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C & p ch 6


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C & p ch 6

  1. 1. Chapter Six Foot, Ankle & Lower Leg
  2. 2. Anatomy <ul><li>The foot is the site of some of the most debilitating conditions suffered by athletes. </li></ul><ul><li>Include: </li></ul><ul><li>Blisters </li></ul><ul><li>Calluses </li></ul><ul><li>Athletes foot </li></ul><ul><li>Turf toe </li></ul><ul><li>Ligament Sprains </li></ul><ul><li>Ingrown toe nails </li></ul><ul><li>Heel bruises </li></ul><ul><li>Arch strains </li></ul><ul><li>Fractures </li></ul>
  3. 3. Anatomy <ul><li>The foot has stresses that exceed the demands placed on any other area of the body. </li></ul><ul><li>Stabilizes & Supports During: </li></ul><ul><ul><li>Standing </li></ul></ul><ul><ul><li>Walking </li></ul></ul><ul><ul><li>Running </li></ul></ul><ul><ul><li>Jumping </li></ul></ul><ul><ul><li>The foot absorbs up to 3 times the body weight! </li></ul></ul>
  4. 4. Anatomy <ul><li>Individually, the parts of the foot (bones, muscles, ligaments) are weak. </li></ul><ul><li>Collectively, they can withstand most of the demands placed on them in athletics. </li></ul>
  5. 5. Anatomy <ul><li>The key to proper function of the foot is a set of four arches. </li></ul><ul><li>Help absorb the impact of walking, running, & jumping. </li></ul><ul><li>The arches are: </li></ul><ul><li>Metatarsal </li></ul><ul><li>Transverse </li></ul><ul><li>Medial Longitudinal (inner) </li></ul><ul><li>Lateral Longitudinal (outer) </li></ul>
  6. 6. Anatomy <ul><li>The foot contains ¼ of the total number of bones in the body. </li></ul><ul><li>26 Bones </li></ul><ul><ul><li>7 Tarsal bones </li></ul></ul><ul><ul><li>5 Metatarsal bones </li></ul></ul><ul><ul><li>14 Phalanges </li></ul></ul><ul><ul><li>There are also 38 joints! </li></ul></ul>
  7. 7. Anatomy <ul><li>Tarsal Bones: </li></ul><ul><li>Talus </li></ul><ul><li>Calcaneus </li></ul><ul><li>Navicular </li></ul><ul><li>Cuboid </li></ul><ul><li>Medial, Intermediate, & Lateral Cuniform Bones (that’s 3 of them) </li></ul><ul><li>Mid-foot region has 5 Metatarsal Bones </li></ul><ul><li>The toes (AKA Phalanges ) have 14 Bones </li></ul>
  8. 8. Anatomy METATARSAL
  9. 9. Anatomy <ul><li>The ankle joint (Talocrural Joint) </li></ul><ul><li>The most commonly injured joint in athletics. </li></ul><ul><ul><li>Most injuries are either ligament sprains or muscle strains. </li></ul></ul>
  10. 10. Anatomy <ul><li>The ankle joint has 2 joints: </li></ul><ul><li>Talocrural Joint </li></ul><ul><ul><li>Bones: Tibia, Fibula, & Talus </li></ul></ul><ul><li>Subtalar </li></ul><ul><ul><li>Bones: Talus & Calcaneus (2 largest Bones of the foot) </li></ul></ul><ul><li>Note: </li></ul><ul><li>Large boney Prominences on either side of the foot are the Medial Malleoli (tibia) & Lateral Malleoli (fibula) </li></ul>
  11. 11. Anatomy <ul><li>Tibia </li></ul><ul><li>Transmits the weight or force placed on the lower leg to the talus. </li></ul><ul><ul><li>Mounted directly on top of the talus & extends over the medial side forming the medial malleolis </li></ul></ul><ul><li>Fibula </li></ul><ul><li>On the lateral side forming the lateral malleolis helps to stabilize the ankle joint </li></ul>
  12. 12. Range of Motion <ul><li>Talocrural J oint </li></ul><ul><li>a hinge joint. </li></ul><ul><li>Dorsiflexion “toes to the nose” </li></ul><ul><li>Plantar Flexion extension “Point the Toes” </li></ul>
