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Chapter 18 The Foot

• Jennifer L. Doherty, MS, LAT, ATC
• Academic Program Director, Entry-Level ATEP
• Florida International University
• Acute Care and Injury Prevention

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Review of Anatomy
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Arches of the Foot
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Plantar Fascia
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Muscles of the Foot and Lower Leg
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Nerve Supply and Blood Supply
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Excessive Pronation

• Major cause of stress injuries
• Overload of structures during stance phase
• Prolonged pronation into propulsive phase
• Results in loose foot
• Excessive midfoot motion
• Decreased stability of first ray
• Increased pressure on metatarsals
• Increased tibial rotation at knee

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Excessive Pronation

• Causes weakness push off
• Does not allow foot to resupinate to provide
  rigid lever
• Less powerful, less efficient force produced
• Common injuries
• 2nd metatarsal stress fracture, Plantar fascitis
  Posterior tibialis tendinitis, Achilles
  tendinitis, Tibial stress syndrome, and Medial
  knee pain

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Excessive Supination

• Results in rigid foot
• Decreased mobility of calcaneocuboid joint
• Decreased mobility of first ray causing weight
  absorption on 1st and 5th metatarsals
• Increased tension of peroneus longus
• Inefficient shock absorption
• Common injuries
• Inversion sprains, Tibial stress syndrome,
  Peroneal tendinitis, IT-Band friction syndrome,
  and Trochanteric bursitis

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Foot Injuries
Apophysitis of the Calcaneus (Severs Disease)

• Etiology
• Traction injury at apophysis of calcaneus
• Where Achilles tendon attaches to calcaneous

• Signs and Symptoms
• Pain occurs at posterior heel below Achilles
  attachment
• Pain occurs during vigorous activity
• Pain ceases following activity

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Foot Injuries

• Apophysitis of the Calcaneus
• (Severs Disease) cont.
• Management
• Best treated with ice, rest, stretching and
  NSAIDs
• Heel lift could also relieve some stress

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Foot Injuries
Retrocalcaneal Bursitis (Pump Bump)

• Etiology
• Caused by inflammation of bursa beneath Achilles
  tendon
• Result of pressure and rubbing of shoe heel
  counter
• Chronic condition that develops over time
• May take extensive time to resolve
• Exostosis may also develop

• Signs and Symptoms
• Pain with palpation superior and anterior to
  Achilles insertion
• Swelling on both sides of the heel cord

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Foot Injuries

• Retrocalcaneal Bursitis (Pump Bump) cont.
• Management
• RICE and NSAIDs used as needed
• Ultrasound can reduce inflammation
• Routine stretching of Achilles
• Heel lifts to reduce stress
• Donut pad to reduce pressure
• Possibly invest in larger shoes with wider heel
  contours

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Metatarsal Injuries
Pes Planus Foot (Flatfoot)

• Etiology
• Excessive pronation and forefoot varus
• Wearing tight shoes
• Weakens supportive structures with shoe
• Being overweight
• Excessive exercise placing undo stress on arch

• Signs and Symptoms
• Pain, weakness, or fatigue in medial longitudinal
  arch
• Calcaneal eversion
• Bulging navicular
• Flattening of medial longitudinal arch
• Dorsiflexion with lateral splaying of 1st
  metatarsal

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Metatarsal Injuries

• Pes Planus Foot (Flatfoot) cont.
• Management
• If no signs and symptoms dont fix what isnt
  broken
• If problems develop
• Orthotics with a medial wedge may be used
• Taping of arch can also be used for additional
  support

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Metatarsal Injuries
Pes Cavus (High Arches)

• Etiology
• Excessive supination
• Associated with forefoot valgus
• Accentuated high medial longitudinal arch

• Signs and Symptoms
• Poor shock absorption
• Metatarsalgia
• Foot pain
• Clawed or hammer toes
• Shortening of Achilles and plantar fascia
• Heavy callus development on ball and heel of foot

