Foot, Ankle, and Lower Leg

MOI- Turf Toe

Acute hyperextension of great toe spraining the inferior ligaments and capsule

S/S- Turf Toe (5)

1. Pain with passive and/or active hyperextention of great toe
2. Swelling
3. Decrease/Increase ROM
4. Decreased Strength (strain in flexor muscle/swelling&pain is not allowing movement)
5. Tender plantar surface of metatarsophalangeals

Tx- Turf Toe (8)

1. RICE
2. NSAIDS
3. Ultrasound
4. Iontophoresis
5. Tape
6. Steel Plate
7. Check shoes
8. Change activity

Prev- Turf Toe (4)

1. Good flexibility
2. Good shoes with firm sole (too much flexibility in shoes cause stress)
3. Good technique
4. Proper training

R/O- Turf Toe

Sesamoid (bone enclosed in tendon) fx/ -itis
Sesamoid bones create leverage points (overuse)

Bunion aka

Hallux Valgus

MOI- Bunion

Wearing narrow shoes cause thickening of bursa and deformity of great toe
(Narrow or small shoes= rub against bursa -> calcify and thicken -> start to angle -> overlapping with toes)

S/S- Bunion (3)

1) Swelling
2) Tenderness
3) Obvious deformity w/ angulated great toe

Tx- Bunion (5)

1) Tape-align toes
2) Pad-stops rubbing
3) Spacer- Prevent moving of toes
3) Better shoes- avoid rubbing and MOI
4) Surgery- realign

MOI- Ingrown Toenail

Toenail grows laterally into skin
Caused by small/narrow shoes or improper trimming nail trimming (should be trimmed straight across)

S/S- Ingrown Toenail (5)

1. Pain
2. Swelling
3. Swollen, red nail fold
4. Infection
5. Pustulent

TX- Ingrown Toenail (4)

1. Soak in hot water (w/ betadine if infected)- softens/unstiffens; prepares for prying
2. Pry out nail out of skin, place piece of cotton under nail (help raise it out of skin)
3. Cut V in the middle of the nail? - limited effectiveness
4. Physician remo

Prev- Ingrown Toenail (2)

1. Proper trimming (straight across)
2. Proper shoes

MOI- Fx Toe (3)

1. Trauma
2. Crushing
3. Stubbing

S/S- Fx Toe (5)

1. Swelling
2. Pain
3. Deformity
4. Decrease in Function
5. Crepitus

TX- Fx Toe (6)

1. X-ray- confirm fx
2. Buddy tape- use other toe to splint fx toe
3. Splint- support and immobilize
4. Steel insole- limits dorsiflexion
5. RICE- relieve pain
6. NSAIDs- relieve pain

Special Tests- Fx Toe (2)

1. Tap test- flick toe (contusion hurts where it is hit; fx hurts everywhere)
2. Manipulation test- Aka pencil break/fulcrum test; Wiggle bone lightly
(positive=pain)

MOI- Subungual Hematoma (2)

1. Crushing
2. Repetitive jamming into shoe

S/S- Subungual Hematoma (3)

1. Pain
2. Swelling
3. Discoloration

Tx- Subungual Hematoma

Aspirate (drain) w/ needle/saftey pin/ cautery; after, clean/wash out/compress to prevent infection

MOI- Heel Contusion (4)

1. Repetitive contact
2. Contact, running on hard surfaces
3. Landing
4. Stepping on something

S/S- Heel Contusion (4)

1. Pain/ttp-calcaneous; hurt only there and no where else
2. Swelling
3. Discoloration
4. Negative squeeze test- squeeze around heel; shouldn't hurt (if it hurts=stress fx/fx-(review history/MOI)

TX- Heel Contusion (4)

1. RICE
2. NSAIDS
3. Heel cup- cushions heel, distribute pressure evenly, eliminate swelling
4. Donut pad- reduce pressure

Prev- Heel Contusion

Good shoes- supportive, fits correctly

Fat Pad Facts- Heel Contusion (2)

1. Can traumatize the fat pad over the calcareous causing chronic inflammation
2. Fat pad decreases with age and training

MOI- Foot Sprains (2)

1. Twisting
2. Landing unevenly

S/S- Foot Sprains (4)

1. Pain between bones
2. Swelling
3. Decreased function
4. No crepitus (not fx)
(Best to get x-ray if s/s in mid foot)
Diagnosis of exclusion- r/o everything else

Tx- Foot Sprains (4)

1. RICE-pain
2. NSAIDS-pain
3. Steel insole-stabilize
4. Walking boot-support/immobilize

Special Tests- Foot Sprains (2)

1. Rocking test-Pencil test (positive-pain)
2. Squeeze test (squeeze away from sight; pain should increase where initial pain is, not where you are squeezing it)

