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Care and Prevention Chapters 18-20

Foot, Ankle and Lower Leg, Knee

CHAPTER 18 - THE FOOT

Bones:  26 total
1.  Talus

2.  Calcaneus
3.  Tarsals (midfoot bones) - Navicular, (medial, intermediate, lateral) Cuneiforms, Cuboid

4.  Metatarsals  (5)
5.  Phalanges (14)

Joints:

1.  Talocalcaneal
2.  Tarsometatarsal
3.  Metarsophalangeal (MP)- 
5

4.  Interphalangeal- 1-5 Proximal (PIP) & Distal (DIP)

Arches:  For shock absorption and space for blood vessels, nerves, and tendons
1.  Medial longitudinal
2.  Lateral longitudinal
3.  Transverse (across midfoot)
4.  Metatarsal (across ball of foot)

Pes cavus high medial longitudinal arch

Pes planus flat foot, no medial longitudinal arch


Muscles:
1.  Tibialis anterior

2.  Extensor muscle group

3.  Triceps surae (calf muscles):  a. Gastrocnemius, b. Soleus
4.  Peroneals

Foot Injuries

Blisters
MOI:  Friction, Stiff shoes, Too big shoes, soft skin, callous build up
S&S:  Build up of fluid between epidermal layers
Treatment:  2nd skin, Doughnut pad, skin lube, release fluid and inject with zinc oxide

Ingrown Toe Nail:
MOI:  Tight shoes, Improperly cut toe nails
S&S:  Corner of nail grows into skin
Treatment:  Cut V in middle of nail and put cotton under the corner, soak in warm betadine.  In extreme cases, a physician visit is necessary to have the embedded toenail removed.



Stone Bruise (heel bruise)
MOI:  direct blow to calcaneus causing periostitis (inflammation of bone periosteum)
Treatment:  rest, ice, heel cup or doughnut pad (may consider using ultrasound if fracture has been ruled out). 
Complications- poor circulation to area

Medial Longitudinal Arch Sprain
Sprain of calcaneonavicular ligament
MOI:  overweight, repetitive pounding, poorly fitted shoes
S&S:  1st degree- mild swelling, pain stops after activity, pt tender.
2nd degree- ligament begins to loose elasticity, arch begins to drop, more painful, constant pain.
3rd degree- arch falls and loses ability to support foot. As changes become permanent, pain decreases.
Treatment:  RICE, Tape, arch supports, NSAID, exercises to strengthen arch.

Rigid and supple flat foot test:
NWB- note position of arches
WB- note position of arches
Flat foot in both positions 3rd degree permanent changes
Flat foot WB, Normal NWB= 2nd degree (supple flat feet)

Turf Toe (Great toe sprain)
Sprain and contusion of 1st MP joint
MOI:  Hyperextension of great toe, exposing joint surfaces to ground, over stretching the plantar ligament
S&S:  Swelling, ecchymosis, point tender, pain with toe extension
Treatment:  Turf toe tape, ice, pad, steel shank inserts into shoes to limit toe hyperxtension at the metatarsal-phalange joints. 

Morton's Neuroma

Commonly seen in individuals with a longer second metatarsal
Nerve inflammation, most commonly inflammation of the plantar nerve as it passes between the 3rd and 4th metatarsal heads.
S&S:  Pain with activity but subsides after activity, pain when squeezing metatarsals, feels like a rock in their shoe, may cause tingling, burning, numbness
Treatment:  Wider shoes, metatarsal arch pad, injection, surgery, ice, phonophoresis.

Metatarsal Stress Fracture (March Fracture)

Commonly involves the shaft of the second metatarsal
MOI:  either through blunt trauma, or constant pounding
S&S:  pain with bearing weight, pt tender on MT, Swelling, crepitus, bone scan
Treatment:  NWB in short cast or PWB in walking boot

Jones Fracture:
Fracture to the diaphysis at the base the fifth metatarsal; may be differentiated from an avulsion fracture of the distal head which is referred to as a styloid fracture.
MOI:  Inversion ankle sprain
S&S:  pain on 5th metatarsal head, deformity, pain with resistive eversion
Treatment:  NWB in short leg cast or PWB in walking boot; in some cases, internal fixtation is needed.

