1. Chapter 18: The Foot

2. Foot Anatomy: Bones  Toes –Phalanges –Sesamoid Bones  Metatarsals  Tarsal Bones –Calcaneus –Talus –Navicular –Cuboid –Cuneiforms

3. Foot Anatomy: Arches  Anterior Metatarsal Arch –Shaped by heads of 1 st -5 th metatarsals  Transverse Arch –Primarily cuboid & internal cuneiform  Medial Longitudinal Arch –Calcaneus, talus, navicular, 1 st cunieform, & 1 st metatarsal –Calcaneonavicular Ligament  Lateral Longitudinal Arch –Calcaneus, cuboid, & 5 th metatarsal

4. Foot Anatomy: Plantar Fascia  Fibrous connective tissue  Originates at medial tuberosity of calcaneus  Inserts at proximal heads of metatarsals  Supports foot against downward forces

5. Foot Anatomy: Articulations  Interphalangeal Joints  Metatarsophalangeal Joints  Intermetatarsal Joints  Tarsometatarsal Joints  Intertarsal Joints  Subtalar Joint –Articulation between talus in calcaneous –Inversion, eversion, pronation, & supination  Midtarsal Joint –Consists of two joints: Calcaneocuboid and Talonavicular –Directly related to position of subtalar joint

6. Movements  Dorsiflexion  Plantar Flexion  Inversion  Eversion  Adduction  Abduction  Supination  Pronation  Flexion  Extension

7. Intrinsic Muscles of Foot  Extensor Digitorum Brevis  Abductor Hallucis  Flexor Digitorum Brevis  Abductor Digiti Minimi  Quadratus Plantae  Lumbricales  Flexor Hallucis Brevis  Adductor Hallucis  Flexor Digit Minimi Brevis  Plantar Interossei  Dorsal Interossei

8. 8 Muscle & Action  Extensor Digitorum brevis (dorsal muscle) –extends the 2nd-5th toes  Abductor Hallicus –abducts the great toe  Flexor Digitorum Brevis –flexes the 2nd-5th toes  Abductor Digiti Minimi –abducts the small toe 8

9. 9 Muscles & Actions  Quadratus Plantae –Aids in flexing the 2nd-5th toes  Lumbricles –flexes the 2nd-5th toes  Flexor Hallucis Brevis –flexes the great toe  Adductor Hallicus –adducts the great toe 9

10. 10 Muscles & Actions  Flexor Digiti Minimi Brevis –flexes the small toe  Plantar interossei –adducts the toes toward the 2nd toe  Dorsal interossei –Abducts the toes from the 2nd toe; moves the 2nd toe medially and laterally 10

11. Nerve & Blood Supply  Nerve Supply –Tibial Nerve  Posterior Leg & Plantar aspects of foot –Common Peroneal Nerve  Anterior Leg & Foot  Blood Supply –Anterior & Posterior Tibial Arteries

12. Gait  Stance Phase –Initial contact to toe-off –Five periods  Initial Contact  Loading Response  Mid Stance  Terminal Stance  Pre-Swing (Toe Off)  Swing Phase –Period of non-weight bearing –Three periods  Initial Swing  Mid Swing  Terminal Swing

13. Prevention of Foot Injuries  Selecting Appropriate Footwear  Using a Shoe Orthotic  Foot Hygiene

14. Foot Assessment  History –What? When? How? Previous hx?  Observation –Symptoms –Structural Deformities –Shoe Wear Patterns  Palpation –Bony Palpations –Soft-Tissue Palpation –Pulses  Range of Motion –AROM (athlete performs ROM) –PROM (ATC performs ROM) –RROM (Adds resistance)  Special Tests –Tinel’s Sign –Morton’s Tests - Squeeze Test –Fracture Tests (Bump Test) –Neurological Assessment

15. 15  Morton’s test (Neuroma) –Put the foot in a supine position –Apply tranverse pressure to the –heads of the metatarsals –+ test is a sharp p! in the forefoot 15 Special Tests

16. 16 Special Tests  Tinel’s Sign –Tapping over the posterior tibial nerve –Produces tingling distal to that area –+ sign numbness, tingling, and paresthesia (prickling sensation) –Indicates possible tarsal tunnel syndrome 16

17. Recognition Of Injuries  Fractures –Talus –Calcaneus –Phalanges –5 th Metatarsal  Jones Fx –1 st or 2 nd Metatarsal  March Fx –Tarsometatarsal  Lisfranc Injury  Bursitis –Retrocalcaneal  Apophysitis –Calcaneus (Sever’s Disease)  Morton’s Neuroma  Contusions –Heel –“Bone Bruise”  Subluxation/Dislocations –Cuboid –Phalanges  Arches –Pes Planus –Pes Cavus –Longitudinal Strain –Metatarsal Strain –Plantar Fascitis  Bunions –Hallux Valgus  Inflammation –Sesamoiditis  Toes –Sprains –Turf Toe –Hammer, Mallet, or Claw –Overlapping –Subungual Hematoma

18. 18 Injuries  Fractures of the Talus –Etiology: occurs laterally from a severe IV & DF force or medially from an IV and PF force –Treatment  X-ray for accurate diagnosis, immobilization –S&S  hx of repeated trauma to the ankle  p! on weight bearing, complains of catching and snapping  intermittent swelling  talar dome is tender on palpation 18

19. 19 Injuries  Fracture of the Calcaneus –Etiology  occurs from landing after a jump or fall from a height –S&S  immediate swelling and p!  can not bear weight –Management  RICE immediately  X-rays  Immobilize 19

20. 20 Injuries  Sever’s Disease –Etiology  occurs in young, physically active patients  injury at the apophysis (bone protrusion) of the calcaneus where the Achilles tendon attaches –S&S  p! occurs at the posterior heel  p! occurs during vigorous activity –Management  Rest, Ice, stretching the Achilles tendon  Anti-inflammatory medications (IBU, Advil) 20

21. 21 Injuries  Tarsal Tunnel Syndrome –Etiology  tarsal tunnel is behind the medial malleolus  tibialis posterior, flexor hallucis & flexor digitorum pass through this tunnel. Any trauma to this area can compromise these structures –S&S  p! and paesthsia along the medial & plantar aspect  + Tinel’s sign –Management  anti-inflammatory medication, orthotics, surgery 21

22. 22 Injuries  Pes Planus Foot (Flatfoot) –Etiology  medial longitudinal arch appears to be flat/fallen  repeated pounding –S&S  P! or fatigue in the medial longitudinal arch –Management  no p!=no treatment  P!= orthotic 22

23. 23 Injuries  2nd Metatarsal Stress Fracture (Morton’s Toe) –Etiology  the 1st metatarsal is longer than the 2nd –S&S  p! both during & after activity  point tenderness –Management  no symptoms= no correction  medial wedge orthotic 23

24. 24 Injuries  Plantar Fascitis – Etiology  can occur in patients with pes cavus or pes planus –S&S  p! in the anterior medial heel  p! is increased when the patient bears weight in the morning or after sitting for long periods of time  p! in dorsiflexion –Management  Orthotic  Arch taping and stretching the plantar fascia 24

25. Foot Rehabilitation  General Body Conditioning  Weight Bearing –Progress from NWB to WB –Correct Gait  Joint Mobilization –Anterior/Posterior Glides  Flexibility –Triceps Surae & Plantar Fascia  Muscular Strength –Exercises?  Neuromuscular Control –Proprioception Exercises –Closed Kinetic Chain  Foot Orthotics & Taping