INJURIES TO THE LOWER LEG, ANKLE, AND FOOT

Anatomy Review. The skeleton of the lower leg consists of the tibia and fibula; the tibia is the larger and stronger of the two. The 26 bones in the foot are interconnected and supported by numerous ligaments. Many joints within the foot assist with support and movement (refer to Figures 16.1 and 16.2 on page 234).
A. The talocrural joint, where the tibia, fibula, and talus bones join, provides mainly plantar flexion and dorsiflexion of the foot. The subtalar joint, which is the articulation of the talus and calcaneus, is mainly responsible for inversion and eversion of the foot. Both of these joints are surrounded by a capsule and supported by ligaments.
B. The major ligaments of the ankle joint are shown in Figures 16.3 and 16.4 on page 235. The ankle joint is strongest when in the dorsiflexed position.
C. The joints, ligaments, and muscles help create and maintain the two basic arches of the foot, the longitudinal and the traverse arches. These arches serve as shock absorbers and provide propulsion off surfaces during movement. Refer to Time Out 16.1 on pages 236 and 237 for a review of main muscle groups in the foot and ankle as well as their actions and innervations.
1. The anterior compartment muscles include the tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius. Anterior compartment muscles produce dorsiflexion and inversion of toes. These muscles are tightly packed into a small space.
2. The posterior compartment of the lower leg mainly functions to provide plantar flexion of the foot and is commonly called the calf muscles. This compartment contains the gastrocnemius, soleus, and plantaris muscles. Some anatomy books divide the posterior compartment into superficial and deep sections. Deep in this compartment are the tibialis posterior, flexor digitorum longus, flexor hallicus longus, and popliteus muscles. The gastrocnemius and soleus muscles have a common attachment on the calcaneus via the Achilles tendon. The popliteus muscle is important in knee flexion and initiates the action by unlocking the knee.
3. The lateral compartment of the lower leg contains the peroneus longus and peroneus brevis muscles. The peroneus brevis attaches at the base of the fifth metatarsal bone and is subject to avulsion. The peroneal nerve is superficial and susceptible to injury. The posterior tibial artery supplies blood to the peroneal muscles because there is no major artery in the lateral compartment.

I. Common Sports Injuries. Traumatic injuries to the lower leg, ankle, and foot usually involve skeletal structures; chronic injuries usually involve soft tissues in the area. Overuse, however, can cause fractures, and trauma can cause soft-tissue damage.

A. Skeletal Injuries.
1. Fractures. Direct trauma through contact causes most fractures to the lower leg as well as to the foot. However, violent trauma is not necessary to cause fractures in these tissues. Stress fractures can occur from overuse or micro trauma. Running, for example, causes a small amount of bone trauma each time the foot strikes the ground. Although the body repairs the damage as quickly as possible, repeated micro trauma to a specific bone can overwhelm the repair process and result in a stress fracture in the bone.
a. An avulsion of the fifth metatarsal can accompany a lateral ankle sprain; this type of sprain should be evaluated for such a fracture.
b. Signs and symptoms of a fracture in the lower leg or foot include swelling and/or deformity at the location of the trauma, discoloration at the site of the fracture, and broken bone ends may project through the skin. The athlete may report that a snap or pop was sensed when the injury occurred, and he or she may not be able to bear weight on the extremity.
1) In the case of a stress fracture or a growth plate fracture, the athlete will complain of extreme point tenderness and pain at the side of the suspected injury.
c. First aid care includes watching and treating for shock, applying sterile dressings to any related wounds, carefully immobilizing the foot and leg using a splint, and arranging for transport to medical facility.
1) If the fracture requires a cast, the athlete will be immobilized for a specified time. The physician will release the athlete for rehabilitation, practice, and competition, in that order. Participating in sports while a fracture is healing is not recommended.
B. Soft-Tissue Injuries.
1. Ankle Injuries. One of the most common sports injuries to the lower leg and ankle is a sprained ankle. Refer to Chapter 1 for a detailed description of the three levels of sprains.
The noncontractile structures on the lateral aspect of the ankle are most susceptible to injury. The lateral ligaments are more prone to damage via excessive movement than the deltoid ligament on the medial aspect of the ankle.
a. As the severity of the ankle sprain increases, so does the ankle’s instability. An eversion ankle sprain is thought to be more severe, causes greater instability, and should be treated more conservatively than inversion sprains. Inversion ankle sprains are more common, however.
b. Signs and symptoms depend on the severity.
1) A first-degree sprain includes pain, mild disability, point tenderness, little laxity, and little or no swelling.
2) A second-degree sprain includes pain, mild to moderate disability, point tenderness, loss of function, some laxity, and mild to moderate swelling.
3) A third-degree sprain involves pain and severe disability, point tenderness, loss of function, laxity, and moderate to severe swelling.
c. First aid care includes the immediate application of ice, compression, and elevation. A horseshoe- or doughnut-shaped pad kept in place by an elastic bandage aids in the compression and reduction of fluid (refer to Figure 16.7 on page 240).
1) Have the athlete rest and use crutches for walking if a second- or third –degree sprain has occurred.

