BPK 241 Week 3

Skin Function

Skin Function

• Protection (barrier from infections, UV light)

• Themoregulation (open + close pores, control heartbeat, dilate and constrict blood vessels)

• Sensation (feet or hands damaged when harmed)

Skin Structure

• Epidermis (most closest)

  • Basal cells

  • Keratinocytes/ Squames

  • Melanocytes

• Dermis (sweat glands, hair follicle)

• Subdermal adipose tissue (hypodermis) - blood vessels, fat help with temp + energy storages

Hyperhydrosis

• Cause: sweating too much (exercise)

• Secondary effects: most skin cause more friction, medication, low sugar

• Treatment: Stay hydrated, rest breaks, prevent secondary effects, baby powders

Blisters

• Shearing

• Treatment: Changing socks, less friction, stay dry, prevent clot

Calluses, corn

• Repeated blisters in one area

• Shear or pressure

• Treatment: Surgically remove it

Ingrown nails

• Causes: Nail grow into nail bed laterally or medially

• Secondary paronychia

• Treatment: Proper trimming of nails, clippers, tweezers, ointment

Fungal Infections

• Causes: Warmth, Darkness, Moisture

• Contamination - direct/ indirect contact

Fungal Varieties: Tinea corporis

Body (ringworm)

Fungal Varieties: Tinea capitis

Scalp (rash & alopecia)

Fungal Varieties: Tinea Crotis

Groin

Fungal Varieties: Tinea Pedis

Feet

Fungal Varieties: Tinea ungulm

• Nails and nail beds

• Note responsive to tropical treatment

Bacterial Infections

• Causes: Direct skin to skin contact

• Indirect contact through contaminated objects ie. towels, mats, equipments

• Treatments: Topical and oral antibiotics

  • Isolation of affected athlete from other competitors

Three Bacterial Infection Categories

• Staphylococcus

• Streptococcus

• Bacillus

Talus

• Proximal & Superior to calcaneus

• Articulates with tibia and fibula

Calcaneus (heel)

• Weight-bearing

• Achilles tendon insertion

Transverse tarsal bones

• Navicular (medial)

• Cuboid (lateral)

• Cuneiforms

Metatarsals (MT)

• I - V

• I = medial (articulates with great toe)

• V = lateral (articulates with pinky toe)

Phalanges

• Phalanx = singular

• Total = 14 per foot (2 in great toe, 3 in toes 2 through 5)

Sesamoid bones

• 2 (medial and lateral)

• At head of 1st Metatarsal (plantar surface)

• Gives greater mechanical advantage (levers)

• Reinforces push or flex actions

Areas of the Foot

• Forefoot

• Midfoot

• Hindfoot/Rearfoot

Hindfoot joints

• Subtalar (Inversion, eversion)

  • Talus & Calcaneus

Midfoot joints

• Navicular with cuneiform & cuboid with cuneiform bone

• Tarso-metatarsal

  • Cuneiforms & cuboid with MTs (Liz Frank joints)

Forefoot joints

• Metatarsophalangeal (MTP)

  • Flexion & extension

  • Some abduction & adduction

• Interphalangeal (IP)

• Proximal and Distal (2-5 MTs)

• Flexion & Extension - Hinge (Big toe)

Foot Muscle Flexors

• Flexor Hallucis longus (FHL)

• Flexor Hallucis brevis (FHB)

• Flexor digitorum longus (FDL)

• Flexor digitorum brevis (FDB)

  • All flex at MTP & IP joints

  • Also assist foot plantar flexion

Foot Muscle Extensors

• Extensor Hallucis Longus (EHL)

• Extensor Hallucis Brevis (EHB)

• Extensor Digitorum Longus (EDL)

• Extensor Digitorum Brevis (EDB)

  • All extend at MTP & IP

  • Also assist foot dorsiflexion

Plantar Fascia

• Thick band of connective tissue at bottom of foot (calcaneus to tarsal heads)

• Helps bend/arch foot

Foot posture: Pes Cavus, Neutral & Pes Planus

• Looking at feet change

• Looking at different degrees of arch

• Symmetry? Higher or Lower? Footprints?

