Injuries to the Lower Leg, Ankle, and Foot

Injuries to the Lower Leg, Ankle, and FootInjuries to the Lower Leg, Ankle, and FootFor an athlete to move well, there must be excellent functioning of the lower leg, ankle, and footThe foot must provide a stable base of support and as the same time be flexible and extremely mobileThis chapter discusses the skeletal and muscular anatomy of the foot and lower legWe will discuss:Ligaments of the ankle, compartments of the lower leg, muscular actions of each compartmentFractures as well as common sprains of ankle ligamentsInjuries to the Lower Leg, Ankle, and FootTreatment of ankle sprains and control of possible future sprains Recognition, care, and treatment of tendon injuries along with compartment problemsTreatment and care of athletes with shin splints and considers ways to enhance the performance of these athletesDiscuss foot disorders such as plantar fasciitis, heel spurs, Morton's neuroma, arch problems, bunions, blisters and calluses, providing guidelines for recognition, first aid treatment, and long term careAnd FINALLY ANKLE TAPING

Anatomy Review The lower leg, ankle, and foot work together to provide a stable base of support and a dynamic system of movementThe skeleton of the lower leg consist of the tibia and fibula

Anatomy Review Tibia is the larger and stronger of the two (commonly called the shin bone)Supports 98% of body wgtActs as an attachment for various muscles and helps to provide a mechanical advantage for some of them

Anatomy ReviewNormal foot contains 26 bones that are interconnected and supported by numerous ligamentsMany joints within the foot also assist with support and movement

Anatomy Review

Movements of the Anklehttp://www.youtube.com/watch?v=0R4zRSE_-40

Volunteer please DorsiflexionPlantar flexionInversionEversionAnatomy ReviewThe ankle joint (talocrural joint) is where the tibia, fibula, and talus joinProvides mainly plantar flexion and dorsiflexion of the footSubtalar joint is the articulation of the talus and the calcaneusResponsible for inversion and eversion of the footBoth joints are synovial, which means they are surrounded by a capsule and supported by ligaments

Anatomy Review The ankle joint is supported on the medial side by the large and strong deltoid ligamentOn the lateral side, the joint is supported by the anterior talofibular, the posterior talofibular, and the calcanefibular ligaments

Anatomy ReviewThese ligaments are not as large or strong as the deltoid ligamentAdditional lateral stability for the ankle joint is provided by the length of the fibula on the lateral side of the ankleThe ankle joint is strongest when placed in dorsiflexionThe talus fits much tighter between the tibia and fibula in this positionJoint is weakest when placed in plantar flexionAnatomy ReviewJoints, ligaments, and muscles help to create and maintain the two basic arches in the footLongitudinal arch has medial lateral divisionsTransverse arch runs from side to sideThese arches assist the foot as shock absorbers; also provide propulsion off surfaces during movement

Anatomy ReviewMuscles are divided into anterior (front), posterior (back), and lateral (side) compartmentsMuscles of the Anterior compartment essentially produce dorsiflexion and extension of the toesTibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertiusVery compact area with little room for any extra tissue or fluid Anatomy ReviewPosterior compartment mainly functions to produce plantar flexion of the footReferred to as the calf musclesIs divided into two compartments, superficial section and deep sectionSuperficial sectionGastrochnemius, soleus, and plantar musclesGastrochnemius and soleus attach on the calcaneus via the achilles tendonPlantars muscle is small and insignificant in actionAnatomy ReviewDeep section of this compartment houses the tibialis posterior, flexor digitorum longus, flexor hallucis longus, and popliteus musclesBesides the popliteus these muscles course behind the medial mallelous of the tibia and along the bottom of the footThey help with the plantar flexion as well as flexion of the toesThe popliteus muscle is important in knee flexion

Anatomy ReviewLateral compartment of the lower leg contains the peroneus longus and peroneus brevis musclesMainly evertors (to turn the foot outward) of the foot but do assist with some plantar flexionBoth of these muscles course behind the lateral mallelous of the fibulaPeroneus longus courses under the lateral side of the foot and runs across the bottom to the first metatarsal and cuneiform bonesThe peroneus brevis attaches at the base of the 5th metatarsal and is subject to avulsion (forcible tearing away or separation)Compartments of the Leg

