Chapter 18 ( pp 487-496) - PowerPoint Presentation

Slide1

Chapter 18 (pp 487-496)

Injuries to the

Foot & Ankle

Slide2

ObjectivesIdentify…

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

Slide3

The bonesThe foot contains 28

bones

Phalanges (16)

Proximal (1-5)

Intermediate (2-5)

Distal (1-5)Sesamoids (1)

Slide4

The bonesThe foot contains

28

bones

Metatarsals (5)

Tarsal bones (7)

CuneiformsMedial, intermediate

, lateralCuboid, Navicular

Talus,

Calcaneous

Slide5

The bonesTibiaFibula

Slide6

PhalangesThere are 14 total phalanges

Great toe =

2

All other toes =

3

Each toe has a proximal, intermediate, & distal phalange (except Great toe)

Slide7

PhalangesGreat toe has 2

sesamoid

bones

Act like “mini patella” to increase

leverage and

protect

the joint

Slide8

metatarsalsEach 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

Slide9

Tarsal bonesThe 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)

Slide10

Bones of the legTibia and fibula

extend past the

talus

bone

Distal end is referred to as the malleolus

Medial = tibial

Lateral = fibular

Slide11

Bones of the legTibiaLarger of the two bones

Primary

weight bearing

bone

Slide12

Bones of the legFibula

Smaller bone, extends more

distally

Provides for muscle attachments

≤

10% weight bearing

Slide13

the ligamentsImportant ligaments in the foot:Calcaneonavicular ligament (spring ligament)

Slide14

The ligamentsMedial ankle:Deltoid ligament

Slide15

The ligamentsLateral ankle:Anterior

talofibular

(ATF)

Calcaneofibular

(CF)

Posterior talofibular(PTF)

Not shown

Slide16

The ligamentsLower leg:Distal anterior

tibiofibular

ligament

Distal posterior

tibiofibular

ligamentInterosseous membrane

Slide17

OA 11.5Identify the bones:A

D

E

C

17

Slide18

articulationsInterphalangeal

(IP, PIP, DIP)

Metatarsophalangeal

(MP or MTP) joints

Intermetatarsal

jointsTarsometatarsal (TMT) joints Subtalar

jointTalocrural joint

Slide19

Subtalar jointArticulation of the

talus

&

calcaneus

Slide20

Talocrural jointTibia, fibula, talus

Mortise &

tenon

configuration

Talus is

wedge-shapedLateral malleolus extends more distally than medial

malleolus

Slide21

Arches of the footSupport body weightAbsorb forces from the

ground

Provide space for blood vessels, tendons, & muscles

Slide22

Arches of the footMetatarsal Arch –

across metatarsal heads

Transverse Arch

–

across metatarsal bases & cuneiforms

Medial Longitudinal Arch –

along the medial aspectLateral Longitudinal Arch –

along the lateral aspect

Slide23

Arches of the foot

Slide24

Plantar fasciaBroad, thick tissue covering the bottom of the footExtends from the

calcaneus

to the

base of each metatarsal

Supports the foot against downward forces

Slide25

Muscles & tendonsIntrinsic muscles of the foot:Toe extensor

Toe flexors (3)

Great toe & 5th toe abductors

Great toe adductor

Slide26

Muscles & tendonsExtrinsic muscles of the foot:Divided by compartments

Anterior

Lateral

Superficial

posteriorDeep posterior

Slide27

Slide28

Muscles & tendonsAnterior compartmentTibialis anterior

Extensor

hallucis

longus

Extensor digitorum longus

Dorsiflex

the foot

Slide29

Muscles & tendonsLateral compartmentPeroneus

longus

Peroneus

brevis

Evert the foot

Slide30

Muscles & TendonsSuperficial posterior compartmentGastrocnemius

Soleus

Plantaris

Plantarflex

the foot

Slide31

Muscles & tendonsDeep posterior compartmentTibialis posterior

Flexor

hallucis

longus

Flexor digitorum longus

Plantarflex

& invert the foot

Slide32

Neurological & VascularTibial nerve

Posterior leg &

plantar

aspect of foot

Common peroneal nerve

Anterior

leg & foot

Blood supply

Anterior

tibial

artery



Dorsal pedal artery

Posterior

tibial

artery

Slide33

Distal pulse

Slide34

OA 11.12If 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?

34

Slide35

The Foot & AnkleEvaluation

Slide36

ObjectivesIdentify…

Pertinent information to gather during a foot & ankle evaluation

Important observations to make during a foot & ankle evaluation

???

Slide37

The Secondary SurveyAfter 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 AssessmentDOCUMENT EVERYTHING!

Slide38

Hops technique

Slide39

The Evaluation ProcessH.O.P.S.