Rearfoot/Hindfoot position

Pronation & Supination

Over Pronation ←→ Over Supination

Increase pressure on soft tissue

Pronation

• Medial arch collapse down a bit

• Comes from mid foot joint

• Allows foot to relax

Supination

High arch

Normal Walking Gait - Stance Phase

• Heel-strike occurs when landing on heel, foot should be in supination

• Midstance immediately follows with foot moving into pronation

• Toe-off follows midstance, foots return to supination prior to & during push off

Normal Walking Gait - Swing Phase

• Occurs when foot leaves ground & leg moves forward to another point of contact (40%)

Walking

Once foot is always in contact with ground

Running

Point when neither foot is in contact with ground

Foot Arches

• Four in number

  • Medial longitudinal

  • Lateral longitudinal

  • Anterior metatarsal

  • Transverse

Foot Forms of support

• Bony anatomy

• Ligaments

• Tendons/Plantar Fascia

• Muscle Activity

Keystone Bones

• Support for arches of the foot

• Either middle of highest point of arch

• Integral for the structure of the bone

Ligament “Staple” support for arch of foot

• Long plantar ligament hold’s bone together

• Underside: Plantar calcaneonavicular ligament

“Tie beam/cable” support for arch of foot

• Plantar fascia holding two ends of arch

• Flexor Hallucis longus connecting to plantar fascia

“Suspension” support for arch of foot

• Lots of suspension

• Cable(muscles) attaching at the top of arch structure

• Tibialis anterior (medial longitudinal arch) and Peroneus longus (lateral longitudinal arch) are the cables of the foot

What is Windlass Mechanism?

Looks at movement of the medial longitudinal arch and how it is essential for BOTH shock absorption/ dissipation of forces AND stiff for propulsion

How is Windlass Mechanism accessed?

• Prior to heel strike, ankle is in dorsiflexion, Plantar Fascia (PF) is taught, medial arch is high

• During midstance, PF is relaxed to allow medial arch to collapse pronation for shock absorption

• Prior to toe-off, first toe is in extension, PF become taught again, foot is stiff for take off, medial arch is high again

• Relies on ability of 1st toe to extend normally

• Published values range from 45 to 55 degrees of 1st toe extension to 60-70 degrees 1st toe extension required for normal gait

Ground Reaction Force Dissipation: Walking/ Running & Injury

Problems can arise when:

• Foot too flexible & remains in pronation past midstance - soft tissue injuries

• Foot is too rigid & does not pronate adequately - bony injuries

Exostoses

• Causes: Excess bony growth, increase stress on the bone/joint, too much calcium around area

• Obesity & abnormal weight bearing

• Faulty footwear

• Heredity

• Mechanism: continued pull/tension, plantar flexion will respond to stress

• Treatment: Correct predisposing factors, doughnut pad, may require surgery

Bunion (Hallux vulgus)

• Valgus deformity at MTP 1 (decrease in lateral joint angle)

• Causes: Tight shoes, Heredity

• Symptoms: Bone growth on medial side, increased pressure on medial metaphalanges

• Treatment: Warm socks, Improved footwear +/ or orthoses, Wedge pads or taping, Surgery, try to decrease inflammation

Bunion Pads/ Braces

Fixes orientations of bone

Plantar (Morton’s) Neuroma

• Usually between MTs III & IV

• Causes: interdigital nerve becomes entrapped between metatarsal heads, Running & pounding +/ or tight shoes, when nerves gets compressed, it gets irritated and swells up

• Differential Diagnosis: Anterior arch sprain

• Symtoms: Lateral forefoot pain: intermittent, Spontaneous, Reduced when barefoot, Excruciating and click & pain with MT compression.

