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
Joints and Ligaments
of the Foot
Muscles of the Foot and Lower Leg
Nerve Supply and Blood Supply
Foot Biomechanics

Foot, ankle, and leg segments form a
kinetic chain
Movement of one segment effects
proximal and distal segments
 Entire kinetic chain must be considered
when evaluating an injury
 Biomechanical factors must be
considered when pain occurs during
walking and running

Normal Gait
Two phases:
1. Stance or support phase
 Begins at initial heel strike
 Ends at toe-off
2.
Swing or recovery phase
 Represents time
from toe-off to
heel strike

Stance Phase
– Involves weight bearing in closed kinetic chain
– Five periods
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Initial contact (double limb support)
Loading response (double limb support)
Mid stance (single limb support)
Terminal stance (single limb support)
Pre swing
Swing Phase
– Period of non-weight bearing
– Three periods
 Initial swing
 Mid swing
 Terminal swing
Running vs. Walking
Gait patterns for running and walking
have same components
 During running gait…

– Loading and mid-stance = more rapid
– After toe off = period of no ground contact
– Stance phase = 33% of running gait cycle
 Accounts for 60% of walking gait cycle

At heel strike, the foot serves as shock
absorber to adapt to uneven surfaces
during the stance phase
– Running: lateral aspect of foot makes
contact with the surface placing the
subtalar joint in supination
At push-off, foot serves as rigid lever to
provide propulsive force
 Runners:

– Distance runners follow heel strike pattern
– Sprinters tend to be forefoot strikers

Upon initial contact with the surface, external
rotation of the tibia occurs with subtalar
supination

As loading occurs, the foot and subtalar joint
pronates and internal rotation of the tibia
occurs
– Pronation allows for unlocking of midfoot, which
allows for shock absorption
– Pronation also provides for even distribution of
forces throughout the foot

At toe-off, the foot supinates which locks the
midfoot creating a lever formation to produce
greater force
Subtalar Joint
Pronation and Supination
Excessive, or prolonged, pronation and
supination can contribute to overuse injuries
 Subtalar joint allows foot to make stable
contact with ground and get into weight
bearing position
 Excessive motion = compensation for
structural deformities, such as…

– Excessive pronation: forefoot and rearfoot varus
– Excessive supination: forefoot valgus
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
Prevention of Foot Injuries
Select appropriate footwear
 Correct biomechanical structural
deficiencies

– Orthotics

Foot hygiene
Appropriate Footwear
Select a rigid shoe for pronators
 Select a flexible shoe with additional
cushioning for supinators
 Other considerations:

– Midsole design: controls motion along medial
aspect of foot
– Heel counters: controls motion in rearfoot
– Outsole contour and composition
– Lacing systems
– Forefoot wedges
Orthotics
Utilized to correct biomechanical
problems in the foot
 May be constructed of…

– Plastic
– Rubber
– Cork
– Leather

Can be prefabricated or custom fitted
Foot Hygiene
Keep toenails trimmed correctly
 Shave down excessive calluses
 Keep feet clean
 Wear clean socks and shoes that fit
correclty
 Keep feet as dry as possible

– Prevents development of athlete’s foot
Foot Assessment
History
 Generic history questions
– What, when, where, how???

Questions specific to the foot
– Location of pain - heel, foot, toes, arches?
– Training surfaces or changes in footwear?
– Changes in training, volume or type?
– Does footwear increase discomfort?
Foot Assessment
Observations

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



Does athlete favor a foot, limp, or unable to
bear weight?
Does foot color change while weight bearing?
Is there pes planus/cavus?
How is foot alignment?
Are there structural deformities?
Shoe wear patterns?
– Excess pronation = wear under 2nd metatarsal
– Excess supination = wear on lateral border
Foot Assessment
Palpations

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Medial calcaneus
Calcaneal dome
Medial malleolus
Sustentaculum tali
Talar head
Navicular tubercle
First cuneiform
First metatarsal and
metatarsophalangeal
joint
First phalanx




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Lateral calcaneus
Lateral malleolus
Sinus tarsi
Peroneal tubercle
Cuboid bone
Styloid process
Fifth metatarsal
Fifth
metatarsalphalangeal
joint
Fifth phalanx





Second, third and
fourth metatarsals,
metarsophalangeal
joints, phalanges
Third and fourth
cuneiform
Metatarsal heads
Medial calcaneal
tubercle
Sesamoid bones



