Clinical Assessment of Foot & Toe Injuries Part II Chapter 4 Clinical Assessment of Foot & Toe Injuries Part II

Student Learning Outcomes Identify common midfoot & forefoot injuries based on their presenting history, symptoms, visual signs (inspection), & palpation findings Identify special tests that might be used to evaluate these injuries Discuss basic management strategies for dealing with these injuries Discuss anatomical or biomechanical predisposing factors associated with these common midfoot & forefoot injuries

Location of Pain: Medial Calcaneus/Medial Arch Injuries to consider (continued from Ch. 4 Part 1) tarsal tunnel syndrome impingement & inflammation of the posterior tibial nerve within the tarsal tunnel

History Tarsal tunnel syndrome Symptoms Onset pain, numbness, or parasthesia along medial or plantar aspect of foot may mimic plantar fasciitis Onset Acute or chronic

History Tarsal tunnel syndrome MOI EV or PF/EV ankle injury (acute) Forced PF (acute) Repetitive stress associated with pes planus foot Previous history of tarsal fx

History Tarsal tunnel syndrome Possible related factors Training surface Distance Shoes

Inspection Tarsal tunnel syndrome pes planus foot typically no swelling, discoloration, or deformity

Palpation Tarsal tunnel syndrome Point tenderness proximal, over, and distal to the flexor retinaculum

ROM Tarsal tunnel syndrome AROM PROM RROM normal EV may reproduce symptoms PROM PF & EV may reproduce symptoms RROM may demonstrate weakness of toe flexors

Stress Tests/Special Tests Tarsal Tunnel Syndrome n/a

Neurological Tests Tarsal Tunnel Syndrome Tinel’s sign Decreased sensation over nerve distribution

Management Tarsal Tunnel Syndrome Ice NSAIDs Orthotics Surgical release (in severe cases)

Location of Pain: Midfoot Injuries to consider fx/dislocation sprain strain/inflammation of tendon insertion sites tarsal coalition

Location of Pain: Midfoot Injuries to consider fx/dislocation Lisfranc injury navicular stress fx Lisfranc injury

Location of Pain: Midfoot Injuries to consider: sprain midtarsal joints tarsometatarsal joints

Location of Pain: Midfoot Injuries to consider: strain/inflammation of muscle/tendon at insertion sites tibialis posterior tibialis anterior peroneal longus peroneal brevis

Location of Pain: Midfoot Injuries to consider: Tarsal coalition abnormal union between two or more tarsals bony fibrous Cartilaginous

Location of Pain: Midfoot Injuries to consider: Tarsal coalition typically presents between 3 – 16 yrs of age 3 – 5 yrs: talonavicular coalition jt. 8 – 12 yrs: calcaneonavicular jt. 12 – 16 yrs: talocalcaneal jt.

Location of Pain: Midfoot Injuries to consider: Tarsal coalition will present clinically as a rigid pes planus limitations in subtalar joint

Strain/inflammation of tendon insertion site(s) History Location of pain (midfoot) Symptoms Onset MOI Fx/dislocation Acute; trauma Dropping something on the foot; stepping in hole or on uneven ground - twisting the foot Lisfranc fx** Dropping something on the foot; stepping in hole or on uneven ground - twisting the foot** Sprain Twisting the foot Strain/inflammation of tendon insertion site(s) Acute or chronic Forceful contraction; repetitive stress Tarsal coalition congenital n/a **often mistaken for midfoot sprain

Inspection/Observation Location of pain (midfoot) Signs Deformity? Swelling? Discoloration? Fx/dislocation Possible Lisfranc fx Common Sprain No Strain/inflammation of tendon insertion site(s) Minimal if at all Typically not Tarsal coalition Rigid pes planus; ABD of forefoot, medial displacement of talus; navicular drop

