Foot, ankle, lower leg s12
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Foot, ankle, lower leg s12






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  • Periostitis tib post/ant, but most is post <br />

Foot, ankle, lower leg s12 Foot, ankle, lower leg s12 Presentation Transcript

  • MEDIAL BONY ANATOMY • Tibia• Medial Malleolus • Talus • Calcaneus • Navicular (Tubercle)
  • LATERAL BONY ANATOMY FibulaLateral Malleolus Talus Calcaneus
  • MEDIAL LIGAMENTOUS ANATOMY (DELTOID LIGAMENT) Deep Portion - Anterior Tibiotalar Superficial Portion - Tibonavicular - Tibialcalcaneal - Posterior Tibiotalar
  • ANKLE SPRAINS Inversion Ankle Sprain Anterior Talo-fibular (ATF) Calcaneofibular Posterior Talo-fibular Eversion Ankle Sprain Deltoid Ligament **What type of sprain is more common? Why?
  • LATERAL LIGAMENTOUS ANATOMY Lateral View Posterior View
  • MEDIAL MUSCULATURE “Tom” Tibialis Posterior “Dick “ Flexor Digitorum Longus “An” Posterior Tibial Artery & Nerve “Harry” Flexor Hallicus Longus
  • FOOT/ANKLE ASSESSMENT History Generic history questions Questions specific to the foot/ankle Location of pain - heel, foot, toes, arches? Training surfaces or changes in footwear? Changes in training, volume or type? Does footwear increase discomfort?
  • OBSERVATIONS Does athlete favor a foot, limp, or is unable to bear weight? Is there pes planus/cavus? How is foot alignment? Are there structural deformities?
  • ANKLE SPRAINS **Single most common injury in athletics caused by sudden inversion or eversion moments Inversion Sprains •Most common and result in injury to the lateral ligaments •Anterior talofibular ligament is injured with inversion, plantar flexion and internal rotation •Occasionally the force is great enough for an avulsion fracture to occur w/ the lateral malleolus
  • Severity of sprains is graded (1-3) The most common type of sprain in an inversion ankle sprain ?What structures are injured?
  • EVERSION ANKLE SPRAINS Etiology • Bony protection and ligament strength decreases likelihood of injury • Eversion force results in damage to deltoid ligament and possibly fx of the fibula • Deltoid can also be impinged and contused with inversion sprains -(Represent 5-10% of all ankle sprains)
  • SIGNS AND SYMPTOMS • 1st degree • Mild pain and disability; weight bearing is minimally impaired; point tenderness over ligaments and no laxity • 2nd degree • Feel or hear pop or snap; moderate pain w/ difficulty bearing weight; tenderness and edema • Positive ligament tests • Possible tearing of the anterior talofibular and calcaneofibular ligaments (inversion sprain) or deltoid ligament (eversion sprain) • 3rd degree • Severe pain, swelling, hemarthrosis, discoloration • Unable to bear weight • Positive ligament tests – torn ligaments
  • SYNDESMOTIC SPRAIN Etiology • Injury to the distal tibiofemoral joint (anterior/posterior tibiofibular ligament) • Torn w/ increased external rotation or dorsiflexion • Injured in conjunction w/ medial and lateral ligaments Signs and Symptoms • Severe pain, loss of function; passive external rotation and dorsiflexion cause pain • Pain is usually anterolaterally located
  • ANKLE FRACTURES/DISLOCATIONS Etiology Number of mechanisms Signs and Symptoms Swelling and pain may be extreme with possible deformity
  • ACHILLES TENDINITIS Etiology • Inflammatory condition involving tendon, sheath or paratenon • Tendon is overloaded due to extensive stress • Presents with gradual onset and worsens with continued use • Decreased flexibility exacerbates condition Signs and Symptoms • Generalized pain and stiffness, localized proximal to calcaneal insertion • Warm and painful with palpation, also presents with thickening • May limit strength • May progress to morning stiffness • Crepitus with active plantar flexion and passive dorsiflexion • Chronic inflammation may lead to thickening
  • ACHILLES TENDON RUPTURE Etiology • Occurs w/ sudden stop and go; forceful plantar flexion w/ knee moving into full extension • Commonly seen in athletes > 30 years old • Generally has history of chronic inflammation Signs and Symptoms • Sudden snap (kick in the leg) w/ immediate pain which rapidly subsides • Point tenderness, swelling, discoloration; decreased ROM • Obvious indentation and positive Thompson test • Occurs 2-6 cm proximal the calcaneal insertion
  • POSTERIOR TIBIALIS TENDINITIS Etiology • Common overuse condition in runners with foot hypermobility or over pronation • Repetitive microtrauma Signs and Symptoms • Pain and swelling in area of medial malleolus • Edema, point tenderness and increased pain during resistive inversion and plantar flexion
  • PERONEAL TENDINITIS Etiology • Not common, but can be found with athletes that have pes cavus due to excessive supination placing stress on peroneal tendon Signs and Symptoms • Pain behind lateral malleolus during push-off or when rising on ball of foot • Pain along distolateral aspect of calcaneus and beneath the cuboid
