Chapter 18: The Foot

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Chapter 18 The Foot

• Jennifer L. Doherty, MS, LAT, ATC
• Academic Program Director, Entry-Level ATEP
• Florida International University
• Acute Care and Injury Prevention

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Review of Anatomy
3
Arches of the Foot
4
Plantar Fascia
5
Joints and Ligaments of the Foot
6
Muscles of the Foot and Lower Leg
7
Nerve Supply and Blood Supply
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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

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Normal Gait

• Two phases
• Stance or support phase
• Begins at initial heel strike
• Ends at toe-off
• Swing or recovery phase
• Represents time
  from toe-off to
  heel strike

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• Stance Phase
• Involves weight bearing in closed kinetic chain
• Five periods
• 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

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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

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• 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

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• 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

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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

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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

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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

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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

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Prevention of Foot Injuries

• Select appropriate footwear
• Correct biomechanical structural deficiencies
• Orthotics
• Foot hygiene

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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

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Orthotics

• Utilized to correct biomechanical problems in the
  foot
• May be constructed of
• Plastic
• Rubber
• Cork
• Leather
• Can be prefabricated or custom fitted

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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 athletes foot

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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?

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Foot Assessment

• Observations
• 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

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Foot Assessment
Palpations

• Medial calcaneus
• Calcaneal dome
• Medial malleolus
• Sustentaculum tali
• Talar head
• Navicular tubercle
• First cuneiform
• First metatarsal and metatarsophalangeal joint
• First phalanx

• Lateral calcaneus
• Lateral malleolus
• Sinus tarsi
• Peroneal tubercle
• Cuboid bone
• Styloid process
• Fifth metatarsal
• Fifth metatarsalphalangeal joint
• Fifth phalanx

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• Second, third and fourth metatarsals,
  metarsophalangeal joints, phalanges
• Third and fourth cuneiform
• Metatarsal heads
• Medial calcaneal tubercle
• Sesamoid bones

• 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

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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

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Foot Assessment

• Special Tests
• Movement
• Extrinsic and intrinsic foot muscles should be
  assessed for pain, AROM, PROM, RROM
• Tinels Sign
• Tap over posterior tibial nerve
• Positive test tingling distal to area
• Indicates presence of tarsal tunnel syndrome

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• Mortons Test
• Transverse pressure applied to heads of
  metatarsals
• Positive test pain in forefoot
• Indicate presence of neuroma or metatarsalgia

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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

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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

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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

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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

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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

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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

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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

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Foot Injuries
Apophysitis of the Calcaneus (Severs 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

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Foot Injuries

• Apophysitis of the Calcaneus
• (Severs Disease) cont.
• Management
• Best treated with ice, rest, stretching and
  NSAIDs
• Heel lift could also relieve some stress

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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

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Foot Injuries

• Retrocalcaneal Bursitis (Pump Bump) cont.
• Management
• RICE and NSAIDs 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

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Foot Injuries
Heel Contusion

• Sign and Symptoms
• Severe pain in heel
• Unable to withstand stress of weight bearing
• Often warmth and redness over the tender area

• 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

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Foot Injuries

• Heel Contusion cont.
• Management
• Reduce weight bearing for 24 hours
• RICE and NSAIDs
• Resume activity with heel cup or doughnut pad
  after pain has subsided
• Wear shock absorbent shoes

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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

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Foot Injuries

• Cuboid Subluxation cont.
• Management
• Dramatic results may be obtained with joint
  mobilization
• Orthotic can be used to maintain position of
  cuboid

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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

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Foot Injuries

• Tarsal Tunnel Syndrome cont.
• Signs and Symptoms
• Pain and paresthesia along medial and plantar
  aspect of foot
• Motor weakness and atrophy may result
• Increased pain at night
• Positive Tinels Sign
• Management
• NSAIDs and anti-inflammatory modalities
• Orthotics
• Possibly surgery if condition is recurrent

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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

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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

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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