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Tibialis posterior
Flexor hallucis longus
Flexor digitorum longus
Deltoid ligament
Calcaneonavicular
ligament
Medial longitudinal arch
Plantar fascia
Transverse arch



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Anterior talofibular
ligament
Calcaneofibular
ligament
Posterior talofibular
ligament
Peroneus longus
tendon
Peroneus brevis
tendon





Peroneus tertius
Extensor hallucis
longus
Extensor digitorum
longus tendon
Extensor digitorum
brevis tendon
Tibialis anterior
tendon
Pulses
Must ensure proper
circulation to foot
 Dorsalis pedis pulse

– Located between extensor
digitorum and hallucis
longus tendons

Posterior tibial pulse
– Located behind medial
malleolus along Achilles
tendon
Foot Assessment
Special Tests
 Movement
– Extrinsic and intrinsic foot muscles should be
assessed for pain, AROM, PROM, RROM

Tinel’s Sign
– Tap over posterior tibial nerve
– Positive test = tingling distal to area
– Indicates presence of tarsal tunnel syndrome

Morton’s Test
– Transverse pressure applied to heads of
metatarsals
– Positive test = pain in forefoot
– Indicate presence of neuroma or metatarsalgia
Foot Assessment
Neurological Assessment
 Reflexes
– Tendon reflexes should elicit a response
– Achilles reflex should be assessed for the
foot
 Sensation
– Cutaneous distribution of nerves must be
tested
– Sensation can be tested by running hands
over all surfaces of foot and ankle
Foot Injuries
Fracture of the Talus

Etiology
– Lateral fracture
 MOI: severe
inversion/dorsiflexion
force
– Medial fracture
 MOI: severe
inversion/plantarflexion
force with tibial external
rotation

Signs and Symptoms
– History of repeated
ankle trauma
– Pain with weight
bearing
– Intermittent swelling
– Catching/snapping
– Talar dome tender
upon palpation
Foot Injuries
Fracture of the Talus cont.
 Management
– X-ray required for diagnosis
– Placed on weight bearing progression
– Rehab focuses on ROM and strengthening
– If conservative management unsuccessful,
surgery may be required
 Return to play in 6-8 months following surgery
Foot Injuries
Fractures of the Calcaneus

Etiology
– Occurs from jump or
fall from height
– Often results in
avulsion fractures
anteriorly or
posteriorly
– May present as
posterior tibialis
tendinitis

Signs and Symptoms
– Immediate swelling
– Pain and inability to
bear weight
– Minimal deformity
unless comminuted
fracture occurs
Foot Injuries
Fractures of the Calcaneus cont.
 Management
– RICE immediately
– Refer for X-ray diagnosis
– For non-displaced fracture, immobilization and
early ROM exercises when pain and swelling
subside
Foot Injuries
Calcaneal Stress Fracture

Etiology
– Occurs due to
repetitive trauma
– Characterized by
sudden onset of pain
in plantar-calcaneal
area

Signs and Symptoms
– Weight bearing
(particularly at heel
strike) causes pain
– Pain continues
following exercise
– May require bone scan
for diagnosis
Foot Injuries
Calcaneal Stress Fracture cont.
 Management
– Conservative for 2-3 weeks
 Including rest and AROM
– Non-weight bearing cardio training should
continue
– As pain subsides, activity can be returned
gradually
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
Foot Injuries
Heel Contusion

Etiology
– Caused by sudden
starts, stops or
changes of direction
– Irritation of fat pad
– Pain often on the
lateral aspect due to
heel strike pattern

Sign and Symptoms
– Severe pain in heel
– Unable to withstand
stress of weight
bearing
– Often warmth and
redness over the
tender area
Foot Injuries
Heel Contusion cont.
 Management
– Reduce weight bearing for 24 hours
– RICE and NSAID’s
– Resume activity with heel cup or doughnut
pad after pain has subsided
– Wear shock absorbent shoes
Foot Injuries
Cuboid Subluxation

Etiology
– Pronation and trauma
resulting in
displacement of the
cuboid
– Often confused with
plantar fascitis
– Pain due to stress on
long peroneal muscle
with the foot in
pronation

Signs and Symptoms
– Pain along 4th and 5th
metatarsals
– Pain over the cuboid
– May refer pain to heel
area
– Pain may increase
following long periods
of weight bearing
Foot Injuries
Cuboid Subluxation cont.
 Management
– Dramatic results may be obtained with joint
mobilization
– Orthotic can be used to maintain position of
cuboid
Foot Injuries
Tarsal Tunnel Syndrome
 Tunnel behind medial malleolus
– Osseous floor
– Roof composed of flexor retinaculum

Etiology
– Any condition that compromises tibialis
posterior, flexor hallucis longus, flexor
digitorum, and tibial nerve, artery, or vein
– May result from previous fracture,
tenosynovitis, acute trauma, or excessive
pronation
Foot Injuries
Tarsal Tunnel Syndrome cont.