Lateral compartment of the leg

Anatomy ReviewIncluded is also the peroneal nerve, a superficial nerve that is susceptible to injuryThe posterior tibial artery supplies blood to the peroneal muscles because there is no major artery in the lateral compartment

Common Sports InjuriesMany injuries occur to the lower leg, ankle, and footSome can be classified as traumatic, and others are chronic in natureTraumatic injuries typically involve skeletal structuresChronic injuries usually involve damage to soft tissues

Skeletal InjuriesFracturesDirect trauma through contact causes most Magnitude of contact necessary to fracture a bone such as the A fracture can be caused by being kicked by an opponent in a soccer match or by having a 300 pound lineman land on a leg http://www.youtube.com/watch?v=I-iEOoM1N-w

Skeletal InjuriesFracturesFractures to the foot can also However, violent trauma is not always required in Stress fractures can occur from overuse or microtrauma ()

Skeletal InjuriesfracturesIn running, for example, each time the foot strikes the ground it This trauma damages a few bone cells, which the body must repair as quickly as possibleWhen the body cannot maintain the repair process and keep up with Additionally, an avulsion fracture of the Therefore the possibility of such a fracture should be examined when an athlete sprains his/her ankleSkeletal InjuriesfracturesS&SSwelling of the traumaDiscoloration at the site of the traumaPossible through the skinAthlete reports that a The athlete may not be able to bear weight on the affected extremityIn the case of a stress fracture or a growth plate fracture that did not result from a traumatic event, the

Skeletal InjuriesfracturesTX:Watch and Apply sterile dressings to any related wounds (ex open fx)Carefully Arrange for transport to a medical facilityIn the event that Athlete will be immobilized for a specified time

Skeletal InjuriesfracturesWhen the fracture has healed properly, practice, and competition in that orderParticipation while a fracture is healing is There is a possibility of nonunion of a fracture,, as a result of a diminished blood supply

Soft-Tissue Injuriesankle injuriesOne of the most common sports injuries to the Are abnormal stresses placed on of damageSprains can occur to the lateral or medial ligaments of the ankle depending on which direction the foot moves when http://www.youtube.com/watch?v=Da5Dumbo2HsSoft-Tissue Injuriesankle injuriesThe of the ankle are most susceptible to injuryThe formation of the bones of the ankle helps to stabilize it; The ligaments on the lateral side, are not as large or strong as the deltoid ligament on the medial side of the ankle joint

Soft-Tissue Injuriesankle injuriesIt is estimated that occur to the lateral ligaments (Ryan et al., 1986)An interesting note is that authors are suggesting that (Omey & Micheli, 1999)

Soft-Tissue Injuriesankle injuriesCan occur in virtually any sport and can limit the abilities of the athlete in performance until resolution of the injury is completeAs the severity of the ankle sprain increases, so does the It is generally accepted that ankle sprain is more severe, with greater instability, and should be cared for more conservatively (Ryan et al., 1986)However, an is more common, with the lateral ligaments being involved inSoft-Tissue Injuriesankle injuriesS&S of a lateral ankle sprain1st degree sprainpain, mild disability, point tenderness, 2nd degree sprainPain, mild-moderate disability, point tenderness, loss of function, some laxity

Soft-Tissue Injuriesankle injuries3rd degree sprainPain and severe disability, point tenderness, loss of function, laxity

Soft-Tissue Injuriesankle injuriesTX:Immediately apply ice, compression, and elevationA kept in place by an elastic bandage aids at this stage in the compression and reduction of fluid Have the athlete rest and use crutches to ambulate with a If there is any hesitation about the severity, splint and refer for further evalSoft-Tissue Injuriesankle injuriesIt is important to recognize the possibility of a in conjunction with or masquerading as a lateral ankle sprainToo often a , which is inappropriate and will not allow the athlete to progress in the healing process

