The Foot and Toes

1
Chapter 4

• The Foot and Toes

2
Introduction

• The foot provides a stable platform to balance
  and support the body
• Phases of Gait figure 4-1, pg 87
• Foot, toes, and ankle are highly interrelated

3
Clinical Anatomy

• Intrinsic vs. extrinsic muscles
• Divided into 3 sections (Figure 4-2, pg 88)
• Rearfoot
• Midfoot
• Forefoot
• Tarsals, metatarsals, phalanges

4
Rearfoot

• Calcaneus and talus
• Ankle mortis Figure 4-4, page 89
• Talus articulations

5
Midfoot

• Shock-absorbing segment
• Navicular, 3 cuneiforms, cuboid
• Navicular keystone of medial longitudinal arch

6
Forefoot and Toes

• 5 MTs and 14 phalanges
• Acts as a lever during preswing phase

7
Articulations and Ligamentous Support

• Ligaments
• Thin dorsal tarsal ligaments
• Thick plantar tarsal ligaments
• Interosseous tarsal ligaments

8
Subtalar Joint

• 1o of freedom of movement
• Supination and pronation
• No muscles attach to talus
• Ligament names reflect bony attachments

9
Midfoot

• Talocalcaneonavicular joint (TCN)
• Calcaneocuboid joint (CC)
• Spring ligament plantar calcaneonavicular
  ligament
• Midtarsal joint
• increases ROM during inversion and eversion
• Allows for compensation for uneven terrain

10
Forefoot

• Tarsometatarsal joint Lisfrancs joint
• Deep transverse ligament secures distal joints
• Plantar and dorsal joint capsules
• Collateral ligaments

11
Muscles Acting on the Foot and Toes

• Intrinsic vs. Extrinsic
• Table 4-2, pages 92-94
• Table 4-3, page 95
• Table 4-4, page 96
• Figure 4-5, page 96

12
Arches of the Foot

• Shock absorber
• Increase foots flexibility
• Weight-bearing vs. non-weight-bearing

13
Medial Longitudinal Arch

• Five bones form arch
• Importance of navicular bone
• Ligamentous support
• Plantar fascia (Figure 4-7, page 97)
• Static vs. dynamic weight-bearing

14
Lateral Longitudinal Arch

• Lower and more rigid than medial arch
• Calcaneus, cuboid, fifth MT
• Continuation of medial arch
• Rarely injured

15
Transverse Metatarsal Arch

• Figure 4-9, page 98
• Originates at MT heads and continues to calcaneus
• 1st and 5th MT heads weight-bearers
• 2nd MT apex of arch

16
Clinical Evaluation of Foot and Toe Injuries

• May involve evaluation of lower extremity
• Athletic Trainer and athlete/patient must be
  prepared
• Evaluation Map, Page 99

17
History

• Location of pain (Table 4-5, page 100)
• Retrocalcaneal pain
• Heel pain
• Medial arch pain
• Metatarsal pain
• Greta toe pain
• Lateral arch pain
• Onset and mechanism of injury
• Acute onset
• Insidious onset
• Playing surface, distance, duration, shoes

18
Inspection

• Begins immediately
• Gross deformity, swelling, redness
• Inspect footwear for wear patterns and
  appropriateness
• Weight-bearing vs. non-weight-bearing

19
General Inspection of the Foot

• Foot Type (pronated, neutral, supinated)
• Figure 4-11, page 102
• Table 4-6, page 103
• Box 4-1, page 104
• Calluses and blisters
• Improperly fitting shoes, poor biomechanics, or
  underlying bony or soft tissue dysfunction

20
Inspection of the Toes

• General toe alignment (Box 4-2, pg 105)
• Mortons alignment
• Claw toes
• Hammer toes
• Hallux abducto valgus
• Corns
• Ingrown toenail (Figure 4-12, page 104)
• Subungual hematoma (Figure 4-13, page 106)

21
Inspection of Structures

• Medial
• Medial longitudinal arch
• Weight-bearing vs. non-weight-bearing
• Lateral
• Fifth metatarsal
• Dorsal

22
Inspection of Structures

• Plantar Surface
• Plantar warts (Figure 4-14, page 106)
• Verruca vulgaris
• Calloused skin, excessive stress
• stepping on a pebble

23
Inspection of Posterior Structures

• Achilles Tendon
• Relationship/alignment to tibia
• Figure 4-15, page 107
• Calcaneus
• Retrocalcaneal exostosis (pump bump)
• Figure 4-16, page 107

24
Non-Weight-Bearing Inspection of Foot and
Calcaneal Alignment

• Assessment of talar position
• Subtalar neutral position
• Alignment of forefoot and rearfoot
• Mobility of the first ray
• Pes planus hypermobility
• Pes cavus rigid ray

25
Inspection of Foot Alignment

• Forefoot vs. rearfoot
• Weight-bearing, non-weight-bearing and/or both
• Figure 4-18, page 107
• Foot Posture
• Subtalar joint in neutral position
• Box 4-3, page 109
• Plantarflexed first ray
• Pes cavus, genu varum, it is NOT forefoot valgus

