Lower Leg Ankle and Foot Conditions

					Lower Leg, Ankle, and Foot
             Anatomy (Cont’d)
• Forefoot
  – Metatarsals and phalanges; numerous joints
  – Support and distribute body weight throughout
    the foot
• Midfoot
  – Navicular, cuboid, 3 cuneiforms; numerous joints
• Hindfoot
  – Calcaneus and talus
            Anatomy (cont.)
• Ligaments supporting the midfoot and
  hindfoot region
                 Anatomy (cont.)
• Plantar arches
   – Support and distribute
     body weight
   – Longitudinal arch—
     medial and lateral
   – Transverse arch
   – Ligaments
       • Spring
       • Long plantar
       • Short plantar
              Anatomy (cont.)
• Plantar arches
  – Plantar fascia
             Anatomy (cont.)
• Muscles
  – Lateral and medial view
             Anatomy (cont.)
• Muscles
  – Posterior view
• Gait cycle
  – Consists of alternating periods of single-leg and
    double-leg support
  – Requires a set of coordinated, sequential joint
    actions of the lower extremity
• Motions
  – Toe — flexion and extension
  – Ankle (subtalar) — dorsiflexion and plantarflexion
  – Foot and ankle
     • Inversion and eversion
     • Pronation and supination
• Bones subject to several loading patterns
• Running
  – Foot sustains forces 2–3× body weight
  – Bones are typically 2–4× strength needed
• Repeated forces—stress fractures
• Foot deforms during weight bearing
  – Absorbing a smaller force of longer duration than if
    it were rigid
  – Deformation causes storage of mechanical energy in
    the stretched tendons, ligaments, and plantar fascia
                  Injury Prevention
• Physical conditioning
  – Strengthening
     • Extrinsic muscles
     • Intrinsic muscles
  – Flexibility
     • Achilles tendon
• Footwear
  – Demands of sport; wear shoe for its intended purpose
  – Proper fit
• Protective equipment
  – Taping; braces; orthotics
       Toe and Foot Conditions
• Bunion
  – Medial aspect of MTP joint of great toe; lateral
    aspect of the 5th toe
  – Thickening of capsule and bursa
  – Due to constant rubbing against inside of shoe
  – S&S (as condition worsens)
     • Lateral shift of great toe
     • Rigid, nonfunctional hallux valgus deformity
  – Once deformity occurs, little can be done to
    correct condition
  Toe and Foot Conditions (cont’d.)
• Toe deformities
   – Hallux valgus
      • Thickening of the medial capsule and bursa,
        resulting in severe valgus deformity of great toe
      • Asymptomatic or
      • Treatment—
   Toe and Foot Conditions (cont.)
• Hammer toe
   – Extension of MTP joint, flexion at PIP joint, and
     hyperextended at the DIP joint
• Claw toe
   – Hyperextension of MTP joint and flexion of DIP and
     PIP joints
• Mallet toe
   – Neutral position at MTP and PIP joints, flexion at DIP
• Difficult to treat conservatively
              Hammer Toe