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Metatarsal Injuries

• Pes Planus Foot (Flatfoot) cont.
• Management
• If no signs and symptoms dont fix what isnt
  broken
• If problems develop
• Orthotics with a medial wedge may be used
• Taping of arch can also be used for additional
  support

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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

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Metatarsal Injuries

• Pes Cavus (High Arches) cont.
• Management
• If no signs and symptoms dont fix what isnt
  broken
• If problems develop
• Orthotics with a lateral wedge may be used
• Stretch Achilles and plantar fascia

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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

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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

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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

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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
  gastroc-soleus complex

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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

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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
• NSAIDs and occasionally steroidal injection

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Metatarsal Injuries
Jones Fracture

• Signs and Symptoms
• Immediate swelling
• Pain over 5th metatarsal
• High nonunion rate
• Course of healing is unpredictable

• Etiology
• Inversion and plantar flexion
• Direct force (stepped on)
• Repetitive trauma
• Most common fracture site is at the base of the
  5th metatarsal

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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

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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

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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

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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 (Tailors bunion)
• Impacts 5th metatarsophalangeal joint
• Causes medial displacement of 5th toe

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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

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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

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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

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Metatarsal Injuries

• Sesamoiditis cont.
• Management
• Orthotics that include metatarsal pads, arch
  supports, and metatarsal bars
• Decrease activity to allow inflammation to
  subside

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Metatarsal Injuries
Metatarsalgia

• 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

• Etiology
• Decreased flexibility of gastroc-soleus complex
• Typically emphasizes toe off phase during gait
• Fallen metatarsal arch
• Pes Cavus

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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

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Metatarsal Injuries
Metatarsal Arch Strain

• Etiology
• Fallen metatarsal arch
• Pes Cavus
• Excessive pronation

• Signs and Symptoms
• Pain or cramping in metatarsal region
• Point tenderness
• Weakness
• Positive Mortons test

• Management
• - Pad to elevate metatarsals just behind ball of
  foot

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Metatarsal Injuries

• Mortons 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

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Metatarsal Injuries

• Mortons Neuroma cont.
• Signs and Symptoms
• Burning paresthesia in forefoot
• Severe intermittent pain in forefoot
• Pain relieved with non-weight bearing
• Toe hyperextension increases symptoms

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Mortons 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

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Injuries to the Toes
Sprained Toes

• 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

• Etiology
• Kicking a non-yielding object
• Joint goes beyond normal ROM
• Twisting motion on the toe may damage ligaments
  and joint capsule

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Injuries to the Toes

• Sprained Toes cont.
• Management
• RICE
• Buddy taping
• To immobilize the toes
• Begin weight bearing as tolerable

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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

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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

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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

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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

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Injuries to the Toes
Mortons Toe

• Signs and Symptoms
• Possible stress fracture
• Pain during and after activity with possible
  point tenderness
• Positive bone scan
• Callus development under 2nd metatarsal head

• 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

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Injuries to the Toes

• Mortons Toe cont.
• Management
• If no signs and symptoms dont fix what isnt
  broken
• If associated with structural forefoot varus,
  orthotics with a medial wedge would be helpful

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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

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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
• NSAIDs
• Surgery may be requires
• Osteotomy to remove mechanical obstructions in
  effort to return to normal functioning

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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

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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

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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

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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

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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

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Injuries to the Toes

• Subungual Hematoma
• Etiology
• Direct pressure
• Dropping an object on toe
• Kicking another object
• Repetitive shear forces on toenail

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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

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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

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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

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Foot Rehabilitation

• Joint Mobilizations
• Can be very useful in normalizing joint motions

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Foot Rehabilitation

• Flexibility
• Must maintain or re-establish 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

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Foot Rehabilitation

• Strengthening
• Writing alphabet
• Picking up objects
• Ankle circumduction
• Gripping and spreading toes
• Towel gathering
• Towel Scoop

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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 athletes ability to
  maintain center of gravity without losing balance

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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

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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

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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

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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

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Foot Rehabilitation

• Functional Progression
• Athletes must engage in a functional progression
  to gradually regain the ability to
• Walk
• Jog
• Run
• Change directions, and
• Hop