Chapter 18: The Foot
Jennifer L. Doherty, MS, LAT, ATC
Academic Program Director, Entry-Level ATEP
Florida International University
Acute Care and Injury Prevention
Review of Anatomy
Arches of the Foot
Plantar Fascia
Muscles of the Foot and Lower Leg
Nerve Supply and Blood Supply
Excessive Pronation

Major cause of stress injuries
– Overload of structures during stance phase
– Prolonged pronation into propulsive phase

Results in loose foot
– Excessive midfoot motion
– Decreased stability of first ray
– Increased pressure on metatarsals
– Increased tibial rotation at knee
Excessive Pronation

Causes weakness push off
– Does not allow foot to resupinate to provide
rigid lever
– Less powerful, less efficient force produced

Common injuries:
– 2nd metatarsal stress fracture, Plantar fascitis
Posterior tibialis tendinitis, Achilles tendinitis,
Tibial stress syndrome, and Medial knee pain
Excessive Supination

Results in rigid foot
– Decreased mobility of calcaneocuboid joint
– Decreased mobility of first ray causing
weight absorption on 1st and 5th metatarsals
– Increased tension of peroneus longus
– Inefficient shock absorption

Common injuries:
– Inversion sprains, Tibial stress syndrome,
Peroneal tendinitis, IT-Band friction
syndrome, and Trochanteric bursitis
Foot Injuries
Apophysitis of the Calcaneus
(Sever’s Disease)

Etiology
– Traction injury at
apophysis of calcaneus
 Where Achilles tendon
attaches to calcaneous

Signs and Symptoms
– Pain occurs at
posterior heel below
Achilles attachment
– Pain occurs during
vigorous activity
– Pain ceases following
activity
Foot Injuries
Apophysitis of the Calcaneus
(Sever’s Disease) cont.
 Management
– Best treated with ice, rest, stretching and
NSAID’s
– Heel lift could also relieve some stress
Foot Injuries
Retrocalcaneal Bursitis (Pump Bump)

Etiology
– Caused by inflammation
of bursa beneath Achilles
tendon
– Result of pressure and
rubbing of shoe heel
counter
– Chronic condition that
develops over time
 May take extensive time to
resolve
– Exostosis may also
develop

Signs and Symptoms
– Pain with palpation
superior and anterior
to Achilles insertion
– Swelling on both
sides of the heel cord
Foot Injuries
Retrocalcaneal Bursitis (Pump Bump)
cont.

Management
–
–
–
–
–
–
RICE and NSAID’s used as needed
Ultrasound can reduce inflammation
Routine stretching of Achilles
Heel lifts to reduce stress
Donut pad to reduce pressure
Possibly invest in larger shoes with wider heel
contours
Metatarsal Injuries
Pes Planus Foot (Flatfoot)

Etiology
– Excessive pronation
and forefoot varus
– Wearing tight shoes
 Weakens supportive
structures with shoe
– Being overweight
– Excessive exercise
placing undo stress on
arch

Signs and Symptoms
– Pain, weakness, or
fatigue in medial
longitudinal arch
– Calcaneal eversion
– Bulging navicular
– Flattening of medial
longitudinal arch
– Dorsiflexion with
lateral splaying of 1st
metatarsal
Metatarsal Injuries
Pes Planus Foot (Flatfoot) cont.
 Management
– If no signs and symptoms – “don’t fix what
isn’t broken”
– If problems develop…
 Orthotics with a medial wedge may be used
 Taping of arch can also be used for additional
support
Metatarsal Injuries
Pes Cavus (High Arches)

Etiology
– Excessive supination
– Associated with
forefoot valgus
– Accentuated high
medial longitudinal
arch

Signs and Symptoms
–
–
–
–
–
Poor shock absorption
Metatarsalgia
Foot pain
Clawed or hammer toes
Shortening of Achilles
and plantar fascia
– Heavy callus
development on ball and
heel of foot
Metatarsal Injuries
Pes Cavus (High Arches) cont.
 Management
– If no signs and symptoms – “don’t fix what
isn’t broken”
– If problems develop…
 Orthotics with a lateral wedge may be used
 Stretch Achilles and plantar fascia
Metatarsal Injuries
Plantar Fasciitis