Soft-Tissue Injuriesankle injuriesIt is important to know that there is a significant difference With the lateral ankle sprain, there is an inversion mechanism, In the followed by axial loading of the lower leg, with external rotation of the foot and internal rotation of the lower legTypically, athletes have their foot planted firmly with the foot in external rotation, and the lower leg twist medially, forcing the talus into the ankle mortiseThe axial load forces the tibia and fibula to separate slightly and Soft-Tissue Injuriesankle injuriesS&S of a Mechanism of injury is different from a lateral ankle sprain; are combined with internal rotation of the lower legTypical ankle sprain test may be positive but the athlete will c/o a great deal

Soft-Tissue Injuriesankle injuriesPerforming the squeeze test (); elicits pain in the syndesmosis areaTXImmediately apply ice, A kept in place by an elastic bandage aids Have the athlete rest and use crutches to ambulate for the first 72 hours, followed by use of a walking boot for a minimum of 3 days and preferably for 7 days following the initial injuryIf there is any question refer for further evaluationSoft-Tissue Injuriesankle injuriesIt is recognized that either taping or bracing can reduce the number of ankle sprains (Verhagen, van Mechelen, & de Vente, 2000)Some prefer to use the as a prophylactic tx for ankles with no HX of an injuryOthers choose to augment the taping procedure to prevent In published research studies, ankle taping as been demonstrated to help with the neuromuscular response of the muscles and to provide stability if done in a specific mannerBoth contribute to reduction of ankle sprainsSoft-Tissue Injuriesankle injuriesMost researchers agree that the best known method of ankle support, the prophylactic adhesive-taping procedure, supports the ankle for only a short period of time after exercise begins (Frankeny et al., 1993)Therefore, some researchers now maintain that bracing is better than taping for the prevention of ankle injuries, owing to the reduction in ROM, either at excessive points or within normal ranges ()The combination of high-top shoes and taping or bracing can be helpful to athletes in reducing the number of ankle sprains they experience

Soft-Tissue Injuriesankle injuriesProprioception and the ankle is a very intense area of studyProper ankle (Hintermann, 1999)Also be important part of both the preventative and rehabilitative aspects of ankle functioning (Hertel, 2000)

Soft-Tissue Injuriesankle injuriesWhatever the choice of the coach or athlete, many factors must be These include:Type of activity, compliance of the athlete in wearing braces or prophylactic taping, cost to the school or athlete, effectiveness of the brace as reported in research studiesThere are some consequences of using adhesive tape, including:Blisters,

Tendon-related InjuriesThe , basketball players, and tennis playersThe onset of tendinitis may be slow among runners, but much more rapid among basketball or tennis players Great many jumping or rapid motion from side to side

Tendon-related injuriesSome controversy exists about the actual injury that constitutes Achilles tendinitisThe Achilles tendon itself, which attaches the However, either tendon sheath or the subcutaneous bursa

Tendon-related injuriesMost agree that athletes who and who do so running on hard, uneven, or uphill surfaces are prone to Achilles tendinitis (Omey & Micheli, 1999)It is estimated that 11% of runners and up to 52% of former elite runners experience an Achilles tendinopathy ()http://www.youtube.com/watch?v=F2e6LmQsJps

Tendon-related injuriesSuperficially, ; moreover, the tendon is painful on touch and movement and appears thickenedThis pain associated with this condition is localized to a small Can be seen over an extended period of time (days to weeks)Or over a shorter period of time (days)

Tendon-related injuriesTX for chronic :Immediate rest until the swelling subsidesNSAIDS, small heel lift assist the reduction of swelling and Stretching has also been shown to be beneficial to athletes with Achilles Tendinitis (Taylor et al., 1990)Controlled stretching on a slant board or against a wall Additionally, if an athlete must exercise or run, it is advised this be done in a controlled environment (swimming pool)Tendon-related injuriesControlled gradual stressing exercises using the An athletes activity level and type of exercise must be closely monitored during the healing phaseWithout the proper amount of rest, the body has a hard time repairing injury,