Signs and Symptoms

Management
– Pain and paresthesia along medial and plantar
aspect of foot
– Motor weakness and atrophy may result
– Increased pain at night
– Positive Tinel’s Sign
 NSAID’s and anti-inflammatory modalities
 Orthotics
 Possibly surgery if condition is recurrent
Foot Injuries
Tarsometatarsal Fracture Dislocation
(Lisfranc Injury)

Etiology
– Foot is
hyperplantarflexed
when foot is already
plantaflexed
– Rearfoot is locked
resulting in dorsal
displacement of
metatarsal bases

Signs and Symptoms
– Pain
– Inability to bear
weight
– Swelling
– Tenderness localized
on dorsum of foot
– Possible metatarsal
fractures
– Sprains of 4th and 5th
tarsometatarsal joints
 May cause severe
disruption of ligaments
Foot Injuries
Tarsometatarsal Fracture Dislocation
(Lisfranc Injury) cont.
 Management
– Refer to physician
 Key to treatment is recognition, realignment, and
maintaining stability
– Generally requires surgery
 Open reduction with fixation
– Complications include:
 Metatarsalgia
 Decreased metatarsophalangeal joint ROM
 Long term disability
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
Longitudinal Arch Strain

Etiology
– Early season injury
due to increased stress
on arch
– Flattening of foot
during midsupport
phase causing strain
on arch
– May appear suddenly
or develop slowly

Sign and Symptoms
– Pain with running and
jumping
– Pain below posterior
tibialis tendon
accompanied by
swelling
– May also be associated
with sprained
calcaneonavicular
ligament and flexor
hallucis longus strain
Metatarsal Injuries
Longitudinal Arch Strain cont.
 Management
– Immediate care is RICE
 Reduction of weight bearing
– Weight bearing must be pain free
– Arch taping may be used to allow pain free
walking
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
Metatarsal Stress Fractures
 Etiology
– Change in running pattern, mileage, hills,
or surface
– Forefoot varus, hallux valgus, flatfoot or
short 1st metatarsal
– Occasional fracture at base of 5th
metatarsal at the insertion site for the
peroneus brevis
Metatarsal Injuries
Metatarsal Stress Fractures cont.
 Management
– Bone scan may be necessary for diagnosis
– 3-4 days of partial weight bearing followed by
two weeks rest
– Return to running should be gradual
– Orthotics correcting excessive pronation
should be used
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
Metatarsal Injuries
Sesamoiditis

Etiology
– Caused by repetitive
hyperextension of the
great toe
– Results in
inflammation

Signs and Symptoms
– Pain under great to
 Especially during push off
– Palpable tenderness
under first metatarsal
head
Metatarsal Injuries
Sesamoiditis cont.
 Management
– Orthotics that include metatarsal pads, arch
supports, and metatarsal bars
– Decrease activity to allow inflammation to
subside
Metatarsal Injuries
Metatarsalgia

Etiology
– Decreased flexibility of
gastroc-soleus
complex
– Typically emphasizes
toe off phase during
gait
– Fallen metatarsal arch
 Pes Cavus

Signs and Symptoms
– Pain in ball of foot
 In the area of the 2nd
and 3rd metatarsal
heads
– Flattened transverse
arch
– Depressing 2nd, 3rd,
and 4th metatarsal
bones
Metatarsal Injuries
Metatarsalgia cont.
 Management
– Orthotics that elevate the depressed
metatarsal heads and/or medial aspect of
calcaneus may be used
– Remove excessive callus build-up
– Stretching of heel cord
– Strengthening exercises for the intrinsic foot
muscles
Metatarsal Injuries
Metatarsal Arch Strain

