chapter 16 foot, ankle, and lower leg conditions
DESCRIPTION
Chapter 16 Foot, Ankle, and Lower Leg Conditions. Anatomy. Skeletal features of the lower leg, ankle, and foot. Anatomy (cont’d). Forefoot Metatarsals and phalanges; numerous joints Support and distribute body weight throughout the foot Toes - PowerPoint PPT PresentationTRANSCRIPT
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Chapter 16
Foot, Ankle, and Lower Leg Conditions
Chapter 16
Foot, Ankle, and Lower Leg Conditions
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Anatomy Anatomy Skeletal features of the lower leg, ankle, and foot
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Anatomy (cont’d)Anatomy (cont’d)
• Forefoot
– Metatarsals and phalanges; numerous joints
– Support and distribute body weight throughout the foot
– Toes
• Smooth the weight shift to the opposite foot during walking
• Help maintain stability during weight-bearing
– 1st digit – hallux or “great toe” – main body stabilizer during walking or running
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Anatomy (cont’d)Anatomy (cont’d)
• Midfoot
– Navicular, cuboid, 3 cuneiforms; numerous joints
– Talocalcaneonavicular joint (TCN)
• Talus moves simultaneously on calcaneus and navicular
• Combined action of talonavicular and subtalar joint
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Anatomy (cont’d)Anatomy (cont’d)
• Hindfoot
– Calcaneus and talus
– Talocrural joint (ankle joint)
• Hinge joint; plantarflexion and dorsiflexion
• Articulation of talus, tibia, and fibula
• Fibula extends farther distally than tibia – limits eversion
• Talar dome wider anteriorly – more stable in dorsiflexion
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Anatomy (cont’d)Anatomy (cont’d)
• Hindfoot (cont’d)
– Talocrural joint (ankle joint) (cont’d)
• Ligaments
• Medial: deltoid
• Lateral :anterior talofibular; posterior talofibular; calcaneofibular
– Subtalar joint
• Behaves as a flexible structure
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Anatomy (cont’d)Anatomy (cont’d)
• Ligaments supporting the midfoot and hindfoot region
Ligaments supporting the midfoot and hindfoot region, lateral and medial views
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Anatomy (cont’d)Anatomy (cont’d)
• Tibiofibular joints
– Superior—proximal
– Inferior—distal
– Interosseous membrane
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Anatomy (cont’d)Anatomy (cont’d)
• Plantar arches
– Support and distribute body weight
– Longitudinal arch—medial and lateral
– Transverse arch
– Ligaments
• Spring (calcaneonavicular)
• Long plantar
• Short plantar
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Anatomy (cont’d)Anatomy (cont’d)
Arches of the foot Medial longitudinal arch
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Anatomy (cont’d)Anatomy (cont’d)• Plantar arches
– Plantar fascia
• Provides support for the longitudinal arch
Plantar fascia
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Anatomy (cont’d)Anatomy (cont’d)
• Nerves
– Sciatic nerve
• Tibial nerve
• Common peroneal nerve—deep and superficial peroneal nerves
– Femoral—saphenous
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Anatomy (cont’d)Anatomy (cont’d)
• Blood supply
– Femoral artery
– Popliteal
– Anterior and posterior tibial
– Anterior tibial
• Dorsal pedal
Blood supply to the leg, ankle, and foot region
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Kinematics and Major Muscle ActionsKinematics and Major Muscle ActionsMuscles of the lower leg and foot. A. Lateral and medial view
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
Muscles of the lower leg and foot. B. Posterior view
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
Intrinsic muscles of the foot. A. Dorsal view
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
Intrinsic muscles of the foot. B. Plantar view
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
MUSCLE COMPARTMENT PRIMARY ACTION
Tibialis anterior Anterior Dorsiflexion, inversion
Extensor digitorum longus
Anterior Toe extension, dorsiflexion
Extensor hallucis longus
Anterior Extension of great toe
Peroneus tertius Anterior Eversion, dorsiflexion
Peroneus longus Lateral Eversion, plantar flexion
Peroneus brevis Lateral Eversion, plantar flexion
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
MUSCLE COMPARTMENT PRIMARY ACTION
Flexor digitorum longus
Posterior, deep Toe flexion, plantar flexion
Flexor hallucis longus Posterior, deep Flexion of he great toe, plantar flexion
Tibialis posterior Posterior, deep Inversion, plantar flexion
Gastrocnemius Posterior, superficial Plantar flexion, knee flexion
Soleus Posterior, superficial Plantar flexion
Plantaris Posterior, superficial Plantar flexion, knee flexion