Tendon-related injuriesExplosive jumping or direct trauma from some type of impact can cause traumatic injuries to the Can occur in many different sports

Tendon-related injuriesS&SSwelling and deformity at the site of injuryReports a Pain in the lower leg, which may range from mild to extremeLoss of function, TX:Immediately apply rice and Immobilize the foot by Arrange for transportation to the nearest medical facilityTendon-related issuesDuring the acute phase of the healing process, minimizeThis movement can produce more damage and The long term effects of a ruptured Achilles tendon depend on the If surgery is necessary, the athlete will most likely be out of commission for the rest of the seasonThe athlete will need to be careful and aware of the http://www.youtube.com/watch?v=hP2medWpDLETendon-related issuesOther tendon problems typically occur with the tendons on the lateral side of the anklePeroneus These muscles originate on the lateral aspect of the tibia and fibulaThe tendons then run an inferior course behind the and attach on the lateral and posterior aspects of the foot

Tendon-related issuesThere is a small and running posteriorly to the calcaneusThis

Tendon-related issuesAs these tendons run their course behind the as a result of trauma or extreme forceThey can actually pop across the Can be very painful, but not usualThe athlete with the tendon problem should be seen by a member of the medical teamSometimes these problems can be controlled by taping or Compartment Syndromecan result from a This syndrome is associated with the lower leg, which is Anterior compartmentLateral compartmentDeep Superficial The majority of compartment syndrome problems occur in the anterior compartment,

Compartment SyndromeCan be caused by chronic overuse that creates swelling of tissues in the compartment or by trauma that triggers bleeding and effusion (Black & Taylor, 1993)

Some athletes The resulting extra fluid creates a lack of space and places extreme pressure on the blood vessels and nerves Thereby compromising their functionsCompartment SyndromeIn addition, trauma to the anterior portion of the leg () can create blood loss and swelling into the compartment

Compartment SyndromeMany soccer athletes tend to want to wear shin guards that are smallThe athletes contend that large shin guards inhibit their play, so they dont like to wear themWhen athletes wear shin guards that are too small, they run the risk of being kicked in the lower leg

Compartment SyndromeS&SPain and The athlete may There may be a loss of There can be a loss of pulse to the footInability to extend the great toe or dorsiflex the foot

Compartment SyndromeTX:Apply ice and elevateDo not If the foot becomes numb, there is loss of movement, or there is loss of pulse to the foot, seek medical help immediatelySeek proper medical advice early because these Shin SplintsAnother very common disorder of the lower leg is shin splints, Courture and Karlson (2002) define shin splints as This disorder does not have definite parameters to follow for Shin SplintsTypes of activities that produce this problem and the However, to the date there has not been a positive link between any one specific cause and the resulting leg painMoreover, it is generally accepted that with rest the pain will Shin SplintsS&SLower leg pain either Typically, the athlete reports a chronic problem that gets progressively worseThe TXApply ice and have the athlete restNSAID may helpShin SplintsTo help the athlete work through shin splints, Run in water, reduce running, or eliminate the irritating May also want to have his/her gait analyzed to look for biomechanical deficiencies Myraid related problems can exacerbate the pain and discomfort associated with shin spintsIf the problem worsens, must seek medical adviceFoot DisordersContains many bones, joints, ligaments, muscles, and other tissuesSome injuries are more common to specific sports

Foot Disorders...Plantar FasciitisThe plantar fascia is a dense collection of tissuesIncluding muscles and tendonsBegin at the plantar aspect of the If it becomes tight or inflamed by overuse or trauma, it can produce pain and disability in the bottom of the foot

Foot Disorders...Plantar FasciitisA change in shoes, training technique, activity, or Typically is a combined problem with calcaneal apophysitis (growth plate, believed to be caused by repetitive microtrauma from the pull of the Achilles tendon on the apophysis)This condition may also include the medial arch and/or heel pain

