chapter 18 (pp 487-496) injuries to the foot & ankle
TRANSCRIPT
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Chapter 18 (pp 487-496)
Injuries to the
Foot & Ankle
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Objectives
Identify…• The bones of the foot & ankle• The ligaments of the foot & ankle• The muscles of the foot & ankle• The tendons of the foot & ankle• The blood vessels & nerves of the foot &
ankle• Other structures
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The bones
• The foot contains 28 bones– Phalanges (16)
• Proximal (1-5)• Intermediate (2-5)• Distal (1-5)• Sesamoids (1)
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The bones
• The foot contains 28 bones– Metatarsals (5)– Tarsal bones (7)
• Cuneiforms– Medial, intermediate,
lateral• Cuboid, Navicular• Talus, Calcaneous
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The bones
• Tibia• Fibula
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Phalanges
• There are 14 total phalanges– Great toe = 2– All other toes = 3
• Each toe has a proximal, intermediate, & distal phalange (except Great toe)
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Phalanges
• Great toe has 2 sesamoid bones– Act like “mini patella”
to increase leverage and protect the joint
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metatarsals
• Each toe has a corresponding metatarsal (MT)
• Important areas:– Head of the 1st MT– Base of the 5th MT– In-between the 2-3
MT heads
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Tarsal bones
• The tarsal bones make up the mid- & rear-foot– Cuneiforms (E, F, G)
• Medial (G)• Intermediate (F)• Lateral (E)
– Cuboid (C)– Navicular (D)– Talus (B)– Calcaneous (A)
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Bones of the leg
• Tibia and fibula extend past the talus bone
• Distal end is referred to as the malleolus– Medial = tibial– Lateral = fibular
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Bones of the leg
• Tibia– Larger of the two
bones– Primary weight
bearing bone
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Bones of the leg
• Fibula– Smaller bone, extends
more distally– Provides for muscle
attachments– ≤ 10% weight bearing
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the ligaments
• Important ligaments in the foot:– Calcaneonavicular
ligament (spring ligament)
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The ligaments
• Medial ankle:– Deltoid ligament
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The ligaments
• Lateral ankle:– Anterior talofibular
(ATF)– Calcaneofibular
(CF)– Posterior talofibular
(PTF)• Not shown
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The ligaments
• Lower leg:– Distal anterior
tibiofibular ligament– Distal posterior
tibiofibular ligament– Interosseous
membrane
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articulations
• Interphalangeal (IP, PIP, DIP)
• Metatarsophalangeal (MP or MTP) joints
• Intermetatarsal joints• Tarsometatarsal (TMT)
joints • Subtalar joint• Talocrural joint
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Subtalar joint
• Articulation of the talus & calcaneus
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Talocrural joint
• Tibia, fibula, talus• Mortise & tenon
configuration• Talus is wedge-
shaped• Lateral malleolus
extends more distally than medial malleolus
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Arches of the foot
• Support body weight• Absorb forces from
the ground• Provide space for
blood vessels, tendons, & muscles
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Arches of the foot
• Metatarsal Arch – across metatarsal heads
• Transverse Arch – across metatarsal bases & cuneiforms
• Medial Longitudinal Arch – along the medial aspect
• Lateral Longitudinal Arch – along the lateral aspect
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Arches of the foot
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Plantar fascia
• Broad, thick tissue covering the bottom of the foot– Extends from the
calcaneus to the base of each metatarsal
– Supports the foot against downward forces
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Muscles & tendons
• Intrinsic muscles of the foot:– Toe extensor– Toe flexors (3)– Great toe & 5th toe
abductors– Great toe adductor
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Muscles & tendons
• Extrinsic muscles of the foot:– Divided by compartments
• Anterior• Lateral• Superficial posterior• Deep posterior
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Muscles & tendons
• Anterior compartment– Tibialis anterior– Extensor hallucis
longus– Extensor digitorum
longus
• Dorsiflex the foot
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Muscles & tendons
• Lateral compartment– Peroneus longus– Peroneus brevis
• Evert the foot
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Muscles & Tendons
• Superficial posterior compartment– Gastrocnemius– Soleus– Plantaris
• Plantarflex the foot
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Muscles & tendons
• Deep posterior compartment– Tibialis posterior– Flexor hallucis
longus– Flexor digitorum
longus
• Plantarflex & invert the foot
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Neurological & Vascular
• Tibial nerve– Posterior leg &
plantar aspect of foot
• Common peroneal nerve– Anterior leg & foot
• Blood supply– Anterior tibial artery Dorsal pedal artery
– Posterior tibial artery
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Distal pulse
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34
OA 11.12
If an athlete came to you complaining of ankle pain, how would you address them?• What questions would you ask to
gather clues about what is going on?• What are some relevant observations
to make regarding their body?
