Injury Assessment:Injury Assessment:Lower ExtremityLower Extremity

FOOT & ANKLEFOOT & ANKLE

AnatomyAnatomy Talar DomeTalar Dome CalcaneusCalcaneus Tibia/FibulaTibia/Fibula 55thth Metatarsal Metatarsal ATFL/CLF/PTFLATFL/CLF/PTFL Deltoid LigamentDeltoid Ligament Achilles TendonAchilles Tendon Plantar FasciaPlantar Fascia Dorsal Pedis PulseDorsal Pedis Pulse Post. Tibialis PulsePost. Tibialis Pulse

DeformitiesDeformities

• Pes cavus/planusPes cavus/planus

• Bunion (hallux valgus)Bunion (hallux valgus)

Special Tests: ROMSpecial Tests: ROM

Ankle:Ankle: DorsiflexionDorsiflexion PlantarflexionPlantarflexion InversionInversion EversionEversion

Evaluation, Treatment, and Evaluation, Treatment, and Prevention of Foot & Ankle Prevention of Foot & Ankle

InjuriesInjuries

Ankle Sprain:Ankle Sprain: Mild to moderate pain around ankleMild to moderate pain around ankle 80-90%: Lateral ankle sprains (ATFL, CFL, PTFL)80-90%: Lateral ankle sprains (ATFL, CFL, PTFL) Felt or heard popFelt or heard pop Swelling and bruisingSwelling and bruising

Treatment:Treatment: RICE, NSAID’sRICE, NSAID’s Crutches if limpingCrutches if limping

RTP:RTP: Pain freePain free Full strength/ROMFull strength/ROM Min. to no swellingMin. to no swelling Able to perform sport-specific testingAble to perform sport-specific testing

Prevention:Prevention: Ankle strengthening/balance exercisesAnkle strengthening/balance exercises Bracing as neededBracing as needed

Turf Toe:Turf Toe:

Forced extension or flexion of great toeForced extension or flexion of great toe Sprain/strain both possibleSprain/strain both possible Mild to severe pain superior or inferiorMild to severe pain superior or inferior Pain with (or inability to) walking/running/jumpingPain with (or inability to) walking/running/jumping

Treatment: Treatment: Rest, ice, NSAID’s, tapingRest, ice, NSAID’s, taping

RTP:RTP: Pain free or to tolerancePain free or to tolerance Able to complete sport-specific testingAble to complete sport-specific testing

Prevention:Prevention: Proper footwearProper footwear

Achilles Tendonitis:Achilles Tendonitis:

Repeated forceful contraction/stretch of gastroc-soleus Repeated forceful contraction/stretch of gastroc-soleus complexcomplex

Mild to severe pain over achilles tendon Mild to severe pain over achilles tendon Pain with dorsi- and plantarflexionPain with dorsi- and plantarflexion Pain with contraction of calf/running/jumpingPain with contraction of calf/running/jumping

Treatment:Treatment: Rest, ice, NSAID’s Rest, ice, NSAID’s Stretching Stretching Crutches/boot as neededCrutches/boot as needed

RTP:RTP: Pain free, taping, full strength/ROMPain free, taping, full strength/ROM

Prevention:Prevention: Stretching/strengthening, proper warm-upStretching/strengthening, proper warm-up

Achilles Rupture:Achilles Rupture: Most severe muscular injury to lower legMost severe muscular injury to lower leg Most common: 30-50 y/oMost common: 30-50 y/o MOI: explosive push-offMOI: explosive push-off Hear and feel pop/Severe painHear and feel pop/Severe pain May be able to walk/limpMay be able to walk/limp Inability to dorsiflex footInability to dorsiflex foot Positive Thompson testPositive Thompson test Swelling/bruisingSwelling/bruising Visible defect in tendon Visible defect in tendon

Treatment:Treatment: Ice, compression wrap (toes to knee), immobilize in posterior splint, Ice, compression wrap (toes to knee), immobilize in posterior splint,

immediate referral to orthopedicimmediate referral to orthopedic Surgery usually required for athletesSurgery usually required for athletes

RTP:RTP: Cleared by MDCleared by MD 6+ months for full strength/ROM6+ months for full strength/ROM

Prevention:Prevention: Strength/stretch gastroc-soleous complexStrength/stretch gastroc-soleous complex Allow overuse injuries to completely healAllow overuse injuries to completely heal

