Foot and Lower Leg Anatomy & Injuries

Learning Objectives for Foot and Lower Leg

• Key anatomical structures related to foot and lower leg injuries should be recognized.
• Understand how foot conditions impact gait and injury risks.
• Knowing the etiology, symptoms, and appropriate kinesiology interventions is key for foot and lower leg conditions.
• Symptoms should be understood in relation to the severity of lower leg injuries.

Anatomical Structures of the Foot

• Medial structures include the distal phalanx, proximal phalanx, first metatarsal bone, medial cuneiform bone, intermediate cuneiform bone, lateral cuneiform bone, navicular tubercle, talus head, and talar dome.
• Lateral structures encompass the distal phalanx, middle phalanx, proximal phalanx, fifth metatarsal bone, cuboid bone, sinus tarsi, and calcaneus and tuberosity of calcaneus.
• Common structures are phalanges sesamoid bones, metatarsal bones(head and body), and tarsal bones.

Arches of the Foot

• The foot has a metatarsal arch, a transverse arch, a lateral longitudinal arch and a medial longitudinal arch.

Lower Leg Anatomy

• Key structures include the Achilles tendon, calcaneus, and plantar fascia.

Surface Anatomy of the Foot

• Features include the lateral and medial malleolus, anterior tibialis tendon, base and head of the 5th metatarsal, sustenaculum tali, extensor digitorum longus and hallucis longus tendons, plantar fascia insertion, and calcaneus.

Biomechanics of the Foot

• The foot is integral to the lower extremity kinetic chain.
• Lower extremity chronic and overuse injuries are influenced by biomechanical factors, including foot and ankle mechanics.

Pronation and Supination

• Pronation involves movement in all 3 planes of motion (frontal, sagittal, and horizontal).
• Supination involves movement in all 3 planes of motion (frontal, sagittal, and horizontal).

Phases of Normal Gait

• Stance phase starts with initial heel contact on the ground and ends with toe-off.
• Swing represents the time between toe-off and the subsequent initial contact.
• The stance phase accounts for 60% of the gait cycle and involves weight bearing in a closed kinetic chain.
• The swing phase is the period of non-weight bearing.

Take Home Points on Gait

• The foot acts as a shock absorber at heel strike and adapts through mid-stance to toe-off.
• Supination transitions to pronation at midstance to unlock the midfoot and allow shock absorption.
• The foot becomes a rigid lever for propulsive force at toe-off.
• Knee and hip movement can affect supination and pronation in the foot, and vice versa.

Foot Assessment

• Questions about the location of pain (heel, toes, arches), training surfaces, and footwear comfort are important.

• Assess if the patient favors the foot, has an antalgic gait, or cannot bear weight.

• Observe the arch shape and the static/dynamic foot alignment, watch for structural deformities.

Foot Palpation

• Palpate the medial and lateral calcaneus and malleolus.
• Check the navicular tubercle and cuboid bone.
• Examine the first cuneiform and styloid process of the 5th metatarsal.
• Assess the metatarsals, metatarsophalangeal joints, phalanges, medial longitudinal arch, plantar fascia, and transverse arch.

Pes Planus (Flatfoot) Characteristics

• Associated with excessive pronation, weak supportive structures, and consistent high-impact activity.
• Symptoms include pain, weakness, fatigue in the medial longitudinal arch, flattening of the arch, and a bulging navicular.

Effects of Excessive Pronation

• Can cause a stress injury by straining muscles supporting the medial arch and foot supination.
• Overloads structures during the propulsive phase, resulting in a hypermobile foot.
• Causes increased pressure on metatarsals and tibia internal rotation.
• Prevents the foot from resupinating, hindering the rigid lever needed for toe-off.

Pes Planus Management

• If asymptomatic, intervention may not be needed.
• Symptoms may present through the kinetic chain, not just in the foot.
• Orthotics can support the medial longitudinal arch by reducing strain on musculature and the plantar fascia.
• Taping the arch and strengthening posterior lower leg/intrinsic foot muscles can be beneficial.

Foot Strengthening.

• Exercises should stress the intrinsic muscles of the foot.
• Exercises should work the posterior muscles of the leg (TP, FHL, FDL).
• This can be achieved through deliberate exercise.
• Big toe and lesser toes extensions, toe spread outs and squeezes, short foot exercise, towel curl, marble pick ups, big toe and lesser toes press, heel raises, big toe flexion, lesser toes flexion, singe leg stance, toe waking, hoping.

Pes Cavus (High Arch Foot) Characteristics

• Involves a higher-than-normal arch, often with excessive supination.
• Accentuated high medial longitudinal arch and poor shock absorption are common
• Symptoms include heavy callus development on the ball/heel and pain into the lower leg.

Effects of Excessive Supination

• Causes the foot to remain rigid or hypomobile which includes decreased mobility of the calcaneocuboid joint.
• Decreased mobility in the 1st ray leads to inefficient force absorption during midstance and toe-off.
• Limits tibia internal rotation, impacting the kinetic chain.
• Increases the risk of ankle sprains, iliotibial band friction syndrome, trochanteric bursitis, and patellofemoral pain.

Pes Cavus Management

• Symptomatic cases may not require intervention.
• Symptoms can present through the kinetic chain.
• Orthotics aid in force absorption and the release of the Achilles/Gastroc complex and plantar fascia.