  13. 13. Range of Motion <ul><li>Subtalar Joint </li></ul><ul><li>triplanar movement with around the oblique axis. </li></ul><ul><li>Most stable when placed in dorsiflexion </li></ul>
  14. 14. Range of Motion <ul><li>Talus </li></ul><ul><li>Moves Anteriorly (forward) & Posteriorly (Backward) </li></ul><ul><li>Talus sit on top of the calcaneous </li></ul><ul><li>The ankle joint despite # of injuries in the area is still very strong. </li></ul><ul><li>Stresses in athletics is the cause of ankle injuries </li></ul>
  15. 15. Anatomy <ul><li>After bony structure strong ligaments make up the first line of defense against ankle sprains. </li></ul><ul><li>Most ligaments involved in supporting the ankle are attached to the rough edges of the malleoli. </li></ul>
  16. 16. Anatomy / Ligaments <ul><li>Ligaments are named for the bones they connect. </li></ul><ul><ul><li>Most commonly injured are on the Lateral side (outside) of the ankle. </li></ul></ul><ul><ul><ul><li>Anterior talofibular (ATF) </li></ul></ul></ul><ul><ul><ul><li>Anterior tibiofibular </li></ul></ul></ul><ul><ul><ul><li>Calcaneofibular </li></ul></ul></ul><ul><ul><ul><li>Posterior talofibular </li></ul></ul></ul><ul><ul><li>Ligaments on the Medial side (inside) of the ankle (fyi, sprain to medial ligaments often associated with a fx) </li></ul></ul><ul><ul><ul><li>Deltiod </li></ul></ul></ul>
  17. 17. Anatomy / Muscles <ul><li>13 Major Muscle that support the ankle joint </li></ul><ul><li>2 of the most important: </li></ul><ul><ul><li>Achilles Tendon </li></ul></ul><ul><ul><li>Peroneus Muscle Group </li></ul></ul>
  18. 18. Anatomy / Muscles <ul><li>Achilles Tendon </li></ul><ul><li>The attachment of the Gastronemius and Soleus Muscles (Calf Muscles) </li></ul><ul><ul><li>Attach to the Calcaneus </li></ul></ul><ul><ul><li>Tightness of Achilles Tendon is often the cause of recurrent ankle sprains. </li></ul></ul>
  19. 19. Anatomy / Muscles <ul><li>Peroneal Muscle </li></ul><ul><li>Group of muscles along the Lateral side of the leg & foot </li></ul><ul><ul><li>The Peroneal Brevis attach to several areas of the foot </li></ul></ul><ul><ul><li>The Peroneal Longus runs across the plantar surface of the foot </li></ul></ul><ul><ul><li>When the Peroneal group contracts it everts the foot </li></ul></ul><ul><ul><li>This helps to prevent Lateral ankle sprains. </li></ul></ul>
  20. 20. Anatomy / Shin <ul><li>2 Bones of the Leg: </li></ul><ul><li>Tibia </li></ul><ul><li>Fibula </li></ul><ul><li>Shin – is the area in the front of the leg </li></ul><ul><li>Interosseous Membrane – associated with anterior (front) shin pain (Shin Splints) </li></ul><ul><li>Dermatome – A sensory distribution of a nerve root. </li></ul><ul><ul><li>Produces sensation in the corresponding area </li></ul></ul><ul><li>Myotome – a single nerve root </li></ul><ul><ul><li>Produces movement of anatomical structures </li></ul></ul>
  21. 21. Bones <ul><li>Tibia </li></ul><ul><li>Fibula </li></ul><ul><li>Talus </li></ul><ul><li>Calcaneus </li></ul><ul><li>Navicular </li></ul><ul><li>Cuniforms (1-3) </li></ul><ul><li>Cuboid </li></ul><ul><li>Metatarsals (1 – 5) </li></ul><ul><li>Phalanges (1 – 5) </li></ul>