H

istory

O

bservation

PalpationRange of motion

Special tests

H.I.P.S.

H

istory

I

nspection

P

alpation

Range of Motion

S

pecial tests

Slide40

HistoryWhat happened?Gain information about the patient and the injury

Most critical part of the evaluation!

Past medical history

History of the present condition

Slide41

HistoryStart with generic history questions

Chief complaint

Age

Occupation / sport / position etc.

General health

conditionActivity levelMedications

Slide42

HistoryHistory of previous injuriesWhat happened?

Who did you see?

What did they tell you?

How long were you out?

Has it fully resolved?

Slide43

HistoryMechanism of injuryHow did it happen?

Tension

= sprain; fracture; strain

Torsion

= sprain; fracture

Compression

= contusion; fractureShear

= fracture; sprain

Bending

= fracture

Slide44

Slide45

History

Ask 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?

Slide46

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

Slide47

HistorySounds & sensationsDid you hear any sounds? Did you hear any pops, crackles, snaps, clicks?

What could this

indicate???

Did you feel

anything unusual?

Slide48

HistorySpecific 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

Slide49

ObservationAthlete Moving?Position of athlete?

Conscious?

Primary Survey

Inspect injury site

Secondary

Survey

Slide50

ObservationWhen does this begin?Compare each side

bilaterally

to identify what is normal for

that person

We look for:

Deformity, asymmetry,

edema, ecchymosis

Slide51

Observation

We assess:

Gait

Gross motor function

Posture/position

Facial expressionGuarding

Slide52

ObservationGait – 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

Slide53

ObservationCan the athlete move the limb on their own through normal function?

Is the arch maintained while both weight-bearing and non-weight bearing

Slide54

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.

Slide55

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.

Slide56

OA 11.13Identify 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?

56

Slide57

PalpationAllows us to

feel

what is going on

Compares

normal to

abnormalUtilizes touch to gather information

Slide58

PalpationBony Structures

Alignment

Crepitus

– crackling sound with movement

Joint alignment!

Soft TissuesSwelling

Painful areasMuscle/tendon deficit

Slide59

Range of motionDefinition: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

Slide60

Range of motionTypesActive range of motion (

AROM

)

Passive range of motion (

PROM

)Resistive range of motion (RROM)

Slide61

Range of motionAROMThe patient’s ability to move a joint

under their own strength

PROM

The joint’s ability to be

moved through a range of motion

RROMMeasurement of the muscle strength of a joint through the ROM

Slide62

Range of motionPerformed bilaterally on the

uninjured

side first

Why??

Allows us to get a look at what is normal for that athlete!

Slide63

Range of motionFor the foot…ROM occurs at each joint

Only the MTP & IP joints of the toes are assessed

Slide64

Range of motionFor the ankle…ROM occurs at the subtalar

and

talocrural

joints

Both are assessed as

one unit

Slide65

MovementsThe foot & ankle

act

together during movement

The toes are

assessed

together

Slide66

MovementsAnkle Movements

Dorsiflexion

Plantar

Flexion

Inversion

Eversion

Toe Movements

Flexion

Extension

Adduction

Abduction

Only for Great & 5

th

toe

Slide67

Ankle movementsDorsiflexion (DF)

– elevating the toes above the ankle joint

Aka:

walking on your heels

Normal: 20

o

Slide68

Ankle movementsPlantarflexion

(PF)

– depressing the toes below the ankle joint

Aka:

walking on your toes

, pushing a gas pedalNormal: 50o

Slide69

Ankle movementsInversion (INV)

– bringing the sole of the foot medial

Aka:

walking on the outside of the foot

Normal:

20o

Slide70

Ankle movementsEversion (EV)

– bringing the sole of the foot lateral

Aka:

walking on the arch/inside of the foot

Normal:

5o

Slide71

Toe movementsFlexion (FLEX)

– decreasing the joint angle by bringing the bones together

Aka:

curling the toes

Normal:

45-90o

Slide72

Toe movementsExtension (EXT)

– increasing joint angle by separating the bones

Aka:

straightening the toes

Normal:

70o at the MTP joints

Slide73

Toe MovementsAbduction (ABD) & Adduction (ADD) (Great & 5

th

toe):

Simply known as

splaying or squeezing the toes

Normal: ??

Slide74

Assessing ROMWhen assessing, make note of:

Differences in AROM

Pain during PROM

Decreased strength during RROM

Slide75

Assessing AROMHave 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 downBring little toe out and up

Slide76

Assessing AROMHave the patient

flex & extend, ABD & ADD the toes

Curl your toes

Straighten them

Splay the toes

Squeeze the toes

Slide77

Assessing PROMThe 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.