Plantar Fascia Strain (thick connective tissue on bottom of foot)
MOI:  (acute) sudden overstretching, (chronic) repetitive pounding (plantar fasciitis)
S&S:  Pain on passive toe extension, point tender especially at calcaneal attachment, discoloration
Treatment:  ice massage, donut pad, arch tape, calf stretching, towel curls, night splint

If conservative treatment doesn't help; may need to get a corticosteroid injection and ambulate with a walking boot

CHAPTER 19 - ANKLE & LOWER LEG

Bones:

1.  Tibia
2.  Fibula
3.  Talus
4.  Calcaneus or Calcaneal bone


Malleolus- Distal portion of tibia and fibula

Joints:

1.  Superior and Inferior Tibiofibular joint

2.  Talocrural joint (ankle joint) (articulations between the tibia and talus; medial malleolus and talus; lateral malleolus and talus); movements include dorsiflexion and plantarflexion

3.  Subtalar joint (talus and calcaneal articulation); movements include inversion and eversion

 

Ligaments:

1.  Tibiofibular
2.  Anterior Talofibular

3.  Calcaneofibular
4.  Posterior Talofibular

5.  Deltoid Ligament group

Lateral ankle sprain (inversion ankle sprain)

Ligaments involved:  anterior talofibular (ATF), calcaneofibular (CF), posterior talofibular (PTF)
Approximately 90% of all ankle sprains are lateral because the triceps surae (calf) is stronger than the ankle dorsiflexors (which when non-weight bearing leads to a plantarflexed and inverted foot position), fibula extends down farther on the lateral side, and the deltoid ligaments-on the medial side of the ankle) are stronger than the lateral ligaments.
MOI:  forced inversion with plantar flexion
S&S:  Swelling, pt tender on ligaments, decreased strength, decreased ROM
Treatment:  RICE, NSAID, Tape or brace, Early motion and rehab to strengthen the ankle dorsiflexors; calf stretching, balance

 

3 grades of lateral ankle sprain:
1st degree- involves 1st or 2nd degree tear ATF
2nd degree- involves 2nd or 3rd degree tear ATF and 1st or 2nd degree tear of CF
3rd degree- involves 3rd degree tear of ATF, 2nd or 3rd degree tear of CF, and 2nd or 3rd degree tear of PTF


Medial ankle sprain (eversion ankle sprain) 10%
Ligaments involved:  deltoid ligaments

MOI:  Forced eversion
S&S:  Same as with lateral
Graded the same as lateral, but with anterior, Middle, and posterior portions of Deltoid ligament.
Treatment:  Same as lateral ankle sprain

Tib-Fib Sprain
Sprain of the tibiofibular ligament and syndesmosis
MOI:  Dorsiflexion and External rotation
S&S:  similar to ankle sprain, pt tender over Tib-fib ligament
Graded 1,2,3 based on amount of laxity at tibiofibular joint
Treatment:  same as ankle sprain, but avoid eversion and external rotation
(injury is slow to heal due to lack of blood supply to ligament and syndesmosis)

Achilles Tendon strain or rupture
MOI:  acute- forced dorsiflexion
chronic- (tendonitis) occurs over time from excessive running and jumping
S&S:  acute-sudden pain, swelling, point tender, weakness with plantar flexion, pain or irritation in stretching. Sudden snap or tearing, deformity or deficit (rupture)
Chronic- mild swelling, pt tender, aching, pain before and after activity but not during, mild thickening of tendon.
Thompson Test- (calf squeeze test) Positive if no plantar flexion with calf squeeze (rupture)
Negative if foot plantar flexes with calf squeeze
Treatment:  RICE, light stretch on slant board, calf exercises, heel lifts in shoes, Achilles tape.

