Foot Conditions
Chapter 19
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Anatomy
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy (Cont’d)
• Forefoot
– Metatarsals and phalanges; numerous joints
– Support and distribute body weight throughout the
foot
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Anatomy (cont.)
• Midfoot
– Navicular, cuboid, 3 cuneiforms; numerous joints
– Talocalcaneonavicular joint (TCN)
• Talus moves simultaneously on calcaneus and navicular
• Combined action of talonavicular and subtalar joint
• Close-packed position—supination
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Anatomy (cont.)
• Ligaments supporting the
midfoot and hindfoot
region
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Anatomy (cont.)
• Hindfoot
– Calcaneus and talus
– Talocrural joint (ankle joint)
• Articulation of talus, tibia, and fibula
• Close-packed position—dorsiflexion
• Medial ligament—deltoid
• Lateral ligament—anterior talofibular;
posterior talofibular; calcaneofibular
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Anatomy (cont.)
• Hindfoot
– Subtalar joint
• Behaves as a
flexible
structure
• Axis of rotation
of the subtalar
joint lies
oblique in the
sagittal and
frontal planes
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Anatomy (cont.)
• Plantar arches
– Support and distribute
body weight
– Longitudinal arch—
medial and lateral
– Transverse arch
– Ligaments
• Spring
(calcaneonavicular)
• Long plantar
• Short plantar
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Anatomy (cont.)
• Plantar arches
– Plantar fascia
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Anatomy (cont.)
• Muscles
– Lateral and medial view
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Anatomy (cont.)
• Muscles
– Posterior view
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Anatomy (cont.)
• Muscles
– Intrinsic muscles of the foot – dorsal view
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Anatomy (cont.)
• Muscles
– Intrinsic muscles of the foot – plantar view
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Anatomy (cont.)
• Nerves
– Sciatic nerve
• Tibial nerve
• Common peroneal nerve — deep and
superficial peroneal nerves
– Femoral — saphenous
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Anatomy (cont.)
• Blood supply
– Femoral artery
– Popliteal
– Anterior and posterior
tibial
– Anterior tibial
• Dorsal pedal
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Kinematics
• Gait cycle
– Consists of alternating periods of single-leg and double-leg
support
– Requires a set of coordinated, sequential joint actions of
the lower extremity
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Kinematics (cont.)
• Motions
– Toe — flexion and extension
– Ankle (subtalar) — dorsiflexion and
plantarflexion
– Foot and ankle
• Inversion and eversion
• Pronation and supination
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Kinetics
• Bones subject to several loading patterns
• Running
– Foot sustains forces 2–3× body weight
– Bones are typically 2–4× strength needed
• Repeated forces—stress fractures
• Foot deforms during weight bearing
– Absorbing a smaller force of longer duration than if it
were rigid
– Deformation causes storage of mechanical energy in
the stretched tendons, ligaments, and plantar fascia
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Injury Prevention
• Physical conditioning
–
Strengthening
• Extrinsic muscles
• Intrinsic muscles
–
Flexibility
• Achilles tendon
• Footwear
–
Demands of sport; wear shoe for its intended purpose
–
Proper fit
• Protective equipment
–
Taping; braces; orthotics
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Toe and Foot Conditions
• Foot Deformities
– Pes cavus
• High arch and rigid
foot
– Pes planus
• Flatfoot and mobile
foot
– Associated with
common injuries
(refer to Box 19.1)
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Toe and Foot Conditions (cont.)
• Toe deformities
– Hallux rigidis
• Degenerative arthritis in first MTP
• S&S
• Tender, enlarged first MTP joint
• Loss of motion
• Difficulty wearing shoes with an elevated heel
• Hallmark sign—restricted toe extension
• Management: shoe modification
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Toe and Foot Conditions (cont.)
• Toe deformities
– Hallux valgus
• Thickening of the
medial capsule and
bursa, resulting in
severe valgus
deformity of great toe
• Asymptomatic or
symptomatic
• Treatment—
symptomatic
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Toe and Foot Conditions (cont.)
• Hammer toe
– Extension of MTP joint, flexion at PIP joint, and
hyperextended at the DIP joint
• Claw toe
– Hyperextension of MTP joint and flexion of DIP and
PIP joints
• Mallet toe
– Neutral position at MTP and PIP joints, flexion at DIP
joint
• Difficult to treat conservatively
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Toe and Foot Conditions (cont.)