Plantar Fasciitis:Plantar Fasciitis: Inflammation of plantar fasciaInflammation of plantar fascia Caused by: pes cavus, pes planus, no arch support, Caused by: pes cavus, pes planus, no arch support,

tight calf muscles, sudden increases in activity tight calf muscles, sudden increases in activity Mild to severe pain on bottom of footMild to severe pain on bottom of foot Pain with walking/running/jumpingPain with walking/running/jumping Swelling possibleSwelling possible

Treatment:Treatment: Ice, rest, NSAID’sIce, rest, NSAID’s

RTP:RTP: Pain freePain free

Prevention:Prevention: Proper footwear/orthoticsProper footwear/orthotics Gradual increases in activityGradual increases in activity

HIP & KNEEHIP & KNEE

AnatomyAnatomy FemurFemur TibiaTibia

Tibial TuberosityTibial Tuberosity Tibial PlataeuTibial Plataeu

Fibular HeadFibular Head Patella (“knee cap”)Patella (“knee cap”) ACL/PCL/LCL/MCLACL/PCL/LCL/MCL Meniscus Meniscus IT BandIT Band Patellar TendonPatellar Tendon Quad/Hip Flexor/Hamstring/Gastroc-Quad/Hip Flexor/Hamstring/Gastroc-

Soleus ComplexSoleus Complex

DeformitiesDeformities

Genu RecurvatumRecurvatum Genu Varum Genu Valgum

ROMROM

Hip:Hip: Flexion/extensionFlexion/extension Adduction/abduction Adduction/abduction Internal/external Internal/external

rotation rotation

Knee: Knee: Flexion/extensionFlexion/extension Internal/external Internal/external

rotationrotation

Evaluation, Treatment, and Evaluation, Treatment, and Prevention of Hip & Knee InjuriesPrevention of Hip & Knee Injuries

Hip SubluxationHip Subluxation Moderate to severe painModerate to severe pain Limping Limping Possible neurovascular signsPossible neurovascular signs

Treatment:Treatment: Ice, monitor, immobilize leg, call 911?Ice, monitor, immobilize leg, call 911?

Hip DislocationHip Dislocation Severe painSevere pain Unable to walkUnable to walk 70-80% 70-80% posteriorposterior dislocations dislocations Injured leg shorter Injured leg shorter Neurovascular signsNeurovascular signs

Treatment:Treatment: Ice, monitor, immobilize leg, Ice, monitor, immobilize leg,

call 911call 911 RTP:RTP:

Pain free, full ROM, full strength, released by MDPain free, full ROM, full strength, released by MD Prevention:Prevention:

Strengthening ex’sStrengthening ex’s

Hip Pointer:Hip Pointer:

Bruise of iliac crest (hip bone)Bruise of iliac crest (hip bone) Mild point tenderness to severe painMild point tenderness to severe pain May not be able to perform hip flexionMay not be able to perform hip flexion Swelling possibleSwelling possible

Treatment: Treatment: Ice, rest, monitorIce, rest, monitor

RTP:RTP: To tolerance, may need to pad, pain may last up to 2 To tolerance, may need to pad, pain may last up to 2

monthsmonths Prevention:Prevention:

Wear padding when appropriateWear padding when appropriate

Femur FractureFemur Fracture Severe painSevere pain Neurovascular signsNeurovascular signs DeformityDeformity Limb shortness Limb shortness Heard or felt popHeard or felt pop Unable to move legUnable to move leg Involves significant traumaInvolves significant trauma

• Not common in sportsNot common in sports

Treatment:Treatment: Call 911, ice, immobilize leg, monitorCall 911, ice, immobilize leg, monitor

RTP: RTP: Full ROM & strength, cleared by MD Full ROM & strength, cleared by MD

Prevention:Prevention: Wear protective padsWear protective pads

Muscle Strains:Muscle Strains:

Mild, moderate, or severe painMild, moderate, or severe pain Pain or inability to lift legPain or inability to lift leg Possibly felt or heard popPossibly felt or heard pop Pain or inability to run/sprintPain or inability to run/sprint Possible deformity: ReferPossible deformity: Refer

Treatment:Treatment: Ice, light stretch, rest, crutches?Ice, light stretch, rest, crutches?

