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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot Conditions Chapter 19.

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Presentation on theme: "Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot Conditions Chapter 19."— Presentation transcript:

1 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot Conditions Chapter 19

2 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy

3 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

4 Anatomy (Cont’d) Forefoot –Metatarsals and phalanges; numerous joints –Support and distribute body weight throughout the foot

5 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Midfoot –Navicular, cuboid, 3 cuneiforms; numerous joints –Talocalcaneonavicular joint (TCN) Talus moves simultaneously on calcaneus and navicular Combined action of talonavicular and subtalar joint Close-packed position—supination

6 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Ligaments supporting the midfoot and hindfoot region

7 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Hindfoot –Calcaneus and talus –Talocrural joint (ankle joint) Articulation of talus, tibia, and fibula Close-packed position—dorsiflexion Medial ligament—deltoid Lateral ligament—anterior talofibular; posterior talofibular; calcaneofibular

8 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Hindfoot –Subtalar joint Behaves as a flexible structure Axis of rotation of the subtalar joint lies oblique in the sagittal and frontal planes

9 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Plantar arches –Support and distribute body weight –Longitudinal arch— medial and lateral –Transverse arch –Ligaments Spring (calcaneonavicular) Long plantar Short plantar

10 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Plantar arches –Plantar fascia

11 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Muscles –Lateral and medial view

12 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Muscles –Posterior view

13 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Muscles –Intrinsic muscles of the foot – dorsal view

14 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Muscles –Intrinsic muscles of the foot – plantar view

15 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Nerves –Sciatic nerve Tibial nerve Common peroneal nerve — deep and superficial peroneal nerves –Femoral — saphenous

16 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Blood supply –Femoral artery –Popliteal –Anterior and posterior tibial –Anterior tibial Dorsal pedal

17 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics Gait cycle –Consists of alternating periods of single-leg and double-leg support –Requires a set of coordinated, sequential joint actions of the lower extremity

18 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics (cont.) Motions –Toe — flexion and extension –Ankle (subtalar) — dorsiflexion and plantarflexion –Foot and ankle Inversion and eversion Pronation and supination

19 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinetics Bones subject to several loading patterns Running –Foot sustains forces 2–3× body weight –Bones are typically 2–4× strength needed Repeated forces—stress fractures Foot deforms during weight bearing –Absorbing a smaller force of longer duration than if it were rigid –Deformation causes storage of mechanical energy in the stretched tendons, ligaments, and plantar fascia

20 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Injury Prevention Physical conditioning –Strengthening Extrinsic muscles Intrinsic muscles –Flexibility Achilles tendon Footwear –Demands of sport; wear shoe for its intended purpose –Proper fit Protective equipment –Taping; braces; orthotics

21 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions Foot Deformities –Pes cavus High arch and rigid foot –Pes planus Flatfoot and mobile foot –Associated with common injuries (refer to Box 19.1)

22 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont.) Toe deformities –Hallux rigidis Degenerative arthritis in first MTP S&S Tender, enlarged first MTP joint Loss of motion Difficulty wearing shoes with an elevated heel Hallmark sign—restricted toe extension Management: shoe modification

23 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont.) Toe deformities –Hallux valgus Thickening of the medial capsule and bursa, resulting in severe valgus deformity of great toe Asymptomatic or symptomatic Treatment— symptomatic

24 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont.) Hammer toe –Extension of MTP joint, flexion at PIP joint, and hyperextended at the DIP joint Claw toe –Hyperextension of MTP joint and flexion of DIP and PIP joints Mallet toe –Neutral position at MTP and PIP joints, flexion at DIP joint Difficult to treat conservatively

25 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

26 Toe and Foot Conditions (cont.) Turf toe –Sprain of the plantar capsular ligament of 1st MTP joint –Mechanism: forced hyperflexion or hyperextension of great toe –Acute or repetitive overload –Valgus ↑ susceptibility –S&S Pain, point tenderness, and swelling on plantar aspect of MP joint Extreme pain with extension –Potential for tear in flexor tendons or fracture of sesamoid bones –Management: standard acute; rest; protection from excessive motion

27 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont.) Ingrown toenail –Preventable with proper hygiene and nail care –Edge of nail grows into lateral nail fold and surrounding skin –Nail margin reddens; painful –Paronychia—fungal or bacterial infection –Management: refer to Application Strategy 19.2

28 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont.) Metatarsalgia –General discomfort around the metatarsal heads –Constant overloading leads to flattening of transverse arch –Contributing factors—intrinsic and extrinsic (refer to Box 19.2) –Management: activity modification; footwear examination; strengthening exercises

29 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont.) Bunion –Medial aspect of MTP joint of great toe; lateral aspect of the 5th toe –Thickening of capsule and bursa –Due to constant rubbing against inside of shoe –S&S (as condition worsens) Lateral shift of great toe Rigid, nonfunctional hallux valgus deformity –Once deformity occurs, little can be done to correct condition

30 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Retrocalcaneal bursitis –Due to external pressure— constrictive heel cup, coupled with excessive pronation or varus hindfoot –“Pump bump” –Management: standard acute; shoe modification; AT stretching Toe and Foot Conditions (cont.)

