The Foot & Toes

how many bones are composed in the lower leg, ankle and foot?

28 bones

bones and joints of foot provide a foundation for (4)

• shock absorption

• adaptation to uneven terrain

• propulsion

• stability for keeping body upright

foot 3 distinct regions

1) rearfoot

2) midfoot

3) forefoot

rearfoot made up of (2)

talus and calcaneus

midfoot made up of (4)

tarsals

navicular

cuboid

3 cuneiforms

forefoot made up of (2)

metatarsals and phalanges

7 functional joints of the foot

• subtalar joint (aka talocalcaneonavicular joint)

• talonavicular joint

• calcaneocuboid joint

• tarsometatarsal joints

• intermetatarsal joints

• metatarsophalangeal (MTP) joint

• interphalangeal (IP) joints

3 arches of the foot

medial longitudinal arch

lateral longitudinal arch

transverse arch

medial longitudinal arch

point of reference for foot posture

L: calcaneus to MT heads

medial longitudinal arch foundation is

navicular bone

transverse arch

spans from medial and lateral sides of the foot (across tarsals & MTs)

transverse arch apex of arch is

base of 2nd MT

pes planus aka

flat foot

pes cavus aka

high arch

main passive supporting structures of the foot are (4)

• plantar fascia

• spring ligament

• long plantar

• short plantar

extrinsic foot muscles

muscles that exist outside the foot and many cross multiple joints from the knee → toes

intrinsic foot muscles

have both attachments (O/I) within the foot

• directly contribute to foot stability through concentric and eccentric contractions

intrinsic foot muscle example

extensor digitorum brevis

Fx to lateral process talus

• rare

• caused by acute hyper-dorsiflexion with inversion

Posterior Fx of the talus

• 15-30 yo common

• caused by activities requiring forced PF

S/Sx of Talus Fx (6)

• mod to severe swelling, tenderness, discolouration

• Palp: point tenderness at dome of talus

• recurrent ankle swelling

• stiffness/feeling of instability

• possible crepitus/locking

• deep aching pain aggravated by activity

Fx of Talus management

due to high risk of complications with avascular necrosis Fx suspicions need immediate immobilized and referred to physician

Fx of calcaneus overview & ethology (3)

• rare

• MOI: high-energy axial loads (falling from a height)

• 75% extend into subtler joint

Fx of calcaneus S/Sx (3)

• severe heel pain

• inability to walk/WB

• palpable intense pain over calcaneus process

Fx of calcaneus management (4)

• immobilization

• ice, elevation

• non displaced Fx: short-leg cast/walking boot (~6 weeks)

• displaced: repaired surgically

stress Fx overview & etiology (3)

• tiny crack in bone caused by repetitive stress

• AFAB w amenorrhea higher rate of stress Fx

• often seen in running and jumping activities 

  • change in surface

  • inc in intensity

  • change in shoe type

  • inc in training mileage 

low risk stress Fx classification (3)

medial tibia

fibula

2-4th MTs

high risk stress Fx classification (6)

anterior tibia

medial malleolus

talus

navicular

5th metatarsal

sesamoids

stress Fx S/Sx (4)

• pain usually limited to Fx site

• prolonged pain

• pain begins insidiously, inc w activity dec w rest

• advanced = excessive swelling & pain with talking may be present

stress Fx management (5)

• early x-rays are negative (<2 weeks)

• bone scans / MRIs more sensitivite

• RTP should not be underestimated

• Tx = relative rest, NSAIDs, stretching, strengthening

• protected weight bearing (stiff shoe/walking cast)

anatomical name for growth plate

apophysitis

apophysitis of calcaneus aka

“sever’s disease”

apophysitis of calcaneus overview & etiology (3)

• seen in years 7-10

• associated w growth spurts, dec flexibility of posterior chain, biomechanics abnormalities + RELATED TO SHOCK ABSORPTION

• hard surfaces, poor quality shoes, landing off balance may all precipitate the condition

apophysitis of calcaneus S/Sx (4)

• unilateral/bilateral posterior heel pain that occurs shortly after beginning new sport/season

• pain worse during and after activity

• gait normal or altered

• point tenderness @ insertion of achilles tendon

sever’s sign pain with (2)

mediolat compression of calcaneus

standing on tiptoes

apophysitis of calcaneus management (4)

• RICE + refer to physician

• condition usually resolves w closure of apophysis 

• heel lifts/taping in slight PF could provide relief

• inc strength & flex in gastroc and soleus

lisfranc injury overview & etiology (3)

• disruption of the tarsometatarsal joint w or w/o associated Fx

• notorious for delayed diagnosis

• typical MOI: severe twisting injury that causes an axial load along metatarsal 

lisfranc injury S/Sx (5)

• 1st MT often dislocates from 1st cunieform

• other 4 Mts lat displaced

• blood supply to forefoot can be compromised = compartment syndrome may develop

• delayed swelling

• severe midfoot pain, paresthesia, swelling along midfoot region

lisfrance injury management (2)

• nondisplaced = short-leg non walking cast (6 weeks) followed by walking cast for another 6 weeks

• most injuries require surgery (screw plates)

jones fracture overview & etiology (2)