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The Foot & Ankle
Evaluation
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Objectives
Identify…• Pertinent information to gather during a
foot & ankle evaluation• Important observations to make during
a foot & ankle evaluation
???
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The Secondary Survey
• After ruling out life-threatening injuries, we begin the secondary survey– Treat for major injuries with acute on-field
care• Begins with an assessment of vital signs• Musculoskeletal Assessment
DOCUMENT EVERYTHING!
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HOPS TECHNIQUE
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The Evaluation Process
H.O.P.S.• History• Observation• Palpation
– Range of motion
• Special tests
H.I.P.S.• History• Inspection• Palpation
– Range of Motion
• Special tests
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History
• What happened?– Gain information about the patient and the
injury– Most critical part of the evaluation!– Past medical history– History of the present condition
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History
• Start with generic history questions– Chief complaint– Age– Occupation / sport / position etc.– General health
condition– Activity level– Medications
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History
• History of previous injuries– What happened?– Who did you see?– What did they tell you?– How long were you out?– Has it fully resolved?
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History
• Mechanism of injury– How did it happen?
Tension = sprain; fracture; strain
Torsion = sprain; fracture
Compression = contusion; fracture
Shear = fracture; sprain
Bending = fracture
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HistoryAsk these questions regarding PAIN• P-rovocation – what causes it? what
makes it better?• Q-uality – what does it feel like?
neurological symptoms?• R-egion – where does it hurt? can you point
w/one finger?• S-everity – how bad does it hurt? (1-10)
• T-iming – when does it hurt? how long?
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History
Type of Pain Structure
Cramping, dull, aching Muscle
Dull, aching Ligament, joint capsule
Sharp, bright, lightning-like, burning Nerve
Deep, nagging, dull Bone
Sharp, severe, intolerable Fracture
Throbbing, diffuse Vasculature
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History
• Sounds & sensations– Did you hear any sounds? Did you hear
any pops, crackles, snaps, clicks?• What could this
indicate???
– Did you feelanything unusual?
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History• Specific to the foot & ankle
– Previous history = chronic ankle instability– Mechanism of injury = ROM (Inversion,
Eversion, Plantarflexion, Dorsiflexion)– Location of pain – heel, foot, toes, arches,
lateral ankle, medial ankle, etc.• Determines what is injured
– Changes in activity,footwear, or training surfaces
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Observation
• Athlete Moving?• Position of athlete?• Conscious?• Primary Survey• Inspect injury site• Secondary Survey
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Observation
• When does this begin?• Compare each side bilaterally
to identify what is normal forthat person
• We look for:– Deformity, asymmetry,
edema, ecchymosis
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Observation
We assess:• Gait• Gross motor function• Posture/position• Facial expression• Guarding
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Observation
• Gait – how a person walks– Difficulty walking = antalgic gait
• Does the athlete favor one foot, limp, or is unable to bear weight?
• Does the athlete carry their weight on their toes or heel?
• Is the arch maintained while both weight-bearing and non-weight bearing
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Observation
• Can the athlete move the limb on their own through normal function?
• Is the arch maintained while both weight-bearing and non-weight bearing
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Critical thinking…
An athlete limps in to the ATR complaining of pain on the lateral aspect of his right ankle. He said he stepped off the curb funny and heard a pop in his foot. Now he is feeling sharp pain, and points to the lateral aspect of his ankle, just anterior to the lateral malleolus. You inspect the ankle and find edema beginning to form around the lateral malleolus.
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Critical thinking…
An athlete limps in to the ATR complaining of pain on the lateral aspect of his right ankle. He said he stepped off the curb funny and heard a pop in his foot. Now he is feeling sharp pain, just anterior to the lateral malleolus. You inspect the ankle and find edema beginning to form around the lateral malleolus. He states the pain is a 6/10 and he can’t put all his weight on the ankle.
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56
OA 11.13
• Identify 3 history questions to ask a soccer player who complains of discomfort in his dominant foot.
• List 5 anatomical areas you would observe.– What are you observing for?
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Palpation
• Allows us to feel what is going on
• Compares normal to abnormal
• Utilizes touch to gather information
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Palpation
• Bony Structures– Alignment– Crepitus – crackling
sound with movement– Joint alignment!