  22. 22. Ligaments / Muscles <ul><li>Anterior Talofibular Ligament </li></ul><ul><li>Posterior Talofibular Ligament </li></ul><ul><li>Deltoid Ligament </li></ul><ul><li>Gastrocnemius – Plantar Flexes the foot & </li></ul><ul><li>Flexes the lower leg. </li></ul><ul><li>Soleus - Plantar Flexes the foot </li></ul><ul><li>Peroneus Longus – everts & abducts foot, </li></ul><ul><li>Plantar Flexes foot </li></ul><ul><li>Peroneus Brevis – everts & abducts foot, Plantar </li></ul><ul><li>Flexes foot </li></ul><ul><li>Popliteus – Knee Flexon, medial rotation of tibia </li></ul>
  23. 23. <ul><li>Metatarsal </li></ul><ul><li>Transverse </li></ul><ul><li>Medial Longitudinal (inner) </li></ul><ul><li>Lateral Longitudinal (outer) </li></ul>Arches
  24. 24. Range of Motion <ul><li>Dorsiflexion – the act of drawing the toe or </li></ul><ul><li>foot toward the dorsal aspect </li></ul><ul><li>of the proximally conjoined </li></ul><ul><li>body segment. </li></ul><ul><li>Toes to the nose </li></ul><ul><li>Plantar Flexion – the act drawing the toe or </li></ul><ul><li>foot toward the dorsal aspect </li></ul><ul><li>of the proximally conjoined body </li></ul><ul><li>segment. </li></ul><ul><li>Point the toe </li></ul>
  25. 25. Range of Motion <ul><li>Inversion – turning the sole of the foot inward </li></ul><ul><li>Eversion – turning the sole of the foot outward </li></ul><ul><li>Flexion (toes) – decreasing the angle between </li></ul><ul><li>the toes and the sole of the </li></ul><ul><li>foot </li></ul><ul><li>Extension (toes) – Increasing the angle </li></ul><ul><li>between the toes and the sole of </li></ul><ul><li>the foot </li></ul>
  26. 26. Range of Motion <ul><li>Pronation – combined motions of calcaneal </li></ul><ul><li>eversion, foot abduction and </li></ul><ul><li>dorsiflexion. </li></ul><ul><li>Supination - combined motions of calcaneal </li></ul><ul><li>inversion, foot adduction and </li></ul><ul><li>plantar flexion. </li></ul><ul><li>Abduction – movement of body segments </li></ul><ul><li>away from the midline </li></ul><ul><li>Adduction - movement of body segments </li></ul><ul><li>towards from the midline </li></ul>
  27. 27. Evaluation <ul><li>The first purpose of an evaluation is to determine if a serious injury has occurred. </li></ul><ul><li>Always suspect a fx till proven otherwise </li></ul><ul><li>Signs of Fracture </li></ul><ul><li>Direct or indirect pain </li></ul><ul><li>Deformity </li></ul><ul><li>Grating sound </li></ul><ul><li>Loss of function </li></ul>
  28. 28. Evaluation <ul><li>Note: some fractures are not accompanied by swelling or pain. </li></ul><ul><li>If a Fracture is suspected the extremity should be splinted & the athlete transported for medical evaluation. </li></ul>
  29. 29. HISTORY <ul><li>Mechanism of Injury </li></ul><ul><ul><li>How did it happen? </li></ul></ul><ul><li>Location of Pain </li></ul><ul><ul><li>Where does it hurt? </li></ul></ul><ul><li>Sensation experienced </li></ul><ul><ul><li>Did you hear a “pop” or a “snap”? </li></ul></ul><ul><li>Previous History </li></ul><ul><ul><li>Have you injured this area before? </li></ul></ul>
  30. 30. Observation <ul><li>Look for signs of trauma: Compare involves vs. </li></ul><ul><li>Uninvolved </li></ul><ul><li>Bleeding </li></ul><ul><li>Deformity </li></ul><ul><li>Swelling </li></ul><ul><li>Discoloration </li></ul><ul><li>Scars </li></ul>
