Chapter 16-18

Lower Extremity

Label the bones

1. phalnges
2. tuberosity of the 5th metatarsal
3. cuboid
4. midtarsal joint

Label the bones

1. metatarsals
2. cuneiforms
3. navicular
4. talus
5. calcaneus
6. sesamoid

Label the midfoot, forefoot, hindfoot

1. forefoot
2. midfoot
3. hindfoot

Label the medial ligaments

1. deltoid
2. dorsal talonavicular
3. calcaneonavicular
4. long plantar

What are the motions of the talocrural joint

dorsiflexion

plantar flexion

What are the motions of the subtalar joint

pronation

supination

Intrinsic foot muscles

originate and insert on the foot and produce toe movement

Extrinsic foot muscles

originate on the leg and produce ankle movement

What does this imaginary line determine

extrinsic muscle function: medial

What does this imaginary line determine

lateral, anterior, and posterior components

What is this

contents of the anterior compartment of the leg

Anterior palpation- foot/ lower leg

tibial crest

anterior tibiofibular joint

anterior dome of talus

anterior tibialis

extensor hallicus longus tendon

extensor digitorum longus tendon

dorsal pedal pulse

cuneiforms

metatarsals

phalanges

Medial palpation- foot/ lower leg

tibial shaft

medial malleolus

deltoid ligament

tibialis posterior, flexor digitorum, and hallicus longus tendond

posterior tibial artery

navicular tuberosity

medial cuneiform

first metatarsal base, shaft, and head

first toe

Lateral palpation- foot/ lower leg

fibula

peroneal muscles and tendons

lateral malleolus

anterior and posterior talofibular ligaments

calcaneofibular ligament

sinus tarus

cuboid

base of fifth metatarsal

fifth phalanx

Posterior palpation- foot/ lower leg

gastronemius and soleus

achilles tendon

calcaneus

calcaneal fat pad

plantar aponeurosis

metatarsal heads

sesamoid bones

Active ROM exam- foot/ lower leg (non-weight bearing)

\*bilateral

* dorsiflexion
* plantar flexion
* inversion
* eversion
* toe extension, flexion, and abduction

Active ROM exam- foot/ lower leg (weight bearing)

Bilateral

* plantar flexion
* dorsiflexion
* inversion
* eversion

Accessory joint motion- foot/ lower leg

distal tibiofibular ventral and dorsal glide

talocrural distraction

dorsal talor glide

ventral talor glide

subtalar joint medial-lateral glide

midtarsal joint anterior-posterior glide

tarsometarsal joint anterior- posterior glide

MP and IP distraction, rotation, dorsal, and ventral glides

Strength exam- foot/ lower leg

manual muscle test for same movements performed for active ROM

include knee flexion

Sensory testing- foot/ lower lateral leg

deep peroneal nerve- first dorsal web space

superficial peroneal nerve- dorsum of the foot and lateral leg

tibial nerve- posteromedial heel

medial plantar nerve- medial three digits

lateral plantar nerve- fifth digit

Motor testing- foot/ lateral leg

all the nerves

What does posterior tibial nerve test

plantar flexion and toe flexion

What does superficial peroneal nerve test

eversion

What does deep peroneal nerve test

dorsiflexion and toe extension

What does medial plantar nerve test

great toe abduction

What does lateral plantar nerve test

fifth toe abduction

Reflex testing- foot/ knee

posterior tibialis tendon (L4-L5); not a common site

achilles tendon (s1-s2)

Vascular examination- foot/ lower leg

dorsalis pedis between tibialis anterior and extensor digitorum longus

posterior tibial artery just posterior to medial malleolus

changes in skin color

changes in temperature

Most common ankle sprain

lateral ankle sprains

How do lateral ankle sprains occur

inversion mechanism with or without plantar flexion

What ligament is most involved for lateral ankle sprains

anterior talofibular ligament (most often)

What fracture can occur with a lateral ankle sprain

avulsion fracture

What kind of injury is this

lateral ligaments of the ankle

What test is this

anterior drawer test

What test is this

medial talar tilt test

How do medial ankle sprains occur

eversion forces and are generally uncommon

What kind of instability can you have with a medial ankle sprain

chronic instability which can result in pes planuss or excessive pronation

What kind of stability does medial ankle sprains have

greater stability from joint structure and ligaments

What test is this

lateral talar tilt test

What test is this

Kleiger test

Syndesmotic sprains

aka high- ankle sprains

interruption of the tibiofibular ligaments and the interosseous membrane

result from excessive dorsiflexion or extereral rotation of the foot

What is this

syndesmotic sprain of the tibiofibular joint

What is this

modified kleiger test for syndesmotic separation

What is this

squeeze test for syndesmotic separation

Foot sprains

less common than ankle sprains

injury possible from direct and indirect forces

Lisfranc’s injury

spain of the ligament between first and second tarsometatarsal joints

Toe sprains

aka turf toe

result from direct contact, stubbing, or jamming

mechanism that results in the joint goin beyond its normal ROM

Signs and symptoms of turf toe

pain

swelling

decreased ROM

painful push-off (affects gait and running)

How does an achilles tendon rupture occur

results from a sudden or violent plantar flexion during eccentric loading in full weight bearing