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
• 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
Gait
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
• Motions
– Toe—flexion and extension
– Ankle (subtalar)—dorsiflexion and plantarflexion
– Foot and ankle
• Inversion and eversion
• Pronation and supination
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
Motions of the foot and ankle. A. Dorsiflexion and plantar flexion. B. Eversion and inversion. C. Supination of the subtalar joint
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Injury PreventionInjury Prevention
• Physical conditioning
– Strengthening
• Extrinsic muscles
• Intrinsic muscles
– Flexibility
• Achilles tendon
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Injury Prevention (cont’d)Injury Prevention (cont’d)
• Protective equipment
– Braces; orthotics
• Footwear
– Demands of sport; wear shoe for its intended purpose
– Proper fit
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Toe and Foot ConditionsToe and Foot Conditions
• Toe deformities
– Hallux rigidus
• Degenerative arthritis in first MTP
• S&S
• Tender, enlarged first MTP joint
• Loss of motion
• Difficulty wearing shoes with an elevated heel
• Hallmark sign—restricted toe extension
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Toe and Foot Conditions (cont’d)Toe and Foot Conditions (cont’d)
• Toe deformities
– Hallux valgus
• Thickening of the medial capsule and bursa, resulting in severe valgus deformity
• Asymptomatic or symptomatic
• Treatment—symptomatic
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Toe and Foot Conditions (cont’d)Toe and Foot Conditions (cont’d)
Hallux valgus
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Toe and Foot Conditions (cont’d)Toe and Foot Conditions (cont’d)
• 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 joint
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Toe and Foot Conditions (cont’d)Toe and Foot Conditions (cont’d)
• S&S: painful callus formation on dorsumIP joints
Toe deformities
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Toe and Foot Conditions (cont’d)Toe and Foot Conditions (cont’d)
• Pes cavus
– Excessively high arch that does not flatten during weight bearing
– Causes can vary
– Rigid foot
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Toe and Foot Conditions (cont’d)Toe and Foot Conditions (cont’d)
• Pes planus
– Flat foot; arch or instep of the foot collapsing & contacting the ground
– Typically, acquired deformity resulting from injury or trauma
– Mobile foot
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Toe and Foot Conditions (cont’d)Toe and Foot Conditions (cont’d)
• Both conditions can be asymptomatic, but associated with common injuries
Common foot deformities
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Contusions Contusions
• Heel contusion
– Thick padding of adipose tissue—does not always suffice
– Stress in running, jumping, changing directions
– S&S
• Severe pain in heel
• Unable to bear weight
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Contusions (cont’d)Contusions (cont’d)
• Heel contusion (cont’d)
– Management: cold; heel cup or doughnut pad; referral
– Condition may persist for months
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Contusions (cont’d)Contusions (cont’d)
• Gastrocnemius contusion
– S&S
• Immediate pain and weakness
• Rapid hemorrhage and muscle spasm → palpable mass
– Management:
• Cold with gentle stretch
• If symptoms persist > 2-3 days, physician referral
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Contusions (cont’d)Contusions (cont’d)
• Tibial contusion (shin bruise)
– Vulnerable lack of padding
– Minor injury—caution: repeated blows → damage periosteum
– Management: standard acute
– Key: prevention
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Lower Leg Contusions Lower Leg Contusions
• Acute compartment syndrome
– Lower leg includes 4 nonyielding compartments
– MOI: direct blow anterolateral aspect of the tibia
– Rapid ↑ in tissue pressure → neurovascular compromise
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Lower Leg Contusions (cont’d)Lower Leg Contusions (cont’d)
• Acute compartment syndrome (cont’d)
– S&S
• History of trauma
• Increasingly severe pain—out of proportion to situation
• Firm and tight skin over anterior shin
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Lower Leg Contusions (cont’d)Lower Leg Contusions (cont’d)
• Acute compartment syndrome (cont’d)
– S&S (cont’d)
• Loss of sensation between 1st and 2nd toes on dorsum of foot
• Diminished pulse—dorsalis pedis artery
• Functional abnormalities within 30 minutes
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Lower Leg Contusions (cont’d)Lower Leg Contusions (cont’d)
• Acute compartment syndrome (cont’d)
