The Foot www.peakorthopedics.com/book/export/html/45 Chapter 17

Foot Anatomy 26 Bones 7 Tarsal 5 Metatarsal 14 Phalanges 38 Joints 4 Arches

Toes Designed to give wider base for balance and for propelling the body forward First toe has 2 phalanges the remaining toes have 3 Sesamoids under the first metatarsal (in the flexor hallucis tendon) assist with reducing pressure in weight bearing, increase the mechanical advantage of the flexor tendons of the great toe, act as sliding pulleys for tendons

Sesamoid Bones 2 (medial and lateral) Under great toe Functionpulley, increase leverage of tendons that control great toe

Metatarsals Five bones that lie between and articulate with the tarsals and the phalanges Ligamentous arrangement gives elasticity to the foot in weight bearing MTP joints permit hinge action of phalanges First metatarsal functions as the main weight bearing support during walking and running

Tarsals Calcaneous Talus Largest tarsal bone; supports the talus and shapes the heel Main functions: convey the body weight to the ground and serves as attachment of Achilles Tendon and plantar structures Talus Situated above the calcaneous; consists of the body, neck and head Trochlea articulates with the medial and lateral malleoli to form the ankle joint

Tarsals Navicular Anterior to the talus on the medial aspect of the foot Articulates with the three cuneiform bones Cuboid On the lateral aspect of the foot Articulates posteriorly with the calcaneous and anteriorly with the fourth and fifth metatarsals Cuneiforms Three cuneiforms located between the navicular and the base of the three metatarsals on the medial aspect of the foot

Bones of the Foot

Bones of the Foot

Bones of the Foot

Tarsal Bones Talus Calcaneus Navicular Cuboid Cuniforms Medial Intermediate Lateral

Metatarsals & Phalanges

Regions of the Foot

Arches of the Foot Arches provide support in weight bearing, absorb shock, and provide space on plantar surface of blood vessels, nerves, and muscles

Foot Arches Functions Support body weigh in an economical fashion Absorb the shock of weight bearing Provide a space on the plantar aspect of foot for blood vessels, nerves, and muscles

Arches of the Foot Lateral Longitudinal Arch On outer aspect of the foot, formed by the calcaneous, cuboid and fifth metatarsal bone

Medial Longitudinal Arch Highest of 3 arches of foot Calcaneus, Talus, Navicular, Cuniforms & 1st three metatarsals Supports— Ligaments: Spring ligament Plantar fascia Tendons: Tibialis posterior Tibialis anterior

Lateral Longitudinal Arch Lower and flatter Calcaneus, Talus, Cuboid, 4th & 5th metatarsals Supports— Ligaments: Short plantar ligament Plantar fascia Tendons: Peroneus longus

Arches of the Foot Transverse Arch Medial Longitudinal Arch Extends across the cuboid, and the internal cuneiform Protects the soft tissue and increases foot mobility Medial Longitudinal Arch Originates on medial border of the calcaneous and extends forward to the distal head of the first metatarsal Main supporting ligament = plantar calcaneonavicular ligament (spring ligament)

Transverse Arch Cuniforms, Cuboid, & 5th metatarsal

Plantar Fascia Thick white band of fibrous tissue originating from the medial tuberosity of the calcaneus and ending at the proximal heads of the metatarsals Work with ligaments to support arches during weigh bearing and downward forces

Joints of the Foot Tibiotalar Talocrural Subtalar Talonavicular Calcaneocubiod Metarsocunieform Tarsometatarsal Joint Subtalar Joint Midtarsal Joint

Joints of the Foot Metatarsophalangeal Joint Proximal Interphalangeal Joint Distal Interphalangeal Joint

Joints of the Foot Tarsometatarsal Joint Formed by junction of the bases of the metatarsal bones with the cuboid and all three cuneiforms – allows for some gliding Also known as the Lisfranc’s joint

Joints of the Foot Intermetatarsal Joint Interphalangeal Joint Designed for flexion and extension Reinforced by collateral ligaments Metatarsophalangeal Joint Condyloid type joints permitting flexion, extension, adduction and abduction Intermetatarsal Joint Sliding joints: include two sets of articulations

Joints of the Foot Subtalar Joint Articulation between the talus and calcaneous Allows for inversion, eversion, pronation, and supination In weight bearing pronation refers to combined movement of talar plantarflexion and adduction and calcaneal eversion In weight bearing supination refers to combined movement of talar dorsiflexion, abduction and calcaneal inversion

