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Foot, Ankle and Lower Leg.doc

10 Pages
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Department
Kinesiology & Health Science
Course Code
KINE 3575
Professor
Gus Kandilas

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Description
Foot, Ankle and Lower Leg - Consists of: 26 bones, 14 phalanges, 5 metatarsals, 7 tarsals, the tibia and fibula Range of Motion - Ankle Inversion and Eversion: o More inversion range than eversion  Talus pushing up against the tibia prevents too much eversion  Medial ligament (“deltoid” – which prevents eversion) is much stronger than lateral ligaments (which prevent inversion)  80% of sprains are inversion o Occur at the subtalar joint (between talus and calcaneus)  Calcaneus moves medially = inversion, laterally = eversion  Pronation and supination are combined movements here • Supinated foot – pes cavus – high arch • Pronated foot – pes planus – flat foot o Inverting muscles: tibialis anterior, tibialis posterior o Everting muscles: peroneus longus, peroneus brevis, peroneus tertius - Ankle Dorsiflexion and Plantarflexion: o Occur at tibiotalar joint (between tibia and trochlea of talus) o Normal position = 90˚ o Plantarflexing muscles: gastrocnemius, soleus, plantaris, peroneous longus, peroneous brevis, tibialis posterior, flexor hallucis longus, flexor digitorum longus o Dorsiflexing muscles: tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneous tertius - Ankle Abduction and Adduction Bony Landmarks - Bony palpation used to rule out fracture, determine anatomical structures and find sites of pain/point tenderness/bumps/deformities o Can guide to soft tissue structures (ligaments, tendons, bursae) o All structures of the posterior, anterior, medial and lateral aspects of the foot and ankle may be palpated *See slides for bones of the foot* - Sinus Tarsi: a depression between the calcaneus and talus where swelling accumulates in inversion sprains o On lateral side of foot (under lateral malleolus) o Found here: anterior talofibular ligament, fat pad, extensor digitorum brevis - Medial Tubercle: where plantar fascia originates from on the calcaneus – inserts on the proximal heads of the metatarsals o Plantar fascia = thick, white band of fibrous tissue that is the superficial layer of the plantar surface of the foot, attached to the medial surface of the calcaneus  Supports the foot against downward forces  Helps maintain the medial longitudinal arch  Palpate inner heel (medial tuberosity) to look for plantar fasciitis (pain) - Sesamoid Bones – within the flexor hallucis brevis tendon o There are two o Located at ball of foot, under first metatarsal head o Reduce pressure of weight bearing o Increase the advantage of the flexor tendons of the big toe (flexor halluces brevis and flexor halluces longus)  Act as a lever/fulcrum o For push off and stopping Retinaculum: band of thick, deep fascia that holds the long tendons of the ankle in place - Lateral Retinaculum: hold peroneals (in lateral compartment) in place o Can be torn in inversion sprains because it blends with ligament o Superior (lateral malleolus to lateral surface of calcaneus) and inferior o Work to prevent peroneal subluxation - Extensor Retinaculum: superior and inferior o Holds anterior compartment of extrinsic muscle together - Flexor Retinaculum: covers medial portion of ankle o Contains the deep posterior compartment of extrinsic muscles of the leg (“Tom, Dick And Not Harry”)  Tibialis posterior, flexor Digitorum muscles, posterior tibial Artery, tibial Nerve, flexor Hallucis longus o Makes up the roof of the tarsal tunnel  Tarsal tunnel syndrome: when swelling compresses the above mentioned structures within the tunnel  Symptoms - pain, motor weakness, atrophy  Treatment - anti-inflammatories, orthotics, surgery Muscle: - Intrinsic (originate and insert in the joint) - Extrinsic (bigger, insert in joint, originate elsewhere) Compartments: - 4 compartments of extrinsic muscle of the lower leg – separated by fascia (retinaculum) o Anterior Compartment: tibialis anterior (strongest here), extensor halluces longus, extensor digitorum longus, anterior tibial artery  For dorsiflexion  Help together by extensor retinaculum o