– Management:
• Cold
• NO compression or elevation
• immediate referral to ER or summon EMS
– Irreversible damage can occur within 12–24 hours
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Toe and Foot SprainsToe and Foot Sprains
• IP & MP joints
– MOI: tripping or stubbing the toe
– S&S
• Pain, dysfunction, immediate swelling
• Dislocation—gross deformity
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Toe and Foot Sprains (cont’d)Toe and Foot Sprains (cont’d)
• Midfoot sprains
– MOI: severe dorsiflexion, plantarflexion, or pronation
– More frequent in activities in which foot is unsupported
– S&S
• Pain and swelling is deep on medial aspect of foot
• Weight bearing may be too painful
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Toe and Foot Sprains (cont’d)Toe and Foot Sprains (cont’d)
• Turf toe
– Sprain of the plantar capsular ligament of 1st MTP joint
– MOI: forced hyperflexion or hyperextension of great toe
– Acute or repetitive overload
– Valgus ↑ susceptibility
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Toe and Foot Sprains (cont’d)Toe and Foot Sprains (cont’d)
• Turf toe (cont’d)
– S&S (cont’d)
• Pain, point tenderness, and swelling on plantar aspect of MP joint
• Extreme pain with extension
– Potential for tear in flexor tendons or fracture of sesamoid bones
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Toe and Foot Sprains (cont’d)Toe and Foot Sprains (cont’d)
• Management toe and foot sprains
– Standard acute
– Physician referral
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Ankle SprainsAnkle Sprains
• Inversion ankle sprain
– MOI: plantarflexion and inversion
– Predisposing factors
• Lateral malleolus projects farther downward
• Least stable position of ankle is plantar flexion
• Weakness in peroneals
• ↓ ROM in Achilles tendon
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)Inversion ankle sprain
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)
SIGNS AND SYMPTOMS
1st Pain and swelling on anterolateral aspect of lateral malleolusPoint tenderness over ATFL
2nd Tearing or popping sensation felt on lateral aspectPain and swelling on anterolateral and inferior aspect of lateral malleolusPainful palpation over ATFL and CFLMay also be tender over PTFL, deltoid ligament, and anterior capsule area
3rd Tearing or popping sensation felt on lateral aspectDiffuse swelling over entire lateral aspect with or without anterior swellingCan be very painful or absent of pain
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)
• Eversion ankle sprain
– Mechanism: excessive dorsiflexion and eversion
– Deltoid ligament
– Potential
• Lateral malleolus fx; bimalleolar fx
• Tear of anterior tibiofibular ligament &interosseous membrane
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)
• Eversion ankle sprain (cont’d)
– Predisposing factors
• Excessive pronation
• Hypomobile foot
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)
• Eversion Sprain (cont’d)
– S&S
• 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
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)
• Eversion sprain (cont’d)
– S&S (eversion sprain)
• Mild to moderate injuries
• Swelling
• May not be as evident as a lateral sprain
• Between posterior aspect of lateral malleolus and Achilles tendon
• Point tenderness in involved ligaments
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)
• Eversion Sprain (cont’d)
– S&S
• Severe injuries
• PROM pain-free in all motions except dorsiflexion
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)
• Syndesmosis sprain (High Ankle Sprain)
– Spreading of space at distal tibiofibular joint
– MOI: dorsiflexion and external rotation
– Common: anterior inferior tibiofibular ligament
– S&S
• Point tenderness over the anterolateral tibiofibular joint
• Significant pain and swelling
• Difficulty bearing weight
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)
• Management of ankle sprains
– Standard acute
– Use of crutches if unable to walk without limp
– Physician referral
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)
• Subtalar dislocation
– MOI: fall from a height (as in basketball or volleyball); foot lands in inversion
– Disrupts interosseous talocalcaneal & talonavicular ligament
![Page 57: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/57.jpg)
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)
• Subtalar dislocation (cont’d)
– S&S
• Extreme pain and total loss of function is present
• Gross deformity may not be clearly visible
• Foot may appear pale and feel cold to the touch
• Individual may show signs of shock
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Ankle Sprains (cont’d)Ankle Sprains (cont’d)
• Subtalar dislocation
– Concern: potential for peroneal tendon entrapment and neurovascular damage