Strain/inflammation of tendon insertion site(s) Palpation Location of pain (midfoot) Point tenderness? Deformity? Swelling? Crepitus? Fx/dislocation Directly over 1 or more tarsals Possible Sprain Over involved joint No Strain/inflammation of tendon insertion site(s) Over tendon or insertion site Usually not Possible, would be minimal Tarsal coalition Typically not

Physical Exam (midfoot) n/a Location of pain ROM? Stress Tests? Special Tests? Neurological? Fx/dislocation n/a Sprain Intermetatarsal glide test Midtarsal joint glides Tarsometatarsal joint glides Strain/inflammation of tendon insertion site(s) Pain w/passive stretching of muscle/tendon; Pain w/resisted action of muscle tendon Tarsal coalition May have limitation in IN/EV

Management Midfoot fx/dislocations Ice Walking boot or NWB Spring steel innersole Surgery (when severely displaced)

Management Lisfranc fx/dislocation Cast NWB Rigid orthotic Surgery when necessary to stabilize

Management Midfoot sprain Ice NSAIDs Spring steel innersole or rigid orthotic Strengthening of intrinsic foot muscles

Management Inflammation at tendon insertion sites Ice NSAIDs Stretching Strengthening of involved muscle with emphasis on eccentrics

Management Tarsal coalition referral to orthopedist

Location of Pain: Forefoot Injuries to consider Fx midshaft avulsion Jones’ fx Intermetatarsal (Morton’s) neuroma metatarsalgia

History (forefoot) Location of pain Symptoms Onset MOI Midshaft fx Pain directly over metatarsal Acute or chronic (stress fx) Acute: Getting stepped on or having something dropped onto MT; stepping in hole or onto uneven surface; Chronic: repetitive stress, weakness of toe flexors Avulsion fx Most common site: styloid process of 5th MT Pain over fracture site; may have heard/felt pop Acute Base of 5th MT: forceful contraction of peroneal brevis Jones’ fx Pain over distal styloid of 5th metatarsal Force inversion with ankle in PF; landing on lateral aspect of foot Morton’s neuroma Pain, burning Metatarsalgia Pain under head(s) of metatarsals; may feel like “stepping on pebble” Acute/chronic

Inspection/Observation Location of pain (forefoot) Signs Deformity? Swelling? Discoloration? Midshaft fx  Avulsion fx Jones’ fx Morton’s neuroma -- Possible Metatarsalgia

Palpation  (forefoot) Location of pain Point tenderness? Deformity? Swelling? Crepitus? Midshaft fx  Avulsion fx Jones’ fx Morton’s neuroma Over neuroma n/a Metatarsalgia Over head of involved MT Involved head may feel lower than others Minimal if present

Tap test; Morton’s test Physical Exam Location of pain (forefoot) ROM? Stress Tests? Special Tests? Neurological? Midshaft fx Toe flex/ext may increase pain -- Tap test; Morton’s test Avulsion fx May have limitation if motion stresses fx site Jones’ fx May be limited in EV Morton’s test Morton’s neuroma Toe ext. may increase symptoms Metatarsalgia

Management Midshaft fx/dislocation Ice NSAIDs Boot/cast Spring steel innersole Surgery with comminuted or displaced fx

Management avulsion fx Boot/cast Surgery when necessary to stabilize

Management Jones’ fx Boot/cast – NWB Known for nonunions Surgery when necessary to stabilize

History Symptoms MOI Location of pain Forefoot between metatarsals neuroma intrinsic muscles Symptoms Burning pain Electric shock Dull ache MOI Gradual onset Improper shoes Forceful contraction Stretching beyond normal limits of ROM

Inspection/Palpation Forefoot injuries between metatarsals neuroma intrinsic muscles Signs swelling? Palpation Point tenderness Compression of neuroma reproduces pain

Stress/Special Tests Tests Forefoot injuries between metatarsals neuroma intrinsic muscles Tests Morton’s Test Abd/add of toes

Management Forefoot injuries Treatment between metatarsals Ice neuroma intrinsic muscles Treatment Ice Anti-inflammatories Orthotics

Questions?