Claw Toe

           Mallet Toe
   Toe and Foot Conditions (cont.)
• Turf toe
   – Sprain of the plantar capsular ligament of 1st MTP joint
   – Mechanism: forced hyperflexion or hyperextension of great toe
   – Acute or repetitive overload
   – Valgus ↑ susceptibility
   – S&S
      • Pain, point tenderness, and swelling on plantar aspect of MP
      • Extreme pain with extension
   – Potential for tear in flexor tendons or fracture of sesamoid
   – Management: standard acute; rest; protection from excessive
  Toe and Foot Conditions (cont.)
• Ingrown toenail
  – Preventable with proper hygiene and nail care
  – Edge of nail grows into lateral nail fold and
    surrounding skin
  – Nail margin reddens; painful
  – Paronychia—fungal or bacterial infection
   Toe and Foot Conditions (cont.)
• Retrocalcaneal bursitis
   – Due to external pressure—constrictive heel cup,
     coupled with excessive pronation or varus
   – “Pump bump”
   – Management: standard
   acute; shoe modification;
   AT stretching
           Lower Leg Contusions
• Gastrocnemius contusion
   – S&S
      • Immediate pain and weakness
      • Rapid hemorrhage and muscle spasm → palpable mass
   – Management: cold with gentle stretch
• Tibial contusion (shin bruise)
   – Vulnerable lack of padding
   – Minor injury—caution: repeated blows → damage
   – Key: prevention
     Lower Leg Contusions (cont.)
• Acute compartment syndrome
   – Lower leg includes 4 nonyielding compartments
   – Mechanism: direct blow anterolateral aspect of the tibia
   – Consequence: rapid ↑ in tissue pressure → neurovascular
   – S&S
       •   History of trauma
       •   Increasingly severe pain—out of proportion to situation
       •   Firm and tight skin over anterior shin
       •   Loss of sensation between 1st and 2nd toes on dorsum of foot
       •   Diminished pulse—dorsalis pedis artery
       •   Functional abnormalities within 30 minutes
   – Management: cold; no compression or elevation; immediate physician
   – Irreversible damage can occur within 12–24 hours
                     Ankle Sprains
• Inversion ankle sprain
   – Mechanism: plantarflexion
     and inversion
   – Predisposing factors
      • Lateral malleolus projects
        farther downward
      • Weakness in peroneals
      • ↓ ROM in Achilles tendon
               Ankle Sprains (cont.)
• Eversion ankle sprain
   – Mechanism: excessive
     dorsiflexion and eversion
   – Deltoid ligament
   – Potential
       • Lateral malleolus fracture;
         bimalleolar fracture
       • Tear of anterior tibiofibular
         ligament and interosseous
   – Predisposing factors
       • Excessive pronation
       • Hypomobile foot
         Ankle Sprains (cont.)
– S&S (eversion sprain)
   • Mild to moderate injuries
        Often unable to recall the mechanism
        Some initial pain at time of injury, but often
         subsides and individual continues to play
        Swelling
           » May not be as evident as a lateral sprain
           » Between posterior aspect of lateral malleolus
             and Achilles tendon
           » Point tenderness in involved ligaments
   • Severe injuries
        PROM pain-free in all motions except dorsiflexion
             Ankle Sprains (cont.)
• Syndesmosis sprain
  – Spreading of space at distal tibiofibular joint
  – Mechanism: dorsiflexion and external rotation
  – Common: anterior inferior tibiofibular ligament
  – Assessment based on:
     •   External rotation test
     •   Squeeze test
     •   Syndesmosis ligament palpation
     •   Passive dorsiflexion test
          Ankle Sprains (cont.)
• Management of ankle sprains
  – Standard acute
  – Assessment for additional damage (e.g., fracture)
  – Use of appropriate immobilization
  – Moderate/severe—physician referral
    Strains of Foot and Lower Leg
• Gastrocnemius strain
  – Medial head or musculotendinous junction
  – Mechanism
     • Forced dorsiflexion while knee is extended
     • Forced knee extension while foot is dorsiflexed
     • Muscular fatigue with fluid–electrolyte depletion and
  – S&S
     • Immediate pain, swelling, loss of function
  – Management: standard acute; gentle stretching; heel
  Strains of Foot and Lower Leg (cont.)
• Achilles tendinitis
   – Risk factors
      • Tight heel cords
      • Foot malalignment deformities
      • Recent change in shoes or running surface
      • Sudden increase in workload or change in exercise environment
   – Acute S&S
       • Aching or burning pain in posterior heel, ↑ with passive dorsiflexion and
         resisted plantarflexion
       • Point tenderness and crepitus at bony insertion
       • Local nodules
   – Chronic S&S
       • Pain worse after exercise
       • Thickened tendon
       • Tightness in gastrocnemius–soleus
   – Management: cryotherapy; NSAIDs; activity modification
 Strains of Foot and Lower Leg (cont.)
• Achilles tendon rupture
  – Mechanism: push-off of forefoot while knee is extending
  – More common in athletes over age 30
  – S&S
     •   “Pop”
     •   Inability to stand on toes
     •   Visible defect
     •   Excessive passive dorsiflexion
