AT 359
Chapter 18 - The Foot

Bones of the Foot: (26 total)

4 Arches of the Foot:
Anterior Metatarsal - across 1st thru 5th metatarsal heads
Transverse - across 1st row of tarsal bones
Medial Longitudinal - from medial calcaneus to distal head of the 1st metatarsal
Lateral Longitudinal - from lateral calcaneus to distal head of the 5th metatarsal

*Plantar Fascia - thick band of fibrous tissue originating from medial calcaneus to metartarsal heads

Joints:
Interphalangeal - between bones of toes; designed only for flexion and extension
Metatarsophalangeal - between metatarsals and phalanges; "condyloid"; permits flexion, extension,
            adduction and abduction
Intermetatarsal - "sliding" joints; between metatarsal heads
Tarsometatarsal - base of metatarsals and tarsal bones
Subtalar - between talus and calcaneus; permits inversion, eversion, pronation and supination
Midtarsal - consists of calcaneocuboid and talonavicular joints

Primary Ligaments:
Plantar calcaneonavicular - "spring" ligament; connects from navicular tubercle to sustentaculum tali
Bifurcated "Y" - "Y" shaped; attaches from calcaneus to navicular and cuboid; midtarsal ligament;
                found in sinus tarsi area


Main Musculature:

Nerve Supply: (both of the following divisions originate from sciatic nerve)
Tibial nerve - supplies muscles on the back of the leg and on the plantar aspect of foot
Common Peroneal nerve - splits into deep and superficial peroneal nerve; supplies front of leg and foot

Blood Supply:
Anterior Tibial artery - comes down on top of foot just lateral to Tibialis Anterior; supplies dorsum of foot
Posterior Tibial artery - comes down behind medial malleolous; supplies plantar aspect of foot

Normal Gait:
With running or walking, the heel usually comes into contact with the ground first.  At this very moment, the subtalar joint is supinated.  As contact occurs and weight is transferred to the foot, pronation occurs.  As the momentum carries on to and from the midstance phase, the subtalar joint supinates again to allow for the push-off phase.  See fig. 18-9 in book.

Structural Deformities: (assess by having athlete lay prone on table with feet hanging off end; observe from above foot looking down)
-Forefoot Varus - causes excessive pronation
-Forefoot Valgus - causes excessive supination
-Rearfoot Varus - causes excessive pronation

Excessive Pronation:
-First Ray - composed of 1st metatarsal and 1st cuneiform bones; become hypermobile
-injuries include: 2nd metatarsal stress fx's, plantar fasciitis, posterior tibial tendonitis, achilles tendonitis,
            tibial stress syndrome, and medial knee pain

Excessive Supination:
-majority of weight is absorbed by 1st and 5th metatarsals; not efficient absorption
-injuries include: inversion ankle sprains, tibial stress syndrome, peroneal tendonitis, iliotibial band friction syndrome,
            and trochanteric bursitis

Shoe Selection:
-Pronated feet need a shoe that is less flexible and good rearfoot control; also a straight-lasted shoe is best
-Supinated feet need a shoe that is more flexible with plenty of cushioning
-Nike = tight, narrow shoe; Adidas, New Balance = wider shoes

Special Tests:
Tinel's Sign
        -tapping over the posterior tibial nerve will induce tingling, numbness, and/or parasthesia

Morton's Test
        -with athlete in supine position, squeeze the metatarsal heads (ball of foot) together.
        -positive sign is sharp pain in forefoot
        -indicative of neuroma or metatarsalgia

Specific Injuries:
Talus Fx's-
        -can have a chip fx off of bone; i.e. os trigonum fx
        -osteochondritis dissecans

Calcaneus Fx's-
        -usually occurs from a jumping or falling from a great height
        -could be avulsion fx's

Calcaneal Stress Fx-
        -are among the most common stress fx's of the foot
        -seen more among distance runners; repetitive foot impact
        -non-weight bearing activities for several weeks

Sever's Disease-
        -calcaneal apophysitis - traction injury at the bony protuberence (apophysis) where Achilles attaches
        -affects children and adolescents
        -can use heel lift

Retrocalcaneal Bursitis-
        -rubbing over heel of shoe
        -chronic condition
        -exostosis can develop from constant irritation - called a "pump bump"
        -can use a heel lift

Heel Contusion-
        -pounding injury; jumping, bounding MOI
        -protected by tough skin and fat pad
        -usually on lateral aspect of heel/calcaneus as opposed to plantar fasciitis on the medical aspect
        -needs cushioning such as fatty pad tape job with a heel cup

Cuboid Subluxation-
        -can be caused by pronation or trauma
        -can be mistaken for plantar fascia
        -can manipulate foot in prone position looking for a "pop" upon movement of cuboid

Tarsal Tunnel Syndrome-
        -located behind medial malleolus
        - composed of posterior tibial, FHL and FDL tendons along with posterior artery and nerve
        -tendonitis, tenosynovitis, fractures can all cause this condition
        -tinel's sign will be positive for numbness or tingling

Tarsometatarsal Fracture/Dislocation (Lisfranc injury)-
        -named after French surgeon who amputated injuries at this joint
        -is a rare injury, more likely to see in baseball players sliding into base
        -hard to heal even with surgery

