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

2. 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

3. 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

4. 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

5. 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

6. History Tarsal tunnel syndrome Possible related factors
Training surface
Distance
Shoes

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

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

9. 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

10. Stress Tests/Special Tests
Tarsal Tunnel Syndrome
n/a

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

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

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

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

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

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

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

18. 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.

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

20. 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

21. 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

22. 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

23. 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

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

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

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

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

28. Management
Tarsal coalition
referral to orthopedist

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

30. 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

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

32. 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

33. 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

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

35. Management
avulsion fx
Boot/cast
Surgery when necessary to stabilize

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

37. 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

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

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

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

41. Questions?