• Turf toe
–
Sprain of the plantar capsular ligament of 1st MTP joint
–
Mechanism: forced hyperflexion or hyperextension of great toe
–
Acute or repetitive overload
–
Valgus ↑ susceptibility
–
S&S
• Pain, point tenderness, and swelling on plantar aspect of MP
joint
• Extreme pain with extension
–
Potential for tear in flexor tendons or fracture of sesamoid bones
–
Management: standard acute; rest; protection from excessive
motion
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Toe and Foot Conditions (cont.)
• Ingrown toenail
– Preventable with proper hygiene and nail care
– Edge of nail grows into lateral nail fold and
surrounding skin
– Nail margin reddens; painful
– Paronychia—fungal or bacterial infection
– Management: refer to Application Strategy 19.2
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Toe and Foot Conditions (cont.)
• Metatarsalgia
– General discomfort around the metatarsal heads
– Constant overloading leads to flattening of
transverse arch
– Contributing factors—intrinsic and extrinsic (refer to
Box 19.2)
– Management: activity modification; footwear
examination; strengthening exercises
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Toe and Foot Conditions (cont.)
• Bunion
– Medial aspect of MTP joint of great toe; lateral aspect of
the 5th toe
– Thickening of capsule and bursa
– Due to constant rubbing against inside of shoe
– S&S (as condition worsens)
• Lateral shift of great toe
• Rigid, nonfunctional hallux valgus deformity
– Once deformity occurs, little can be done to correct
condition
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Toe and Foot Conditions (cont.)
• Retrocalcaneal bursitis
– Due to external pressure—
constrictive heel cup, coupled
with excessive pronation or varus
hindfoot
– “Pump bump”
– Management: standard acute;
shoe modification; AT stretching
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Foot Contusions
• Trauma to the midfoot or forefoot: need to rule out fracture
and damage to extensor tendons
• Hindfoot—heel bruise
– Thick padding of adipose tissue—does not always suffice
– Stress in running, jumping, changing directions
– S&S
• Severe pain in heel
• Unable to bear weight
– Management: cold; heel cup or doughnut pad
– Condition may persist for months
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Toe and Foot Sprains
• IP & MP joints
– Sprains of MP and IP joints of the toes may occur by
tripping or stubbing the toe
– S&S
• Pain, dysfunction, immediate swelling
• Dislocation—gross deformity
– Management—strapping
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Toe and Foot Sprains (cont.)
• Midfoot sprains
– Mechanism: severe dorsiflexion, plantarflexion, or
pronation
– More frequent in activities in which the foot is unsupported
– S&S
• Pain and swelling is deep on medial aspect of foot
• Weight bearing may be too painful
– Management: standard acute; limited weight bearing
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Overuse Conditions
• Plantar fasciitis
– Extrinsic and intrinsic risk factors
– S&S
• Pain with first steps in the morning
• Point tenderness at medial calcaneal tubercle
• ↑ pain with passive extension of great toe and ankle
dorsiflexion
• ↑ pain with weight bearing
• Pain relieved with activity, but recurs after rest
– Management: standard acute; refer to Application
Strategy 19.4
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Neurologic Conditions
• Plantar interdigital neuroma (Morton’s neuroma)
– Trauma or repetitive stress → abnormal pressure
on plantar digital nerves
– Common—web space between 3rd and 4th
metatarsals; less common, between 2nd and 3rd
metatarsals
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Neurologic Conditions (cont.)
– S&S
• Sensation of having a stone in the shoe that worsens
when standing
• Tingling or burning, radiating to the toes, along with
intermittent symptoms of a sharp shock-like sensation
• Pain subsides when activity is stopped or when the shoe
is removed; desire to remove the shoe and massage
foot—classic sign
– Management: metatarsal pad; broad, soft-soled shoe with
a low heel
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Neurologic Conditions (cont.)
• Tarsal tunnel syndrome
– Posterior tibial nerve (or branch) constricted beneath
fibrous roof of foot flexor retinaculum
– Often linked to excessive pronation or excessive
valgus deformity
– S&S
• Pain at medial malleolus radiating into sole and
heel
• Paresthesia, dysesthesia, or hyperesthesia in
nerve distribution
• + Tinel’s sign
– Management: rest; NSAIDs; orthoses; gradual
return to activity
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Foot and Lower Leg Fractures
• Repetitive microtraumas → apophyseal or stress
fractures
• Tensile forces associated with severe ankle sprains →
avulsion fractures of 5th metatarsal
• Severe twisting → displaced and undisplaced fractures in
foot, ankle, or lower leg
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Foot and Lower Leg Fractures (cont.)
