Lecture 5 - Lower Leg Injuries Flashcards
How many bones are in the foot?
- 26
What is the talo crural joint?
- true ankle joint; allows for dorsiflexion & plantarflexion
- The ankle joint is most stable in dorsiflexion
What is dorsiflexion & plantarflexion?
- Dorsiflexion: 10-20 degrees from 90 degree position or 0 degree
- Plantar flexion: 45-50 degrees from 90 degree position
What are the 4 arches of the foot?
- medial longitudinal arch
- lateral longitudinal arch
- transverse arch
- anterior metatarsal arch
What is the medial longitudinal arch ?
- runs along inside of the foot
What is the lateral longitudinal arch ?
- runs along the outside of the foot
What is the transverse arch?
- runs across the distal heads of the tarsals
What is the anterior metatarsal arch?
- runs over the distal heads of the metatarsals
What is Pes planus?
- the loss of the medial longitudinal arch of the foot, heel valgus deformity, and medial talar prominence
- Known as “flat foot’ or an over-pronated foot
What is pes cavus?
- A foot with an abnormally high plantar longitudinal arch
- known as a supinated foot
What are the 2 main ankle ligaments ?
- planter calcaneo navicular (spring ligament)
- deltoid ligament
What is the plantar calcaneo navicular (spring ligament)?
- holds the medial longitudinal arch’s shape
- Runs form the sustentaculum tali to the navicular made up of many elastic fibers it provides a shock absorbency action to the arch
What is the deltoid ligament?
- holds the tibia, talus, & calcaneus together
What are the 3 lateral ankle ligaments?
- anterior talofibular ligament (ATFL)
- calcaneo fibular ligament (CFL)
- posterior talofibular ligament (PTFL)
What is the anterior talofibular ligament (ATFL)?
- runs from the anterior fibular malleolus to the talus
What is the calcaneo ligament (CFL)?
- runs from the mid fibular malleolus to the calcaneus
What is the posterior talofibular ligament (PTFL)?
- runs from the posterior fibular malleolus to the talus
What are the 4 compartments of the leg?
- anterior compartment
- lateral compartment
- superficial posterior compartment
- deep posterior compartment
What is the anterior compartment of the leg?
- Enclosed by a tight fascia covering from the posterior border of the tibia to the lateral aspect of the leg
- It contains the foot dorsiflexors & toe extensors
What are the 3 muscles of the anterior compartment of the lower leg?
- tibialis anterior, extensor hallicus longus, extensor Digitorum longus
- also contains the anterior tibial artery & the deep perineal nerve
What is the lateral compartment of the leg?
- contains the peroneal muscles that evert the foot
What are the 3 muscles of the lateral compartment of the leg?
- Peroneus Longus, Peroneus Brevis, Superficial Peroneal Nerve
- also contains the tibial artery
What is the superficial posterior compartment of the leg?
- the muscles the plantar flex the foot
What are the 3 muscles of the superficial posterior compartment of the leg?
- gastrocnemius, soleus, plantaris
- also contains the tibial artery
What is the deep posterior compartment of the leg?
- contains the muscles that invert the foot, plantar flex the ankle & flex the toes
What are the 3 muscles in the deep posterior compartment of the leg?
- tibialis posterior, flexor hallicus longus, flexor Digitorum longus (known as TOM, DICK & HARRY)
- also contains the posterior tibial nerve
What are the 2 types of ankle injuries?
- inversion sprain
- eversion sprain
Why do inversion sprains occur?
- the medial malleolus is shorter, allows greater inversion
- ligaments on the outside of the ankle are fewer & weaker
- Shape of the Talus predisposes laxity of the joint
What are the 4 types of inversion sprains?
- plantar flexion inversion sprain
- mid stance (90°) inversion sprain
- dorsiflexion inversion sprain
- anterior shear sprain
What is a plantar flexion inversion sprain?
- occurs when the foot is forcefully plantar flexed while simultaneously turning inwards (inversion)
- causes damage to the anterior talofibular ligament (ATFL)
What is a Mid stance (90°) inversion sprain?
- causes damage to the calcaneofibular ligament (CFL) by pivoting or twisting
What is a dorsiflexion inversion sprain?
- occurs when the foot is dorsiflexed & inverted
- causes damage to the posterior talofibular ligament (PTFL)
What is an anterior shear sprain?