• Soft Tissues– Swelling– Painful areas– Muscle/tendon deficit
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Range of motion
• Definition:– Range of motion refers to the distance
and direction a joint can move between the flexed position and the extended position
– In true clinical settings,we use a goniometerto measure ROM
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Range of motion
• Types– Active range of motion (AROM)– Passive range of motion (PROM)– Resistive range of motion (RROM)
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Range of motion
• AROM– The patient’s ability to move a joint under
their own strength• PROM
– The joint’s ability to be moved through a range of motion
• RROM– Measurement of the muscle strength of a
joint through the ROM
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Range of motion
• Performed bilaterally on the uninjured side first– Why??
Allows us to get a look at what is normal for that athlete!
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Range of motion
• For the foot…– ROM occurs at
each joint– Only the MTP &
IP joints of the toes are assessed
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Range of motion
• For the ankle…– ROM occurs at
the subtalar and talocrural joints
– Both are assessed as one unit
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Movements
• The foot & ankle act together during movement
• The toes are assessed together
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Movements
Ankle Movements• Dorsiflexion• Plantar Flexion
• Inversion• Eversion
Toe Movements• Flexion• Extension
• Adduction• Abduction
– Only for Great & 5th toe
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Ankle movements
• Dorsiflexion (DF) – elevating the toes above the ankle joint
• Aka: walking on your heels
• Normal: 20o
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Ankle movements
• Plantarflexion (PF) – depressing the toes below the ankle joint
• Aka: walking on your toes, pushing a gas pedal
• Normal: 50o
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Ankle movements
• Inversion (INV) – bringing the sole of the foot medial
• Aka: walking on the outside of the foot
• Normal: 20o
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Ankle movements
• Eversion (EV) – bringing the sole of the foot lateral
• Aka: walking on the arch/inside of the foot
• Normal: 5o
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Toe movements
• Flexion (FLEX) – decreasing the joint angle by bringing the bones together
• Aka: curling the toes• Normal: 45-90o
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Toe movements
• Extension (EXT) – increasing joint angle by separating the bones
• Aka: straightening the toes
• Normal: 70o at the MTP joints
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Toe Movements
• Abduction (ABD) & Adduction (ADD) (Great & 5th toe):–Simply known as
splaying or squeezing the toes
• Normal: ??
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Assessing ROM
• When assessing, make note of:– Differences in AROM– Pain during PROM– Decreased strength during RROM
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Assessing AROM
• Have the patient move their ankle through the 4 movements– Toes up like walking on heels– Point toes like pushing on gas pedal– Bring big toe in and down– Bring little toe out and up
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Assessing AROM
• Have the patient flex & extend, ABD & ADD the toes– Curl your toes– Straighten them– Splay the toes– Squeeze the toes
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Assessing PROM
• The examiner will move the ankle through the ROMs to the extreme end – why??– I am going to move your foot/ankle for you.
Just try to relax and let me know if you feel discomfort, pain, or anything unusual.
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Assessing RROM
• The athlete will move through each ROM as the examiner places resistance against the movement– DF – pull the dorsal foot downward– PF – resist the sole of the foot– INV – push against the 1st MTP joint– EV – push against the 5th MTP joint
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Assessing RROM
• The athlete will move through each ROM as the examiner places resistance against the movement– Toe FLEX – resist the curling of the toes– Toe EXT – resist the straightening of the
toes
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Resistive range of motion
• Each motion is caused by certain muscles or muscle groups
• DF: tibialis anterior• PF: gastrocnemius &
soleus (calf muscles)• INV: tibialis posterior• EV: peroneal muscle
group
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Grading ROM
• AROM & PROM are graded as within normal limits (WNL) or decreased/limited & why– AROM: R = WNL, L = decreased DF due to
pn
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Grading ROM
• RROM is graded on a 0-5 scale
0. Absent – no muscle contraction 1. Trace – contraction without movement 2. Poor – full ROM without gravity 3. Fair – full ROM against gravity 4. Good – 3 + some resistance 5. Normal – 3 + full resistance
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Documenting ROM
• When documenting ROM, each movement must be listed & assessed.