Plantar Fasciitis

• It is a term for pain in the transverse arch and heel.
• The plantar fascia is a dense connective tissue band that attaches to the calcaneus and spans the plantar foot.
• It maintains foot stability and braces the longitudinal arch.

Etiology & Sign of Plantar

• Fasciitis Increased tension, stress on fascia during toe-off.
• Changing to flexible footwear.
• Common with excessive pronation.
• Pain, mainly in the anterior medial heel.
• Increase pain in the morning or at the first step.
• Increase pain with dorsiflexion and toe extension.

Plantar Fasciitis Management

• Conservative treatment, soft orthotics, deep heel cups.
• Simple arch tapping, utilizing night split to maintain a position of static stretch. Vigorous Achilles/Gastroc stretching and exercises that increase toe extension and dorsiflexion.

Metatarsal Stress Fractures Etiology

• A second metatarsal fracture is most common.
• "March fracture," Change in running pattern, increased mileage, hills, or harder surface.
• A dull ache during weight bearing, progresses rest. It progresses from diffuse localized pain and is symptomatic usually after training.

Metatarsal Stress Fractures Management

• Medical management includes imaging, weight bearing until asymptomatic.
• Using initial immobilization until weight bearing, return to running should be gradual.
• Biomechanics and footwear must be looked at.

Great Toe Hyperextension (Turf Toe)

• Turf Toe is hyperextension injury resulting in sprain of first metatarsophalangeal joint and or resulting trauma.
• Symptoms are an increase of pain and swelling, and it increases during the push off when walking running and jumping.
• Increase of rigidity in the forefoot region, utilize a tape to prevent dorsiflexion an and or encourage activity.

Calcaneus

• Also known as severs disease with the etiology of traction of the apophysis, where there is achilles attachment.

Severs Symptoms

• Predominant in youth, pain occurs at the posterior heel below achilles attachment and can be mistaken for plantar fasciitis.
• Management involves using the "POLICE" principle and heel lift to release some stress, including soft tissue restrictions.

Talocrural Joint: Ankle and Lower Leg

• Components: Tibiofibular joint, tibia, fibula.

Key Ligaments

• Lateral ligaments: Posterior talofibular, calcaneofibular, and anterior talofibular ligaments.
• Medial ligament: Deltoid ligament with posterior tibiotalar, tibiocalcaneal, anterior tibiotalar, and tibionavicular portions.

Functional Anatomy of the Lower Leg

• The ankle is a stable hinge joint, with the talus shape adding stability.
• The malleoli prevent medial or lateral displacement.
• The most stable position is during dorsiflexion and lease stable is during plantarflexion .

Assessing the Leg and Ankle History

• Questions about past injury, the mechanism of injury, quality of pain and sound.
• Previous disability due to the injury, swelling, and or previous treatments.

Assessing the Leg and Ankle Observation

• Observing with range of motion and obvious pain.
• Also, seeing if there are any deformities or asymmetries.

Leg and Ankle Palpation

• Palpate the fibular head and shaft, tibia, medial and lateral maleous and calcaneus. Also to be palpated was Tibialis Interior, gastrocnemius, achilles tendon, anterior talofibular, calcaneofibular and or deltoid ligament.

Ankle Inversion

• The most common results are injury to the lateral ligaments and an anterior talofibular ligament injury.

Ottawa Ankle Field Assessments

• Rules field assessment are based by the bear weight for 4 steps and examination due to inability.
• Tenderness over posterior position.

Ankle Sprains Grade 1.

• Mild disability weight bearing, tenderness over a ligament. Utilized police for care and limited weight bearing as needed. Tape for support and return to activity in 7 to 21 days.

Ankle Sprains Grade 2.

• • Feel or hear a pop and or snap, moderate pain with bearing edemas.
• POLICE first for 72 days, crutches or aircast until ready to pain free. Easy range of motion or brace, rehabilitation.

Ankle Sprains Grade 3.

• Injury due to forces and cause of damaging to post/ant ligaments. Includes severe pain, swelling, discoloration and unable to bear weight. POLICE, immobilized for 4-6 weeks, NWB surgery.

Eversion

• 5-10 precent of ankle sprains are injuries to bony protection, deltoid ligaments. Mirror symptoms of an inversion sprain, pain is medially, potential lateral malleoli pain and has to be handled by same course as inversion sprains with grade 2.

High Ankle

• Injured due to forced rotation while weight bearing and dorsiflexion. Injuries including severe pain, loss of function, pain with weight bearing and doorsflexion and often needs to be difficult to treat. Total re hab can lake longer. Usually requires surgery.

Chronic Ankle Instability

• Common in cases requiring a poorly done rehab, and structural vs functional stability. Retraining and limb rehab.

Achilles Injury

• Etiology: inflammatory can also be overloaded due to resistance, but the presentations continue to be gradual and worsen.

Etiology Signs

• Symptoms includes pain and stiffness, palpable. It worsen in the morning , and increasing of pattern.
• Management: NSAIDS.

Achilles rupture

• It is caused by a sudden forceful flex ion and knee. There has often been no factors.
• Management: Sudden snap or kit to the leg with immediate pain and rapid subsidence With obvious indentation.

shin splints

• Pain in the anterior portion Caused by weak muscles and the static Foot structure.
• Management is a physician referral for scan.