- the ankle joint is stressed in an anterior direction, causing the anterior & distal anterior talofibular ligament (ATFL) to be damaged
What are the 3 classifications of inversion sprains?
- 1st degree (mild sprain)
- 2nd degree (moderate sprain)
- 3rd degree (severe sprain)
What is a 1st degree ankle sprain?
- Some stretching of ligament, no tearing, no major disability, able to bear weight
- Full range of motion (R.O.M.) very little swelling
- Recovery 2-3 days: can return to participation at this time with support
- prevention of re-injury conditioning protocol is essential
What is a 2nd degree ankle sprain?
- Moderate to severe stretching, some tearing, moderate swelling, increased pain
- Decreased ROM (due to pain & swelling)
- Some instability in the ankle joint (test within first 10 or 15 min. or too much swelling occurs & may masks findings)
- Recovery 2-4 weeks (usually 4) return to activity good support required (I.e.. tape or brace)
What is a 3rd degree sprain?
- Involves rupture of ATFL & CFL ligaments, Severe swelling & pain (initially)
- Severe sprain can be accompanied by dislocation & subluxation
- The only way to tell the difference between 3rd degree & 2nd degree is through stress X-Ray
- In 2nd & 3rd degree sprains always have x-ray done to check for fracture
What is the recovery for a 3rd degree sprain?
- Recovery is 6-8 weeks - may be even longer if surgery in required
- surgery may be required should occur within ten days (ie ligaments will shrink to resting length) otherwise reconstructive surgery is required
What is an eversion sprain ?
- occurs when the foot is in dorsi-flexion & forced into eversion
- The deltoid ligament complex is damaged due to the strength of the ligament complex
- it is not uncommon to see avulsion
What are 6 general exam guidelines of an ankle sprain?
- Review MOI & Past History of Injury
- Rule out fracture
- Observe for Obvious Signs Of Injury
- Complete; Active, Passive, & Isometric Resisted Tests
- Perform Ligament Stress Tests; Drawer, Inversion, & Eversion
- Palpate all Specific structures of the joint
What are 3 general treatment guidelines for an ankle sprain?
- Always rule out fractures first
- Use PIER (pressure, ice, elevation rest) 1-20 mins every 1 1/2 hours 4x/day; Do this for the first 24-48 hours after injury
- can use contrast baths & Heat related modalities
What are the 2 stages of ROM & strengthening exercises for an ankle sprain?
- early stage
- mid to late stage
What are the ROM & strengthening exercises in the early stage for an ankle sprain?
- writing the alphabet while in the hot whirlpool
- Towel stretches (for calf and Achilles)
- Pulling up a flat towel with toe scrunches (strengthens intrinsic foot muscles)
What are the ROM & strengthening exercises in the mid to late stage for an ankle sprain?
- Surgical tubing all foot extrinsic muscles
- Toe raises - strengthens the calf muscles
What are proprioception exercises for an ankle sprain?
- challenge & improve your sense of body position & movement
- They can help stabilize joints and reduce the risk of injury
- these exercise can be instituted after acute period
- in most cases the athlete can be doing something within 2 days
How can you incorporate cardiorespiratory activity after an ankle sprain?
- typically low-impact exercises like swimming or stationary biking
- they allow you to maintain cardiovascular fitness without putting additional stress on your injured ankle
- for the athlete this must be considered as early as possible
How do you progress to return to activity after an ankle sprain?
- able to bear weight without pain, full ROM, no swelling, demonstrate normal strength, & perform sport-specific movements without discomfort
- essentially, your ankle should be fully functional & pain-free
- using Functional patterns; cutting, stop start , figure 8 etc
What are some general ankle stretches?
- Towel stretch, standing calf stretch, standing soleus stretch, ankle ROM, resisted dorsiflexion/plantarflexion, reisisted inversion/eversion, heel raises, step-up, static & dynamic balance exercises
How to prevent ankle injuries?
- Proper conditioning & Ankle proprioception:
- Wearing proper shoes: preferably high cut shoes
- Ankle wraps/ or appropriate brace
- Taping along with high cut shoes show great reduction in ankle injury
- A drawback exists with tape in that after 15 min you lose 30-40% of the support of the tape
What are 5 types of ankle fractures?
- potts-fracture
- bimalleolar fracture
- tri malleolar fracture
- avulsion fracture
- Epiphyseal fracture
What is a Potts-fracture?
