The Foot

THE FOOT

ANATOMY OF THE FOOT

  • Bones of the Foot:
    • Tibia
    • Fibula
    • Talus
    • Navicular
    • Cuneiforms (Medial, Intermediate, Lateral)
    • Metatarsals
    • Calcaneus (Heel Bone, Largest Tarsal)
    • Cuboid
    • Phalanges (Bones of the Toes)
    • Distal Phalanx (plural: Phalanges)

JOINTS OF THE FOOT

  • Key Articulations:
    • Intermetatarsal Joints (Heads of metatarsals)
    • Metatarsophalangeal Joints (MTP)
    • Interphalangeal Joints (IP)
    • Tarsometatarsal Joints (Lisfranc’s joint)
    • Subtalar Joint (Between Talus and Calcaneus)
    • Midtarsal Joints (Chopart’s joints)
    • Calcaneocuboid Joint
    • Talonavicular Joint

ARCHES OF THE FOOT

  • Medial Longitudinal Arch:
    • Supported by the calcaneal navicular ligament.
  • Lateral Longitudinal Arch
  • Anterior Metatarsal and Transverse Arch
  • Plantar Fascia (Plantar Aponeurosis):
    • Thick band of fibrous tissue extending from the medial tuberosity of the calcaneus to the proximal heads of metatarsals.

PREVENTING FOOT INJURIES

  • Essential Considerations:
    • Appropriate footwear
    • Biomechanical or structural deformities
    • Use of orthotics
    • Environmental considerations
    • Avoid training errors (especially intensity)
    • Maintain foot hygiene

FOOT ASSESSMENT

  • History Gathering:
    • General and specific questions about foot issues.
    • Pain location checks: heel, foot, toes, arches.
    • Training surfaces or changes in footwear.
    • Changes in training volume/type.
    • Observations: favoring a foot, limping, weight-bearing difficulties.
    • Check for color changes with weight-bearing and structural deformities: pes planus or pes cavus.

PALPATION OF SOFT TISSUE

  • Key Ligaments and Tissues:
    • Lateral Ankle Ligaments:
    • Anterior Talofibular Ligament
    • Calcaneofibular Ligament
    • Posterior Talofibular Ligament
    • Lateral Muscles:
    • Peroneus Longus Tendon
    • Peroneus Brevis Tendon

SPECIAL TESTS AND IMAGING

  • Movement Assessments:
    • Extrinsic and intrinsic muscles checked for pain.
    • Assess Active Range of Motion (AROM), Passive Range of Motion (PROM), Resisted Range of Motion (RROM).
  • Joint Play Assessment:
    • Determine firmness, softness, or lack of end-feel.
  • Tinel’s Sign Test:
    • Tapping over posterior tibial nerve causing tingling distal to area, indicating possible tarsal tunnel syndrome.
  • X-Ray Evaluation:
    • Look for displacement or misalignment of bones.

INJURIES TO THE TARSAL REGION

  • Fracture of the Talus:
    • Etiology:
    • Caused by lateral inversion/dorsiflexion or medial inversion/plantarflexion with tibial external rotation. Typically affects the dome of the talus.
    • Signs & Symptoms:
    • History of ankle trauma, weight-bearing pain, intermittent swelling, catching/snapping, tenderness upon palpation.
    • Osteochondritis Dissecans may occur (bone fragments).
    • Management:
    • X-ray for diagnosis, weight-bearing progression, rehab focusing on ROM and strength. Surgery if conservative treatment fails, with a return to play in 6-8 weeks post-surgery.
  • Apophysitis of the Calcaneus (Sever’s Disease):
    • Etiology:
    • Traction injury at the calcaneus where the Achilles attaches, akin to Osgood-Schlatter Disease.
    • Signs & Symptoms:
    • Pain at the posterior heel below the Achilles during vigorous activity.
    • Management:
    • Treat with ice, rest, stretching, NSAIDs, and possibly heel lifts.
  • Retrocalcaneal Bursitis (Pump Bump):
    • Etiology:
    • Inflammation caused by friction of shoe heel against the bursa beneath the Achilles tendon.
    • Signs & Symptoms:
    • Pain with palpation near Achilles; may see swelling.
    • Management:
    • Use of RICE, NSAIDs, routine Achilles stretching, and potentially larger shoes.

INJURIES TO METATARSAL REGION

  • Tarsometatarsal Fracture Dislocation (Lisfranc Injury):

    • Etiology:
    • Hyperplantarflexion resulting in dorsal displacement of metatarsal bases.
    • Signs & Symptoms:
    • Pain, inability to bear weight, localized swelling.
    • Management:
    • Early recognition is critical; may require open reduction with fixation.

  • Pes Planus Foot (Flatfoot):

    • Etiology:
    • Related to excessive pronation, tight shoes, being overweight, or excessive exercise.
    • Signs & Symptoms:
    • Pain or weakness in the medial longitudinal arch; visible bulging of navicular.

  • Management:

    • If asymptomatic, no corrective action is necessary; otherwise, orthotics can be prescribed.

  • Pes Cavus (High Arch Foot):

    • Etiology:
    • Associated with excessive supination, abnormal arch height.
    • Signs & Symptoms:
    • Poor shock absorption, metatarsalgia, claw or hammer toes.
    • Management:
    • Similarly, if asymptomatic, no correction; otherwise, orthotics recommended.

  • Plantar Fasciitis:

    • Etiology:
    • Related to heel spurs, plantar fascia irritation; common in athletes.
    • Signs & Symptoms:
    • Pain in the proximal arch and heel; worse in the mornings or after long periods of standing.
    • Management:
    • Extended treatment (8-12 weeks) involving orthotics, stretching, NSAIDs, possibly injections.

FRACTURES AND DEFORMITIES

  • Jones Fracture:
    • Etiology:
    • Occurs due to direct force or repetitive stress on the base of the 5th metatarsal.
    • Signs & Symptoms:
    • Swelling, pain, high nonunion rate.
    • Management:
    • Crutches and gradual weight bearing; may require internal fixation if nonunion occurs.
  • Bunion (Hallux Valgus Deformity):
    • Etiology:
    • Caused by exostosis, inflammation of the bursa.
    • Signs & Symptoms:
    • Tenderness, swelling, and joint enlargement.
    • Management:
    • Correct shoe fitting, orthotics, and possible bunionectomy.

FUNCTIONAL FOOT REHABILITATION

  • General Body Conditioning:
    • Implement alternative conditioning methods during non-weight bearing periods; pool running, ergometer.
  • Weight Bearing Guidance:
    • Crutch walking if necessary; progression to full weight bearing as tolerated.
  • Flexibility Maintenance:
    • Essential to maintain normal foot flexibility, particularly stretching the plantar fascia and Achilles.
  • Strengthening Exercises:
    • Incorporate exercises like writing the alphabet with toes, towel gathering, and ankle circumduction.
  • Neuromuscular Control:
    • Re-establish control and proprioception to maintain balance during movement.
  • Focusing on Closed Kinetic Chain Activities:
    • Integrate walking, running, and jumping on various surfaces during rehabilitation.