2) If there is any question about the severity of the injury, splint and transport to medical facility for evaluation.
d. A tibiofibular (tib/fib) syndesmosis sprain may occur along with or masquerading as a lateral ankle sprain. In the lateral ankle sprain, there is an inversion mechanism that includes supination. In the tib/fib syndesmosis sprain, the mechanism is one of dorsiflexion followed by axial loading of the lower leg, with external rotation of the foot and internal rotation of the lower leg.
1) Signs and symptoms of a tib/fib syndesmosis sprain include the typical ankle sprain tests bring positive, and the athlete is in a great deal of pain and have point tenderness in the area of the tib-fib syndesmosis. Performing the “squeeze” test in the area will cause pain in the syndesmosis area (refer to Figure 16.8 on page 240).
2) First aid includes the application of ice, compression, and elevation. A horseshoe- or doughnut-shaped pad kept in place by an elastic bandage aids in the compression and reduction of fluid. Have the athlete rest and use crutches for first 72 hours, followed by a walking boot for 3 to 7 days. If there is any question about the severity of the sprain, splint and transport to medical facility for a physician’s evaluation.
e. Control of subsequent ankle sprains and related problems is controversial in sports medicine, but either taping or bracing reduces the number of ankle sprains. Ankle taping loses its prophylactic effectiveness over time possibly because the soft tissues in the ankle region become more mobile and the athlete relies on them more as exercise progresses. Some researchers think bracing is better than taping for preventing ankle injuries, because the brace reduces the ROM (refer to Figures 16.9, 16.10, and 16.11 on page 241). Wearing high-top shoes along with taping or bracing can be helpful as well as proprioception training for reducing chronic ankle instability.
1) Improperly applied adhesive taping can result in blisters, tape cuts, and loss of circulation.
2. Tendon-related Injuries. The Achilles tendon is commonly injured by long-distance runners, basketball players, and tennis players.
a. The onset of tendinitis may be slow among runners, but more rapid among basketball and tennis players. Achilles tendinitis can occur when the tendon, the tendon’s sheath, or the subcutaneous bursa dorsal to the tendon become inflamed.
1) Signs and symptoms of Achilles tendinitis include pain upon touching and moving the tendon. The pain typically intensifies when movement is initiated after a period of rest. Treatment involves immediate rest and usually the application of ice, NSAIDs, and a small heel lift. Controlled stretching on a slant board or against a wall can be beneficial. Rest is important because it allows the body to heal itself.
b. The Achilles tendon can be torn or ruptured.
1) Signs and symptoms include swelling and deformity at the site, the athlete reports of a pop or snap associated with the injury, pain in the lower leg, and loss of function, mainly in plantar flexion.
2) First aid includes the immediate application of ice and compression to the area. An air cast or splint should immobilize the foot. Arrange for transportation to the nearest medical facility.
3) Movement can produce more damage and inflammation, so the athlete should minimize dorsiflexion and eliminate forced dorsiflexion. If surgery is necessary, the athlete will probably be unable to participate for the rest of the season.
c. Other tendon problems affect the peroneus longus and peroneus brevis muscles. These tendons can dislocate and/or subluxate due to trauma or extreme force.
d. Athletes with tendon problems should be seen by a member of the medical team. Taping or bracing and strengthening the muscles in the area may be helpful. Recurrent problems, however, need to be investigated by a physician.
3. Compartment Syndrome. This syndrome is associated with the trauma to, or overuse of, the lower leg, which is divided into four compartments (refer to Time Out 16.1 on page 236). The majority of compartment syndrome problems occur in the anterior compartment because there is little room for expansion if there is swelling or effusion into it. Some athletes chronically overuse the muscles in the anterior compartment, and the extra fluid that accumulates in the compartment places extreme pressure on blood vessels and nerves. The other compartments of the lower leg can also be affected in a similar manner.
a. Shin guards can protect against blows to the lower leg.
b. The signs and symptoms include pain and swelling in the lower leg, and the athlete may complain of chronic or acute injury to the area. There may be a loss of sensation and motor control to the lower leg and/or foot, and a loss of pulse. Additionally, the athlete is unable to extend the great toe or dorsiflex the foot.