26
Palpation

• Patient positioning
• Refer to list of Clinical Proficiencies
• Utilize pages 108 112 in textbook

27
Range of Motion Testing

• Focus on MTP joints (flexion extension)
• Bilateral comparison
• Box 4-4 Foot Goniometry, page 113

28

• Active ROM (first MTP)
• Extension 75-850
• Flexion 35-450
• Compensatory motion
• Passive ROM
• Figures 4-22 4-23, page 114
• Resisted ROM
• Box 4-5, page 115

29
Ligamentous and Capsular Testing

• MTP and IP Joints
• MCL, LCL, joint capsule
• Overpressure
• Box 4-6, page 116
• Intermetatarsal Joints
• Deep transverse ligament and interosseous
  ligaments
• Gliding
• Box 4-7, page 117

30
Ligamentous and Capsular Testing

• Tarsometatarsal Joints
• Dorsal and Plantar glide
• Box 4-8, page 118
• Midtarsal Joints
• Dorsal and Plantar glide of cuneiforms
• Box 4-9, page 119

31
Neurologic Examination

• L4 S2 nerve roots
• Neurologic symptoms
• Box 1-5, Chapter 1
• Tarsal Tunnel Syndrome/Interdigital neuroma
  (Figure 4-24, page 117)

32
Pathologies and Related Special Tests

• Improper biomechanics or result of compensation
  by foot for biomechanical deficits elsewhere in
  lower extremity

33
Arch Pathologies

• Most commonly occur congenitally
• Increasing or decreasing height of arch
• Arch height (Figure 4-25, page 120)
• Navicular drop indicates change in height from
  non-weight-bearing to weight-bearing

34
Pes Planus

• Figure 4-26, page 120
• Congenital origin, biomechanical changes, or
  acute trauma
• Affects function of subtalar and calcaneocuboid
  joints
• Acute trauma to supporting structures
• Accessory navicular (Fig. 4-27, pg 121)
• Mechanical Factors

35

• Rigid (structural) vs. flexible (supple)
• Box 4-10, page 122
• Navicular drop test (Box 4-11, page 123)
• Should not be left untreated

36
Pes Cavus

• Figure 4-28, page 124
• Congenital, neurologic, disease
• Associated with stiffness and impaired ability to
  absorb ground contact forces
• Dorsal pads under calcaneus and MT heads appear
  smaller than normal
• Claw toes, calluses over PIP joints
• Treatment options

37
Transverse Metatarsal Arch Pathology

• Only slightly visible
• Deficiency can produce pain under heads of second
  through fifth MTs
• Intertarsal neuroma
• Inspect, palpate plantar surface

38
Plantar Fasciitis

• Table 4-7, page 125
• Causes of the inflammation
• Trauma to plantar fascia can lead to many
  problems
• Signs and symptoms
• Accompanied by other dysfunctions
• Treatment options

39
Heel Spur

• Exostosis of medial calcaneal tubercle
• Relationship with plantar fascia
• Similar signs, symptoms and treatments to plantar
  fasciitis

40
Plantar Fascia Rupture

• Dorsiflexion of foot combined with extension of
  toes
• Risk of rupture
• Signs and symptoms

41
Tarsal Coalition

• Bony, fibrous or cartilaginous union between two
  or more tarsal bones
• Hereditary condition calcaneonavicular,
  talonavicualr, talocalcaneal joints
• Signs and symptoms
• Treatment
• Figure 4-29, page 126

42
Tarsal Tunnel Syndrome

• Entrapment of posterior tibial nerve as it passes
  through tibial tunnel
• Tunnel formed anteriorly by tibia and talus and
  laterally by calcaneus
• Flexor retinaculum fibrous roof (Fig 4-30, pg
  127)
• Acute, predisposing conditions, anatomical
  factors, biomechanics
• Patient complaints
• Evaluation/Treatment
• Table 4-8, page 127
• Figure 4-31, page 128

43
Metatarsal Fractures

• Direct trauma or overuse
• Base of fifth (Figure 4-32, page 128)
• Jones fracture (Figure 4-33, page 129)
• Stress fractures
• March fractures
• Signs and symptoms (Figure 4-34, page 129)
• Management
• Table 4-9, page 130

44
Phalangeal Fractures

• Longitudinal force or crushing force
• Figure 4-35, page 130
• Signs and symptoms
• Treatment

45
Intermetatarsal Neuroma

• Entrapment of nerve between two MT heads
• Mortons Neuroma
• Causes/predisposing factors
• Signs and symptoms
• Treatment
• Figure 4-36, page 131

46
Hallux Rigidus

• Progressive degeneration of first MTP joint
• Hallux limitus/ankylosis
• Causes
• Signs and symptoms
• Treatment
• Figure 4-37, page 132

47
First Metatarsophalangeal Joint Sprains

• Mechanism of injury
• Turf Toe
• Signs and symptoms
• Management

48
On-Field Evaluation of Foot Injuries

• Equipment considerations
• On-field history
• On-field inspection
• On-field palpation
• On-field ROM tests

49
On-Field Management of Foot Injuries

• Plantar fascia ruptures
• Fractures and Dislocations