Plantar fascia
– Dense, broad band of connective tissue attaching
proximal and medially on the calcaneus and fans out
over the plantar aspect of the foot
– Works in maintaining stability of the foot and bracing
the longitudinal arch

Plantar Fasciitis
– “Catch all” term used for pain in proximal arch and
heel
– Common in athletes and nonathletes
– Attributed to heel spurs, plantar fascia irritation, and
bursitis
Metatarsal Injuries
Plantar Fasciitis cont.
 Etiology
– Increased tension and stress on fascia
 Particularly during push off of running phase
– Change from rigid supportive footwear to
flexible footwear
– Running on soft surfaces while wearing shoes
with poor support
– Poor running technique
– Leg length discrepancy, excessive pronation,
inflexible longitudinal arch, or tight gastrocsoleus complex
Metatarsal Injuries
Plantar Fasciitis cont.
 Signs and Symptoms
– Pain in anterior medial heel and along medial
longitudinal arch
– Increased pain in morning
 Plantar fascia loosens after first few steps thus
decreasing pain
– Increased pain with forefoot dorsiflexion
Metatarsal Injuries
Plantar Fasciitis cont.

Management
– Extended treatment (8-12 weeks)
– Orthotic therapy is very useful
 Soft orthotic with deep heel cup
–
–
–
–
–
Simple arch taping
Night splint to stretch plantar fascia
Vigorous heel cord stretching
Exercises that increase great toe dorsiflexion
NSAID’s and occasionally steroidal injection
Metatarsal Injuries
Jones Fracture

Etiology
– Inversion and plantar
flexion
– Direct force (stepped
on)
– Repetitive trauma
– Most common fracture
site is at the base of
the 5th metatarsal

Signs and Symptoms
– Immediate swelling
– Pain over 5th
metatarsal
– High nonunion rate
– Course of healing is
unpredictable
Metatarsal Injuries
Jones Fracture cont.
 Management
– Controversial treatment
– Crutches with no immobilization
– Gradual progression to weight bearing as pain
subsides
 May allow athlete to return in 6 weeks
– If nonunion of the fracture is evident, surgery
with internal fixation may be required
Metatarsal Injuries
Bunion (Hallux Valgus Deformity)
 Etiology
– Exostosis of 1st metatarsal head
– Associated with…
 Forefoot varus
 Wearing shoes that are too narrow or too short
 Wearing shoes with pointed toes
– Bursa becomes inflamed and thickens
 Enlarges the joint and causes lateral malalignment of
the great toe
 Bunionette (Tailor’s bunion)
– Impacts 5th metatarsophalangeal joint
– Causes medial displacement of 5th toe
Metatarsal Injuries
Bunion (Hallux Valgus Deformity) cont.
 Signs and Symptoms
– Initially…
 Tenderness
 Swelling
 Enlargement of joint
– As inflammation continues…
 Angulation of the joint increases
 Painful ambulation
– Tendinitis in great toe flexors may develop
Bunion (Hallux Valgus Deformity) cont.

Management
– Early recognition and care is critical
– Wear correct fitting shoes
– Orthotics may be used
– Padding over 1st metatarsal
head with a tape splint
between 1st and 2nd toe
may be used
– Exercises for flexor and extensor
muscles
– Bunionectomy may be necessary
Injuries to the Toes
Turf Toe

Etiology
– Hyperextension injury
– Results in sprain of 1st
metatarsophalangeal
joint
– May be the result of
single or repetitive
trauma

Signs and Symptoms
– Pain and swelling
– Both increase during…
 Push off in walking
 Running
 Jumping
Injuries to the Toes
Turf Toe cont.
 Management
– Orthotics to increase rigidity of forefoot
region within the shoe
– Taping the toe to prevent dorsiflexion
– Ice and ultrasound
– Rest
 Discourage activity until pain free
Injuries to the Toes
Fractures and Dislocations of
the Phalanges