AROM: R = WNL, L = WNL
PROM: R = WNL, L = WNL with Pn
RROM: R = 5/5DF, 5/5PF, 5/5INV, 5/5EV; L = 5/5DF, 3/5PF due to Pn, 3/5INV due to Pn, 2/5EV due to Pn
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So far…
• Gathered clues by taking a history• Observed for signs of injury• Palpated the structures for
abnormalities• Tested ROM to find differences
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Differential Diagnosis
• By now the choices of injury should be narrowed down to a handful of options…
• A list of possible injuries is known as a Differential Diagnosis (DDx)
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Rule Them Out
• In order to determine the injury, we must rule out the DDx
• To do this we use special tests
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Special Tests
• Ligamentous• Joint play• Neurological• Vascular
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88
OA 11.14
• What does HOPS stand for?• Which part is most important?• A list of possible injuries is known as
a…
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SPECIAL TESTS FOR FRACTURES
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Long Bone Compression Test
• Patient: supine• Examiner: standing in front of patient’s
feet• Action: grasp one MT by the head and
apply an axial force down the length of the bone.
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Long bone compression test
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Long Bone Compression Test
• Positive: pain along the MT shaft• Pathology: MT fracture
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Tap test
• Patient: supine• Examiner: standing in front of patient’s
feet• Action: tap on the end of the phalange
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Tap test
• Positive: pain along the phalange• Pathology: phalangeal fracture
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Squeeze test
• Patient: supine• Examiner: adjacent to injured leg, hands
cupped behind tibia/fibula• Action: gently squeeze the tibia/fibula,
progress towards site of pain
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Squeeze test
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Squeeze test
• Positive: pain; crepitus• Pathology: fibular fracture; syndesmosis
sprain
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Bump test
• Patient: supine• Examiner: standing in front of involved
heel• Action: Dorsiflex the ankle and bump
the calcaneus
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Bump test
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Bump test
• Positive: pain• Pathology: stress fracture of talus or leg
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SPECIAL TESTS FOR SPRAINS
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Anterior drawer test• Patient: Sitting over edge of table with knee
flexed• Examiner: Sitting in front of patient
– Hand 1 stabilizing leg above malleoli– Hand 2 cups calcaneus with foot on forearm
• Action: Calcaneus and talus drawn forward while stabilizing leg
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Anterior drawer test
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Anterior drawer test• Positive: Increased translation of talus; lack
of end feel; pain• Pathology: ATF ligament sprain
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Talar tilt test (INVersion)
• Patient: Supine or Sitting over edge of table with knee flexed
• Examiner: In front of patient– Hand 1 grasps calcaneus– Hand 2 stabilizes leg above malleoli
• Action: Hand 1 provides inversion stress
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Talar tilt test (Inversion)
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Talar tilt test (INVersion)
• Positive: Increased tilt of talus or gap; lack of end feel; pain
• Pathology: CF ligament sprain & possible ATF sprain
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Talar tilt test (EVersion)
• Patient: Supine or Sitting over edge of table with knee flexed
• Examiner: In front of patient– Hand 1 grasps calcaneus– Hand 2 stabilizes leg above malleoli
• Action: Hand 1 provides eversion stress
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Talar tilt test (Eversion)
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Talar tilt test (EVersion)
• Positive: Increased tilt of talus or gap; pain
• Pathology: Deltoid ligament sprain
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SPECIAL TESTS FORTENDON RUPTURES
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Thompson’s test
• Patient: Prone with feet off edge of table• Examiner: Side of patient
– Hand 1 over gastroc muscle• Action: Squeeze gastroc while
observing plantar flexion of foot
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Thompson’s test
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Thompson’s test
• Positive: No plantar flexion• Pathology: Achilles tendon rupture
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INJURIES
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objectives
• Identify pathologies that occur in the foot & ankle, differentiating their signs & symptoms–Bony pathologies–Ligamentous pathologies–Musculotendinous pathologies–Other structural/functional pathologies
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STRUCTURAL DEFORMITIESOf the foot
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Foot malalignments
• Pes Planus (flat foot)– Rigid or flexible– Trauma/weakness to supporting structures
of the arch• Pes Cavus (hollow foot)
– Congenital– Less effective at absorbing ground forces
than pes planus
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Pes planus and pes cavus
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Foot malalignments
• Mallet toe – DIP flexion
• Hammer toe – PIP flexion
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SKELETAL PATHOLOGIESOf the foot
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fractures
• Can occur to any bone in the foot/ankle• Some are more typical than others• All may have general Sx/Sy:
– Deformity– Limited ROM– Crepitus– Localized pain– Radiating pain– Swelling– Inability to bear weight
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Jones vs. base of 5th fracture
Jones Fx• Proximal base of
the 5th metatarsal – 1 cm from styloid process
Base of 5th Fx• Attachment of
peroneus brevis muscle
• Often avulsion fx from countering INV mechanism
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Jones vs. base of 5th fracture
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Metatarsal stress fracture
• Known as aMarch Fx
• Stress fx of metatarsal 2-4 (typically)–Very localized pain–Dull pain–Worsens with activity
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What is the diagnosis?