  31. 31. Palpation <ul><li>Palpate above & below injury site. </li></ul><ul><li>Work your way down to injury. </li></ul><ul><ul><li>Gain confidence of athlete </li></ul></ul><ul><ul><li>Involve the athlete as much as possible </li></ul></ul><ul><ul><li>Compare </li></ul></ul><ul><li>Areas to check: </li></ul><ul><li>Neurological (motor/sensory) </li></ul><ul><li>Circulation </li></ul><ul><li>Anatomical Structures </li></ul><ul><li>Fracture Test (palpation, compression, distraction) </li></ul>
  32. 32. Special Test <ul><li>Testing instability, disability, & pain. </li></ul><ul><li>Before you start, can you make it worse? </li></ul><ul><li>Only a NATABOC certified athletic trainer is considered competent to perform these test and give a proper evaluation (other medical professional as well) </li></ul><ul><li>Test performed to assess the following: </li></ul><ul><li>1. Joint Stability 2. Muscles / Tendons </li></ul><ul><li>3. Accessory Anatomical Structures </li></ul><ul><li>4. Inflammation 5. ROM ( active, assistive, passive, resistive ) </li></ul><ul><li>6. Pain / weakness </li></ul>
  33. 33. Special Test <ul><li>Assessment Test: </li></ul><ul><li>Bony Integrity </li></ul><ul><li>Heel Tap Test : Check the Tibia, Fibula, & Talus </li></ul><ul><li>Squeeze Test: Check the Tibia & Fibula </li></ul><ul><li>Ligament Stability </li></ul><ul><li>Anterior Drawer Test: Test anterior talofibular and </li></ul><ul><li>calcaneofibular ligaments </li></ul><ul><li>Talar Tilt: Calcaneofibular, anterior talofibular, but </li></ul><ul><li>also the (medial) deltoid ligaments </li></ul>
  34. 34. Special Test <ul><li>Muscle Function </li></ul><ul><li>Thompson Test: Test the Achilles tendon </li></ul>
  35. 35. Refer When <ul><li>There is: </li></ul><ul><li>Gross Deformity </li></ul><ul><li>Significant Pain </li></ul><ul><li>Increase swelling </li></ul><ul><li>Circulation or Neurological Issues </li></ul><ul><li>Joint Instability </li></ul><ul><li>Suspected Fracture </li></ul><ul><li>Abnormal Sensations ( clicking, popping, grating, or </li></ul><ul><li>weakness) </li></ul><ul><li>Any doubts! </li></ul>
  36. 36. Injuries <ul><li>Ankle Sprains </li></ul><ul><li>Most common injury to the ankle </li></ul><ul><ul><li>Usually caused by excessive plantar flexion with inversion </li></ul></ul><ul><ul><li>“ stepping in a hole” </li></ul></ul>
  37. 37. Injuries (Ankle Sprain) <ul><ul><li>3 Categories </li></ul></ul><ul><ul><li>1. First Degree – (mild) 1 or more supporting ligaments </li></ul></ul><ul><ul><li>are stretched </li></ul></ul><ul><ul><ul><li>Minor discomfort, point tenderness, swelling. </li></ul></ul></ul><ul><ul><ul><li>No instability </li></ul></ul></ul><ul><ul><li>2. Second Degree – (moderate) a portion 1 or more </li></ul></ul><ul><ul><li>ligaments are torn </li></ul></ul><ul><ul><ul><li>There is pain, point tenderness, swelling, disability, & loss of function </li></ul></ul></ul><ul><ul><ul><li>There is some abnormal movement in the joint </li></ul></ul></ul><ul><ul><li>3. Third Degree – (Severe) 1 or more ligaments are </li></ul></ul><ul><ul><li>completely torn </li></ul></ul><ul><ul><ul><li>Joint is unstable </li></ul></ul></ul><ul><ul><ul><li>Pain can be extreme to very little (torn nerve endings), loss of function, point tenderness, rapid swelling </li></ul></ul></ul><ul><ul><ul><li>Usually associated with a fracture </li></ul></ul></ul>