31 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot Contusions Trauma to the midfoot or forefoot: need to rule out fracture and damage to extensor tendons Hindfoot—heel bruise –Thick padding of adipose tissue—does not always suffice –Stress in running, jumping, changing directions –S&S Severe pain in heel Unable to bear weight –Management: cold; heel cup or doughnut pad –Condition may persist for months

32 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Sprains IP & MP joints –Sprains of MP and IP joints of the toes may occur by tripping or stubbing the toe –S&S Pain, dysfunction, immediate swelling Dislocation—gross deformity –Management—strapping

33 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Sprains (cont.) Midfoot sprains –Mechanism: severe dorsiflexion, plantarflexion, or pronation –More frequent in activities in which the foot is unsupported –S&S Pain and swelling is deep on medial aspect of foot Weight bearing may be too painful –Management: standard acute; limited weight bearing

34 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions Plantar fasciitis –Extrinsic and intrinsic risk factors –S&S Pain with first steps in the morning Point tenderness at medial calcaneal tubercle ↑ pain with passive extension of great toe and ankle dorsiflexion ↑ pain with weight bearing Pain relieved with activity, but recurs after rest –Management: standard acute; refer to Application Strategy 19.4

35 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Conditions Plantar interdigital neuroma (Morton’s neuroma) –Trauma or repetitive stress → abnormal pressure on plantar digital nerves –Common—web space between 3rd and 4th metatarsals; less common, between 2nd and 3rd metatarsals

36 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Conditions (cont.) –S&S Sensation of having a stone in the shoe that worsens when standing Tingling or burning, radiating to the toes, along with intermittent symptoms of a sharp shock-like sensation Pain subsides when activity is stopped or when the shoe is removed; desire to remove the shoe and massage foot—classic sign –Management: metatarsal pad; broad, soft-soled shoe with a low heel

37 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

38 Neurologic Conditions (cont.) Tarsal tunnel syndrome –Posterior tibial nerve (or branch) constricted beneath fibrous roof of foot flexor retinaculum –Often linked to excessive pronation or excessive valgus deformity –S&S Pain at medial malleolus radiating into sole and heel Paresthesia, dysesthesia, or hyperesthesia in nerve distribution + Tinel’s sign –Management: rest; NSAIDs; orthoses; gradual return to activity

39 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

40 Foot and Lower Leg Fractures Repetitive microtraumas → apophyseal or stress fractures Tensile forces associated with severe ankle sprains → avulsion fractures of 5th metatarsal Severe twisting → displaced and undisplaced fractures in foot, ankle, or lower leg

41 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont.) Freiberg's disease –Avascular necrosis of 2nd metatarsal head –Active adolescents ages 14–18 Sever's disease –Traction-type injury of calcaneal apophysis –Seen in ages 7–10 –S&S Heel pain with activity + “squeeze” test + Sever’s sign Decreased heel cord flexibility –Management: standard acute; physician referral

42 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont.) Stress fractures –Often seen in running and jumping, especially after significant ↑ training mileage; change in surface, intensity, or shoe type –Common sites 2nd metatarsal Sesamoid bones Navicular Calcaneus Tibia and fibula

43 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont.) –S&S Pain begins insidiously; ↑ with activity and ↓ with rest Pain usually limited to fracture site Pain with percussion, tuning fork, or ultrasound –Management: standard acute; physician referral

44 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

45 Foot and Lower Leg Fractures (cont.) Avulsion fractures –Eversion sprain—deltoid ligament avulses portion of distal medial malleolus –Inversion sprain—plantar aponeurosis or peroneus brevis tendon avulses base of 5th metatarsal (type II) –Jones fracture Type I transverse fracture into the proximal shaft of 5th metatarsal at junction of diaphysis and metaphysis Often overlooked in conjunction with a severe ankle sprain Complications: nonunions and delayed unions are common –Management: standard acute; physician referral

46 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

47 Foot and Lower Leg Fractures (cont.) Phalanges/ metacarpals –Standard S&S –Relatively minor Tarsal fractures –LisFranc injury Disruption of tarsometatarsal joint, with or without associated fracture Caused by a severe twisting injury

48 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont.) 1st metatarsal dislocated from 1st cuneiform; other 4 metatarsals are displaced laterally, usually in combination with fracture at base of 2nd metatarsal History of severe midfoot pain, paresthesia, or swelling in midfoot region with variable flattening of arch or forefoot abduction

49 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

50 Foot and Lower Leg Fractures (cont.) –Lateral process of talus Due to traumatic ankle sprain Persistent ankle pain; inability to walk for long periods –Posterior fracture to talus Forced plantarflexion Pain with running, jumping; resisted plantarflexion and great toe flexion –Neck of talus Forced dorsiflexion May compromise blood supply to talus

51 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont.) –Maisonneuve fracture External rotation of foot Associated fracture of proximal third of fibula S&S: tenderness over deltoid and fracture site

52 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont.) Fracture management –Remove shoe and sock to expose injured area –Assess neurovascular integrity –Mild Standard with physician referral –Serious conditions Assess and treat for shock Activate EMS –Refer to Application Strategy 19.6

53 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment History Observation/inspection Palpation Physical examination tests

54 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neutral Talar Position

55 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Range of Motion (ROM) AROM –Ankle dorsiflexion (20°) –Ankle plantarflexion (30–50°) –Pronation (15–30°) –Supination (45–60°) –Toe extension and flexion –Toe abduction and adduction PROM –Normal end feel Dorsiflexion, plantarflexion, pronation, supination, toe flexion and extension—tissue stretch

56 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.)

57 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) RROM

58 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurological dysfunction Tinel’s sign

59 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurological dysfunction Morton’s test

60 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests Myotomes –Knee extension—L3 –Ankle dorsiflexion—L4 –Toe extension—L5 –Ankle plantarflexion, foot eversion, or hip extension—S1 –Knee flexion—S2 Reflexes –Patella—L3, L4 –Achilles tendon—S1

61 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests (cont.) Dermatomes Peripheral nerve distribution

62 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Rehabilitation Restoration of motion Restoration of proprioception and balance –Closed-chain exercises Muscular strength, endurance, and power –Open-chain exercises –PNF-resisted exercises Cardiovascular fitness


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