Slide78

Assessing RROMThe athlete

will move

through each ROM as the

examiner

places resistance against the movementDF – pull the dorsal foot downwardPF – resist the sole of the foot

INV – push against the 1st MTP jointEV – push against the 5th MTP joint

Slide79

Assessing RROMThe athlete

will move

through each ROM as the

examiner

places resistance against the movementToe FLEX – resist the curling of the toesToe EXT – resist the straightening of the toes

Slide80

Resistive range of motionEach motion is caused by certain muscles or muscle groups

DF:

tibialis

anterior

PF: gastrocnemius & soleus (calf muscles)

INV: tibialis posteriorEV:

peroneal muscle group

Slide81

Grading ROMAROM & PROM are graded as within normal limits

(

WNL

) or decreased/limited

& why

AROM: R = WNL, L = decreased DF due to pn

Slide82

Grading ROMRROM is graded on a 0-5 scale

Slide83

Documenting ROMWhen documenting ROM, each movement must be

listed

&

assessed

.

AROM: R = WNL, L = WNLPROM: R = WNL, L = WNL with

PnRROM

: 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

Slide84

So far…Gathered clues by taking a history

Observed

for signs of injury

Palpated

the structures for abnormalities

Tested ROM to find differences

Slide85

Differential DiagnosisBy 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

)

Slide86

Rule Them OutIn order to determine the injury, we must rule out

the

DDx

To do this we use

special tests

Slide87

Special TestsLigamentousJoint play

Neurological

Vascular

Slide88

OA 11.14What does HOPS stand for?Which part is most important?

A list of possible injuries is known as a…

88

Slide89

Special tests for fractures

Slide90

Long Bone Compression TestPatient: 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.

Slide91

Long bone compression test

Slide92

Long Bone Compression TestPositive: pain along the MT shaft

Pathology

: MT fracture

Slide93

Tap testPatient: supine

Examiner

: standing in front of patient’s feet

Action

: tap on the end of the phalange

Slide94

Slide95

Tap testPositive: pain along the phalange

Pathology

: phalangeal fracture

Slide96

Squeeze testPatient: supine

Examiner

: adjacent to injured leg, hands cupped behind tibia/fibula

Action

: gently squeeze the tibia/fibula, progress towards site of pain

Slide97

Squeeze test

Slide98

Squeeze testPositive: pain; crepitus

Pathology

: fibular fracture;

syndesmosis

sprain

Slide99

Bump testPatient: supine

Examiner

: standing in front of involved heel

Action

:

Dorsiflex the ankle and bump the calcaneus

Slide100

Bump test

Slide101

Bump testPositive: pain

Pathology

: stress fracture of talus or leg

Slide102

Special tests for sprains

Slide103

Anterior drawer testPatient

: 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

Slide104

Anterior drawer test

Slide105

Anterior drawer testPositive

: Increased translation of talus; lack of end feel; pain

Pathology

: ATF ligament sprain

Slide106

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 malleoliAction

: Hand 1 provides inversion stress

Slide107

Talar

tilt test (Inversion)

Slide108

Talar tilt test (INVersion)

Positive

: Increased tilt of talus or gap; lack of end feel; pain

Pathology

: CF ligament sprain & possible ATF sprain

Slide109

Talar tilt test (EVersion)

Patient

: Supine or Sitting over edge of table with knee flexed

Examiner

: In front of patient

Hand 1 grasps calcaneusHand 2 stabilizes leg above malleoli

Action: Hand 1 provides eversion stress

Slide110

Talar

tilt test (Eversion)

Slide111

Talar tilt test (EVersion)

Positive

: Increased tilt of talus or gap; pain

Pathology

: Deltoid ligament sprain

Slide112

Special tests fortendon ruptures

Slide113

Thompson’s testPatient: Prone with feet off edge of table

Examiner

: Side of patient

Hand 1 over

gastroc

muscleAction: Squeeze

gastroc while observing plantar flexion of foot

Slide114

Thompson’s test

Slide115

Thompson’s testPositive: No plantar flexion

Pathology

: Achilles tendon rupture

Slide116

injuries

Slide117

objectivesIdentify pathologies that occur in the foot & ankle, differentiating their signs & symptoms

Bony pathologies

Ligamentous pathologies

Musculotendinous

pathologies

Other structural/functional pathologies

Slide118

Structural deformitiesOf the foot

Slide119

Foot malalignmentsPes

Planus

(

flat foot

)Rigid or flexibleTrauma/weakness to supporting structures of the arch

Pes Cavus

(

hollow foot

)

Congenital

Less effective at absorbing ground forces than

pes

planus

Slide120

Pes planus and pes cavus

Slide121

Foot malalignmentsMallet toe –

DIP

flexion

Hammer toe –

PIP

flexion

Slide122

Skeletal pathologiesOf the foot

Slide123

fracturesCan occur to any bone in the foot/ankleSome are more typical than others