Etiology
– Kicking unyielding
object
– Stubbing toe
– Being stepped on
– Dislocations are less
common than
fractures

Signs and Symptoms
– Immediate and intense
pain
– Obvious deformity with
dislocation
Injuries to the Toes
Fractures and Dislocations of the
Phalanges cont.
 Management
– Dislocations should be reduced by a physician
– Casting may occur with great toe or multiple
toe fractures
– Buddy taping is generally sufficient
Injuries to the Toes
Hammer Toe, Mallet Toe, or Claw Toe
 Etiology
– Hammer toe
 Flexion contracture of the PIP joint, which can become fixed
– Mallet toe
 Flexion contracture of the DIP joint, which can become fixed
– Claw toe
 Flexion contracture of the DIP joint with hyperextension at
the MP joint
– All may be caused by wearing short shoes over an
extended period of time
Injuries to the Toes
Hammer Toe, Mallet Toe, or Claw Toe
cont.
 Signs and Symptoms
– The MP, DIP, and PIP can all become fixed
– Swelling
– Pain
– Callus formation
– Occasionally infection
Injuries to the Toes
Hammer Toe, Mallet Toe, or Claw Toe
cont.
 Management
– Wear shoes with more room for toes
– Use padding and taping to prevent irritation
– Shave calluses
– Once the contracture becomes fixed, surgery
will be required to correct
Injuries to the Toes
Subungual Hematoma
 Etiology
– Direct pressure
– Dropping an object
on toe
– Kicking another
object
– Repetitive shear
forces
on toenail
Injuries to the Toes
Subungual Hematoma cont.

Signs of Injury
– Accumulation of blood underneath toenail
– Likely to produce extreme pain
– May result in loss of toe nail

Management
– RICE immediately
 Reduces pain and swelling
– Relieve pressure within 12-24 hours
 Lance or drill nail
 Must be sterile to prevent infection
Foot Rehabilitation
General Body Conditioning
 A period of non-weight
bearing is common,
therefore alternative means
of conditioning must be
introduced
– Pool running
– Upper body ergometer

General strengthening and
flexibility should be included
as allowed by injury
Foot Rehabilitation
Progression to Weight Bearing
 If unable to walk without a limp, crutch
or cane walking should be utilized
 Poor gait mechanics will impact other
joints within the kinetic chain
– Could result in additional injuries

Progress to full weight bearing as soon as
tolerable
Foot Rehabilitation
Flexibility

Must maintain or reestablish normal
flexibility of the foot
– Full range of motion is
critical for normal
function

Stretching of the
plantar fascia and
Achilles tendon is very
important
Foot Rehabilitation
Strengthening






Writing alphabet
Picking up objects
Ankle circumduction
Gripping and
spreading toes
Towel gathering
Towel Scoop
Foot Rehabilitation
Neuromuscular Control
 Critical to re-establish because it is the
single most important element dictating
movement
 Muscular weakness, proprioceptive
deficits, and ROM deficits challenge the
athlete’s ability to maintain center of
gravity without losing balance
Foot Rehabilitation
Neuromuscular Control cont.
 Must be able to adapt to changing surfaces
– Involves highly integrative
and dynamic process that
utilizes multiple neurological
pathways

Proprioception and
kinesthesia is essential
in athletics
Orthotics

Use of orthotics is common practice
– Used to control abnormal compensatory
movement of the foot by “bringing the
floor up to meet the foot”
Orthotic works to place foot in neutral
position, preventing compensatory
motion
 Also works to provide platform for foot
that relieves stress being placed on soft
tissue, allowing for healing

Foot Rehabilitation
Functional Progression
 Athletes must engage in a functional
progression to gradually regain the
ability to…
– Walk
– Jog
– Run
– Change directions, and
– Hop