c. First aid care includes application of ice and elevation. Do not apply compression, because there is too much pressure in the area already. If the foot becomes numb or there is a loss of movement or pulse, seek medical help immediately. It is important to obtain medical advice early because these conditions can worsen quickly.
4. Shin Splints. A very common lower leg disorder is “shin splints,” exercise-induced leg pain. The exact cause of the dubious problem is unknown, and the types of activities and the manifestations of the injury vary depending on the athlete. With rest, the pain usually subsides and the athlete will be able to participate again.
a. Signs and symptoms include lower leg pain medially or posteromedially.
Typically the pain is chronic and progressively worsens. The pain and discomfort can be bilateral or unilateral.
b. First aid care includes the application of ice and having the athlete rest. NSAIDs may be helpful.
c. Changing the athlete’s workout routine may help. The athlete, for example, can reduce or eliminate running and replace this activity with another type of exercise until the condition resolves.
d. Professional medical help may be necessary to avoid long-term complications.
e. Sometimes preventive taping is used but long-term application of adhesive tape can irritate the skin of the lower leg.
C. Foot Disorders. Athletes participating in different sports will have different foot injuries. Some injuries are more common in certain sports.
1. Plantar Fasciitis. The plantar fascia is a dense collection of tissues that traverses from the plantar aspect of the metatarsal heads to the calcaneal tuberosity. If this tissue becomes tight or inflamed as a result of overuse or trauma, it can produce pain and disability affecting the bottom of the foot (plantar fasciitis).
a. A change in shoes, training technique, activity, or other factors may precipitate this injury. “Weekend athletes” are more likely to develop this problem than full-time athletes.
b. In adolescent athletes, plantar fasciitis often occurs with calcaneal apophysitis.
c. To determine whether the condition is plantar fasciitis, take a thorough history and ask the athlete if he or she experiences unbearable pain in the plantar aspect of the foot when taking his or her first steps out of bed in the morning. This pain usually eases with each step that follows. Also ask if there is point tenderness on the plantar aspect of the calcaneal tuberosity. If both symptoms exist, the athlete probably has plantar fasciitis.
d. First aid care is usually conservative and includes rest, anti-inflammatories, and the application of cold and heat alternatively to enhance healing. A heel pad and stretching the Achilles tendon complex can help. A semirigid orthosis placed in the shoe can be effective, but the device may interfere with the athlete’s participation in sports. If the athlete uses the foot while exercising, the activity aggravates the injury and interferes with healing.
2. Heel Spurs. Heel spurs can be related to plantar fasciitis, because the chronic inflammation results in ossification at the site of attachment on the plantar aspect of the calcaneus. The heel spur becomes problematic during physical activity and often causes long-term disability for the athlete. The athlete needs to consult a physician to determine a treatment plan if the spurs become too incapacitating. Doughnut shaped pads placed beneath the heel and some other therapeutic interventions may enable the athlete to participate in sports, but rarely improve the problem.
3. Morton’s Foot. This condition typically involves either a shortened first metatarsal bone or an elongated second metatarsal bone. As a result, the majority of weight bearing is done on the second metatarsal instead of the first. This can result in pain throughout the foot and difficulty in ambulation. Padding the area may reduce discomfort, but the athlete should see a physician for treatment.
a. Morton’s neuroma is a problem involving a nerve, usually between the third and fourth metatarsal heads. As a result, pain radiates to the third and fourth toes. A neuroma is an abnormal growth on a nerve. Tight-fitting shoes may be responsible for irritating the nerve in many cases of Morton’s neuroma. Going barefoot provides pain relief; a physician should be consulted for proper diagnosis and care.
4. Arch Problems. There are essentially two categories of arch problems; pes planus (“flat feet”) and pes cavus (high arches).