Pes Planus (Flat foot)-
        -refers to medial longitudinal arch that is fallen
        -associated with excessive foot pronation
        -orthotics may be helpful in treating problems
        -can be rigid or supple arch

Pes Cavus (High Arch)
        -also called "clawfoot" or "hollow foot"
        -associated with excessive supination
        -tight medial longitudinal arch
        -poor weight absorption/distribution
        -orthotics may be useful

Longitudinal Arch Strain-
        -caused by pounding on hard surfaces usually
        -arch taping
        -hard to differentiate between muscle strain and arch strain

Plantar Fasciitis-
        -lot of different causes
        -pain on anterior medial heel
        -pain is worse with the 1st few steps in the morning and gradually gets somewhat better during the day
        -hard to get rid of
        -intense stretching, anti-inflammatories, ice and possibly night splints
        -surgery may be needed - bone spurs can also develop due to the irritation
        -orthotics may be useful as well

Jone's Fx-
        -fx to base of 5th metatarsal (styloid process)
        -usually associated with inversion sprains
        -prognosis not usually great
        -surgery is common with a pin/screw, which sometimes do not turn out well either

Metatarsal Stress Fx-
        -commonly found in the 2nd metatarsal (March fx)
        -increases in intensity, running surfaces and shoes can be a factor

Bunion and Bunionettes-
        -bunion=hallux valgus
                -occurs at the 1st metatarsal joint
                -bursa over 1st metatarsal joint becomes inflamed and thickens over time
                -tight shoes lead to bunion formation; also is hereditary
                -extreme cases will need surgery to fix
                wear shoes with a wide toe box
        -bunionette=tailor's bunion
                -occurs at the 5th metatarsophalangeal joint
                -little toe angulates towards the 4th toe

Sesamoiditis-
        -located at the base of the 1st metatarsal head within the flexor and adductor tendons
        -can be caused by repetitive hyperextension of the big toe
        -sometimes there is a fx involved
        -metatarsal pads, bars or doughnut pads can be helpful to take pressure off of inflamed area

Metatarsalgia-
        -catch-all term for pain in the ball of the foot
        -common cause is from fallen metatarsal arch; look for callus formation
        -metatarsal pads can be very effective for treatment
        -also look at calf flexibility; may have to implement calf stretching routine

Metatarsal Arch Strain-
        -athletes with a fallen metatarsal arch or pes cavus are more susceptible
        -pain and/or cramping in area of metatarsal arch
        -use of metatarsal pads/bar may be useful

Morton's Neuroma-
        -occurs between the metatarsals and is usually located between the 3rd and 4th metatarsals
        -between the 3rd and 4th is where the nerve is the thickest
        -bone scan is usually performed to rule out stress fx
        -non-weight bearing is usually helpful in treatment
        -wearing a shoe with a tight toe box can increase s/s
        -morton's test is positive for pain and numbness/tingling

Sprained Toes-
        -"jamming" the toe usually is a result of kicking an object
        -buddy tape toes together - splinting is virtually impossible
        -walk as tolerated

Turf Toe-
        -very debilitating injury; affects the 1st metatarsophalangeal joint
        -usually occurs from hyperextension of big toe; shoe flexibility and playing surface play a role as well
        -adding a rigid insole and a turf toe tape job are the most effective means of treatment

Fx's/Dislocations of Phalanges-
        -pain, swelling, discoloration should be considered to assess for fx
        -casting is not necessary unless the big toe is involved; buddy taping is the most successful
        -a rigid shoe will also help with pain

Morton's Toe-
        -1st metatarsal is shorter than 2nd metatarsal
        -the 1st metatarsal usually absorbs more weight but with Morton's toe, the 2nd bears more than normal
        -stress fx's are common because of the uneven weight distribution
        -a medial heel wedge and a less-flexbile shoe can help problems associated with this condition

Hallux Rigidus-
        -associated with bony spurs on dorsum of 1st metatarsophalangeal joint
        -arthritic condition
        -toe cannot dorsiflex (extend) so athletes tend to bear more weight on the lateral aspect of foot
        -a rigid orthotic and /or shoe can be helpful; same treatment basically as turf toe
        -surgical removal of spurs can be helpful as well

Hammer Toe, Mallet Toe, Claw Toe-
        -usually congenital, but wearing shoes that are too short can result in cramping of the toes
        -athletes with pes cavus are more susceptible to having these as well because of the contracture of
                flexor muscles
        -toes will become fixed (in contracture) and surgery could be necessary
        -wearing shoes with plenty of toe room and taping/padding are the most successful treatments

Overlapping Toes-
        -may be congenital or by wearing shoes that are too narrow
        -taping might be helpful -surgery can be considered in extreme cases


Web Sites for further study/learning:
www.medsite.com  -  Medical Search Engine

www.clarknet/pub/pribut/spsport.html - Dr. Pribut's Running Injuries Page

www.medmedia.com/med.htm - Wheeless' Textbook of Orthopedics

www.bunionbusters.com - North Shore Podiatry Foot Care Center

www.acfas.org - American College of Foot and Ankle Surgeons