– Management: medical emergency; activate EMS; monitor neurovascular function
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Tendinopathies of the Foot & Lower LegTendinopathies of the Foot & Lower Leg
• Strains & Tendinitis
– Common sites
• Achilles tendon just proximal to insertion on calcaneus
• Tibialis posterior just behind medial malleolus
• Tibialis anterior on dorsum of foot just under extensor retinaculum
• Peroneal tendons just behind lateral malleolus and at distal attachment on base of 5th metatarsal
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Tendinopathies of the Foot & Lower Leg (cont’d)
Tendinopathies of the Foot & Lower Leg (cont’d)
• Strains & Tendinitis
– Predisposing factors
• Training errors
• Direct trauma
• Infection from a penetrating wound into tendon
• Abnormal foot mechanics producing friction between shoe, tendon, and bony structure
• Poor footwear that is not properly fitted to foot
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Tendinopathies of the Foot & Lower Leg (cont’d)
Tendinopathies of the Foot & Lower Leg (cont’d)
– S&S (tendinitis)
• History of morning stiffness
• Localized tenderness over tendon
• Swelling or thickness in tendon and peritendon tissues
• Pain with passive stretching and with active and resisted motion
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Tendinopathies of the Foot & Lower Leg (cont’d)
Tendinopathies of the Foot & Lower Leg (cont’d)
– Management
• Do not permit to continue activity until seen by a physician
• Suggest the application of cold to the area to decrease pain and potential spasm
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Tendiopathies of the Foot & Lower Leg (cont’d)
Tendiopathies of the Foot & Lower Leg (cont’d)
• 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 & cramping
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Tendinopathies of the Foot & Lower Leg (cont’d)
Tendinopathies of the Foot & Lower Leg (cont’d)
• Gastrocnemius strain (cont’d)
– S&S
• Immediate pain, swelling, loss of function
– Management:
• standard acute; crutches if unable to walk w/out a limp
• If symptoms persist > 2-3 days or mod-severe injury, physician referral
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Tendinopathies of the Foot & Lower Leg (cont’d)
Tendinopathies of the Foot & Lower Leg (cont’d)
Gastrocnemius muscle strain
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Tendinopathies of the Foot & Lower Leg (cont’d)
Tendinopathies of the Foot & Lower Leg (cont’d)
• Achilles tendon rupture
– MOI: push-off of forefoot while knee is extending
– More common in individuals over age 30
– S&S
• “Pop”
• Inability to stand on toes
• Visible defect
• Excessive passive dorsiflexion
![Page 67: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/67.jpg)
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Tendinopathies of the Foot & Lower Leg (cont’d)
Tendinopathies of the Foot & Lower Leg (cont’d)
• Achilles tendon rupture (cont’d)
– Management
• Compression wrap; immediate transport to emergency care facility or physician
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Tendinopathies of the Foot & Lower Leg (cont’d)
Tendinopathies of the Foot & Lower Leg (cont’d)
• Achilles tendon rupture
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Overuse ConditionsOveruse Conditions
• Plantar fasciitis
– Extrinsic and intrinsic risk factors
– S&S
• Pain at plantar, medial heel
• Pain with first steps in the morning, but diminshes 5-10 min
• ↑ pain with passive extension of great toe and ankle dorsiflexion
• Pain relieved with activity, but recurs after rest
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Overuse Conditions (cont’d)Overuse Conditions (cont’d)
• Plantar fasciitis (cont’d)
– Management:
• Do not permit to continue activity until seen by a physician
• Suggest application of cold to decrease pain and spasm
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Overuse Conditions (cont’d)Overuse Conditions (cont’d)
• Medial tibial stress syndrome
– Periostitis along posteromedial tibial border (distal third)
• Soleus insertion
• Excessive pronation → eccentric contraction of soleus → periostitis
– Other contributing factors
• Recent changes in running distance, speed, footwear, or running surface
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Overuse Conditions (cont’d)Overuse Conditions (cont’d)
• Medial tibial stress syndrome (cont’d)
– 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
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Overuse Conditions (cont’d)Overuse Conditions (cont’d)
– S&S (MTSS) (cont’d)
• Pain with resisted plantar flexion or standing on tiptoe
• Often an associated varus alignment of the lower extremity, including a greater Achilles tendon angle.