- Fibular fracture above the malleolus along with a fracture of the tibial malleolus
What is a bimalleolar fracture?
- Both malleolus are fractured accompanying a forced eversion & torsion of the foot/ankle
What is a tri malleolar fracture?
- Both malleoli & the posterior margin of the tibia are fractured
- the difference between this & a bi-malleolar is that torsion has forced the talus posteriorly, & breaks off the posterior lateral margin of the tibia
What is an avulsion fracture?
- Ligament pulls a piece of bone away from one of the bony attachment at the ankle or foot
What is an epiphyseal fracture?
- Fractures involving the growth plate in children & adolescents
- Caution must be taken with severe ankle sprains as the epiphyseal area may be involved & could affect growth
What is a leg fracture?
- Includes all fractures not involving the malleolus
- Mal-alignment or Mal-union if only tibia is fractured
- Fibula only supports 1/6th of the weight going through that side
- The individual may be able to weight bear if this is the only bone to break\
What is Achilles peri (para) tendonitis?
- Involves tendon swelling, resulting in irritation of the in-folded membrane (i.e., Inflammatory fluid moves into area)
- When injured the individual has difficulty in plantar-flexion actions against resistance
What is the treatment of Achilles tendonitis?
- I.C.E. - repeated 15 - 20 minutes 3-4 x day
- When inflammation is chronic all activity must be stopped
- Most important in chronic overuse symptoms is to rest (2 weeks to 6 months)
- If severe, restricting activity by casting is sometimes used. (Walking boot with range of motion limiters are a better choice.)
What is Achilles tendonosis?
- a degenerative condition, involving the breakdown of the Achilles tendon
- often due to chronic overuse without proper healing, leading to pain, stiffness, & potential weakness
What is Achilles tendonopathy?
- a painful condition affecting the Achilles tendon
- In most cases, Achilles tendinopathy is a type of overuse injury & is more common in younger people
What is an Achilles rupture?
- A rupture of the Achilles tendon is a tearing & separation of the tendon fibers so that the tendon can no longer perform its normal function
What is a tibial contusion?
- a direct blow causes bleeding & fluid buildup under the periosteum (the membrane covering the bone), resulting in pain, swelling, & potential discoloration
What is lower leg stress syndrome?
- known as shin splints
- causes pain between the knee & the ankle
- Results when the stresses in the lower extremity are not absorbed adequately & one or more of the structures in the leg are not able to remodel fast enough
- This results in stress related breakdown of the structure with resultant inflammatory change
Why do forces impact shin splints?
- The concern is not what happens in a single impact, but what happens with the thousands of repetitions that occur over time & affect both soft tissue & bone
- Consideration must also be given to the fact that muscle strength usually increases faster than bone is able to remodel & therefore makes the bone more susceptible to stress syndrome
What are the general tissue damages with shin splints?
- Tearing of the interosseous membrane
- Micro tearing of muscle away from the bone
- Stress Fractures of the tibia &/or fibula
What is periositis?
- Inflammation of the outer lining of bone due to pulling by muscle attached to it
What is a stress fracture?
- tiny cracks in a bone caused by repetitive force, often from overuse
What is the diagnosis of a stress fracture?
- X-rays are initially done after injury or symptoms first assessed, if they are inconclusive x-rays should be repeated after 10- 14 days of rest
- Healing of the fracture causes calcium build up & these can then be seen on x-rays
- A bone scan is often required to detect the problem
How does running on your toes cause shin splints?
- no absorption lack of heel to toe movement; Increased forces directed up leg
- Running or playing sports on hard surfaces increases stress up the leg
- Over pronated or supinated foot posture
How does running on the road cause shin splints?
- camber of road causes increased stress on foot & lower leg (i.e., Top foot will be in increased pronation; While bottom foot forced into supination)
What is knock knees?
- force on medial aspect of foot & lateral aspect of knee joint
What is bow legged?
- force on lateral side of the foot & medial aspect of knee joint
What is the treatment of overuse syndrome?
- must rest the leg for 3 weeks minimum
- If the individual has to play you try & control symptoms so you use ice before & after activity & as much as possible throughout the day
- Correct biomechanical dysfunction
- Correct any strength & or flexibility dysfunction
What is acute anterior compartment syndrome?
