ice and ultrasound
     •   Rest and discourage activity until pain free
     Preventing Foot Injuries
• Appropriate Hygiene
• Appropriate Footwear
• Changing Footwear at appropriate
  intervals
• Correcting Biomechanical Issues
  – Strengthening/Stretching
  – Orthotics
     Preventing Foot Injuries
• Foot Hygiene
  – Keeping toenails trimmed correctly
  – Shaving down excessive calluses
  – Keeping feet clean
  – Wearing clean and correctly fitting socks and
    shoes
  – Keeping feet as dry as possible to prevent
    development of athlete’s foot
           Lower Leg Injuries
•   Shin Contusion
•   Muscle Contusion
•   Leg Cramps & Spasms
•   Tibia Fractures
•   Fibula Fractures
•   Tibia/Fibula Stress Fractures
•   Gastrocnemius Strain
•   Soleus Strain
            Lower Leg Injuries
• Medial Tibial Stress Syndrome (Shin Splints)
  – Causes
     • Pain in anterior portion of shin
     • Catch all for stress fractures, muscle strains, chronic anterior
       compartment syndrome
     • Accounts for 10-15% of all running injuries, 60% of leg pain
       in athletes
     • Caused by repetitive microtrauma
     • Weak muscles, improper footwear, training errors, varus foot,
       tight heel cord, hypermobile or pronated feet and even
       forefoot supination can contribute to MTSS
          Lower Leg Injuries
• Medial Tibial Stress Syndrome (Shin
  Splints)
  – Signs and Symptoms
    • Four grades of pain
       – Pain after activity
       – Pain before and after activity and not affecting
         performance
       – Pain before, during and after activity, affecting
         performance
       – Pain so severe, performance is impossible
            Lower Leg Injuries
• Medial Tibial Stress Syndrome (Shin
  Splints)
  – Management
    •   Physician referral for X-rays and bone scan
    •   Activity modification
    •   Correction of abnormal biomechanics
    •   Ice massage to reduce pain and inflammation
    •   Flexibility program for gastroc-soleus complex
    •   Arch taping and or orthotics
          Lower Leg Injuries
• Compartment Syndrome
  – Cuases
    • Acute compartment syndrome
       – Occurs secondary to direct trauma
       – Medical emergency!!!!!!!
    • Acute exertional compartment syndrome
       – Evolves with minimal to moderate activity
    • Chronic compartment syndrome
       – Symptoms arise consistently at certain point during
         activity
          Lower Leg Injuries
• Compartment Syndrome
  – Signs and Symptoms
    • Complain of deep aching pain & tightness due to
      pressure and swelling
    • Reduced circulation and sensation of foot occurs
    • Intracompartmental measures further define
      severity
    • Must be recognized and treated early
    • Unable to dorsiflex foot
            Lower Leg Injuries
• Compartment Syndrome (continued)
  – Management
     • If severe acute or chronic case, may present as medical
       emergency that requires surgery to reduce pressure or
       release fascia
     • RICE, NSAID’s and analgesics as needed
     • Under acute and exertional cases pressures will be
       monitored and surgical needs will be dependent on findings
        – Following surgical release patient may not return to activity for
          2-4 months
     • In chronic conditions management is initially conservative
     • Fasciotomy may be necessary if conservative measures fail
Compartment Syndrome

				
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posted:3/18/2012
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