• fracture to base of 5th MT

• MOI: sudden inversion and PF mechanism, repetitive microtrauma

jones fracture S/Sx and management

• lateral foot pain

• look at forefoot Fx

forefoot fractures (general) overview & etiology

phalangeal Fx MOI: axial load (jamming toe) or direct trauma

forefoot Fx general S/Sx (3)

• localized swelling, discolouration, pain @ Fx site

• inc pain w WB

• potentially some positive special tests

forefoot Fx general management (3)

• phalanx Fx = buddy tape, shoe w wide toe box, walking boot possibly

• MT Fx= slipper cast, walking boot

• displaced Fx = surgery

Special Tests for suspected foot Fx (5)

• tap test

• heel thump test

• circumferential squeeze test @ midfoot

• tuning fork (vibration)

• compression & distraction

pump bump aka

retrocalcaneal bursitis 

retrocalcaneal bursitis overview & etiology

external pressure from a constrictive heel cup coupled w excessive pronation can lead to irritation of retrocalcaneal bursa

retrocalcaneal bursa location

b/w achilles tendon and calcaneus

retrocalcaneal bursitis S/Sx (4)

• POP of soft tissue just anterior to achilles tendon

• skin may be thickened (esp lat side of heel)

• active PF during push off

• inflamed bursa = pump bump (bone spur)

retrocalcaneal bursitis management (5)

• standard acute care

• stretching exercises for ms associated w achilles

• shoe/skate mod

• heel lift may provide relief

• consider associated achilles tendinopathy if necessary

pump bump also know as

haglund’s deformity

plantar fasciitis extrinsic causes (3)

improper footwear

training erros

unyielding surfaces

plantar fasciitis intrinsic causes (2)

pes cavus/planus

lack of strength/flexibility in calf/foot

plantar fasciitis S/Sx (4)

• pain and stiffness @ plantar/medial heel that is relieved w activity but re-occurs after rest

• severe pain w first steps in morning dec after few minutes

• limited ROM and inc pain w DF & toe extension

• Palp: point tender where plantar fascia attaches to calcaneus 

plantar fasciitis management (5)

• acute care

• non-WB activités when possible

• stretches for calf, plantar aspect of foot

• arch support taping, soft heel left

• possible surgery after 6-12 months f unsuccessful conservative management

cuboid syndrome MOI

sudden plantar-flexion & inversion

**very similar to lateral ankle sprain MOI

tarsal tunnel syndrome overview & etiology (2)

more common in people w flat feet

entrapment of posterior tibial nerve as passes through flexor retinaculum

tarsal tunnel syndrome S/Sx (4)

• pain &N/T radiating around med malleolus into sole and heel

• inc with activity or standing

• dec w rest

• positive tinel’s sign

tarsal tunnel syndrome management

rest, NSAIDs, orthotics, gradual RTP

metatarsalgia overview & etiology (3)

gen discomfort around MT heads

often related to participation in sport/activity

age/arthritic disease/diabetes can predispose to MT pain

metatarsalgia S/Sx (4)

flattening of transverse arch

callus formation

pain gen to MT region 

gradual inc of pain intensity and duration

metatarsalgia management (3)

reduce load on MT through

• activity mod

• footwear examination

• MT pads or bars

Morton’s neuroma aka

plantar interdigital neuroma

morton’s neuroma overview (3)

common if wearing tight fitting or high-heeled shoes

excessive pressure on nerves b/w MT heads

L: webspace of 3rd & 4th Mts

Morton’s neuroma S/Sx (4)

sensation of hot stone in shoe when walking

tingling/burning radiating into toes

pain dec when activity stops or shoe is removed

shock like sensation into affected toes

morton’s neuroma management

standard care, wide shoe w low heel, MT head padding

turf toe aka

great toe hyperextension

turf toe overview (3)

most common injuries in soccer

sprain of plantar capsular ligament of 1st MTP

MOI: forced hyperextension of great toe @ MTP and possible IP

turf toe S/Sx (3)

• pain/tenderness/swelling on plantar aspect of MTP joint of great toe

• AROM/PROM digit 1 extension painful

• bruising/discolouration

turf toe management (4)

• standard care

• turf toe taping to limit extension

• metatarsal pad used

• severe= restrict PA for 3-6 weeks

hallux rigidus overview (3)

• degen arthritis in 1st MTP

• activities involving running and jumping

• typically affects older population

hallux rigidus S/Sx (3)

tender enlarged 1st MTP joint

dec ROM

difficulty wearing shoes w elevated heel

what is the hallmark’s sign for hallux rigidus

limited 1st toe extension to usually less than 60 degrees

hallux rigidus management

standard care, wear low-heel shoes w adequate width/depth

others: steroid injections, surgery, mobilizations

hammer toe sign (3)

ext @ MTP joint

flexed @ PIP joint

hyperextended at DIP joint

mallet toe sign (2)

neutral at MTP and PIP joints

flexed @ DIP joint

claw toe sign (2)

• hyperextension at MTP join

• flexion at DIP and PIP joints

hammer toe, mallet toe, claw toe etiology

may develop due to:

• improperly fitted shoes

• neuromuscular disease

• trauma

• arthritis 

toe deformity managements (4)

• wearing footwear w more room for toes

• padding and taping to prevent irritation

• shave calluses

• possible surgery in extreme cases