RTP:RTP: Full strength & ROM, pain freeFull strength & ROM, pain free

Prevention:Prevention: Stretch & proper warm-upStretch & proper warm-up

Muscle Contusions:Muscle Contusions:

Mild to severe painMild to severe pain Pain w/ walking/running/Pain w/ walking/running/ moving legmoving leg Possible inability to move legPossible inability to move leg Decreased strengthDecreased strength

Treatment:Treatment: RICE, crutches?RICE, crutches?

RTP:RTP: Full strength & ROM, min. to Full strength & ROM, min. to no painno pain

Prevention:Prevention: Wear protective equipmentWear protective equipment

Knee Sprain:Knee Sprain:

ACL, PCL, MCL, or LCLACL, PCL, MCL, or LCL Mild to severe painMild to severe pain Felt or heard a popFelt or heard a pop InstabilityInstability Swelling (ACL especially)Swelling (ACL especially)

Treatment:Treatment: RICE, immobilize, crutches, referRICE, immobilize, crutches, refer

RTP: RTP: Full strength & ROM, no pain, cleared, braceFull strength & ROM, no pain, cleared, brace

Prevention:Prevention: Brace, strengthening ex’sBrace, strengthening ex’s

Degree of MCL SprainsDegree of MCL Sprains

MOI of MCL SprainMOI of MCL Sprain

Dislocated/Subluxated Patella:Dislocated/Subluxated Patella: Felt patella out of placeFelt patella out of place Lateral most common Lateral most common Mild to severe painMild to severe pain Obvious deformityObvious deformity SwellingSwelling

Treatment:Treatment: RICE, crutches, immobilize, monitor, refer if RICE, crutches, immobilize, monitor, refer if

necessary, straiten leg if possible-if patella does not necessary, straiten leg if possible-if patella does not relocate…call 911 relocate…call 911

RTP:RTP: Full strength & ROM, no pain, cleared if seen by MD, Full strength & ROM, no pain, cleared if seen by MD,

Prevention:Prevention: Quad strengthening ex’sQuad strengthening ex’s

Stages of Patellar DislocationStages of Patellar Dislocation

Meniscus Tear:Meniscus Tear: Knee locks, gives out, feels unstableKnee locks, gives out, feels unstable Pain at joint linePain at joint line Felt or heard a popFelt or heard a pop May swellMay swell

Treatment:Treatment: Rest, Ice, crutches?, refer Rest, Ice, crutches?, refer

RTP: RTP: Full ROM & strength, Full ROM & strength,

pain tolerablepain tolerable Prevention:Prevention:

Strengthening ex’sStrengthening ex’s

Other Meniscus TearsOther Meniscus Tears

Patellar Tendonitis:Patellar Tendonitis: Overuse injury caused by repeated contractions of quad Overuse injury caused by repeated contractions of quad

and/or weak/tight quad/hamstring/calfand/or weak/tight quad/hamstring/calf Mild to severe pain below patella w/ Mild to severe pain below patella w/

running/jumping/extensionrunning/jumping/extension Possible localized swellingPossible localized swelling

Treatment:Treatment: Rest, ice, NSAID’sRest, ice, NSAID’s Patellar strap or tapePatellar strap or tape

RTP:RTP: Pain free or pain is tolerablePain free or pain is tolerable

Prevention:Prevention: Strengthen/stretch quads, hamstrings, and calfStrengthen/stretch quads, hamstrings, and calf Proper warm-up prior to activityProper warm-up prior to activity

Osgood Schlatter’s:Osgood Schlatter’s: Traction injury were patellar tendon attaches to tibial tuberosityTraction injury were patellar tendon attaches to tibial tuberosity Beginning of growth spurt:Beginning of growth spurt:

• Girls: 8-13Girls: 8-13• Boys: 10-15 (more common)Boys: 10-15 (more common)

Pain at tibial tuberosity w/ enlargement due to extra bone growthPain at tibial tuberosity w/ enlargement due to extra bone growth Full ROMFull ROM

Treatment:Treatment: Self Limiting (12-24 months)Self Limiting (12-24 months) IceIce Padding (i.e. wrestling)Padding (i.e. wrestling) Shock absorbent insolesShock absorbent insoles

RTP:RTP: To pain toleranceTo pain tolerance

Prevention:Prevention: Quad/hamstring stretchingQuad/hamstring stretching Early padding and iceEarly padding and ice

IT Band Friction Syndrome:IT Band Friction Syndrome:

Common in runners, cyclists, and volleyball Common in runners, cyclists, and volleyball Thick fibers tighten and cause pain at the lateral femoral Thick fibers tighten and cause pain at the lateral femoral

epicondyle and/or greater trochanter of the femurepicondyle and/or greater trochanter of the femur Predisposing factors:Predisposing factors:

• Genu varus, excessive pronation, leg-length, over-trainingGenu varus, excessive pronation, leg-length, over-training Initial pain late in run, then occurs earlierInitial pain late in run, then occurs earlier May occur running up/down hill or climbing stairsMay occur running up/down hill or climbing stairs

Treatment:Treatment: Ice, ice massage, NSAID’s, rest, stretching, avoid hills, Ice, ice massage, NSAID’s, rest, stretching, avoid hills,

modify activity, orthotics, swim for CV maint.modify activity, orthotics, swim for CV maint. RTP:RTP:

Pain freePain free Prevention:Prevention:

Stretching, gradual increases in training, proper footwear, Stretching, gradual increases in training, proper footwear, correct predisposing factors if possiblecorrect predisposing factors if possible

Lower Leg Fracture:Lower Leg Fracture: Severe painSevere pain Pain is point specificPain is point specific Deformity possibleDeformity possible Numbness/tinglingNumbness/tingling Heard or felt popHeard or felt pop

Treatment:Treatment: Ice, immobilize, 911, monitor/treat for shockIce, immobilize, 911, monitor/treat for shock

RTP:RTP: Cleared by MDCleared by MD 4-6 weeks + rehab4-6 weeks + rehab

Prevention:Prevention: Protective padding Protective padding

Shin Splints:Shin Splints: MTSS: inflammation of periosteum of the medial tibial borderMTSS: inflammation of periosteum of the medial tibial border Usually distal 1/3Usually distal 1/3 3-6 cm long3-6 cm long Pain relieved by restPain relieved by rest Pain increases standing on toesPain increases standing on toes Caused by:Caused by:

• Sudden increase in activitySudden increase in activity• Poor footwearPoor footwear• Running on hard surfacesRunning on hard surfaces

Treatment:Treatment: Ice, ice massage, rest, NSAID’s, compression/tapeIce, ice massage, rest, NSAID’s, compression/tape

RTP:RTP: Pain freePain free

Prevention:Prevention: Achilles stretching, orthotics, proper footwear, gradual increases in Achilles stretching, orthotics, proper footwear, gradual increases in

activity, LL strengtheningactivity, LL strengthening

Stress Fracture:Stress Fracture: Repetitive running/jumpingRepetitive running/jumping Sudden increase in mileageSudden increase in mileage Pain begins slowly: increasing with activity and decreasing with restPain begins slowly: increasing with activity and decreasing with rest Pain is limited to the fracture sitePain is limited to the fracture site Positive squeeze test/compression Positive squeeze test/compression

• oror US, tuning fork US, tuning fork Treatment:Treatment:

Refer to MDRefer to MD Rest 4-6 weeks (or longer)Rest 4-6 weeks (or longer) Ice, NSAID’sIce, NSAID’s Strengthening/stretchingStrengthening/stretching NWB CV workouts (i.e. bike, pool)NWB CV workouts (i.e. bike, pool)

RTP:RTP: Pain freePain free Released by MDReleased by MD

Prevention:Prevention: Proper footwear/arch support, gradual increase in activityProper footwear/arch support, gradual increase in activity Strengthening/stretchingStrengthening/stretching

Exertional Compartment Syndrome:Exertional Compartment Syndrome: Unknown etiology: possibly tight fasciaUnknown etiology: possibly tight fascia Pain, burning, aching, cramping during activityPain, burning, aching, cramping during activity

• May subsides after activityMay subsides after activity Tingling in foot or toes possibleTingling in foot or toes possible Loss of circulation possibleLoss of circulation possible Tightness of LLTightness of LL Exercise induced swellingExercise induced swelling Possible muscle weaknessPossible muscle weakness Common bilat.Common bilat.

Treatment:Treatment: Rest, Ice, elevation, NSAID’sRest, Ice, elevation, NSAID’s DO NOT COMPRESSDO NOT COMPRESS Stretching/strengtheningStretching/strengthening Orthotics, activity modificationOrthotics, activity modification

RTP:RTP: Pain/sx freePain/sx free Released by MD Released by MD

Prevention:Prevention: Gradual increase in activity, stretching both may helpGradual increase in activity, stretching both may help

Fascial CompartmentsFascial Compartments