- Deep contusion or Fracture the most likely cause
- Compartment fascia will not allow for sudden compartment expansion due to the bleeding
- Tibial artery, deep peroneal nerve affected
What is the result of acute anterior compartment syndrome?
- necrosis of muscle, inability to dorsiflex the foot, parasthesia in the web space between 1st & 2nd toes
What is intermittent chronic compartment syndrome?
- Involves engorgement of muscles in a given compartment (usually anterior or deep posterior) which then compromises blood flow causing ischemia & pain
- If compression is intense enough may get weakness in involved muscle groups also
- may be Parasthesia in the web space between 1 an 2 toes
- Recurrent episodes of the problem may require surgical release of fascia to allow muscle expansion
What is hyperdrosis? What is the cause? What is the treatment?
- Excessive Perspiration of the feet
- Cause: Overactive Sympathetic nervous System, Susceptible to blisters, infection, skin diseases
- Tx: Foot powders in shoe, Rubbing alcohol to dry feet, Foot antiperspirants, Sympathectomy
What is an ingrown toe nail? What is the cause? What is the treatment?
- also known as onychocrptosis
- Leading edge of toenail grows into the soft tissue of the nail bed
- Causes: Trauma to the nail, Improper cutting of toe nails, Tight shoes or Socks, Abnormal shape of nail plate, Abnormal thickness of nail
- Tx: soak foot in warm water, wear open shoes
What are calluses?
- thickened layers of skin caused by repeated pressure or friction
- Inelastic tissue that may shear off exposing underlying skin to infection
- Tx: Hot water soaks followed by using a scraper or pumice stone to rub & thin out the callus, Pedicure, Proper fitting shoes & socks, Orthotics with MET pads
What are hard corns? What is the cause? What is the treatment?
- Result of high friction over the toe joints
- Cause: tight shoes with shallow toe box, poor fitting shoes
- Tx: donut pad to help protect against friction, hot water soaks gently file down (do not cut)
What are soft corns? What is the cause? What is the treatment?
- a small, inflamed patch of skin with a smooth center
- usually appear between the toes.
- Causes: Moisture & high friction between toes due to tight shoes
- Tx: wear proper fitting shoes & socks, proper foot hygiene; keep toe clean & dry
What are plantar warts? What is the cause? What is the treatment?
- small, rough growths on the feet, on the balls & heels of the feet
- caused by a virus that invades the skin through tiny cuts or abrasions.
- contagious, commonly spread in public swimming pools or communal showers
- more common in children than in adults
- Tx: doctors may burn them off with liquid nitrogen
What is exostoses?
- known as heel spur
- is a protuberance (outgrowth) of the heel bone where the plantar fascia attaches
- Causes: secondary to plantar fasciitis, improper footwear
What is hallux valgus ? What is the cause? What is the treatment?
- also known as bunions
- Seen as the big toe moving in to the middle of the foot
- Causes: Hereditary predisposition to the angulation, Improper shoes with a tight toe box
- Tx: toe wedge or support, orthotics, surgery (if too painful to walk or do daily activities)
What are blisters? What is the cause? What is the treatment?
- Results from shearing forces between skin layers, May be clear, bloody or purulent.
- Tx: decrease friction, wear proper fitting shoes, keep feet dry, wear absorbent socks, & use foot powders
What is Mortons neuroma? What is the cause?
- Compression injury to the interdigital nerve between the Metatarsal Heads.
- Cause: Tight shoes, Over-pronation creating a shearing force during toe off in gait
What is plantar fasciitis ? What is the cause?
- inflammation of the fibrous tissue along the bottom of your foot that connects your heel bone to your toes
- Causes: Tension & stress on the fascia can cause small tears, Repeated stretching & tearing of the facia can irritate or inflame it
What is subungual hematoma?
- Metatarsalgia (or forefoot pain) is a catch-all term that includes several painful foot conditions
- Inclusive of pain at the metatarsal heads, bursitis, arthritis, sesamoiditis, & periostiti
What is athletes foot? What is the cause ?
- a fungal infection that usually begins between the toes but can involve the whole foot
- occurs most commonly in people whose feet have become very sweaty while confined within tight-fitting shoes
What are the signs and symptoms of athletes foot?
- scaly rash, itching, stinging & burning
What is the treatment of athletes foot?
- Athlete’s foot is contagious & can be spread via contaminated floors, towels or clothing
- Requires use of antifungal medication Either topical (oral used in severe cases)