a. Athletes with flat feet may have excess foot pronation, causing difficulties in the navicular bone and some of the ankle joints. Although adhesive taping has been shown to have limited effectiveness, it may be worth trying. The athlete may benefit from orthosis or some other augmentation for flat feet.
1) Coaches should not attempt to apply adhesive tape unless they have been properly trained. For athletes with flat feet, orthotics and proper shoe selection may be helpful in the long term.
2) Athletes with flat feet are not necessarily slower or less mobile than athletes with regular or high arches.
b. A foot with too much arch is often associated with plantar fasciitis and clawing of the toes. High arches may result in generalized discomfort about the foot and ankle because the foot is unable to absorb forces because of the tightness of the joints in that region. Orthotics and proper shoe selection can help an athlete with high arches.
5. Bunions. Bunions are not common in young athletes. They may be simply inflamed bursae or involve complicated joint and bone deformities. Bunions are often caused by improperly fitting shoes; therefore, wearing correctly fitted shoes may resolve the bunion. If an athlete has a bunion for an extended period (weeks or months), he or she should obtain the advice of a physician.
6. Blisters and Calluses. Blisters and calluses are very common on athlete’s feet. Excessive movements can produce a great deal of friction between the layers of skin in the foot and the shoe, resulting in a blister or callus.
a. A blister forms when the layers of skin have been separated and a fluid deposit accumulates as a result of the friction. It is important to observe the color of the fluid in the blister; the fluid is usually clear, but if it is dark, blood is in the small cavity. The pain and discomfort of a blister will interfere with the athlete’s participation in sports. If the blister is large, it should be drained and the area padded to prevent future blister formation.
1) Follow recommended precautions regarding HIV and hepatitis B transmission when draining a blister. Always use sterile instruments and latex gloves or some other barrier to avoid contact with body fluids.
2) Wash the area with warm soapy water and sterilize with rubbing alcohol.
3) Using a sterile needle, puncture the base of the blister and apply direct pressure to drain it. This may need to be repeated during the first 24 hours. When draining the blister, leave the top layer of skin in place until a new layer of skin forms. This will reduce the likelihood of infection. Place a doughnut-shaped pad of felt or a large pad of thin adhesive felt directly over the blister to reduce friction. If the blister opens there is a possibility of infection. Therefore it is important to maintain the top layer of skin over the blister. Apply an antibacterial ointment to the area and cover with a sterile dressing.
4) Check the area daily for redness or pus to determine if the site is infected.
5) After 3 to 7 days, gently remove the top of the blister, apply an antibiotic ointment, and cover with a sterile dressing. Continue checking the area for infection. To allow for healing, avoid any further irritation of the site.
6) Athletes should be encouraged to report the formation of new blisters as soon as possible so padding and protection can be provided. Wearing properly fitted shoes and having a break-in period for new shoes before wearing them for practice or competition can reduce blister formation.
b. Calluses are a build up of excessive tissue on the bottom of the feet. A callus tends to form over the bony areas of the foot. A callus should not be allowed to become large and extremely thick, because friction can produce a blister between the callus and the next lower layer of skin. This type of blister is difficult to drain and very painful. To prevent this from happening, the callus should be shaved regularly to allow only a small buildup of tissue.
c. Toe Injuries. In some sports, toes are stepped on, resulting in torn-off nails or hematoma formation under the nail (see Figure 16.15 on page 247). Commercially available nail drills can be used to bore a small hole in the nail that allows the blood under the nail to drain. Shoes that are too tight can also smash toenails and lead to blood collection under the nail.
a) Ingrown toenails also result from wearing shoes that are too small or tight (refer to Figure 16.16 on page 248). Ingrown toenails need to be treated early to avoid infection and serious problems. Treat by soaking the affected toe in a warm antibacterial solution. Elevate the nail by placing a small cotton roll under the affected part and leaving it there as the nail grows out. To avoid ingrown toenails, athletes need to wear properly fitting shoes.