  • ACUTE LEG FRACTURES Etiology • Fibula has highest incidence of fracture, occurring primarily in the middle third • Tibial fractures occur predominantly in the lower third • Result of direct blow or indirect trauma Signs and Symptoms • Pain, swelling, soft tissue insult • Leg will appear hard and swollen (Compartment Syndrome)
  • MEDIAL TIBIAL STRESS SYNDROME Etiology • 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 • May also involve, stress fractures or exertional compartment syndrome
  • MTSS CONTINUED 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 •Recall you may hear “Periostitis”
  • STRESS FRACTURE Etiology • Common overuse condition, particularly in those with structural and biomechanical insufficiencies • Runners tends to develop in lower third of lower leg (dancers middle third) • Often occur in unconditioned, non-experienced individuals • Often training errors are involved • Component of female athlete triad Signs and Symptoms • Pain more intense after exercise than before • Point tenderness; difficult to discern bone and soft tissue pain • Bone scan results (stress fracture vs. periostitis)
  • INJURIES TO THE FOOT Apophysitis of the Calcaneus (Sever’s Disease) Etiology • Traction injury at apophysis of calcaneus, where Achilles attaches Sign and Symptoms • Pain occurs at posterior heel below Achilles attachment in children and adolescent athletes • Pain occurs during vigorous activity and ceases following activity
  • RETROCALCANEAL BURSITIS (Pump Bump) Etiology • Caused by inflammation of bursa beneath Achilles tendon • Result of pressure and rubbing of shoe heel counter • Chronic condition that develops over time and may take extensive time to resolve, exostosis may also develop Sign and Symptoms • Pain w/ palpation superior and anterior to Achilles insertion, swelling on both sides of the heel cord
  • HEEL CONTUSION Etiology • Caused by sudden starts, stops or changes of direction, irritation of fat pad • Pain often on the lateral aspect due to heel strike pattern Sign and Symptoms • Severe pain in heel and is unable to withstand stress of weight bearing • Often warmth and redness over the tender area
  • INJURIES TO METATARSAL REGION Pes Planus Foot (Flatfoot) Etiology • Associated with excessive pronation, forefoot varus, wearing tight shoes (weakening supportive structures) being overweight, excessive exercise placing undo stress on arch Sign and Symptoms • Pain, weakness or fatigue in medial longitudinal arch; calcaneal eversion, bulging navicular, flattening of medial longitudinal arch and dorsiflexion with lateral splaying of 1st metatarsal
  • PES CAVUS Etiology • Higher arch than normal; associated with excessive supination, accentuated high medial longitudinal arch Sign and Symptoms • Poor shock absorption resulting in metatarsalgia, foot pain, clawed or hammer toes • Associated with forefoot valgus, shortening of Achilles and plantar fascia; heavy callus development on ball and heel of foot
  • PLANTAR FASCIITIS • Common in athletes and nonathletes • Attributed to heel spurs, plantar fascia irritation, and bursitis • Plantar fascia, dense, broad band of connective tissue attaching proximal and medially on the calcaneus and fans out over the plantar aspect of the foot
  • PLANTAR FASCIITIS CONT. Etiology • Increased tension and stress on fascia (particularly during push off of running phase) • 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
  • JONES FRACTURE Etiology • Fracture of metatarsal caused by inversion and plantar flexion, direct force (stepped on) or repetitive trauma • Most common = base of 5th metatarsal Sign and Symptoms • Immediate swelling, pain over 5th metatarsal • High nonunion rate and course of healing is unpredictable
  • METATARSAL STRESS FRACTURES Etiology • 2nd metatarsal fracture (March fracture) • Change in running pattern, mileage, hills, or hard surfaces • Forefoot varus, hallux valgus, flatfoot or short 1st metatarsal • Occasional 5th metatarsal fracture at base and insertion of peroneus brevis
  • BUNION Etiology • Exostosis of 1st metatarsal head; associated with forefoot varus; shoes that are too narrow, pointed or short • Bursa becomes inflamed and thickens, enlarging joint, and causing lateral malalignment of great toe • Bunionette (Tailor’s bunion) impacts 5th metatarsophalangeal joint - causes medial displacement of 5th toe Sign and Symptoms • Tenderness, swelling, and enlargement of joint initially • As inflammation continues, angulation increases causing painful ambulation • Tendinitis in great toe flexors may develop
  • TURF TOE Etiology • Hyperextension injury resulting in sprain of 1st metatarsophalangeal joint • May be the result of single or repetitive trauma Signs and Symptoms • Pain and swelling which increases during push off in walking, running, and jumping
  • SUBUNGUAL HEMATOMA MOI • Direct pressure, dropping an object on toe, kicking another object • Repetitive shear forces on toenail Signs of Injury • • Accumulation of blood underneath toenail Likely to produce extreme pain and ultimately loss of nail