The Foot - Comprehensive Notes

Key Concepts

  • Know the function and anatomy of the foot: important muscles, bones, joints, ligaments, vascular supply, aches and tendons/fascia.

  • Know the biomechanics of the foot/ankle and how it relates to gait and the phases of walking/running.

  • Jones Fracture: know the characteristics, etiology, signs, symptoms and management.

  • Pes Cavus vs Planus: know the associations, presentation and treatment

  • Know when do try to correct foot issues due to flat feet or high arch

  • Plantar Fasciitis: know the characteristics, etiology, signs, symptoms and management.

  • Sever’s disease: know the characteristics, etiology, signs, symptoms and management.

  • Turf Toe: know the characteristics, etiology, signs, symptoms and management.

  • Know the general guidelines for prevention of foot injuries

  • Taping: know the KT plantar fasciitis vs athletic taping (low dye)

  • Taping: know features and names of other arch taping

  • Turf toe taping: know the features and why it’s used

  • Prevention: flexibility and strengthening recommendations

  • Know the importance and features of short foot exercise

  • Know the details of neuromuscular control for the foot

  • Know what should be included in rehab plan of foot injuries.

Introduction: Foot

  • Complex system which consists of 28 bones, 33 joints, 112 ligaments and controlled by over 30 muscles.

  • Functions of the foot:

    • Act as a shock absorber to dissipate the ground reaction forces.

    • Adapts to uneven surfaces

    • Provides traction for movement

    • Provides awareness of joint and body position for balance (proprioception)

    • Rigid lever for propulsion in all directions.

  • Forces created by movements of the foot to the ground place a great deal of stress on the structures of the foot.

  • Critical in walking, running, jumping and changing direction.

Anatomy: Bones in the Foot

  • 26 bones: 14 phalangeal, 5 metatarsal, and 7 tarsal.

  • The toes are designed to give a wider base both for balance and for propelling the body forward.

  • The first metatarsal is the largest and strongest and functions as the main weight-bearing support during walking and running.

  • 7 tarsal bones: calcaneus, talus, navicular, cuboid, and first, second, and third cuneiform bones.

  • Calcaneus supports the talus and shapes the heel; its main functions are to convey the body weight to the ground and to serve as an attachment for both the Achilles tendon and several structures on the plantar surface of the foot.

Anatomy: Joints and Motion

  • Foot can be divided into 3 regions:

    • Hindfoot

      • Tibiofibular joint

      • Talocrural (Mortise)

        • Allows dorsiflexion/plantarflexion)

      • Subtalar joint (talus and calcaneus)

        • Allows inversion/eversion and dorsiflexion/plantarflexion

    • Midfoot

      • Tarsals

        • lock and unlock to allow supination and pronation

      • Tarsal/metatarsal joints are rigid

    • Forefoot allows flexion/extension and adduction/abduction

      • Tarsometatarsal Joints

      • Intermetatarsal Joint

      • Metatarsophalangeal Joints

      • Interphalangeal Joints

Arches of the Foot

  • 4 Arches:

    • Metatarsal Arch- runs from side to side along distal metatarsals

    • Transverse Arch-runs from side to side along tarsals

    • Longitudinal Arch- has medial and lateral divisions

  • Functions:

    • Assist the foot in supporting the body weight

    • Absorbing the shock of weight bearing

    • Provides a space on the plantar aspect of the foot for the blood vessels, nerves, and muscles.

  • There are many tape jobs to support the arches

Anatomy: Tendons and Fascia

  • Achilles Tendon

  • Plantar Fascia

    • Thick, white band of fibrous tissue along the plantar surface of the foot.

    • Along with ligaments, the plantar fascia supports the foot against downward forces.

  • There are over 100 other tendons in the foot which correlate with the muscles.

Biomechanics

  • It is the start of a long kinetic chain that goes up the leg to the ankle, knee and hip.

  • The foot moves in all three planes: coronal, sagittal, transverse.

  • Proper foot biomechanics is specifically important to reduce stress in the rest of the kinetic chain during gait.

  • Two phases in walking gait pattern:

    • Stance phase: starts with heel strike on the ground and ends with toe-off. 60% of gait is stance (weight bearing)

    • Swing phase: the time between toe-off and the subsequent initial contact 40% of gait is swing (non weight bearing)

  • Running and walking gait have same components

  • Difference is running gait has more rapid turn over and after toe-off, there is a period of no ground contact.