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Metatarsal Injuries

• Pes Cavus (High Arches) cont.
• Management
• If no signs and symptoms dont fix what isnt
  broken
• If problems develop
• Orthotics with a lateral wedge may be used
• Stretch Achilles and plantar fascia

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Metatarsal Injuries

• Plantar Fasciitis
• Plantar fascia
• Dense, broad band of connective tissue attaching
  proximal and medially on the calcaneus and fans
  out over the plantar aspect of the foot
• Works in maintaining stability of the foot and
  bracing the longitudinal arch
• Plantar Fasciitis
• Catch all term used for pain in proximal arch
  and heel
• Common in athletes and nonathletes
• Attributed to heel spurs, plantar fascia
  irritation, and bursitis

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Metatarsal Injuries

• Plantar Fasciitis cont.
• Etiology
• Increased tension and stress on fascia
• Particularly during push off of running phase
• Change from rigid supportive footwear to flexible
  footwear
• Running on soft surfaces while wearing shoes with
  poor support
• Poor running technique
• Leg length discrepancy, excessive pronation,
  inflexible longitudinal arch, or tight
  gastroc-soleus complex

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Metatarsal Injuries

• Plantar Fasciitis cont.
• Signs and Symptoms
• Pain in anterior medial heel and along medial
  longitudinal arch
• Increased pain in morning
• Plantar fascia loosens after first few steps thus
  decreasing pain
• Increased pain with forefoot dorsiflexion

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Metatarsal Injuries

• Plantar Fasciitis cont.
• Management
• Extended treatment (8-12 weeks)
• Orthotic therapy is very useful
• Soft orthotic with deep heel cup
• Simple arch taping
• Night splint to stretch plantar fascia
• Vigorous heel cord stretching
• Exercises that increase great toe dorsiflexion
• NSAIDs and occasionally steroidal injection

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Metatarsal Injuries
Jones Fracture

• Signs and Symptoms
• Immediate swelling
• Pain over 5th metatarsal
• High nonunion rate
• Course of healing is unpredictable

• Etiology
• Inversion and plantar flexion
• Direct force (stepped on)
• Repetitive trauma
• Most common fracture site is at the base of the
  5th metatarsal

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Metatarsal Injuries

• Jones Fracture cont.
• Management
• Controversial treatment
• Crutches with no immobilization
• Gradual progression to weight bearing as pain
  subsides
• May allow athlete to return in 6 weeks
• If nonunion of the fracture is evident, surgery
  with internal fixation may be required

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Metatarsal Injuries

• Bunion (Hallux Valgus Deformity)
• Etiology
• Exostosis of 1st metatarsal head
• Associated with
• Forefoot varus
• Wearing shoes that are too narrow or too short
• Wearing shoes with pointed toes
• Bursa becomes inflamed and thickens
• Enlarges the joint and causes lateral
  malalignment of the great toe
• Bunionette (Tailors bunion)
• Impacts 5th metatarsophalangeal joint
• Causes medial displacement of 5th toe

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Metatarsal Injuries

• Bunion (Hallux Valgus Deformity) cont.
• Signs and Symptoms
• Initially
• Tenderness
• Swelling
• Enlargement of joint
• As inflammation continues
• Angulation of the joint increases
• Painful ambulation
• Tendinitis in great toe flexors may develop

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Bunion (Hallux Valgus Deformity) cont.

• Management
• Early recognition and care is critical
• Wear correct fitting shoes
• Orthotics may be used
• Padding over 1st metatarsal head with a
  tape splint between 1st and 2nd toe
  may be used
• Exercises for flexor and extensor muscles
• Bunionectomy may be necessary

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Injuries to the Toes
Turf Toe

• Etiology
• Hyperextension injury
• Results in sprain of 1st metatarsophalangeal
  joint
• May be the result of single or repetitive trauma

• Signs and Symptoms
• Pain and swelling
• Both increase during
• Push off in walking
• Running
• Jumping

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Injuries to the Toes

• Turf Toe cont.
• Management
• Orthotics to increase rigidity of forefoot region
  within the shoe
• Taping the toe to prevent dorsiflexion
• Ice and ultrasound
• Rest
• Discourage activity until pain free