Signs and symptoms of achilles tendon rupture

immediate pain and disability

swelling and discoloration

observable, palpable defect

What test is this

thompson test

How does a plantaris rupture occur

forceful contraction during running, jumping, or rapid direction change

Signs and symptoms of plantaris rupture

usually minimal

* sharp pain
* swelling
* possible loss of function

What does the peroneal retinaculum rupture result from/ what does it affect

tethers the peroneal muscles behind the lateral malleolus

results from direct blow or forceful inversion or eversion

Signs and symptoms of peroneal retinaculum rupture

snapping tendon

pain

swelling

What is this

ruptures peroneal retinaculum, causing disolation of the peroneal tendon

Retrocalcaneal bursitis (results from, what may occur)

results from repetitive overuse with running, direct pressure, or friction from poorly fitted shoes

thickening of the bursa and possible calcium formation may result

What is this

retrocalcaneal bursitis

Signs and symptoms of retrocalcaneal bursitis

localized swelling and inflammation

redness

point tenderness near the calcaneal attachment of the achilles

pain with active or resisted ROM

Plantar fascitis

inflammation of the plantar fascia

often seen in patients with abnormal foot alignment

What is plantar fascitis caused by

overuse

poor footwear or playing surface

improper conditioning

Signs and symptoms of plantar fasciitis

gradual onset of pain

pain upon arising in the morning

pain with direct pressure over the calcaneal tubercle

possible heel spurs

What is this

heel spur resulting from chronic tractioning of a tight plantar fascia

Calcaneal apophysitis

aka severs disease

occurs in skeletally immature athletes

results secondary to repetitive traction stress to the achilles tendon

Signs and symptoms of severs disease

posterior inferior heel pain

point tenderness

increased pain with weight bearing, running, jumping

decreased dorsiflexion ROM

Medial tibial stress syndrome (MTSS)

aka shin splints

inflammation of the periosteum (periostitis)

Predisposing factors of MTSS

excessive pronation

inflexible musculature

pes cavus

pes planus

Signs and symptoms of MTSS

diffuse pain

point tenderness

inflammation along the medial border of the tibia

* need to rule out stress fracture or compartment syndrome

Fractures to the tibia and fibula

results from direct blow or torsional mechanism

avulsion fractures can occur secondary to inversion ankle sprains

What is this

percussion

What is this

Pott’s compression test

Foot fracutres

most often affects the metatarsals and phalanges

Lisfranc’s fracture

fracture/ dislocation between midfoot and forefoot

Jones fracture

base of fifth metatarsal

What is this

Lisfranc’s fracture

Ottawa Ankle Rules (OAR)

validated set of clinical decision rules to rule out acute ankle

* pain in malleollar region
* bony tenderness along distal 6 cm of the posterior edge or tip of either malleolus
* inability to bear weight for at least four steps
* bony tenderness at navicular bone or base of the fifth metatarsal

Tibial Stress fractures

typically occur within the distal 1/3rd of the tibia

Metatarsal stress fractures

occur to the second or third metatarsal

Fifth metatarsal and fibula stress fractures

can be secondary to repetitive stress of the peroneal muscles

Signs and symptoms of stress fractures

insidious onset of pain

pain correlates directly with activity and rest

localized pain and swelling

Dislocations and subluxations

uncommon in the foot and ankle

tremendous force required

usually associated with fracture

Tarsal tunnel sundrome

compression of the tibial nerve in the tarsal tunnel

can result from direct trauma, acute fracture, or dislocation

often results secondary to abnormal foot and ankle mechanics, such as excessive pronation

Signs and symptoms of tarsal tunnel syndrome

pain

numbness in the arch

running active dorsiflexion often increase pain

foot fatigue

What is this

tinel’s sign

Mortons Neuroma

aka metatarsalgia

formation of a fibrous tissue buildup (tumor) around the nerve

occurs at the bifurcation of the lateral plantar nerve as it branches between the third and fourth metatarsal heads

What is this

Morton’s test

Additional nerve injuries- foot/ lower leg

medial plantar nerve compression

peroneal nerve palsy

superficial peroneal nerve palsy

deep peroneal nerve compression

Chronic compartment syndrome

exertional

results from muscle hypertrophy during exercise (tissue pressure high)

usually subsides after activity

pressure is not usually high enoguh to cause vascular collapse

Acute compartment syndrome

results from acute trauma

intracompartmental bleeding increases pressure and causes venous compromise

muscle ischemia and necrosis occur if untreated for 6 to 12 hours

* needs immediate medical attention

Signs and symptoms of compartment syndrome

severe progressive pain

compartment warm to the touch

overlying skin glossy, tense, and pale

sensory and motor loss over deep peroneal nerve distribution

Deep vein thrombophlebitis (DVT)

inflammation of a deep vein

commonly associated with a blood clot (thrombus)

occurs most frequently in the calf

Signs and symptoms of DVT

vague, dull aches in posterior calf

swelling

pallor

diminished or absent pedal pulse

be aware of potential complications, such as a pulmonary embolism

What is this

Homan's’ sign

What is this

Calcaneal- Tibial alignment test

What is this

calcaneal-tibial alignment

Structural abnormalities- foot/ lower leg

forefoot varus and valgus

rearfoot varus and valgus

pes planus and cavus

plantar flexed first ray

Toe deformities

hallux valgus and bunions

hallux rigidus

claw toess

hammer toes

mallet toe

morton’s toe

Label the knee bones and joints

1. shaft of femur
2. patellofemoral joint
3. patella
4. tibiofemoral joint
5. proximal tibiofibular joint
6. tibia
7. fibula

Label the knee ligaments

1. medial collateral
2. posterior cruciate
3. anterior cruciate
4. lateral collateral

Quad muscles

vastus medialis

vastus lateralis

vastus intermedius

rectus femoris