Regions of Foot Forefoot Midfoot Hindfoot Metatarsals Phalanges Navicular Cuboid 3 Cuniforms Hindfoot Calcaneus Talus

Foot Movements Dorsiflexion Plantar Flexion Pronation Inversion Eversion Supination Pronation: combo of PF, eversion, & forefoot abduction Supination: combo of DF, inversion, & adduction

Muscles of Foot Intrinsic Muscles Extrinsic Muscles Relate to specific body part or bone Flexor hallucis longus Flexor hallucis brevis Flexor digitorum longus Extensor digitorum longus Abductor hallucis Abductor digiti minimi Tibialis posterior Muscle outside a body part, organ, or bone Gastrocnemius Gastroc—has long tendons that cross ankle and attach on bones of foot to assist in movement. Talus has no tendon attachment

Muscles of Foot Dorsiflexion: tibialis anterior, extensor digitorum longus, extensor hallucis longus and peroneus tertius Tom, Dick and Harry

Muscles of the Foot Plantarflexion: Gastrocnemius, soleus, plantaris, peroneus longus, peroneus brevis, tibialis posterior, flexor hallucis longus and flexor digitorum longus

Muscles of the Foot Inversion: Tibialis posterior, flexor digitorum longus, flexor hallucis longus, tibialis anterior and extensor hallucis longus

Muscles of the Foot Eversion: Peroneus longus, peroneus brevis, peroneus tertius and extensor digitorum longus

Muscles of the Foot Hallucis muscles move the great toe Digitorum muscles move digits 2-5

Muscles of the Foot

Muscles of the Foot

Muscles of the Foot

Structural Derformities

Pes Planus Flat foot Associated with excessive pronation Multiple causes: Lack of shoe support Weak muscles Pain & weakness in medial longitudinal arch Calcaneal eversion Navicular bulging Flattening of arch If it ain’t broken don’t fix it! If painful, correct the excessive pronation with orthotic; taping may help; strength training of muscles may help

Pronators Prolonged pronation one of major causes of stress injuries Prolonged pronation does not allow the subtalar joint to resupinate, thus there is less power for push-off Injuries occurring from excessive pronation include: stress fractures of the second metatarsal, plantar fasciitis, posterior tibial tendonitis, achilles tendonitis, tibial stress syndrome and medial knee pain

Pes Cavus aka Clawfoot, hollow foot Associated with excessive supination Shock absorption poor General foot pain and metatarsalgia common Abnormally short Achilles tendon Calluses ball and heel Orthotic with lateral wedge; stretch achilles tendon & plantar fascia

Supinators Excessive supination at heel strike does not allow subtalar joint to unlock – foot remains rigid Foot cannot absorb ground reaction forces efficiently Injuries seen include: inversion ankle sprains, tibial stress syndrome, peroneal tendonitis, IT band friction syndrome and trochanteric bursitis

Shoe Wear Patterns Excessive Pronation Excessive Supination Wear out front of shoe under 2nd metatarsal Excessive Supination Wear out lateral border of shoe Common Misconception Wearing out the back lateral corner of the shoe means you pronate This is normal wear pattern

Selecting Appropriate Footwear Pronators Supinators need stability and firmness to reduce excess motion (need board lasted, straight lasted shoe, with good rearfoot control) need cushioning and flexibility as foot is too rigid (need slip lasted or combination lasted, curve lasted shoe)

Selecting Appropriate Footwear

Gait

Common Injuries of the Foot

Assessment of the Foot HOPS

Assessment of the Foot Obtain a thorough history Observation Look for structural Deformities (bunions, check for forefoot varus/valgus deformities, check for rearfoot varus/valgus deformities, flexibility of first ray)

Look at shoe wear patterns Pronators Supinators wear out the front of the shoe under the second metatarsal All have excessive wear on the lateral heel due to heel strike wear out the outside of the shoe All have excessive wear on the lateral heel due to heel strike

Assessment of the Foot Palpation Special Tests Palpate Bones and Soft tissue structures Tinel’s sign: tap over the posterior tibial nerve – numbness, tingling and paresthesia may indicate tarsal tunnel syndrome Morton’s Test: Transverse pressure on metatarsal heads causing sharp pain in forefoot, may indicate presence of neuroma or metatarsalgia

Pulse Posterior Tibial Artery Medial Malleolous Dorsalis Pedis artery Extensor Tendon Great Toe