MOI-Jones Fracture (4)

1. Trauma- step/kick
2. Result from stress fx-chronic
3. Avulsion from ankle sprain- piece of bone is puled away forcibly by ligament
4. Inversion and plantar flexion of foot
(base of the 5th metatarsal) (High arches/pes cavus=more likely)

S/S- Jones Fracture (4)

1. Swelling
2. Pain with eversion over 5th metatarsal- active/passive ROM (redoing moi & making muscles work)
3. Crepitus- rock/squeeze (toes) test
4. Pain/TTP- increases w/ Full weight bearing

TX- Jones Fx (5)

1. X-ray- confirm fx
2. Walking boot- immobilize
3. RICE- Pain
4. NSAIDs- Pain
5. May need surgery to pin bc poor success in healing

MOI-Midfoot dislocation (lisfranc) (2)

1. Falling on toes
2. Twisting of foot (ankle plantar flexed w/ rear foot locked -> sudden forceful hyper-plantar flexion of forefoot )

S/S- Midfoot Dislocation (5)

1. Obvious deformity
2. Pain-metatarsals/midfoot
3. Swelling/tenderness/ttp-over dorsum of foot- widening of foot
4. Decrease in function- inversion/eversion
5. Non weight bearing

TX- Midfoot Dislocation (4)

1. Immobilize/Emergency room
2. Open/closed reduction- surgical/realign
3. Boot/cast- Immobilize/allow healing
4. Rehab

Pump Bump aka

Haglunds Deformity (common in ice hockey, skating, runners)

MOI- Haglunds Deformity

Chronic irritation of heel- poor shoes (calcaneus)

S/S- Haglunds Deformity (3)

1. Pain-elicited by palpating bursa just above and anterior to the insertion of achilles tendon
2. Deformity/swelling-Bump-on both sides of heel cord
3. Decreased function
4. Exotosis- benign bony outgrowth that protrudes from the surface of a bone and us

TX- Haglunds Deformity (7)

1. RICE/NSAIDs-pain
2. Ultrasound-Reduce inflammation
3. Stretching of achilles (routine)
4. Heel lift- take stress off achilles tendon
5. Donut heel pad- take pressure off bursa and existing exostosis
6. Larger shoes w/ wider heel contours- prevent
7. Su

Arch Strain/Fallen Arch

Pes Planus/ Flat feet
Acute=hard landing
Strain=cumulative

MOI- Arch Strain/Fallen Arch (5)

1. Poor shoes- too tights
2. Obesity-pressue causes arch to fall chronically
3. Structural-pes planus=more susceptible to injury
4. Repetitive impact-acute (weaken supportive structures)

S/S- Arch Strain/Fallen Arch (3)

1. Pain- medial longitudinal arch
2. Deformity- flat medial longitudinal arch
3. Decrease in function- pronation

TX- Arch Strain/Fallen Arch (9)

1. Ice- pain
2. NSAIDs- pain
3. Heat-
4. Massage-
5. Stretch-
6. Strengthen- supportive structures (muscles and ligaments) to do its job again
7. Tape-support
8. Orthotics- Support (lots of $$$)
9. Ultrasound

Prev- Arch Strain/Fallen Arch (3)

1. Flexibility
2. Orthotics-support
3. Strength- strengthen supportive structures

Arch Strain/Fallen arch can lead to

Knee-hip-back pain

What does callus on the foot show?

Where stress is (should be on the heel to great toe

MOI- Plantar Fascitis (3)

1. Irritation of plantar fascia (proximal arch and heel)
2. Associated with tight post calf muscle- pull on heel bone making your plantar fascia very taut and prone to injury
3. Running, jumping, pushing off- when weight shifted to ball of foot (head of m

S/S- Plantar Fasciitis (3)

1. PAIN ESPECIALLY WITH FIRST STEP IN THE MORNING
2. Pain w/ toe dorsiflexed
3. Tender/ttp- plantar fasica

TX- Plantar Fasciitis (11)

1. Ice-pain
2. Massage-pain
3. Stretch- plantar fascia and achilles tendon (ex. rolling tennis ball on the surface of foot back and forth)
4. Strengthen- plantar fascia/achilles tendon; exercises tha increase dorsiflexion of great toe
5. Tape- allows pain

Ankle Ligaments

Lateral:
1. Anterior Talofibular (R) 3:30 (L) 8:30
2. Calcaneofibular (R) 6:30 (L) 5:30
3. Posterior talofibular (R) 8:30 (L) 3:30
Medial:
1. Deltoid

MOI- Lateral ATF Sprain (2)

1. Plantar Flexion
2. Plantar flexion/inversion (most common)

Why is plantar flexion/inversion the most common sprain?

