Leg, Ankle, and Foot Injuries
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This is Chapter 27 from RC’s best-selling book:
Second Edition ~ Wiliams & Wilkins
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Chapter 27: Leg, Ankle, and Foot Injuries
The lower leg, ankle, and foot work as a functional unit. Total body weight above is transmitted to the leg, ankle hinge, and foot in the upright position, and this force is greatly multiplied in locomotion. Thus the ankle and foot are uniquely affected by trauma and static deformities infrequently seen in other areas of the body.
Injuries of the Leg
The most common injuries in this area are bruises, muscle strains, tendon lesions, postural stress, anterior and posterior compression syndromes, and tibia and fibula fractures. Bruises of the lower leg are less frequent than those of the thigh or knee, but the incidence of intrinsic strain, sprain, and stress fractures are much greater.
A continual program of running and jogging is typical of most sports. The result is often strengthening of the antigravity muscles at the expense of the gravity muscles — producing a dynamic imbalance unless both gravity and antigravity muscles are developed simultaneously. An anatomic or physiologic short leg as little as an eighth of an inch can affect a stride and produce an overstrain in long-distance track events.
Bruises and Contusions
The most common bruise of the lower extremity is that of the shin where disability may be great as the poorly protected tibial periosteum is usually involved. Skin splits in this area can be most difficult to heal. Signs of suppuration indicate referral to guard against periostitis and osteomyelitis.
Management.Treat as any skin-bone bruise with cold packs and antibacterial procedures, and shield the area with padding during competitive activity. When long socks are worn, the incidence of shinbone injuries is reduced. An old but effective protective method in professional football that does not add weight is to place four or five sheets of slick magazine pages around the shin that are secured by a cotton sock which is covered by the conventional sock. A blow to the shin is reduced to about a third of its force as the paper slips laterally on impact.
This is a common and most debilitating injury in contact sports. It is characterized by severe calf tenderness, abnormal muscle firmness of the engorged muscle, and inability to raise the heel during weight bearing.
Management.Treat with cold packs, compression, and elevation for 24 hr. Follow with mild heat and contrast baths. Massage is contraindicated as it might disturb muscle repair. The danger of ossification is less in the calf than in the thigh, but management must incorporate precautions against adhesions.
Contusion to the greater saphenous vein may lead to rupture resulting in extensive swelling, ecchymosis, redness and other signs of local phlebitis. Tenderness will be found along the course of the vascular channel. During treatment, referral should be made upon the first signs of thrombosis.
Management.Management is by rest, cold, compression, and elevation for at least 24 hr. Later, progressive ambulation, mild heat, and contrast baths should be utilized. Progressive exercises may begin in 4-6 days. When competitive activity is resumed, the area should be provided extra protection.
Nerve trauma exhibits palsy, paresthesia, or anesthesia. These signs commonly result from a kick in sports. Trauma behind the knee to the external popliteal nerve features inability to extend the foot. Trauma to the peroneal nerve along the lateral aspect of the lower third of the leg may result in a palsy characterized by inability to flex the foot (foot drop). Peroneal symptoms are sometimes associated with asymptomatic loose tibiofibular ligaments. The excessive mobile fibula head, with demonstrated false motion, often “clicks” during gait and tends to irritate the peroneal nerve as it winds around the fibula neck.
Management.Treat as any nerve contusion with emphasis on ice massage or cold packs, followed later by deep massage, contrast baths, and graduated exercises. Heel lifts are helpful in relieving tension on the injured nerve. A loose tibiofibular head can be aided by a sponge pad placed over the area and secured by an elastic bandage. Any case exhibiting a degree of atrophy or sensation loss over a few days deserves neurologic consultation.
With the increased interest in jogging, musculoskeletal injury is common but usually minor. During middle age, the most common injury is calf-muscle strain, but knee, ankle, and foot sprain, and shin splints do occur frequently. Occassionally, stress fractures will be associated.
A tear of the musculotendinous junction of the medial belly of the gastrocnemius often occurs in tennis, skiing, squash, and track. At the site of tenderness, a palpable gap in the muscle is usually found. It is identified in a radiographic lateral view as an indentation of the soft-tissue margins.
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