Lateral malleolus Fracture (distal fibula fracture)
fracture of distal fibula
MOI:  inversion ankle sprain
S&S:  pain with WB, crepitus, deformity, point tender on fibula, pain with bump or compression tests, positive x-ray
Treatment:  Splint, refer, NWB in short leg cast

Medial Tibial Stress Syndrome- "shin splints"
MOI:  unknown, could be due to repetitive pounding
S&S:  Shin pain down medial border of calf and tibia
1st degree:  pain after activity
2nd degree:  pain before and after but not during activity
3rd degree:  pain before during and after activity, begins to affect performance
4th degree:  pain does not stop (stress fx)
Treatment:  Ice, analgesic balms, stretching & strengthening, arch & shin tape

Dynamic and Acute Compartment Syndrome
MOI:  direct blow or chronic overuse
S&S:  aching, numbness, feeling of pressure, weakness in dorsiflexors, decreased pulse. In Dynamic it increases with exercise, but decreases when stopped
Treatment:  acute- medical emergency- requires surgery
Dynamic- Ice, NSAID, stretching, Massage


CHAPTER 20 - KNEE

Bones:

1.  Femur

2.  Tibia (bears on weight)
3.  Fibula (bears no weight)

4.  Patella

Ligaments:

Cruciate means to cross

1.  Anterior cruciate ligament (ACL)
2.  Posterior cruciate ligament (PCL)

3.  Medial collateral ligament (MCL)
4.  Lateral collateral ligament (LCL)

 

Movements:

1.  Flexion

2.  Extension

3.  Rotation

4.  Gliding (to a small degree during flexion and extension)


Cartilage (meniscus)

1.  Medial- more C shaped (C - Center)
2.  Lateral- more O shaped (O - Outside)

Genu valgus - "knock kneed"

Genu varus - "bow legged"


 

Muscles:

1.  Quadriceps (4)   (Vastus medialis obliques, vastus lateralis, vastus intermedius, rectus femoris)

2.  Hamstrings (3)   (semimembranosus, semitendinosus, biceps femoris)

3.  Gastrocnemius

Bursitis (inflammation of fluid sacs)
Fluid sacs that provide lubrication for the knee
MOI:  kneeling, blunt trauma

prepatella bursa is irritated by continued kneeling; deep infrapatella bursa is irritated from overuse of the patella tendon
S&S:  Mild swelling, point tender, aching, stiffness
Treatment:  RICE, heat before ice after, usually stay with ice, NSAID, cortisone injection, aspiration - suction out fluid

MCL Sprain:
MOI:  blow to lateral side of knee with foot fixation, produces valgus stress (blow from outside of knee)
S&S:  Pain, point tender on MCL, very little swelling, decreased ability to flex or fully extend
Treatment:  RICE, orthopedic surgeon, limited motion 2-4 weeks, ace bandage and NWB to FWB when symptoms allow, ROM strength exercises-hinge brace
Prophylactic knee bracing: preventive knee bracing
Pre Loaded knee:  bow legged knees tend to tighten up with straight braces, good for down linemen and middle linebackers

LCL Sprain:
MOI:  getting hit medially-not common-produces varus stress (hit from inside knee)with foot fixation (example:  the catcher trying to block the plate)
S&S:  pain, point tender on LCL, varus instability
Treatment:  same as MCL except opposite direction

ACL Sprain:
MOI:  valgus stress with foot fixed, deceleration with cutting motion, torn with contact or non-contact
S&S:  swelling, pt tender, limited ROM, feeling of shifting and instability, hear pop or snap
Complication:  ACL falls onto PCL and sticks, poor circulation, often when it tears, it shreds (rag mop)
Treatment:  reconstruction surgery, 9-12 month rehabilitation, must stress hamstrings early, RICE, immobilization device
Anterior Drawer Test:  flex knee to 90 degrees, sit on foot, pull forward on lower leg, if tibia moves it is a positive test
Lachman's Test:  pull on tibia and push femur, positive if no end point is felt