Foot DisordersPlantar FasciitisTo determine whether the condition is plantar fasciitis, the examiner must take a through hxAsk the athlete if he/she experienced almost unbearable pain in the plantar aspect of the foot With the first steps taken on getting out of bed I the morning and Also ask if there is point tenderness on the plantar aspect of the If both symptoms exist, there is a high probability that plantar fasciitis is the problemFoot DisordersPlantar FasciitisTXIs typically conservativeIncludes rest, (Taunton et al,. 2002)A heel pad and stretching the The use of has also been shown to be effective in recoveringThe more the injury is aggravated, the longer it will take to healFoot DisordersHeel SpursCan also be related to Sometimes with chronic cases of inflammation there is ossification at the Results in long term disability for many athletes

Foot DisordersHeel SpursAdditionally, these small ossifications can occur on the posterior aspect of the Needs to consult a physician to determine the proper tx plan if these spurs become too incapacitatingDoughnut may assist the athlete to participate fully, but rarely do they dissolve the problemhttp://www.youtube.com/watch?v=EulA_06syGoFoot DisordersMortons FootTypically involves either a bone or an elongated second metatarsal boneResult is that the majority of weight-bearing is done on the second metatarsal instead of

Foot DisordersMortons FootThis problem can result in pain throughout the foot and The use of padding can help the athlete, but to have the problem correctly addressed the athlete should see a Foot DisordersMortons NeuromaThis is a problem with the nerve, As a result, pain radiates to the third and forth toesA neuroma is an Tight-fitting shoes have been blamed for some irritationConsequently, going barefoot is one of the best methods of pain relief for this problemMost often taken care of by a doctorFoot DisordersArch problemsAthletes can experience Arch problems can be classified into two categories:Pes planus ()Pes cavus ()Both problems Others with similar foot conditions may never c/o problems associated with archesFoot DisordersArch ProblemsFlat feet may have too much foot pronation, causing difficulties in the Leads to generalized discomfort around the foot and ankle

Foot DisordersArch ProblemsSeveral taping procedures have been developed to augment the arch in athletesResearch concludes that there seems to be limited effectiveness in

Foot DisordersArch ProblemsHowever, it may be worth trying with an athlete to see if the A (BOC)-certified athletic trainer can assist in providing direction in this taping procedureCoaches should not attempt to apply adhesive tape to an Many athletes with flat feet can be helped in the long term by orthotics and proper shoe selection

Foot DisordersArch ProblemsThe athlete with an excessively high arch also has foot problemsA foot with too much arch is often associated with Also have generalized discomfort about the foot and ankle because of the inability of the These athletes can also benefit from some orthotic help and proper shoe selection

Arches

Foot Disorders...BunionsNot very common in athletes at high schools and collegesSimply a , or they can involve complicated bone and joint deformitiesCaused by improper fitting footwearBy getting the athlete into correctly fitting shoes the If an athlete has had a bunion for an extended period of time (weeks to months), then the athlete should seek medical advice

Foot DisordersBlisters and CallusesBlisters and calluses are very common Excessive amounts of movement can produce a great Which results in the formation of either a blister or callusIf a blister forms, the layers of the skin have been separated, and the friction has built up a fluid depositFoot DisordersBlisters and CallusesAlways observe the color of the fluid within the blisterMost often the fluid is clear, but on occasion it will be dark which means there is Many times the pain and discomfort from a blister prevent the athlete from participating in sportsIf the blister is large, the fluid should be drained and the area padded well to prevent further friction and blister formation

Foot DisordersBlisters and CallusesWhen a blister is drained, it is best to leave the top layer of skin in place until a new layer developsWHY?In addition, place a doughnut-shaped pad made of felt or a In case the blister opens inadvertently (), care needs to be taken that the area is clean and does not get infectedApply an antibacterial ointment to the area and cover it as necessaryFoot DisordersBlisters and CallusesWhen draining a blister, be sure to follow the recommended precautions regarding the human immunodeficiency virus (HIV) and hepatitis B:Always use sterile instruments and keep the environment sterileUse latex gloves or some other barrier so that body fluids are not contacted