• Freiberg's disease
–
Avascular necrosis of 2nd metatarsal head
–
Active adolescents ages 14–18
• Sever's disease
–
Traction-type injury of calcaneal apophysis
–
Seen in ages 7–10
–
S&S
• Heel pain with activity
• + “squeeze” test
• + Sever’s sign
• Decreased heel cord flexibility
–
Management: standard acute; physician referral
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Foot and Lower Leg Fractures (cont.)
• Stress fractures
– Often seen in running and jumping, especially after
significant ↑ training mileage; change in surface,
intensity, or shoe type
– Common sites
• 2nd metatarsal
• Sesamoid bones
• Navicular
• Calcaneus
• Tibia and fibula
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Foot and Lower Leg Fractures (cont.)
– S&S
• Pain begins insidiously; ↑ with activity and ↓ with
rest
• Pain usually limited to fracture site
• Pain with percussion, tuning fork, or ultrasound
– Management: standard acute; physician referral
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Foot and Lower Leg Fractures (cont.)
• Avulsion fractures
–
Eversion sprain—deltoid ligament avulses portion of distal
medial malleolus
–
Inversion sprain—plantar aponeurosis or peroneus brevis
tendon avulses base of 5th metatarsal (type II)
–
Jones fracture
• Type I transverse fracture into the proximal shaft of 5th
metatarsal at junction of diaphysis and metaphysis
• Often overlooked in conjunction with a severe ankle sprain
• Complications: nonunions and delayed unions are common
–
Management: standard acute; physician referral
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Foot and Lower Leg Fractures (cont.)
• Phalanges/ metacarpals
– Standard S&S
– Relatively minor
• Tarsal fractures
– LisFranc injury
• Disruption of tarsometatarsal joint, with or
without associated fracture
• Caused by a severe twisting injury
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Foot and Lower Leg Fractures (cont.)
• 1st metatarsal dislocated from 1st cuneiform;
other 4 metatarsals are displaced laterally, usually
in combination with fracture at base of 2nd
metatarsal
• History of severe midfoot pain, paresthesia, or
swelling in midfoot region with variable flattening
of arch or forefoot abduction
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Foot and Lower Leg Fractures (cont.)
– Lateral process of talus
• Due to traumatic ankle sprain
• Persistent ankle pain; inability to walk for long periods
– Posterior fracture to talus
• Forced plantarflexion
• Pain with running, jumping; resisted plantarflexion and
great toe flexion
– Neck of talus
• Forced dorsiflexion
• May compromise blood supply to talus
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Foot and Lower Leg Fractures (cont.)
– Maisonneuve fracture
• External rotation of foot
• Associated fracture of proximal third of fibula
• S&S: tenderness over deltoid and fracture site
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Foot and Lower Leg Fractures (cont.)
• Fracture management
– Remove shoe and sock to expose injured area
– Assess neurovascular integrity
– Mild
• Standard with physician referral
– Serious conditions
• Assess and treat for shock
• Activate EMS
– Refer to Application Strategy 19.6
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Assessment
• History
• Observation/inspection
• Palpation
• Physical examination tests
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Neutral Talar Position
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Range of Motion (ROM)
• AROM
– Ankle dorsiflexion (20°)
– Ankle plantarflexion (30–50°)
– Pronation (15–30°)
– Supination (45–60°)
– Toe extension and flexion
– Toe abduction and adduction
• PROM
– Normal end feel
• Dorsiflexion, plantarflexion, pronation, supination,
toe flexion and extension—tissue stretch
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ROM (cont.)
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ROM (cont.)
• RROM
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Neurological dysfunction
• Tinel’s sign
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Neurological dysfunction
• Morton’s test
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Neurologic Tests
• Myotomes
– Knee extension—L3
– Ankle dorsiflexion—L4
– Toe extension—L5
– Ankle plantarflexion, foot eversion, or hip
extension—S1
– Knee flexion—S2
• Reflexes
– Patella—L3, L4
– Achilles tendon—S1
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Neurologic Tests (cont.)
• Dermatomes
• Peripheral nerve distribution
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Rehabilitation
• Restoration of motion
• Restoration of proprioception and balance
– Closed-chain exercises
• Muscular strength, endurance, and power
– Open-chain exercises
– PNF-resisted exercises
• Cardiovascular fitness
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