Module 6 - Lower Body Injuries

Ankle, Foot, and Lower Leg

What sports have the highest rate of injuries to this body region

• basketball

• soccer

• football

What is the most common sports injury

lateral ankle sprains

How many regions is the foot comprised of

3

• forefoot

• midfoot

• hindfoot

Functions of the ankle, leg, and foot

• provide support to upright body

• enabling propulsion

• adaptation to uneven terrain

• shock absorption

How many bones are in the foot

26

• 14 phalangeal

• 5 metatarsals

• 7 tarsals

List the tarsals

• Talus

• Calcaneus

• Navicular

• Cuboid

• 1st Cuneiform

• 2nd Cuneiform

• 3rd Cuneiform

Joints in the forefoot

• PIP and DIP

• First Digit

• First MTP

• MTP’s

• TMT and IMT

Proximal and Distal Interphalangeal Joints

• same in hands and feet

• reinforced by plantar and dorsal joint capsule and collateral ligaments

First digit joint

• main stabilizer during walking/running

First metatarsal phalangeal joint

• has 2 sesamoid bones serving as a pulley system

Metatarsal phalangeal joints

reinforced by:

• capsule

• medial/lateral ligaments

• plantar side by plantar fascia and plantar ligament

Tarsometatarsal and intermetatarsal joints

• deep transverse MT ligament, ent interconnects all 5 MT

• allows foot to adapt to uneven surfaces

Joints in the midfoot

• navicular

• mid tarsal joint

• calcanea-cuboid

• talo-calcaneo-navicular

Navicular joint

• medial side

• helps to bridge movement between hind foot and forefoot

Midtarsal joint

• two side by side articulations (calcaneocuboid and talonavicular)

• function as a unit

Calcaneo-cuboid joint

• saddle joint

• has a very limited gliding motion

Talo-calcaneo-navicular joint

• combined action of talonavicular and subtalar joint

• mechanically linked to subtler joint

Joints in the hindfoot

• talo-crural

• subtalar

Talo-crural joint

• articulation of talus, tibia and fibula

• lateral malleolus extends more distally, limiting eversion more then inversion

• dome of the talus is wider anteriorly then posteriorly

• No muscle attaches to the talus

• stability of the joint is ligament dependent

Subtalar joint

• lies beneath the talus

• facets of talus articulate with sustenaculum talus on superior calcaneus

Superior tibiofibular joint

• inferior lateral aspect of knee

• tightly reinforced with anterior and posterior ligaments

Inferior tibiofibular joint

• A syndesmosis, dense fibrous tissue binds bones together

• No joint capsule

• Supported by anterior and posterior tibiofibular ligaments and by the interosseous membrane

• This allows for some rotation and slight abduction to occur

Interosseus membrane

• lies between tibia and fibula

• fibrous netting

• connecting superior and inferior tibiofibular joints

Excessive ankle eversion + dorsiflexion can result in widening of the mortise and injuring the ligaments supporting the syndesmosis

True

Function of the arches of the foot

support and distribute body weight from the talus through the foot, through changing weight-bearing conditions and over varying terrain

Longitudinal arch

• higher medial then lateral

• navicular bone at peak

Transverse arch

• The medial to lateral arch of the midfoot/ forefoot

• Structural stability from tarsals, MTs, plantar ligaments and transverse MT ligaments

• Dynamic support from the peroneous longus (lateral), tib post (medial), and foot intrinsics

Medial collateral ligaments

• anterior tibiotalar

• tibiocalcaneal

• posterior tibiotalar

• tibionavicular

Lateral collateral ligaments

• anterior talofibular

• calcaneofibular

• posterior talofibular

Deltoid ligaments

1) Ant Tibiotalar (ATT)

2) Tibio-navicular (TN)

3) Tibio-calcaneal (TC)

4) Post Tibiotalar (PTT)

Anterior tibiotalar O+I

O: anteromedial aspect of medial malleolus

I: superior portion of medial talus

Tibiocalcaneal O+I

O: apex of medial malleolus

I: calcaneus (directly below medial malleolus)

Posterior tibiotalar O+I

O: posterior aspect of medial malleolus

I: posterior portion of talus

Tibionavicular O+I

O: distal and slightly posterior to anterior tibiotalar

I: medial aspect of navicular

Lateral ligaments

1) Ant Talofibular (ATFL)

2) Calcaneofibular (CF)

3) Post Talofibular (PTFL)

Anterior talofibular O+I

O: anterolateral surface of lateral malleolus

I: talus

Calcaneofibular O+I

O: posterior apex of lateral malleolus

I: inferior/posterior calcaneus

Posterior talofibular O+I

O: posterolateral border of lateral malleolus

I: posterior talus and calcaneus

What ligaments are taut when subtalar joint is plantar flexed

• anterior tibiotalar

• tibio-navicular

What ligaments are taut during dorsiflexion

• tibio-calcaneal

• posterior tibio-talar

What ligament limits posterior displacement of the talus on the tibia

Posterior talofibular (PTF) ligament

What ligament is taut in extreme range of dorsiflexion

Calcaneofibular (CF) ligament

What ligament is the primary restraint of talar inversion within midrange of motion

