Chapter Six

Foot, Ankle & Lower Leg

Anatomy

The foot is the site of some of the most debilitating conditions suffered by athletes.

Include: Blisters Calluses Athletes foot Turf toe Ligament Sprains Ingrown toe nails Heel bruises Arch strains Fractures

Anatomy

The foot has stresses that exceed the demands placed on any other area of the body.

Stabilizes & Supports During: Standing Walking Running Jumping

The foot absorbs up to 3 times the body weight!

Anatomy

Individually, the parts of the foot (bones, muscles, ligaments) are weak.

Collectively, they can withstand most of the demands placed on them in athletics.

Anatomy

The key to proper function of the foot is a set of four arches.

Help absorb the impact of walking, running, & jumping.

The arches are:1. Metatarsal2. Transverse3. Medial Longitudinal (inner)4. Lateral Longitudinal (outer)

Anatomy

The foot contains ¼ of the total number of bones in the body.

26 Bones 7 Tarsal bones 5 Metatarsal bones 14 Phalanges

There are also 38 joints!

Anatomy

Tarsal Bones: Talus Calcaneus Navicular Cuboid Medial, Intermediate, & Lateral Cuniform

Bones (that’s 3 of them)Mid-foot region has 5 Metatarsal BonesThe toes (AKA Phalanges) have 14 Bones

Anatomy

Anatomy

The ankle joint (Talocrural Joint) The most commonly injured joint in athletics.

Most injuries are either ligament sprains or muscle strains.

Anatomy

The ankle joint has 2 joints:1. Talocrural Joint

Bones: Tibia, Fibula, & Talus

2. Subtalar Bones: Talus & Calcaneus (2 largest Bones of

the foot)

Note:Large boney Prominences on either side of the

foot are the Medial Malleoli (tibia) & Lateral Malleoli (fibula)

Anatomy

TibiaTibia Transmits the weight or force placed on the

lower leg to the talus. Mounted directly on top of the talus & extends

over the medial side forming the medial malleolis

FibulaFibula On the lateral side forming the lateral

malleolis helps to stabilize the ankle joint

Range of Motion

TalocruralTalocrural Jointoint a hinge joint.

Dorsiflexion “toes to the nose”

Plantar Flexion extension “Point the Toes”

Range of Motion

Subtalar JointSubtalar Joint

triplanar movement with around the oblique axis.

Most stable when placed in dorsiflexion

Range of Motion

TalusTalus

Moves Anteriorly (forward) & Posteriorly (Backward)

Talus sit on top of the calcaneous

The ankle joint despite # of injuries in the area is still very strong.

Stresses in athletics is the cause of ankle injuries

Anatomy

After bony structure strong ligaments make up the first line of defense against ankle sprains.

Most ligaments involved in supporting the ankle are attached to the rough edges of the malleoli.

Anatomy / Ligaments

Ligaments are named for the bones they connect. Most commonly injured are on the Lateral side

(outside) of the ankle. Anterior talofibular (ATF) Anterior tibiofibular Calcaneofibular Posterior talofibular

Ligaments on the Medial side (inside) of the ankle (fyi, sprain to medial ligaments often associated with a fx)

Deltiod

Anatomy / Muscles

13 Major Muscle that support the ankle joint 2 of the most important:

Achilles Tendon Peroneus Muscle Group

Anatomy / Muscles

Achilles Tendon The attachment of the Gastronemius and

Soleus Muscles (Calf Muscles) Attach to the Calcaneus Tightness of Achilles Tendon is often the cause

of recurrent ankle sprains.

Anatomy / Muscles

Peroneal Muscle Group of muscles along the Lateral side of

the leg & foot The Peroneal Brevis attach to several areas of

the foot The Peroneal Longus runs across the plantar

surface of the foot When the Peroneal group contracts it everts the

foot This helps to prevent Lateral ankle sprains.

Anatomy / Shin

2 Bones of the Leg: Tibia Fibula

Shin – is the area in the front of the leg

Interosseous Membrane – associated with anterior (front) shin pain (Shin Splints)

Dermatome – A sensory distribution of a nerve root. Produces sensation in the corresponding area

Myotome – a single nerve root Produces movement of anatomical structures

Bones

Tibia Fibula Talus Calcaneus Navicular Cuniforms (1-3) Cuboid Metatarsals (1 – 5) Phalanges (1 – 5)

Ligaments / Muscles

Anterior Talofibular Ligament Posterior Talofibular Ligament Deltoid Ligament

Gastrocnemius – Plantar Flexes the foot & Flexes the lower leg. Soleus - Plantar Flexes the foot Peroneus Longus – everts & abducts foot, Plantar Flexes foot Peroneus Brevis – everts & abducts foot, Plantar Flexes foot Popliteus – Knee Flexon, medial rotation of tibia

Metatarsal Transverse Medial Longitudinal (inner) Lateral Longitudinal (outer)

Range of Motion

Dorsiflexion – the act of drawing the toe or foot toward the dorsal aspect of the proximally conjoined body segment. Toes to the nosePlantar Flexion – the act drawing the toe or foot toward the dorsal aspect of the proximally conjoined body segment. Point the toe

Range of Motion

Inversion – turning the sole of the foot inward

Eversion – turning the sole of the foot outward

Flexion (toes) – decreasing the angle between the toes and the sole of the footExtension (toes) – Increasing the angle between the toes and the sole of the foot

Range of Motion

Pronation – combined motions of calcaneal eversion, foot abduction and dorsiflexion.Supination - combined motions of calcaneal inversion, foot adduction and plantar flexion.Abduction – movement of body segments away from the midlineAdduction - movement of body segments towards from the midline

Evaluation

The first purpose of an evaluation is to determine if a serious injury has occurred.