Increased space between tallus and talofibular when you plantar flex because the tallus opens up and it is easier to invert/evert

MOI- Lateral CF Sprain (2)

1. Inversion
2. PF/Inv

MOI- Lateral PTF Sprain (1)

1. PF/Inv

MOI- Medial Sprain

Deltoid- Eversion/ER

S/S- Ankle Sprain (6)

1. Pain
2. Swelling
3. Decreased function
4. Pt tender
5. Laxity
6. Special Tests
must include

Ankle Sprain Special Tests

1. Positive Anterior Drawer Test (ATF)- Have ankle at 20 degrees plantar flexion (neutral) , grab back of heel and put your other hand on top of the ankle, pull out like opening a drawer
2. Positive Posterior Drawer Test (PTF)-Have ankle at 20 degrees pla

TX- Ankle Sprain (11)

1. RICE
2. NSAIDs
3. Stim
4. Massage
5. Stretch
6. Strength
7. Heat
8. Ultrasound
9. Tape/brace
10. Rehab
11. Felt Pad- Help w/ Swelling

Prev- Ankle Sprain

1. Tape/Brace- protect
2. Strengthen
3. Proprioception

What should you r/o when dealing w/ an ankle sprain? How?

Fracture
-X-Ray
-Negative Squeeze Test: Athlete is sitting or lying with his/her knee extended; Examiner cups his/her hands behind the tibia & fibula, away from the site of pain;Examiner compresses the tibia & fibula, gradually adding more pressure
-Negat

High Ankle Sprain" aka ____?

Syndesmotic Sprain

What does syndesmotic mean?

An articulation in which the bones are joined by a ligament

Where does a syndesmotic sprain take place?

Injury to anterior tibiofibular and interosseous membrane or posterior Talo-fibular

MOI- Syndesmotic Sprain (3)

1. Sever sprain
2. Severe dorsiflexion
3. External Rotation

S/S- Syndesmotic Sprain (6)

1. Pain- w/ rotation and forced dorsiflexion2. Swelling
3. Tender
4. Limited ROM
5. Increased pain w. ext rotation
6. Special Test-
Klieger's test:Athlete is sitting with his/her legs over the edge of the table. Examiner stabilizes the lower leg with one

TX- Syndesmotic Sprain (5)

1, Very conservative- be cautious, takes long time to heal (scar tissue can ossify and cause problems)
2. RICE
3. STP
4. Crutches, walking boot
5. Surgery- tibfib fusion: reduce separation btwn tibia and fibula (hold together while ligaments heal)

Achilles Tendinitis vs Bursitis vs Severs Disease

Bursitis= Localized pain
Tendinitis= diffused pain
Severs disease= pain in posterior heel below the attachment of achilles tendon insertion of a child/adolescent athlete (as you are growing, muscle and tendons pull bone away from before its matures)

MOI- Achilles tendinitis/Bursitis (5)

1. Overuse-running (uphill can aggravate condition)
2. Chronic- overtime the condition progresses with activity (running/jumping)
3. Shoes- rubbing/irritation
4. Tape- rubbing/irritation
5. Overactive- not giving body time to rest
(6 "S" of overuse- speed

S/S- Achilles Tendinitis/Bursitis (4)

1. Pain- elicited with passive stretching
2. Thickening- achilles tendon (indicate chronicity-could tear)
3. Crepitus- palpated with active plantar/dorsiflexion
4. Decreased function-dorsiflexion ROM and Plantar flexion strength
(Increased risk w/ pes pla

TX- Achilles Tendinitis/Bursitis (12)

1. RICE-pain/inflammation
2. NSAIDs- pain
3. Heat- increase blood flow
4. Ultrasound-increase blood flow
5. Massage-cross friction (break down adhesions that may have formed during healing process and to further improve gliding ability of paratenon
6. Ion

Prev- Achilles Tendinitis/Bursitis (3)

1. Flexibility
2. Strengthen
3. Gradual progress

MOI- Achilles Tendon Rupture/Strain (4)

1. Acute over stretching
2. Violent Contraction
3."Stop and Go" Action- sudden pushing off action of forefoot w/ knee being forced into complete extension
4. Chronic inflammation
Swelling=Grade 2
Rupture=Grade 3
(6 "S" may predispose & "weekend warriors

S/S- Achilles Tendon Rupture/Strain (6)

1. Pain- back of ankle; achilles tendon; "Someone kicked me"
pop
(grade 3)
2. Deformity- grade 3
3. Decreased function- inability to plantar flex (Grade 3)
4. Decreased DF ROM
5. Decreased PF strength
6. Special tests-
Positive Squeeze test
Thompson Test

TX- Achilles Tendon Rupture/Strain (12)