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Injuries to the Toes
Fractures and Dislocations of the Phalanges

• Etiology
• Kicking unyielding object
• Stubbing toe
• Being stepped on
• Dislocations are less common than fractures

• Signs and Symptoms
• Immediate and intense pain
• Obvious deformity with dislocation

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Injuries to the Toes

• Fractures and Dislocations of the Phalanges cont.
• Management
• Dislocations should be reduced by a physician
• Casting may occur with great toe or multiple toe
  fractures
• Buddy taping is generally sufficient

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Injuries to the Toes

• Hammer Toe, Mallet Toe, or Claw Toe
• Etiology
• Hammer toe
• Flexion contracture of the PIP joint, which can
  become fixed
• Mallet toe
• Flexion contracture of the DIP joint, which can
  become fixed
• Claw toe
• Flexion contracture of the DIP joint with
  hyperextension at the MP joint
• All may be caused by wearing short shoes over an
  extended period of time

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Injuries to the Toes

• Hammer Toe, Mallet Toe, or Claw Toe cont.
• Signs and Symptoms
• The MP, DIP, and PIP can all become fixed
• Swelling
• Pain
• Callus formation
• Occasionally infection

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Injuries to the Toes

• Hammer Toe, Mallet Toe, or Claw Toe cont.
• Management
• Wear shoes with more room for toes
• Use padding and taping to prevent irritation
• Shave calluses
• Once the contracture becomes fixed, surgery will
  be required to correct

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Injuries to the Toes

• Subungual Hematoma
• Etiology
• Direct pressure
• Dropping an object on toe
• Kicking another object
• Repetitive shear forces on toenail

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Injuries to the Toes

• Subungual Hematoma cont.
• Signs of Injury
• Accumulation of blood underneath toenail
• Likely to produce extreme pain
• May result in loss of toe nail
• Management
• RICE immediately
• Reduces pain and swelling
• Relieve pressure within 12-24 hours
• Lance or drill nail
• Must be sterile to prevent infection

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Foot Rehabilitation

• General Body Conditioning
• A period of non-weight bearing is common,
  therefore alternative means of conditioning must
  be introduced
• Pool running
• Upper body ergometer
• General strengthening and flexibility should be
  included as allowed by injury

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Foot Rehabilitation

• Progression to Weight Bearing
• If unable to walk without a limp, crutch or cane
  walking should be utilized
• Poor gait mechanics will impact other joints
  within the kinetic chain
• Could result in additional injuries
• Progress to full weight bearing as soon as
  tolerable

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Foot Rehabilitation

• Flexibility
• Must maintain or re-establish normal flexibility
  of the foot
• Full range of motion is critical for normal
  function
• Stretching of the plantar fascia and Achilles
  tendon is very important

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Foot Rehabilitation

• Strengthening
• Writing alphabet
• Picking up objects
• Ankle circumduction
• Gripping and spreading toes
• Towel gathering
• Towel Scoop

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Foot Rehabilitation

• Neuromuscular Control
• Critical to re-establish because it is the single
  most important element dictating movement
• Muscular weakness, proprioceptive deficits, and
  ROM deficits challenge the athletes ability to
  maintain center of gravity without losing balance

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Foot Rehabilitation

• Neuromuscular Control cont.
• Must be able to adapt to changing surfaces
• Involves highly integrative
  and dynamic process that
  utilizes multiple neurological
  pathways
• Proprioception and
  kinesthesia is essential
  in athletics

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Orthotics

• Use of orthotics is common practice
• Used to control abnormal compensatory movement of
  the foot by bringing the floor up to meet the
  foot
• Orthotic works to place foot in neutral position,
  preventing compensatory motion
• Also works to provide platform for foot that
  relieves stress being placed on soft tissue,
  allowing for healing

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Foot Rehabilitation

• Functional Progression
• Athletes must engage in a functional progression
  to gradually regain the ability to
• Walk
• Jog
• Run
• Change directions, and
• Hop