  • Initial heel strike while running (with proper biomechanics) involves contact on lateral aspect of foot

  • There is a transfer to pronation prior to toe off.

  • 80% of runners follow heel-strike pattern

  • Sprinters tend to be forefoot strikers

Common Sports Injuries

  • Acute (traumatic) injuries. (examples?)

    • Fractures, sprains, strains and ruptures.

  • Overuse injuries usually involve repetitive damage to soft tissues in the area but also include stress fractures. (examples?)

    • Tendonitis, bursitis, plantar fasciitis

  • Some soft-tissue damage can result in severe complications.

  • Foot problems are associated with improper footwear, poor hygiene, or anatomical structural deviations.

  • Providers must be aware of potential problems and be capable of identifying, treating and preventing them

Jones Fractures

  • Most common acute fracture is the “Jones Fracture” – Etiology

    • Fracture of base of 5th metatarsal, can be caused by inversion and plantar flexion; by direct force (stepped on); or repetitive stress

  • Sign and symptoms

    • Immediate swelling and pain over fifth metatarsal

    • Difficulty walking

  • Any bone in the foot can be acutely fractured (calcaneus, talus, phalanges)

Fractures: Jones – Management

  • RICE, PRICE, POLICE

  • Crutches and possible casting

  • Gradually progressing to weight bearing as pain subsides

  • May allow athlete to return in six weeks

  • Complication: If nonunion occurs, surgery may be required

  • Bone-growth stimulators have also been suggested

Pain Related to Foot Type

  • Pes Planus (Flatfoot)

    • Associated with excessive pronation (fallen arch) All feet are different and unless the foot type is causing pain or dysfunction, you do not try to correct the foot.

    • Presentation: pain and weakness in the longitudinal arch

    • Custom orthotics can help if there is pain or dysfunction

  • Pes Cavus (High arch foot)

    • Associated with excessive supination (very high arch)

    • Presentation: poor shock absorption and will likely have large callus on ball and heel of foot

    • Custom orthotics can help if there is pain or dysfunction

    • Aggressive stretching of Achilles and plantar fascia

Plantar Fasciitis

  • Overuse/cumulative type injury

  • Attributed to heel spurs, plantar fascia irritation, and bursitis

  • Catchall term used for pain in proximal arch and heel

  • Plantar fascia is a dense, broad band of connective tissue attaching to the medial/plantar surface of the calcaneus and fans out over the plantar aspect of the foot

  • Works in maintaining stability of the foot and bracing the longitudinal arch

  • Etiology

    • Increased tension and stress on fascia (particularly during push-off of running phase)

    • Sudden change in footwear from rigid to flexible.

    • Poor running technique (heel striking and over pronation)

    • Other factors include flat feet, inflexible longitudinal arch, and tight gastrocnemius-soleus complex

  • Sign and symptoms

    • Pain in arch and plantar surface of calcaneus

    • Increased pain in morning (getting out of bed), lessens after first few steps

    • Relieved by rest (non weight bearing)

  • Management

    • Must discover the cause and try to correct it.

    • Extended treatment (8–12 weeks)

    • Modalities such as laser, ultrasound and shockwave help speed healing.

    • Orthotics (insoles) are very useful (soft orthotic with deep heel cup)

    • There are taping techniques that can provide support: KT and athletic tape

    • *Using night splint to maintain a position of static stretch

    • Vigorous Achilles tendon stretching and exercises that increase great toe dorsiflexion

Sever’s Disease

  • Occurs at the attachment point of the Achilles tendon to the calcaneus (heel)

  • Etiology: Push and pull stresses place tension on the attachment point especially with running/sprinting

  • Due to an immature skeleton, the tissue cannot handle the tension.

  • Signs and Symptoms: heel pain in youth

  • Pinching the athlete on both sides of heel will cause pain due to growth plate irritation

  • Generally, it improves as the bone matures

  • Treatment: PRICE plus a walking boot, heel cups or custom orthotics. Refer to physician

  • Calf stretching once the pain goes away

  • No sports specialization

  • Overuse injury at the apophysis in youth athletes especially soccer (what is the apophysis?)