Injuries to the Tarsal Region Fractures of the Talus Fractures of the Calcaneous Calcaneal Stress Fracture Sever’s Disease (Apophysitis of the Calcaneous) Retrocalcaneal Bursitis Heel Contusion Cuboid Subluxation Tarsal Tunnel Syndrome Lisfranc Injury (Tarsometatarsal Fracture/Dislocation

Fractures & Stress Fractures Impair ability to perform competitively NWB More swelling & pain than ligament sprain Point tenderness present Obvious deformity often present Usually occur acutely; result of traumatic episode

Sever’s Disease Traction injury at the apophysis of the calcaneus where the Achilles tendon attaches Young, physically active athletes Comparable to Osgood-Shlatter’s disease (at tibial tubercle of knee) Pain occurs during vigorous activity and does not continue during rest Apophysis-= bone protrusion (bony outgrowth such as a tubercle or tuberosity) Rest, ice, stretching

Retrocalcaneal Bursitis Swelling of the bursa at the back of the calcaneus under the Achilles tendon S/sxs: Pain in heel Painful to touch Pain worse when rising on toes Red, warm skin over back of heel

Heel Spur Bony growth on calcaneus Causes painful inflammation Aggravated by exercise As foot flattens, plantar fascia is stretched & pulled where it attaches to calcaneus calcaneus reacts by forming spur of bony material TX: taping arch or use shoe insert to reduce plantar fascia pull on calcaneus

Heel Contusion Irritation of the lateral aspect of the heel Sudden stop-and-go or sudden change in movement Heel receives, absorbs, and transfers much impact of sports activities (running & jumping) Severe pain in heel; will hurt with WB Calcaneus protected by thick, cornified skin layer and heavy fat pad covering, but even this thick covering cannot always protect against impact of landing or jumping

Heel Contusion—Treatment Cold application before activity Ice & elevation after activity Absorb shock— Heel cups Donut pad

LisFranc Injury Tarsometatarsal fracture/dislocation The midfoot will be affected if the bones are broken (fractured) or the ligaments are torn (ruptured). Injuries can vary, from a simple injury that affects only a single joint to a complex injury that disrupts multiple different joints and includes multiple fractures.

LisFranc Injury

Injuries to Metatarsal Region Pes Planus Foot Pes Cavus Foot Longitudinal Arch Sprain Plantar Fasciitis Metatarsal Stress Fracture Hallux Valgus Deformity (Bunion) Sesamoiditis Metatarsalgia Morton’s Neuroma

Jones Fracture Fracture to the diaphysis at the base of the 5th metatarsal Repetitive stress, direct force, or inversion and PF of foot Healing slow; high nonunion rate

Plantar Fascia Wide, non-elastic ligamentous tissue that extends from the anterior portion of calcaneus to heads of metatarsals Supplies support to longitudinal arch

Plantar Fasciitis Strain/irritation of the plantar fascia Caused by: Overuse Unsupportive footwear Tight Achilles tendon Running on hard surfaces Chronic irritation Pain, tenderness on bottom of foot near heal (especially in am) Untreated will lead to: Bone imbalance Heel spurs Muscle strains Shin splints Continually strained from running and jumping; basketball, volleyball, cross-country (repeated jumping and landing)

Plantar Fasciitis—Treatment Correct training errors Ice Massage Evaluate shoes & activity level Arch support Heel cup or cushion Goal: to reduce shock and shear forces

Arch Sprains Ligaments stretch, thus fail to hold bones of foot in position When arch weakened, it cannot absorb shock normally Causes: Overuse Overweight Fatigue Training on hard surfaces Non-supportive shoes Shoes in poor condition Tx: RICE; most arch sprains are to lateral arch or inner longitudinal arch

Injuries to the Toes Sprained Toes Turf Toe Fractures and Dislocations of Phalanges Hallux Rigidus Subungual Hematoma (blood under toenail)

Turf Toe Great toe strain Hyperextension of the first MTP joint of the big toe Treatment: RICE & Support Limit movement Turf toe taping Great toe important for balance, movement, and speed

Blisters Occur on any part of body where there is friction Most common on feet or heels Treatment Goals: Relieve pain Keep from enlarging Avoid infection

Blisters—Treatment Wash area thoroughly Use sterile blade to cut small hole in blister Squeeze out clear fluid Do not remove skin Prevention: Wear work gloves Break in new skin Petroleum jelly/skin lube Adhesive bandage

Prevention of Foot Injuries Selecting appropriate footwear Using shoe orthotic Foot hygiene

Rehabilitation of the Foot Towel pulls TheraBand® Marble pick-up