  38. 38. Injuries (Arch Sprain) <ul><li>Arches are designed to act as “shock absorbers” </li></ul><ul><li>Most common injuries occur to the metatarsal or the inner longitudinal arches </li></ul><ul><li>Any of the 4 arches can sprain a ligament </li></ul><ul><li>Causes: </li></ul><ul><ul><li>Flat feet </li></ul></ul><ul><ul><li>Overuse </li></ul></ul><ul><ul><li>Overweight </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Training on hard surfaces </li></ul></ul><ul><ul><li>Wearing non supportive, worn, or shoes that do not FIT! </li></ul></ul>
  39. 39. Injuries (Great Toe Sprain) “Turf Toe” <ul><li>A sprain given to the First Metatarsophalangeal Joint. </li></ul><ul><li>Mechanism of injury – hyperextension of the </li></ul><ul><li>great toe. </li></ul>
  40. 40. Injuries (Medial Tibia Stress Syndrome) Shin Splints <ul><li>Thought to be an inflammation of the interosseous membrane, strain to the soleus muscle, or other chronic lower leg condition. </li></ul><ul><li>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 . </li></ul>
  41. 41. Injuries (Plantar Fasciitis) <ul><li>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. </li></ul><ul><li>Supply support to the longitudinal arch of the foot. </li></ul><ul><li>Can strain tissue from overuse, unsupportive footwear, a tight Achilles tendon, or running o hard surfaces. </li></ul>
  42. 42. Injuries (Heel Spur) <ul><li>A bony growth on the calcaneus that causes painful inflammation of the accompanying soft tissue and is aggravated by exercise. </li></ul>
  43. 43. Injuries (Anterior Compartment Syndrome) 4 Compartments <ul><li>Once suspected, anterior compartment syndrome should be treated as a medical emergency </li></ul>
  44. 44. Injuries (Anterior Compartment Syndrome) <ul><li>Cause: </li></ul><ul><li>Direct trauma or excessive exercise can result in hemorrhage & swelling inside the compartment. </li></ul><ul><li>Swelling will increase the pressure on the peroneal nerve, the veins, and finally, the arteries inside the compartment. </li></ul><ul><li>Without arterial circulation, muscle cells will become necrotic and die. </li></ul>
  45. 45. Injuries (Anterior Compartment Syndrome) <ul><li>Signs: </li></ul><ul><ul><li>Pain even after icing down </li></ul></ul><ul><ul><li>Firmness of the muscle </li></ul></ul><ul><ul><li>Numbness of the foot </li></ul></ul><ul><ul><li>Pain with passive ROM </li></ul></ul><ul><ul><li>Lack of strength </li></ul></ul>
  46. 46. Injuries (Achilles Tendon Strain) <ul><li>Achilles Tendon is the strongest in the body </li></ul><ul><li>Injuries range from a minor strain to a complete tear. </li></ul><ul><li>Minor strains should be treated conservatively because many strains will lead to complete tear </li></ul><ul><li>Remember Thomson Test for eval. </li></ul>
  47. 47. Injuries (Stress Fracture) <ul><li>If exercise is too severe, or too long in a duration, a negative change in bone structures will occur and cause stress fracture. </li></ul>
  48. 48. Injuries (muscle cramps) <ul><li>A cramp is a sudden, involuntary contraction of a muscle. </li></ul><ul><li>Cause: unknown </li></ul><ul><li>Can be because of several factors: </li></ul><ul><li>Fatigue </li></ul><ul><li>Fractures </li></ul><ul><li>Dehaydration </li></ul><ul><li>Poor Flexibility </li></ul><ul><li>Previous injury, rehab not completed </li></ul><ul><li>Improper fitted equipment. </li></ul>