• Treatment: Surgery

Metatarsal Pad

Tries to recreate metatarsal arch

Arch Sprains

• Causes: Obesity, heredity, overuse, fatigue, poor footwear, hard surfaces

• Symptoms: Pain with use, more when barefoot

  • 1st degree - slight soreness

  • 2nd degree - inflammation, drop of arch

  • 3rd degree - fallen arch

• Treatment: If we continue to stretch, arch will drop

Heel contusion

• Cause: Traumatic impact to heal

• Symptoms: Difficulty weight-bearing , localized tenderness under heat

• Treatment: Reduce stress (rest padding), Heel cup, taping, NSAID, Physio, X-ray all but mildest cases

• Complications: Fracture (#), Chronicity or recurrence, Periostitis, exostoses

Sprain

• Ligament +/ or capsule damage

• Causes: Kicking, Crush, Twisting

• Symptoms: Localized pain, swelling, decrease of ROM

• Treatment: X-Ray most toe sprains, POLICE, Tape or cast, then rehab

Turf Toe

• Sprain of 1st MTP joint ligament and capsule

  • Forced hyperextension of 1st MTP joint beyond 60 degrees

  • Incidence has increased with artificial turf

• Symptoms: Pain near 1st metatarsal head, decreased ROM, difficulty running or changing directions

  • 1st MTP is red, swollen, tender

  • Pain worst at end range 1st toe extension

• Treatment: Supportive footwear, POLICE, lower body rehab

Plantar Fasciitis

• Predisposing factors

  • Pes Cavus or Pes Planus

  • Running (weight on ball of foot)

  • Change in footwear

• Signs and Symptoms

  • Pain in medial arch/medial distal heel

  • Pain worst in morning and with sitting

  • Swelling and tenderness, heel spur on x-ray

• Treatment

  • Adequate rest

  • Stretching exercises (include Achilles tendon)

  • Physiotherapy with ultrasound

  • Soft orthotics

  • Gradual return to exercise, supervised

Plantar Fasciitis Treatments

• Plantar fascia and Gastrocnemius/ Solues/Achilles Tendon stretching

• Surgery is LAST resort

  • American Association of Foot & Ankle Specialists Position Statement

    • Don’t do surgery for Plantar Fasciitis before 6 months of conservative treatment

    • 97% will resolve with 6 months of consistent nonoperative treatment

Fractures

• General considerations

  • Past History, deformity, crepitus(crunchy sensation),tenderness

  • POLICE, splint, transport, X-Ray(Ottawa Ankle Rules)

• Specific foot fractures

  • Ankle sprains: Talus, Fibula, Tibia

  • Fall or jump: Calcaneus (vertebrae?)

  • Crush injury: metatarsals, Phalanges

  • Overuse(Stress): Metatarsals, Tibia, Fibula, Calcaneus

  • Kicking injury: Phalanges

Navicular Stress Fracture

• History: Pain, often for many months

• Symptoms: Midfoot pain, worse with activity

• Fracture often not evident on X-Ray = therefore delayed diagnosis, bone scan, CT scan, or MRI needed

• Treatment: Non-weight bearing cast, if not healing surgery required

Foot - Rehabilitation/Reconditioning

• POLICE/ Activity Modification

• NSAIDS

• Modalities

• Footwear modification

• Stretching - Early “pain free” ROM

  • Include proximal joints

• Strengthening

  • Early = Toe raise(seated), ankle circumduction, towel gathering

  • Later = running in pool, squats, cycling, swimming

  • Finally = jogging, running, skipping

• Taping/Orthoses

• Surgery?

POLICE/ Activity Modification

• Avoid aggravating activities

• Take few days off running or prolonged standing

• Ice packs for pain, helpful with acute conditions

• NSAIDs - Anti-inflammatory medications (if signs of inflammation present)

Rehabilitation/Reconditioning

• Modalities

  • Contrast bath

  • Ultrasound

  • Shockwave Therapy

  • Laser Therapy

  • Electrical stim

Footwear Modification

• Proper fitting footwear

• Proper shock absorption AND/OR arch support

Stretching

• Gastrocnemius and Soleus Stretching

• Plantar Fascia

Strengthening Exercises

• Towel Scrunches

• Marble pick ups

• Short foot exercises

TAPING/Orthoses

• Low dye arch tape job

• Calcaneal fat pad tape job

• Orthotics

• Heel Cup

• Night splint

Surgery

• Indicated in long term cases when conservative treatment fails

  • Plantar fascia release - increase its length

  • Gastrocnemius lengthening

Ankle Rehab

• Activity Modification/Controlled Weight Bearing

• Strengthening

• Balance/ Proprioception

• Running Progression

• Return to Sport