Meniscus Injury:
Medial is most commonly injured because coronary ligament attaches the medial meniscus peripherally to the tibia and also to the capsular ligament.  The lateral meniscus doesnt attach to the capsular ligament and is more mobile during knee movement.
MOI:  valgus stress, torsion force (twisting), MCL is torn away from attachment at meniscus
S&S- pt tender on joint line, swelling, limits ROM, effusion, locking or catching of knee
Treatment:  ice, exercise to maintain leg strength, arthroscopy, rehab 2-4 weeks
Apley's distraction test:  Lie on back, pick up leg and twist, relax and twist, if positive, it will cause pain
Apley's Compression Test:  Lie on stomach with knee at 90 degrees and push and twist foot
McMurray's Test:  Lie on back, flex and extend the knee while apply varus/valgus stress, and internal/external rotation.

Unhappy Triad Injury:  involves ACL, MCL and medial meniscus

Osteochondritis Dissecans:
Bone chip under articular cartilage, 85% is from medial femoral
S&S:  aching, pain, recurrent swelling
Treatment:  X-ray, arthroscopy, rehab dependent on size, degree and location

Loose Bodies (joint mice):
Floating piece of bone, articular cartilage or meniscus in fluid
S&S:  aching, popping, locking, catching, transient swelling
Treatment:  arthroscopy rehab 2-6 weeks

Patellar Tendonitis:
MOI:  jumping, running on hard surfaces, running hills, weight lifting, repetitive forceful quad exercises
S&S:  aching before and after exercise, pain walking stairs, stiffen up if in one position to long, knee is warmer than usual, decrease in extension and strength
Treatment:  hydrotherapy, heat before and ice after, ultrasound, heat packs, quad exercises, rest, short termed NSAID use, prolonged use may prolong the tendonitis condition.  Emphasis is on reducing the stress placed on the quadriceps at the inferior pole of the patella, which pulls on the tibial tuberosity.  A delicate combination of limited ROM quad strengthening/flexibility, with hamstring strengthening/flexibility is indicated.  You may also ice the infrapatella ligament, while heating the quads to stop inflammation and increase extensibility.  Gaining hamstring flexibility is extremely important.


Chondromalacia patellae
Degeneration of articular cartilage behind the patella
MOI:  direct blow to patella, continued kneeling
S&S:  similar to patellar tendonitis
Treatment:  Ice, hydrotherapy, rest, NSAID

 

Acute patella subluxation or dislocation

MOI:  Planting the foot, decelerating, and simultaneous cutting in opposite direction from the weight-bearing foot, the thigh rotates internally while the lower leg rotates externally, causing the knee to valgus.

S&S:  pain, swelling, loss of function, and kneecap in abnormal position

Treatment:  reduce the patella (realign it), x-ray if first time, ice, splint, wear a horseshoe knee brace, immobilize for 4 weeks or longer

 

Patella femoral stress syndrome

MOI:  lateral deviation of the patella as it tracks in the femoral groove

S&S:  tenderness on lateral facet of patella and some swelling associated with irritation of the synovium as well as reports of a dull ache in the center of the knee.

Treatment:  determine the cause is misalignment, strengthen the adductors, correct alignment of VMO and VL, stretching exercises for the hamstrings, gastrocnemius, and iliotibial band.

 

Runners knee (cyclists knee)

MOI:  repetitive and overuse condition, misalignment of foot and lower leg

Iliotibial band friction syndrome is an overuse condition commonly occurring in runners and cyclists who have genu varum and Pronated feet.  Irritation develops at the bands insertion and, where friction is created, over the lateral femoral condyle.

Pes anserine tendonitis or bursitis is where the sartorius, gracilis, and semitendinosus muscles join to the tibia.  Irritation results from excessive genu valgum and weakness of the vastus medialis muscle.

Treatment:  correction of misalignment, cold packs or ice massage before and after activity, proper warmup and stretching, and avoidance of activities, NSAIDs, orthotics to reduce genu varum

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