Transcript Foot/Ankle - ProvidencePanthersSportsMedicine

The Foot
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
– 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
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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
1. Support body weigh in an economical fashion
2. Absorb the shock of weight bearing
3. 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
• 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
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Tibiotalar
Talocrural
Subtalar
Talonavicular
Calcaneocubiod
Metarsocunieform
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
– 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
 Metatarsals
 Phalanges
 Midfoot
 Navicular
 Cuboid
 3 Cuniforms
 Hindfoot
 Calcaneus
 Talus
Foot Movements
 Dorsiflexion
 Plantar Flexion
 Pronation
 Inversion
 Eversion
 Supination
Muscles of Foot
Intrinsic Muscles
• Relate to specific body
part or bone
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Flexor hallucis longus
Flexor hallucis brevis
Flexor digitorum longus
Extensor digitorum
longus
• Abductor hallucis
• Abductor digiti minimi
• Tibialis posterior
Extrinsic Muscles
• Muscle outside a body
part, organ, or bone
• Gastrocnemius
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
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Pain & weakness in medial longitudinal arch
Calcaneal eversion
Navicular bulging
Flattening of arch
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
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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
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
– 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 cushioning
and flexibility as
foot is too rigid
• (need board lasted,
straight lasted shoe,
with good rearfoot
control)
•
(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
• wear out the
outside of the
shoe
• All have excessive
wear on the lateral
heel due to heel strike
• All have excessive
wear on the lateral
heel due to heel
strike
Assessment of the Foot
Palpation
• Palpate Bones and Soft tissue
structures
Special Tests
• 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
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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
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
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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
Heel Contusion
• Irritation of the lateral aspect of the heel
• Sudden stop-and-go or sudden change in
movement
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
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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:
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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:
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Bone imbalance
Heel spurs
Muscle strains
Shin splints
Plantar Fasciitis—
Treatment
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Correct training errors
Ice
Massage
Evaluate shoes &
activity level
• Arch support
• Heel cup or cushion
Arch Sprains
• Ligaments stretch,
thus fail to hold bones
of foot in position
• When arch
weakened, it cannot
absorb shock
normally
• Causes:
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Overuse
Overweight
Fatigue
Training on hard
surfaces
– Non-supportive shoes
– Shoes in poor
condition
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
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