     •   + Thompson’s test
  – Management
     • Compression wrap and splint; immediate physician referral
                 Overuse Conditions
• Plantar fasciitis
   – Extrinsic and intrinsic risk factors
   – S&S
       •   Pain with first steps in the morning
       •   Point tenderness at medial calcaneal tubercle
       •   ↑ pain with passive extension of great toe and ankle dorsiflexion
       •   ↑ pain with weight bearing
       •   Pain relieved with activity, but recurs after rest
   – Management: standard acute; refer to Field Strategy 18.4
       Overuse Conditions (cont.)
• Medial tibial stress syndrome
  – Periostitis along posteromedial tibial border (distal third)
  – Believed to be related to periostitis of the soleus insertion along
    the posterior medial tibial border
      • Excessive pronation causes an eccentric contraction of soleus →
  – Other contributing factors
     • Recent changes in running distance, speed, footwear, or running
  – S&S
     • Dull pain begins at any point in the workout; occasionally sharp
       and penetrating
     • Pain along posteromedial border of tibia in distal third
     • Pain is relieved with rest, but may recur hours after activity stops
      Overuse Conditions (cont.)
• Exertional compartment syndrome
  – Characterized by exercise-induced pain and swelling that is
    relieved by rest
  – Compartments most frequently affected—anterior (50%–
  – Usually seen in well-conditioned individuals younger than
  – S&S
     •   Aching leg pain and sense of fullness over involved compartment
     •   Often affects both legs
     •   Symptoms relieved with cessation of exercise
     •   Activity-related pain begins at a predictable time
     •   Anterior compartment—mild foot drop; paresthesia on dorsum of
         the foot
  – Perform evaluation after exercise strenuous enough to
    reproduce symptoms
  – Management: assessing contributing factors
          Neurologic Conditions
• Plantar interdigital neuroma (Morton’s neuroma)
  – Trauma or repetitive stress → abnormal pressure on
    plantar digital nerves
  – Common—web space between 3rd and 4th
    metatarsals; less common, between 2nd and 3rd
  – S&S
     • Sensation of having a stone in the shoe that worsens when standing
     • Tingling or burning, radiating to the toes, along with intermittent
       symptoms of a sharp shock-like sensation
     • Pain subsides when activity is stopped or when the shoe is removed;
       desire to remove the shoe and massage foot—classic sign
  – Management: metatarsal pad; broad, soft-soled shoe
    with a low heel
    Foot and Lower Leg Fractures
• Stress fractures
   – Often seen in running and jumping, especially after
     significant ↑ training mileage; change in surface,
     intensity, or shoe type
   – Common sites
      •   2nd metatarsal
      •   Navicular
      •   Calcaneus
      •   Tibia and fibula
   – S&S
      • Pain begins insidiously; ↑ with activity and ↓ with rest
      • Pain usually limited to fracture site
      • Pain with percussion, tuning fork, or ultrasound
   – Management: standard acute; physician referral
 Foot and Lower Leg Fractures (cont.)
• Avulsion fractures
  – Eversion sprain—deltoid ligament avulses portion of distal
    medial malleolus
  – Inversion sprain—plantar aponeurosis or peroneus brevis
    tendon avulses base of 5th metatarsal (type II)
  – Jones fracture
     • Type I transverse fracture into the proximal shaft of 5th metatarsal
       at junction of diaphysis and metaphysis
     • Often overlooked in conjunction with a severe ankle sprain
     • Complications: nonunions and delayed unions are common
  – Management: standard acute; physician referral
 Foot and Lower Leg Fractures (cont.)
• Ankle fracture–dislocation
   – Mechanism
      •   Landing from a height with foot in excessive eversion or inversion
      •   Being kicked from behind while the foot is firmly planted
      •   Foot displaced laterally at a gross angle to lower leg; extreme pain
      •   Can compromise the posterior tibial artery and nerve
• Fracture management
   – Remove shoe and sock to expose injured area
   – Assess neurovascular integrity
   – Mild
      • Standard with physician referral
   – Serious conditions
      • Assess and treat for shock
      • Activate EMS
•   History
•   Observation/inspection
•   Palpation
•   Physical examination tests
        Range of Motion (ROM)

•   AROM
•   PROM
•   RROM
                  Stress Tests
• Anterior drawer test
• Talar tilt
              Stress Tests (cont.)
• External rotation (Kleiger’s) test
• Thompson’s test
            Stress Tests (cont.)
• Homan’s test
• Tinel’s sign
            Stress Tests (cont.)

• Morton’s test
        Ankle Taping Steps
1.   Anchor     10. Close down
2.   Anchor       (eventually horseshoes)
3.   Anchor     11. J-Strap (or Figure 8)
4.   Stirrup    12. Lateral Heel Lock
5.   Anchor     13. Medial Heel Lock
6.   Stirrup    14. Lateral Heel Lock
7.   Anchor     15. Medial Heel Lock
8.   Stirrup    16. Close down
9.   Anchor     17. Final closing strip

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