1. Refer to ER-if torn (surgery)
2. TX for shock
3. Splint-immobilize
4. RICE-pain/swelling
5. NSAIDs-pain
6. Stim- pain/swelling
7. Ultrasound- blood flow
8. Heat- blood flow
9. Massage
10. Strengthen- ROM exercises: DF, PF
11. Tape- protect
12. Surgery-

Prev- Achilles Tendon Rupture/Strain (3)

1. Flexibility
2. Strength
3. Continuously active

MOI- FX

1. Acute trauma

S/S- FX (6)

1. Pain
2. Swelling
3. Deformity
4. Crepitus
5. Decreased function
6. Special tests-
A. *Squeeze test: best
B. Bump Test: For higher fractures
C. Percussion Tap Test: Above or below tibia, tap/knock with fingers hard enough to hear; vibrations will be sen

TX- FX (4)

1. Immobilize-splint
2. Treat for shock
3. Dont reduce- professionals
4. Refer

MOI- Avulsion FX

Torque (twisting) from tendon or ligament during sprain
5th metatarsal, deltoid, lateral ligaments, tibial malleolus

S/S- Avulsion FX (7)

1. Pain
2. "Pop"
3. No obvious deformity
4. Decreased function
5. Swelling
6. Crepitus
7. Tender- tender to bone (think avulsion)

TX- Avulsion FX (3)

1. Splint- immobilize
2. Ice- pain, swelling
3. Refer- surgery or not

MOI- Ankle Dislocation

Severe torque (twisting)

S/S- Ankle Dislocation (4)

1. Pain
2. Deformity
3. Swelling
4. Inability to function

TX- Ankle Dislocation (2)

1. Immobilize
2. Refer (cation w/ air splints: only for closed, EMS if open, Sterile over if open)

MOI- Stress FX

Chronic over use and breakdown of bone (6 "S")
More likely tibia than fibula

S/S- Stress FX (5)

1. Pain w/ act; Decreases w/ rest
2. Point tenderat sight
3. Potential Pm. pain (evening)
4. Positive bone scan>x-ray
5. Special tests
Fulcrum Test
Percussion Test
Tuning fork test
if reoccurring, check iron deficiency

TX- Stress FX

1. RICE- pain/swelling
2. NSAIDs- pain
3. Boot-immobilize/reduce stress
4. Cross training-strengthen (less stress-pool exercises)
5. Progress back slowly: on-off (nwb act) program 1-3, 1-2, 1-1, 2-1
6. Calcium supplements- strengthen
7. Check biomechanics

Shin Splints aka

Medial tibial stress syndrome

MOI- Shin Splints (2)

1. Overuse and irritation of
-Tibal periosteum
-Psterior tibial muscle
-Long flexors
-Soleus muscle
-Interosseous membrane
2. May be enhanced w/
-Pes cavus/planus
-Muscle imbalance
-Tight post muscles

S/S- Shin Splints (4)

1. Distal/medial shin pain
2. Varies between pain w/ activity to pain w/ and after,
3. pain and decr. f'n to no f'n due to pain.
4. All other special tests for fx, compartment syndrome= negative

Tx- Shin Splints (11)

1. Ice
2. NSAIDs
3. Ultrasound
4. Heat
5. Stretch
6. Massage
7. Strengthen- eccentric posterior tibialis; dorsiflexion
8. Orthotics (increased risk if you have pes caves/planus-more pressure)
9. Change Activity
10. Arch tape- support (reduce pressure)
11.

Prev- Shin Splints

1. Flexibility
2. Strengthen
3. Gradual progress

Compartments (4)

1. Anterior (most common)
2. Posterior
3. Deep Posterior
4. Superficial Posterior

MOI- Compartment Syndrome (3)

1. Acute- acute swelling as result of trauma/training (direct trauma)
2. Acute exertional -w/o precipitating trauma and can evolve w. minimal to moderate activity
3. Chronic compartment syndrome- running/jumping activities (symptoms cease when act does)
1

S/S- Compartment Syndrome (10)

1. pain w/ activity & after (active and passive ROM hurts)
2. ?pain after activity w/ chronic or 3. exercise induced
3. ANT= Swollen
4. Big toe is weak in dorsiflexion (blood flow is cut off)
5. Numbness and tingling
6. Resisted Eversion-weakness
7. Skin=

5 P's of compartment Syndrome

1. Pain
2. Pressure
3. Paresthesia (numbness)
4. Paralysis
5. Pulselessness- decreased pulse

TX- Compartment Syndrome (3)

1. Ice, NO COMPRESSION (enough pressure)
2. Refer to ER
3. Surgery-fasciotomy-cut, leave opened for a couple of days, slowly close-lots of antibiotics