Etiology
– Fallen metatarsal arch
 Pes Cavus
– Excessive pronation

Management

Signs and Symptoms
– Pain or cramping in
metatarsal region
– Point tenderness
– Weakness
– Positive Morton’s test
- Pad to elevate metatarsals just behind ball of
foot
Metatarsal Injuries
Morton’s Neuroma
 Etiology
– Thickening of nerve sheath of the common
plantar nerve where it divides into digital
branches
 Commonly occurs between 3rd and 4th metatarsal
heads where medial and lateral plantar nerves come
together
– Also irritated by collapse of transverse arch of
foot
 Places transverse metatarsal ligaments under stretch,
compressing digital nerves and vessels
– Excessive pronation can be a predisposing factor
Metatarsal Injuries
Morton’s Neuroma cont.
 Signs and Symptoms
– Burning paresthesia in forefoot
– Severe intermittent pain in forefoot
– Pain relieved with non-weight bearing
– Toe hyperextension increases symptoms
Morton’s Neuroma cont.

Management
– Must rule out stress fracture
– Teardrop pad can be placed
between metatarsal heads to
increase space
 Decreases pressure on neuroma
– Shoes with wider toe box
would be appropriate
– Surgical excision may be
required
Injuries to the Toes
Sprained Toes

Etiology
– Kicking a non-yielding
object
– Joint goes beyond
normal ROM
– Twisting motion on the
toe may damage
ligaments and joint
capsule

Signs and Symptoms
– Pain is immediate and
intense but short lived
– Immediate swelling
and discoloration
occurring within 1-2
days
– Stiffness and residual
pain will last several
weeks
Injuries to the Toes
Sprained Toes cont.
 Management
– RICE
– Buddy taping
 To immobilize the toes
– Begin weight bearing as tolerable
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
Morton’s Toe

Etiology
– Abnormally short 1st
metatarsal (great toe)
 2nd toe looks longer
– More weight bearing
occurs on 2nd toe as a
result and can impact
gait
– Stress fracture could
develop

Signs and Symptoms
– Possible stress fracture
– Pain during and after
activity with possible
point tenderness
– Positive bone scan
– Callus development
under 2nd metatarsal
head
Injuries to the Toes
Morton’s Toe cont.
 Management
– If no signs and symptoms – “don’t fix what
isn’t broken”
– If associated with structural forefoot varus,
orthotics with a medial wedge would be
helpful
Injuries to the Toes
Hallux Rigidus
 Etiology
– Development of bone spurs on dorsal
aspect of first metatarsophalangeal joint
 Results in impingement
 Loss of active and passive dorsiflexion
– Degenerative arthritic process involving
articular cartilage and synovitis
– If restricted, compensation occurs with foot
rolling laterally
Injuries to the Toes
Hallux Rigidus cont.
 Signs and Symptoms
– Forced dorsiflexion causes pain
– Walking becomes awkward due to weight bearing on
lateral aspect of foot

Management
– Stiffer shoe with large toe box
– Orthotics to increase rigidity of forefoot region within
the shoe
– NSAID’s
– Surgery may be requires
 Osteotomy to remove mechanical obstructions in effort to
return to normal functioning
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
Overlapping Toes

Etiology
– May be congenital
– May be caused by
wearing shoes that are
too narrow

Signs and Symptoms
– Outward projection of
great toe articulation
– Drop in longitudinal
arch
Injuries to the Toes
Overlapping Toes cont.
 Management
– Hammer toe: surgery is the only cure
– Some modalities, such as whirlpool baths can
assist in alleviating inflammation
– Taping may prevent some of the contractual
tension within the sports shoe
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
Joint Mobilizations
 Can be very useful in normalizing joint motions
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

Orthotics

Pad and soft flexible felt orthotics
– Soft inserts, readily fabricated and used for mild
overuse problems

Semirigid orthotics
– Composed of flexible thermoplastics, rubber or
leather
– Molded from a neutral cast
– Well tolerated by athletes whose sports require
speed and jumping

Functional or rigid orthotics
– Made from hard plastic or from neutral casting
– Provide control for most overuse symptoms
Orthotics:
Correcting pronation and supination

To correct forefoot varus…
– A rigid orthotic should be used
– Medial post along the medial longitudinal arch and
the medial aspect of the calcaneus for comfort

To correct forefoot valgus…
– A semirigid orthotic should be used
– Lateral wedge under the 5th metatarsal head and
lateral calcaneus

To correct rearfoot varus…
– A semirigid orthotic should be used
– Medial posting at the calcaneus and head of the
first metatarsal
Foot Rehabilitation
Functional Progression
 Athletes must engage in a functional
progression to gradually regain the
ability to…
– Walk
– Jog
– Run
– Change directions, and
– Hop