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Overuse Conditions (cont’d)Overuse Conditions (cont’d)
– Management:
• Do not permit to continue activity until seen by a physician
• Suggest application of cold to decrease pain and spasm
![Page 75: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/75.jpg)
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Overuse Conditions (cont’d)Overuse Conditions (cont’d)
• Exertional compartment syndrome
– Characterized by exercise-induced pain and swelling that is relieved by rest
– Compartments most frequently affected—anterior (50%–60%) & deep posterior (20-30%)
– Usually seen in well-conditioned individuals <40 yrs old
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Overuse Conditions (cont’d)Overuse Conditions (cont’d)
• Exertional compartment syndrome
– S&S
• Exercise-induced pain that is often described as a tight, cramplike, or squeezing ache and a sense of fullness
• Often affects both legs
• Relieved with rest, only to recur if exercise resumes
• Anterior compartment—mild foot drop; paresthesia dorsum of foot
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Overuse Conditions (cont’d)Overuse Conditions (cont’d)
• Exertional compartment syndrome
– Management:
• Stop activity
• Assessment by qualified health care practitioner
![Page 78: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/78.jpg)
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Foot and Lower Leg FracturesFoot and Lower Leg Fractures
• Repetitive microtraumas → apophyseal or stress fractures
• Tensile forces associated with severe ankle sprains → avulsion fractures of 5th metatarsal
• Severe twisting → displaced and undisplaced fractures in foot, ankle, or lower leg
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Freiberg's disease
– Avascular necrosis of 2nd metatarsal head
– Active adolescents ages 14–18
– S&S: diffuse pain in forefoot
![Page 80: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/80.jpg)
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Sever's disease
– Traction-type injury of calcaneal apophysis
– Seen in ages 7–10
– S&S
• Heel pain with activity
• Decreased heel cord flexibility
• Pain with standing on tiptoes
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Stress fractures
– Common:
• Running and jumping, especially after significant ↑ training mileage; change in surface, intensity, or shoe type
• Women w/ amenorrhea 6 months+ and oligomenorrhea
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Stress fractures (cont’d)
– Common sites
• 2nd metatarsal
• Sesamoid bones
• Navicular
• Calcaneus
• Tibia and fibula
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Stress fracture (cont’d)
– S&S
• Pain begins insidiously; ↑ with activity and ↓ with rest
• Pain usually limited to fracture site
![Page 84: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/84.jpg)
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Avulsion fractures
– Eversion sprain—deltoid lig. avulses distal medial malleolus
– Inversion sprain—plantar aponeurosis or peroneus brevis tendon avulses base of 5th metatarsal (type II)
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Avulsion fractures
– 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
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
Avulsion fractures
![Page 87: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/87.jpg)
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Displaced fractures and dislocations
– MOI
• Direct compression (e.g., falling from a height)
• Compression & shearing (i.e., twisting mechanism)
– Potential neurovascular complications
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Displaced fractures and dislocations (cont’d)
• Phalanges
– MOI: axial load (e.g. jamming toe) or direct trauma (e.g., crushing)
– Swelling; ecchymosis; pain; able to walk
• Metatarsals
– Swelling; pain
– Pain increases with weight bearing
– Potential for displacement
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Displaced fractures and dislocations (cont’d)
– Metatarsals (cont’d)
• 1st metatarsal dislocated from 1st cuneiform; other 4 metatarsals are displaced laterally, usually in combination with fracture at base of 2nd metatarsal
• History of severe midfoot pain, paresthesia, or swelling in midfoot region with variable flattening of arch or forefoot abduction
![Page 90: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/90.jpg)
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Tibia-fibula fractures
– Nearly 60% of tibial fractures involve the middle and lower third of the tibia.
– MOI: torsional force, resulting in either a spiral or oblique fracture of the lower third of the tibia.
![Page 91: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/91.jpg)
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Tibia-fibula fractures (cont’d)
– S&S
• Gross deformity
• Gross bone motion at the suspected fracture site
• Immediate swelling, extreme pain, or pain with motion
![Page 92: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/92.jpg)
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Ankle fracture–dislocation
– MOI
• Landing from a height with foot in excessive eversion or inversion
• Being kicked from behind while the foot is firmly planted
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Ankle fracture–dislocation (cont’d)
– S&S
• Foot displaced laterally at a gross angle to lower leg
• Extreme pain
• Can compromise the posterior tibial artery and nerve
![Page 94: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/94.jpg)
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Foot and Lower Leg Fractures (cont’d)Foot and Lower Leg Fractures (cont’d)
• Fracture management
– Mild
• Standard acute with physician referral
– Serious conditions
• Activate emergency plan, including summoning EMS
• Assess and treat for shock
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Coach and Onsite AssessmentCoach and Onsite Assessment
• S &S that require immediate physician referral (potential for EMS)
– Obvious deformity suggesting a dislocation, fracture, or ruptured Achilles tendon
– Significant loss of motion or muscle weakness
– Excessive joint swelling
– Possible epiphyseal or apophyseal injuries
![Page 96: Chapter 16 Foot, Ankle, and Lower Leg Conditions](https://reader035.vdocuments.site/reader035/viewer/2022062217/56814467550346895db0fb99/html5/thumbnails/96.jpg)
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Coach and Onsite Assessment (cont’d)Coach and Onsite Assessment (cont’d)
• S &S that require immediate physician referral (potential for EMS) (cont’d)
– Abnormal sensation, or absent or weak pulse
– Gross joint instability
– Any unexplained pain that affects normal function
• Refer to Application Strategy 16.2