Turf Toe

  • Great toe hyperextension (turf toe)

    • Can be an acute or overuse type injury

  • Etiology

    • Hyperextension injury resulting in sprain of first metatarsophalangeal joint

    • Damage occurs to the plantar surface

  • Signs and symptoms

    • Pain and swelling, which increases during push off in walking, running, and jumping

    • Bruising

    • Altered gait (walking) pattern

  • Management

    • Rest and Ice (C and E not necessary)

    • Increase rigidity of forefoot region in shoe

    • Flat insoles with thin sheets of steel

    • Taping or brace the toe to prevent dorsiflexion

    • Ultrasound or other modalities
      Tape is used to prevent hyperextension of the Big Toe

Plantar Fasciitis: KT Taping

  • Position ankle in full dorsiflexion

    • Anchor: Adhere two inches of the first half strip with no stretch on the outside of the foot, just ahead of the heel.

    • Apply: With a moderate stretch, apply the tape across the bottom of the foot, toward the inside of the ankle.

    • Finish: With two inches of tape remaining, lay the end down with no stretch.

    • Anchor: Repeat by anchoring the second half strip with no stretch just ahead of strip two.

    • Apply: With a moderate stretch, apply the tape directly over the point of pain.

    • Finish: With two inches of tape remaining, lay the end down with no stretch.

Plantar Fasciitis: Low Dye Taping

  • Low-dye taping technique is designed to off-load the plantar fascia and provide medial ankle arch support.

  • Start by splitting the tape in half so it’s ½”

    1. Anchor strip

    2. Start at anchor and loop around heel return starting point on anchor

    3. Repeat #2 four times and fan out

    4. Apply 3-4 closing anchor strips (full tape width) to cover bottom of foot

Arch Taping (for Longitudinal Arch)

  • Start by splitting the tape in half so it’s ½”

    1. Anchor strip

    2. Start at medial side of anchor, pull diagonally and loop around heel returning to lateral side of anchor

    3. Repeat #2 multiple times, slightly fanning out

    4. Apply finishing anchor to secure all tape ends.

Arch Taping: X Teardrop Arch and Forefoot Support for longitudinal arch support

  • Start by splitting the tape in half so it’s ½”

    1. Anchor strip

    2. Start at medial side of anchor, pull straight down and loop around heel returning to starting point

    3. Start at lateral side of anchor, pull straight down and loop around heel returning to starting point

    4. Repeat #2,3 multiple times

    5. Apply 2-3 (full width) strips to cover bottom of foot

Turf Toe Taping

  • Tape is used to prevent hyperextension of the Big Toe

  • Start by splitting the tape in half so it’s ½”

    1. Anchor strip around big toe

    2. Apply 2-3 anchor strips around base of foot

    3. Making sure toe is not extended, apply connecting strips from big to anchor to foot anchor

    4. Slightly fan out with the anchor to anchor strips

    5. Repeat 5

    6. Apply finishing anchor to big toe

    7. Apply finishing anchor to base of foot

Prevention of Foot Injuries

  • What are the big 3 keys???????

  • The combination of flexibility, strength and neuromuscular control of the foot and ankle are keys to preventing injury.

  • Flexibility

    • Must maintain or reestablish normal flexibility of the foot

    • Full range of motion is critical, ankle circles may help

    • Stretching of the plantar fasciitis and the gastrocnemius- soleus complex is very important for a number of conditions

Prevention of Foot Injuries

  • Strengthening

    • A number of closed chain exercises can be performed

      • Picking up objects

      • Gripping and spreading toes

      • Towel gathering

      • Towel scoop

Strengthening continued : Short Foot Exercises

  • Specific exercises to strengthen arch and small intrinsic foot muscles

  • Learn to “shrink” your arch without rolling the ankle or gripping with toes.

Prevention of Foot Injuries

  • Neuromuscular control (NMC) is key to preventing injuries

    • Critical to reestablish as it is the single most important element dictating movement strategies within the kinetic chain

    • Must be able to adapt to changing surfaces

    • The better your neuromuscular control is the more you will be protected from injury.

Prevention of Foot Injuries

  • Rehabilitation plans are focusing more on closed kinetic chain activities

  • Exercises should incorporate walking, running, and jumping in multiple planes and on multiple surfaces

Additional Ideas for Prevention of Foot Injuries

  • Injuries can be best prevented by

    • Gait analysis

    • Correcting biomechanical structural deficiencies through orthotics

    • Paying attention to hygiene

    • Selecting appropriate footwear, choose the best shoe for your foot type:

      • Neutral shoe for a “normal foot”

      • Cushioned neutral shoe for high arches

      • Stability/motion controlled shoe for flat feet