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Lisfranc injury
• Acute injury• Mechanism of Injury (MOI)
– Rotation of the TMT joints– Forced hyper-plantarflexion– Forced toe extension & DF
• Displacement of the metatarsals• Severe pain & swelling; “pop” or
“tear”• Most require surgery
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SOFT TISSUE PATHOLOGIESOf the foot
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sprains
• Can occur to any ligament in the foot/ankle
• General Sx/Sy– Limited ROM– Localized pain– Swelling - edema– Inability to bear weight– (+) special test for that ligament
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Arch sprain
• Caused by increased stress on arch• Flattening of the foot• Acute or chronic• Sx/Sy:
– Pain with weight bearing activities– swelling
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Plantar fasciitis
• MOI: acute or insidious
• Sx/Sy:– Pain at origin &
plantar fascia after non-weight bearing (NWB)
– Pain w/ DF & toe extension
– Tight gastrocs, old age, ↓ ankle mobility
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Hallux Valgus
• Great toe deformity• Degeneration of 1st MTP joint• Often leads to bunions
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1st MTP Joint sprain
• “Turf toe”• MOI: planted foot w/
DF ankle–Hyperextension of the
MTP joint–Pain with push-off,
joint ROM, quick stops
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Retrocalcaneal bursitis
• “Pump bump”• Inflammation of
the Achilles bursa
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SKELETAL PATHOLOGIESOf the ankle
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Tibial/fibular fracture
• MOI: Direct blow, or INV/EV stress
• May have:– gross deformity– audible “pop”– inability to bear weight
• Sx/Sy:– Localized pain, radiating pain– Crepitus & swelling
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Talus fracture
• MOI: forced dorsiflexion with inversion• May mimic an ankle sprain• Avascular necrosis may develop• Often missed in
x-rays – CT/MRI to confirm
• Surgical fix
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Stress fracture
• MOI: chronic microtraumatic forces• Sx/Sy:
– Gradual onset– Localized pain over shaft of bone
(“aching” pain)– Pain ↑ w/ activity & ↓ w/ rest– Often missed on x-rays– May mimic MTSS
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Stress fracture
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Medial tibial stress syndrome
• AKA: “Shin splints”• MOI: chronic pulling of the periosteum
surrounding the tibia by the posterior tibialis muscle
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Medial tibial stress syndrome
• Sx/Sy:– Gradual onset from overuse, muscle
fatigue, biomechanics– Pain during activity, relieved with rest– Diffuse pain along the medial tibia– Pain with palpation– Pain during RROM for INV
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Medial Tibial Stress Syndrome
• Medial Tibial Stress Syndrome
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SOFT TISSUE PATHOLOGIESOf the ankle
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Lateral ankle sprains
• Inversion with plantarflexion mechanism
• Most common injury to the body– Why?? – anatomically– Stronger deltoid
ligament, lateral malleoli extends further
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Lateral ankle sprains
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Lateral ankle sprains
• Area of pain = ligament involved
• Anterior talofibular = sinus tarsi
• Calcaneofibular = distal to lateral malleolus
• Posterior fibular = posterior to lateral malleolus
• Graded on a 1-3 scale
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Lateral ankle sprains
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Deltoid sprain
• Eversion or rotation mechanism
• Rare injury (5%) – most occur as avulsion fracture
• Sx/Sy:– General ligament
sprain sx/sy
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Deltoid sprain
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Syndesmosis sprain
• AKA “High ankle sprain”• MOI: Forced DF and/or eversion; rotation• Slow to heal
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Syndesmosis sprain
• Sx/Sy:– Pain around & above ankle mortise– Inability to bear weight– Decreased ROM
• Anterior tibiofibular ligament• Interosseous membrane
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Syndesmosis sprain
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Achilles tendinitis
• Inflammation of the tendon due to overuse
• Sx/Sy:– Visibly enlarged Achilles tendon from
posterior aspect– ↓ strength & ROM– Altered gait or physical performance– Localized pain (“burning”)– Crepitus
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Achilles tendinitis
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Compartment syndrome
• Caused by direct blow or injury within fascial compartment– Typically anterior or deep posterior
compartments
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Compartment syndrome
• Sx/Sy:– Severe pain – “ache”, “dull”, “sharp”– Muscle tightness, weakness, cramping; ↓
strength & ROM– Feeling of numbness & tingling in area– Sensation of hot/cold
• Medical emergency
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Compartment syndrome
Compartment Syndrome