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Foot Conditions Chapter 19.

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Presentation on theme: "Foot Conditions Chapter 19."— Presentation transcript:

1 Foot Conditions Chapter 19

2 Anatomy


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

5 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 Anatomy (cont.) Ligaments supporting the midfoot and hindfoot region

7 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 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 Anatomy (cont.) Plantar arches Support and distribute body weight
Longitudinal arch— medial and lateral Transverse arch Ligaments Spring (calcaneonavicular) Long plantar Short plantar

10 Anatomy (cont.) Plantar arches Plantar fascia

11 Anatomy (cont.) Muscles Lateral and medial view

12 Anatomy (cont.) Muscles Posterior view

13 Anatomy (cont.) Muscles Intrinsic muscles of the foot – dorsal view

14 Anatomy (cont.) Muscles Intrinsic muscles of the foot – plantar view

15 Anatomy (cont.) Nerves Sciatic nerve Tibial nerve
Common peroneal nerve — deep and superficial peroneal nerves Femoral — saphenous

16 Anatomy (cont.) Blood supply Femoral artery Popliteal
Anterior and posterior tibial Anterior tibial Dorsal pedal

17 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 Kinematics (cont.) Motions Toe — flexion and extension
Ankle (subtalar) — dorsiflexion and plantarflexion Foot and ankle Inversion and eversion Pronation and supination

19 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 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 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) Pes Cavus Plantar fasciitis Metatarsalgia Stress fractures of the tarsals and metatarsals Peroneal tendonitis Sesamoid disorders Iliotibial band friction syndrome Pes Planus Tibialis posterior tendinitis Achilles tendinitis Medial tibial stress syndrome Patellofemoral pain

22 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 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 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


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 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 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 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 Toe and Foot Conditions (cont.)
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

31 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 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 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 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 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 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


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


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 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 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 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


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


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 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


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 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 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 Assessment History Observation/inspection Palpation
Physical examination tests

54 Neutral Talar Position

55 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 ROM (cont.)

57 ROM (cont.) RROM

58 Neurological dysfunction
Tinel’s sign

59 Neurological dysfunction
Morton’s test

60 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 Neurologic Tests (cont.)
Dermatomes Peripheral nerve distribution

62 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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