II. Preventive Ankle Taping. Although preventive ankle taping is a popular practice among many athletes, some athletic trainers promote the use of lace-up and other rigid braces instead of taping. Such braces have been shown to be just as effective, and possibly more so, as preventive taping in reducing inversion ROM over a 30–60 minute time period.
A. Preventive taping is a skill that must be learned properly, practiced, and then applied in an athletic team setting. Figure 16.17 on page 249 shows the use of prewrap and anchoring strips; Figures 16.18 to 16.20 show how stirrups are used to maintain the foot in a normal or slightly everted position. Figures 16.21 to 16.25 on pages 249–250 demonstrate the use of heel locks to stabilize the subtalar joint. Figures 16.26 to 16.28 on pages 250 and 251 show the use of figure-eights to stabilize the talocrural joint and the transverse tarsal joint. The remaining figures on page 251 show the use of finishing strips.

REVIEW QUESTIONS

1. Name the two bones located in the lower leg.

Answer: Tibia and fibula
Page: 234

2. Explain where the fibula is located and approximately how much body weight is supported by this bone.

Answer: The fibula is a smaller bone that supports 2% of body weight.
Page: 234

3. What is the technical name for the ankle joint?

Answer: The talocrural joint
Page: 234

4. Name the strongest and largest of the ankle ligaments.

Answer: Deltoid ligament
Page: 234

5. Draw or outline the compartments of the lower leg and describe the actions that the muscles in each compartment have on the foot.

Answer: Refer to pages 236–237
Page: 236–237

6. Which compartment of the lower leg presents the most problems with fluid accumulation?

Answer: Anterior compartment
Page: 243

7. Outline the signs and symptoms of a fracture of the lower leg.

Answer:
1.) Swelling and/or deformity at the location of the trauma.
2,) Discoloration at the site of the fracture.
3.) Possible broken bone end projecting through the skin.
4.) Athlete reporting that a snap or a pop was heard or felt.
5.) The athlete may not be able to bear weight on the affected extremity.
6.) In the case of a stress fracture or a growth plate fracture that did not result from a traumatic event, the athlete will complain of extreme point tenderness and pain at the site of suspected injury.
Page: 238

8. True or False: An inversion ankle sprain is more common than an eversion ankle sprain.

Answer: True.
Page: 239

9. Explain which type of ankle sprain is more severe.

Answer: It is generally accepted that an eversion sprain is more severe.
Page: 239

10. Describe where the Achilles tendon attaches and the signs, symptoms, and treatment of Achilles tendinitis.

Answer: Refer to page 242.
Page: 242

11. Explain the possible long-term complications if problems with anterior compartment syndrome are left untreated.

Answer: Compromising the vessels and nerves
Page: 243

12. Explain what types of changes (e.g. biomechanical, training) an athlete may need to make in order to alleviate and prevent further episodes of shin splints.

Answer: To help the athlete work through shin splints, suggest a change in workout routine and have their gate analyzed.
Page: 244

13. Outline the key signs and symptoms of plantar fasciitis and explain how heel spurs are associated with this condition.

Answer:
1.) Almost unbearable pain in the plantar aspect of the foot with the first steps taken on getting out of bed in the morning and pain that eases with each following step
2.) Point tenderness on the plantar aspect of the calcaneal tuberosity

Heel spurs are ossifications at the site of the attachment on the plantar aspect of the calcaneus.
Page: 245

14. What structures are involved in Morton’s foot?

Answer: The first and second metatarsal bone
Page: 245

15. Explain the difference between pes cavus and pes planus.

Answer: Pes planus is an abnormally flat foot and pes cavus is an abnormally high arch in the foot.
Page: 245–246

16. Explain the difference between a blister and a callus.

Answer: A blister is the separation of the layers of skin and a callus is a build up of tissue.
Page: 246–247

17. Outline how a blister should be cared for when it is drained.

Answer: Refer to page 247 for instructions.
Page: 247

18. Explain how blisters can be prevented.

Answer: It is definitely best to help prevent blisters by having properly fitted footwear and giving new shoes a short break-in period before using them in practice or competition.
Page: 247

19. True or False: It is not possible for a callus to form over a blister.

Answer: False. When there is friction between the callus and layers of skin, a blister can form between the callus and the next lower layer of skin.
Page: 247

20. True or False: Callus formation on the plantar aspect of the foot should be trimmed regularly to reduce friction.

Answer: True. A callus should be shaved regularly to allow for only a small amount of buildup.
Page: 247