Always suspect a fx till proven otherwise

Signs of FractureSigns of Fracture Direct or indirect pain Deformity Grating sound Loss of function

Evaluation

Note: some fractures are not accompanied by swelling or pain.

If a Fracture is suspected the extremity should be splinted & the athlete transported for medical evaluation.

HISTORY

1. Mechanism of Injury How did it happen?

2. Location of Pain Where does it hurt?

3. Sensation experienced Did you hear a “pop” or a “snap”?

4. Previous History Have you injured this area before?

Observation

Look for signs of trauma: Compare involves vs.

Uninvolved Bleeding Deformity Swelling Discoloration Scars

Palpation

Palpate above & below injury site. Work your way down to injury.

Gain confidence of athlete Involve the athlete as much as possible Compare

Areas to check:1. Neurological (motor/sensory)2. Circulation3. Anatomical Structures4. Fracture Test (palpation, compression,

distraction)

Special Test

Testing instability, disability, & pain.Before you start, can you make it worse?Only a NATABOC certified athletic trainer is

considered competent to perform these test and give a proper evaluation (other medical professional as well)

Test performed to assess the following:1. Joint Stability 2. Muscles / Tendons3. Accessory Anatomical Structures

4. Inflammation 5. ROM (active, assistive, passive, resistive)6. Pain / weakness

Special Test

Assessment Test:Bony IntegrityHeel Tap Test: Check the Tibia, Fibula, & TalusSqueeze Test: Check the Tibia & Fibula

Ligament StabilityAnterior Drawer Test: Test anterior talofibular and calcaneofibular ligamentsTalar Tilt: Calcaneofibular, anterior talofibular, but also the (medial) deltoid ligaments

Special Test

Muscle FunctionThompson Test: Test the Achilles tendon

Refer When

There is: Gross Deformity Significant Pain Increase swelling Circulation or Neurological Issues Joint Instability Suspected Fracture Abnormal Sensations (clicking, popping, grating, or

weakness)

Any doubts!

InjuriesInjuries

Ankle Sprains Most common injury to the ankle

Usually caused by excessive plantar flexion with inversion

“stepping in a hole”

Injuries (Ankle Sprain)Injuries (Ankle Sprain)3 Categories

1. First Degree – (mild) 1 or more supporting ligaments are stretched

Minor discomfort, point tenderness, swelling. No instability

2. Second Degree – (moderate) a portion 1 or more ligaments are torn

There is pain, point tenderness, swelling, disability, & loss of function

There is some abnormal movement in the joint

3. Third Degree – (Severe) 1 or more ligaments are completely torn

Joint is unstable Pain can be extreme to very little (torn nerve endings), loss of

function, point tenderness, rapid swelling Usually associated with a fracture

Injuries (Arch Sprain)Injuries (Arch Sprain)

Arches are designed to act as “shock absorbers” Most common injuries occur to the metatarsal or

the inner longitudinal arches Any of the 4 arches can sprain a ligament Causes:

Flat feet Overuse Overweight Fatigue Training on hard surfaces Wearing non supportive, worn, or shoes that do not FIT!

Injuries (Great Toe Sprain)Injuries (Great Toe Sprain)“Turf Toe”“Turf Toe”

A sprain given to the First Metatarsophalangeal Joint.

Mechanism of injury – hyperextension of the

great toe.

Injuries (Medial Tibia Stress Injuries (Medial Tibia Stress Syndrome)Syndrome)Shin SplintsShin Splints

Thought to be an inflammation of the interosseous membrane, strain to the soleus muscle, or other chronic lower leg condition.

Cause: muscle weakness or imbalance, lack of proper conditioning, improper or incomplete warm-up, poor flexibility, lack of stretching, running on hard surfaces, improper running form or habits, improper running shoe, or poor anatomical structures.

Injuries (Plantar Fasciitis)Injuries (Plantar Fasciitis)

The plantar fascia is a wide, non – elastic ligamentous tissue that extends from the anterior portion of the calcaneus to the heads of the metatarsals.

Supply support to the longitudinal arch of the foot.

Can strain tissue from overuse, unsupportive footwear, a tight Achilles tendon, or running o hard surfaces.

Injuries (Heel Spur)Injuries (Heel Spur)

A bony growth on the calcaneus that causes painful inflammation of the accompanying soft tissue and is aggravated by exercise.

Injuries Injuries (Anterior Compartment (Anterior Compartment

Syndrome)Syndrome)4 Compartments4 Compartments

Once suspected, anterior compartment syndrome should be treated as a medical emergency

Injuries Injuries (Anterior Compartment (Anterior Compartment

Syndrome)Syndrome)Cause:

Direct trauma or excessive exercise can result in hemorrhage & swelling inside the compartment.

Swelling will increase the pressure on the peroneal nerve, the veins, and finally, the arteries inside the compartment.

Without arterial circulation, muscle cells will become necrotic and die.

Injuries Injuries (Anterior Compartment (Anterior Compartment

Syndrome)Syndrome) Signs:

Pain even after icing down Firmness of the muscle Numbness of the foot Pain with passive ROM Lack of strength

Injuries (Achilles Tendon Injuries (Achilles Tendon Strain)Strain)

Achilles Tendon is the strongest in the body Injuries range from a minor strain to a

complete tear. Minor strains should be treated

conservatively because many strains will lead to complete tear

Remember Thomson Test for eval.

Injuries (Stress Fracture)Injuries (Stress Fracture)

If exercise is too severe, or too long in a duration, a negative change in bone structures will occur and cause stress fracture.

Injuries (muscle cramps)Injuries (muscle cramps)

A cramp is a sudden, involuntary contraction of a muscle.

Cause: unknownCan be because of several factors: Fatigue Fractures Dehaydration Poor Flexibility Previous injury, rehab not completed Improper fitted equipment.