Foot DisordersBlisters and CallusesCaring for a blisterInitially wash the area Using a sterile needle, puncture the base of the blister and This may need to be repeated several times in the first 24 hours.Do NOT remove the top of the blisterApply antibiotic Check the area daily for redness or pus to determine if infection is occurring at the site

Foot DisordersBlisters and CallusesAfter 3 to 7 days, gently remove the top of the blister, apply an antibiotic ointment, and cover with a sterile dressingWatch the area closely for signs of infection such as redness or This allows for healing to occur without further irritationIf the blister is small, padding the area to prevent further friction usually suffices until the blister healsIt is best to prevent by properly fitted footwear and giving new shoes a

Foot DisordersBlisters and CallusesIn addition to blisters, excessive tissue can build up on the bottom of the feet, Calluses tend to build up over a bony area of the foot and should not be If this happens, the callus can begin to move with the shoe and not with the footThis creates an area of friction between the callus and layers of the skin, Foot DisordersBlisters and CallusesThis can cause problems because the blister is difficult to drain and To prevent this from happening, a callus should be shaved regularly to allow for only a small amount of buildup, which then acts as a padding for the areaIf a callus gets too large the athlete will begin to c/o pain and discomfort in the areaToe injuriesIn some sports, toes can be stepped on, This collection of blood under the nail needs to be releasedNumerous techniques to remove the blood existCommercially available nail drills bore a

Toe injuriesThis provides a great deal of relief to the athleteIf an athlete wears shoes that are too tight or small, this can also create a situation in which a toenail is Shoes that are too small or too tight can also result in an ingrown toenailToe injuries..ingrown toenailNeeds to be treated early because delaying care can result in infection and serious problemsThe ingrown nail can produce an open sore on the toe, when the foot is placed in a sport shoe,

Toe injuries..ingrown toenailIngrown toenails should be tx by The nail needs to be elevated so that it will grow in a normal directionThis can be done by placing a small cotton roll under the affected part and It is also important to address the situation that led up to the ingrown toenailShoes that are too small or too tight

Preventative Ankle TapingApplying preventative ankle taping to athletes is a popular practice among The advantages and disadvantages of preventive ankle taping have been discussed widely, Not using taping as a preventative measure to always taping both ankles when participating in any sport

Preventative Ankle TapingSome athletic trainers promote the use of lace-up and Paris, Vardaxis, and Kikkaliaris (1995) indicate though their research that ankle braces are just as effective, it not more so, as preventative taping in reducing It has also been demonstrated that ankle braces do not detract from an athletes ability to run, jump, or Preventative Ankle TapingThere is a time and cost benefit analysis that should be Some coaches believe that taping the ankles is more From a cost analysis, if a player is going to be taped multiple times a day or week, it may be less expensive to use prophylactic braces that the athlete can put on him/her self before each practice or game

Preventative Ankle TapingPreventative ankle taping is an important skill that must be learned properly, practiced until a level of mastery is gained, Taping is an art and a science, and each strip of tape has its own functionIf students are interested in developing taping skills, it is recommended that they work under the direct supervision of a Preventative Ankle TapingThe use of pre-wrap and An adherent is used to help the pre-wrap to stay in place If an adherent is not used, the tape will in most situations, loosen and slide, The use of stirrups is intended to maintain the foot in a normal or slightly everted positionStirrups are combined with horseshoe strips, which help to hold the stirrups in place and reduce the gaps in the tape on the posterior portion of the footPreventative Ankle Taping1. Spray adhesive2. Heel and lace pads3. Pre-wrap4. Anchor strips (Distal and proximal)5. Stirrups (Start medial and pull lateral, interweave with Horseshoes)6. Horseshoes (Start medial and pull lateral, interweave with stirrups)7. Figure-88. Heel locks (2 medial, 2 lateral)9. Closing strips (1 distal, proximal start at malleoli and work proximally)Preventative Ankle Tapinghttp://www.youtube.com/watch?v=8fS883UWWIA