Lateral Compartment: peroneus longus, peroneus brevis, peroneal nerve o Superficial Posterior Compartment: gastrocnemius, soleus  For plantar flexion o Deep Posterior Compartment: “Tom, Dick And Not Harry” Ligaments of the Ankle: - Degree of severity in inversion sprains is dependent on the number of ligaments torn o 1 torn = 1 degree sprain, 2 torn… 3 torn…, 1+ sprain = 1 torn and laxity in a 2 nd - Degree of severity in eversion sprains is measured the standard way - Lateral Ligaments – tear = inversion sprain: o Anterior talofibular ligament (ATL) – in sinus tarsi, restrains anterior displacement of the talus  First ligament to tear with plantar flexion and inversion sprains  Test tear with Anterior Drawer Test o Calcaneal fibular ligament (CFL) – restrains inversion of calcaneus  Second ligament to tear with plantar flexion and inversion sprains • First ligament to tear with pure inversion sprains  Test tear with inversion test/talar tilt test o Posterior talofibular ligament (PTL) – restrains posterior displacement of talus  Last lateral ligament to tear - Medial Ligament – “Deltoid” Ligament, tear = eversion sprain: o Made up of superficial and deep fibres o Split into 4 parts:  Posterior tibiotalar ligament  Tibiocalcaneal ligament  Tibionaviculr ligament  Anterior tibiotalar ligament o Attaches superiorly to the borders of the medial malleolus and inferiorly to the medial surface of the talus o Prevents abduction and eversion of ankle at subtalar joint (calcaneus) o Prevents eversion, pronation and anterior displacement of talus o Swelling here can cause tarsal tunnel syndrome o Tear test – talar tilt test for eversion, Kleiger test - Dorsal pedal and posterior tibial artery pulses should be checked to ensure that circulation has not been cut off Common Peroneal Nerve: - Branches and becomes the: o Superficial peroneal nerve once it has exited the lateral compartment o Deep peroneal nerve once it has exited the anterior compartment  Passes below the extensor retinaculum Injuries to the Toes - Subungual Hematoma: blood under the toe nail (contusion) o Cause: repetitive shearing forces (runners) or direct trauma/compression o Pain: in soft tissue under the nail (no nerves in the nail itself) – gentle pressure causes more pain o Symptoms: ecchymosis, nail falls off o Ice and elevation controls swelling o Drain blood using fine tip, high temperature cautery or a nail drill - Ingrown Toe Nails: o Medial and lateral aspects of the hallux o Anterior corners of nail dig into skin causing swelling and infection to the surrounding tissue o Feels warm and is tender to palpation - Hallux Valugus – bunions: o Hallux is deflected laterally causing a bony prominence to develop over the medial aspect of the metatarsal head and neck  Hypertrophy of local bursa o Contributing factors:  tight footwear  Excessive functional pronation  Tight Achilles tendon  Generalized ligamentous laxity o Braces, surgical intervention - Gout: o Arthritis due to the deposit of monosodium urate monohydrate crystals in previously normal tissue  Causes acute inflammation and eventual tissue damage  These crystals, called “tophi” can be seen in X-rays of the affected joint o Frequently seen in the hallux o Frequently seen in men 30-60 yrs. o Cause:  Obesity/weight gain/high blood pressure  Alcohol/abnormal kidney function (produces the crystals)  Use of certain drugs o Characterized by:  Rapid onset of pain/marked tenderness  Warmth/inflammation  Reddish discoloration o Diagnosed through: specific blood tests, analysis of fluid for uric acid crystals o Prevention:  Reduced alcohol consumption  Proper fluid intake  Weight reduction  Medication  Avoidance of purine-rich foods (meats, shell fish – b/c they can be converted into uric acid in the body) - Turf Toe – hyperextension of hallux: o Traumatic or overuse o Joint capsule can tear off the metatarsal head (weak attachment at proximal phalanx)  Sprain of the metatarsophalangeal joint • Plantar surface = fibrocartilaginous plate made up of the tendons of the flexor hallux brevis, abductor brevis and the deep transverse metatarsal ligament o Sesamoid bones are within the plate o Tendons are very small making it difficult to
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