Calcaneofibular (CF) ligament

What ligament is taut and resists inversion during plantar flexion

Anterior talofibular (ATF) ligament

What ligament limits anterior translation of talus on the tibia

Anterior talofibular (ATF) ligament

Plantar fascia

• a specialized, thick, interconnected band of fascia, covering the plantar aspect of the foot

Origin of plantar fascia

plantar-distal aspect of calcaneus

Insertion of plantar fascia

metatarsal heads

Function of plantar fascia

provide support for longitudinal arch

Windglass effect

during the gait cycle, fascia stretches 9-12% of its resting length and acts like a spring to store mechanical energy to help with the foot at push off

Tibialis anterior origin

lateral/upper ½ of tibial shaft

Tibialis anterior insertion

medial/inferior surface of 1st cuneiform and 1st MT

Tibialis anterior muscle action

• dorsiflexion

• inversion

Extensor digitorum longus origin

lateral/proximal tibia and fibula

Extensor digitorum longus insertion

dorsum of middle/distal phalanges of digits 2-5

Extensor digitorum longus muscle action

• extension of MTP and IP joints

• assist dorsiflexion and eversion

Extensor hallucis longus origin

mid half of anterior fibula

Extensor hallucis longus insertion

base of distal phalanx of great toe

Extensor hallucis longus muscle action

• extension of MTP and IP of 1st toe

• assist dorsiflexion and inversion

Peroneus longus origin

head and upper 2/3 of fibula

Peroneus longus insertion

lateral side of base of 1st MT and medial cuneiform

Peroneus longus muscle action

• plantar flexion

• eversion

Peroneus brevis origin

lower 2/3 of fibula

Peroneus brevis insertion

base of 5th MT

Peroneus brevis muscle action

eversion

Gastrocnemius origin

posterior surface of femoral condyles

Gastrocnemius insertion

achilles tendon on calcaneus

Gastrocnemius action

• knee flexion

• plantar flexion

Soleus origin

• posterior head and shaft of fibula

• soleal line and adjacent medial tibia

Soleus insertion

deep surface of tendon-calcaneus junction (achilles tendon)

Soleus action

plantar flexion

Plantaris origin

• post-lateral femoral condyles

• prox to gastroc origin

Plantaris insertion

medial tendo-calcaneus junction

Plantaris action

• assist knee flexion

• weak plantar flexion

Flexor hallucis longus origin

distal-posterior 2/3 of fibula

Flexor hallucis longus insertion

plantar distal phalanx of big toe

Flexor hallucis longus action

• flexion through 1st toe and MTP

• ankle and foot inversion

Flexor digitorum longus origin

posterior medial tibia

Flexor digitorum longus insertion

plantar aspect of distal phalanges 2-5

Flexor digitorum longus action

• flexion of DIP, PIP, MTP 2-5

• ankle PF and inversion

Tibialis posterior origin

• between FDL and FHL

• posterior-mid 2/3 of tib-fib shafts

Tibialis posterior insertion

• navicular

• 3 cuneiforms

• cuboid

• base of 2-4 MTs

Tibialis posterior action

• inversion

• assist PF

Popliteus origin

lateral femoral condyles

Popliteus insertion

• posterior tibia

• above soleal line

Popliteus action

• medially rotate tibia

• laterally rotate femur

Major vascular structures in the leg

• Femoral artery

• Popliteal artery

• Anterior and Posterior Tibial arteries

• Dorsalis Pedis artery

Major nerves in leg

• Anterior: Femoral (saphenous)

• Posterior: Sciatic nerve

  • Tibia nerve

    • sural nerve

  • Common Peroneal

    • deep peroneal

    • superficial peroneal

Ottawa ankle rules

X-ray required if:

• pain in malleolar zone (crease on top of ankle where leg meet foot)

• bone tenderness on posterior edge/tip of lateral malleolus

• bone tenderness on base of 5th MT

• inability to bear weight

OR

• pain in midfoot zone

• bone tenderness on posterior edge/tip of lateral malleolus

• bone tenderness on navicular

• inability to bear weight

Foot contusion MOI

• compression to the midfoot including plantar region (often from cleat/spike)

• heel compression

• direct blow

Foot contusion S+S

• pain

• swelling

• bruising

• pain while weight bearing barefoot

Injured structures in foot contusion

Lower leg: tibia, fibula, gastrocnemius

Hind-foot: calcaneal fat pad

Fore-foot: extensor tendons, metatarsals, phalanges

Acute management for foot contusion

• NSAID

• PRICE

• heel cup or doughnut in shoe

• avoid aggravating activities

• heel taping

What situations are foot contusions commonly seen in

• running/jumping

• increased body weight

• age

• poor footwear

• change in training

• uneven ground

Recovery timeline for foot contusion

based on severity

RTS considerations for foot contusion

• may not be limited

• within pain tolerance

Metatarsal/Interphalangeal sprains and dislocations MOI

• tripping/stubbing toe

• varus or valgus force to 1st and 5th toes

Injured structures in metatarsal/interphalangeal sprains and dislocations

• collateral ligaments

• capsule

Secondary injuries to metatarsal/interphalangeal sprains and dislocations

• tendons strain

• bone bruise

• osteochondral fracture

Metatarsal/Interphalangeal sprains and dislocations S+S

• pain

• tenderness

• immediate swelling

• limited weight bearing

• gross deformity