All may have general

Sx

/

Sy

:DeformityLimited ROM

Crepitus

Localized pain

Radiating pain

Swelling

Inability to bear weight

Slide124

Jones vs. base of 5th fracture

Jones

Fx

Proximal base of the 5

th

metatarsal –

1 cm from

styloid

process

Base of 5

th

Fx

Attachment of peroneus

brevis

muscle

Often

avulsion

fx

from countering

INV

mechanism

Slide125

Jones vs. base of 5th fracture

Slide126

Metatarsal stress fractureKnown as a

March

Fx

Stress

fx

of metatarsal 2-4 (typically)

Very

localized pain

D

ull pain

Worsens with activity

Slide127

What is the diagnosis?

Slide128

Lisfranc injury

Acute injury

Mechanism of Injury (MOI)

Rotation

of the TMT joints

Forced hyper-plantarflexion

Forced toe extension & DFDisplacement of the metatarsals

Severe pain & swelling; “pop” or “tear”

Most require surgery

Slide129

Soft tissue pathologiesOf the foot

Slide130

sprainsCan occur to any ligament in the foot/ankleGeneral

Sx

/

Sy

Limited

ROMLocalized

painSwelling - edema

Inability to bear

weight

(+) special test for that ligament

Slide131

Arch sprainCaused by increased stress on archFlattening of the foot

Acute or chronic

Sx

/

Sy

:Pain with weight bearing activities

swelling

Slide132

Plantar fasciitisMOI: 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

Slide133

Hallux ValgusGreat toe deformity

Degeneration of

1

st

MTP

jointOften leads to bunions

Slide134

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

Slide135

Retrocalcaneal bursitis

“Pump bump”

Inflammation of the

Achilles bursa

Slide136

Skeletal pathologiesOf the ankle

Slide137

Tibial/fibular fracture

MOI: Direct blow, or INV/EV stress

May have:

gross deformity

audible “pop”

inability to bear weightSx/

Sy:Localized pain, radiating pain

Crepitus & swelling

Slide138

Slide139

Slide140

Talus fractureMOI: forced dorsiflexion with inversion

May mimic an ankle sprain

Avascular necrosis

may develop

Often missed in

x-rays – CT/MRI

to confirmSurgical fix

Slide141

Stress fractureMOI:

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

Slide142

Stress fracture

Slide143

Medial tibial stress syndrome

AKA: “Shin splints”

MOI: chronic pulling of the periosteum surrounding the tibia by the posterior

tibialis

muscle

Slide144

Medial tibial stress syndrome

Sx

/

Sy

:

Gradual onset from overuse, muscle fatigue, biomechanicsPain during activity, relieved with restDiffuse pain along the medial tibia

Pain with palpation

Pain during

RROM for INV

Slide145

Medial Tibial Stress Syndrome

Medial

Tibial

Stress Syndrome

Slide146

Soft tissue pathologiesOf the ankle

Slide147

Lateral ankle sprainsInversion with

plantarflexion

mechanism

Most common injury to the body

Why?? – anatomically

Stronger deltoid ligament, lateral malleoli extends further

Slide148

Lateral ankle sprains

Slide149

Lateral ankle sprainsArea of pain = ligament involved

Anterior

talofibular

=

sinus tarsi

Calcaneofibular = distal to lateral malleolusPosterior fibular =

posterior to lateral malleolusGraded on a 1-3 scale

Slide150

Lateral ankle sprains

Slide151

Deltoid sprainEversion or rotation mechanism

Rare injury (5%) – most occur as avulsion fracture

Sx

/

Sy

:General ligament sprain sx/

sy

Slide152

Deltoid sprain

Slide153

Syndesmosis sprainAKA “High ankle sprain”

MOI:

Forced DF and/or eversion

; rotation

Slow to heal

Slide154

Syndesmosis sprain

Sx

/

Sy

:

Pain around & above ankle mortiseInability to bear weightDecreased ROMAnterior

tibiofibular ligamentInterosseous

membrane

Slide155

Syndesmosis sprain

Slide156

Achilles tendinitisInflammation 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

Slide157

Achilles tendinitis

Slide158

Compartment syndromeCaused by direct blow or injury within

fascial

compartment

Typically

anterior

or deep posterior compartments

Slide159

Compartment syndromeSx/

Sy

:

Severe pain – “ache”, “dull”, “sharp”

Muscle tightness, weakness, cramping;

↓ strength & ROMFeeling of numbness & tingling in area

Sensation of hot/coldMedical

emergency

Slide160

Compartment syndrome

Compartment Syndrome