Foot Flashcards
What are the three regions of the foot?
hindfoot
mid foot
forefoot
Describe the structure of the hindfoot
- composed of the calcaneus and talus
- 1/2 body weight is transferred into the calcaneus.
- calcaneus largest of tarsal bones.
- well suite to accept impact of the heel striking the ground during walking.
- articulate with other tarsal bones on its anterior and dorsal surfaces.
- with the subtler joint articulated, the sulk of the calcaneus and talus form a canal within the subtler joint, known as the tarsal sinus.
Talus:
- provide smooth articular surface for the talocrural joint.
- no muscle attachment to the talus.
- rounded dome: convex posteriorly and slightly concave medial laterally.
- its three articular facets form the subtalar joint.
- sustentaculum tali – shelf-like projection on posteromedial calcaneus for the attachment of flexor hallucis longus
- Achilles tendon attaches to the calcanea tuberosity, a fibroelastic fat pad cushions the heel when weight bearing
- Anteriorly the calcaneus articulates with the cuboid bone
- Hard to heal due to no blood supply.
Describe the mid foot:
- 5 of the 7 tarsal bones arranged in two rows
- cuboid in both rows
- proximal row: navicula medially, cuboid laterally
- distal row: three cuneiforms medially, cuboid laterally
- tarsometatarsophalangeal joints form the boundary between the midfoot and the forefoot.
- cuneiform bones articulate with the 1st, 2nd, 3rd metatarsals. Contribute to the transverse arch of the foot accounting, in part, for the transverse convexity of the dorsal aspect of the midfoot.
- cuboid articulates with the 4th and 5th metatarsals
- tibialis posterior attaches to the tuberosity on the medial surface of the navicula bone
no muscles attach to the cuboid; but peroneus tendon crosses cuboid tuberosity
cuboid provides attachment for the long plantar ligament and the calcaneocuboid ligament - most common structure to sprain and fractures.
- involves in high impact running
Describe the forefoot:
5 metatarsals and phalanges
1st metatarsal bone thicker than the other metatarsals (bears more weight, important in push-off phase of gait)
1st metatarsal provides attachments for tibialis anterior and peroneus longus
2 sesamoid bones located in the flexor hallucis brevis tendon on plantar surface
Peroneus brevis tendon attaches to lateral side of the 5th metatarsal
Several ligaments connect the metatarsophalangeal joints and the interphalangeal joints
Describe the movements of the joints of the foot:
The interphalangeal and metatarsophalangeal joints plantarflex and dorsiflex
Abduction and adduction of the toes are functions of metatarsophalangeal joints
All the joints in the hindfoot and midfoot from the subtalar joint to the tarsometatarsal joints contribute to inversion and eversion of the foot
Explain why the arches of the foot is important:
- important for weight bearing and propulsion
- usually developed by 12 or 13 years of age
- pliability to adapt to uneven surfaces is provided by the multiple bones and joints of the foot
- arches maintained by the irregular and interlocking shape of bone, supporting ligaments and muscles and tendons of the foot.
- Medial longitudinal arch: calcaneus, talus, navicular, cuneiform bones and first three metatarsal
- Lateral longitudinal arch: calcaneus, cuboid, fourth and fifth metatarsals.
- Transverse arch: wedge-shaped cuneiforms, cuboid and bases of the five metatarsal bones
- remember as a clinical purpose, the lateral arches can affect T2-3 and rib 2-3 and vice versa. Cuboid change the ground reaction force and the lateral arches can change gravitation pattern.
- in addition perform cerebellum testing, for proprioceptions, and disruption of foot mechanics. cerebellum has 50% of the brain neurons.
Define fascia and its importance in the foot:
Fascia is internal connective tissue that wraps around organs, providing support and holding parts together. It has the appearance of a very thin spider web, connecting layers of muscle and surrounding all internal body tissues.
When in a normal, healthy state, fascia is somewhat relaxed and wavy, much like a gentle yet supportive hug. The elasticity of fascia is due to many interlocking collagen fibers, or strands of proteins.
Deep fascia of the foot forms the plantar fascia (extends from tuberosity of calcaneus to metatarsal heads) Plantar fascia (aponeurosis) encloses the foot flexor tendons; supports longitudinal arch of the foot
What are the muscles of the foot and their actions:
Intrinsic muscles
within the foot, responsible for movements of the toes, provide support for the arches of the foot
Extrinsic muscles
arise in lower leg, long tendons cross the ankle and insert into bones of the foot; responsible for movements of the ankle and toes; provide some support for the foot arches
What is the nerve supply of the foot:
Common peroneal nerve branches:
Deep peroneal nerve: tibialis anterior (L4, L5), extensor hallucis longus (L5) and extensor digitorum longus (L5)
Superficial peroneal nerve: peroneus longus and brevis (L5, S1)
Tibial nerve: gastrocnemius (S1, S2), soleus (S1, S2), flexor hallucis longus (L5), flexor digitorum longus (L5) and tibialis posterior (L5)
Medial plantar nerve: abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, first lumbrical
Lateral plantar nerve: quadratus plantae, flexor digiti minimi, adductor hallucis, interossei, three lumbricals, abductor digit minimi
What is the blood supply of the foot:
Dorsalis pedis artery, lateral tarsal artery, dorsal metatarsal and digital arteries, lateral plantar artery, medial plantar artery.
What are the special test for the foot:
Morton tests.
Palpation
Named the red flags for the foot:
- Fracture / dislocation
- infection
- peripheral arterial occlusive disease
- DVT
- Cellutitis
What are the commons conditions of the foot:
Congental Pes planus Pes cavus Ankle pronation Hallux valgus Hallux rigidus Claw toes Hammer toes Morton’s foot Plantar fasciitis Morton’s neuroma Metatarsalgia
PES PLANUS
absent or reduced medial longitudinal arch of the foot
talus displaces medially and towards the plantar surface of the foot
approximately 33% of adults
Management
includes wearing shoes with shock absorbing shoes
strengthening intrinsic muscles of the foot (e.g. picking up objects with toes)
Lower limb muscle rehab (e.g. strengthening quadriceps and hamstrings)
stretching gastrocnemius and soleus
referral for orthotics
PES CAVUS
Abnormally high arches often associated with claw toes approximately 20% of adults foot is rigid and absorbs shock poorly may cause knee, hip and low back pain
Management
includes mobilisation and manipulation of the foot
shock-absorbing shoes
stretches to gastrocnemius, plantar fascia and toe flexors
ANKLE PRONATION
Medial deviation of Achilles
tendon suggests ankle pronation
Pronation syndrome accounts for approximately 90% of all soft tissue injuries treated by podiatrists
Management directed to correction of underlying causes (e.g. hindfoot varus, genu varum and valgus, gastrocnemius and soleus contracture, hallux valgus, leg length discrepancy and spinal or pelvis asymmetry)
HALLUX VALGUS
abduction of the 1st metatarsal and adduction of the proximal phalanx of the hallux
often associated with bunion formation
Management includes padding, wide shoes with a low heel mobilisation and manipulation to abduct the big toe Night splints (in younger patients) Toe exercises to abduct hallux
HALLUX RIGIDUS
decreased dorsiflexion of the matatarsophalangeal joint of the hallux usually from degenerative arthritis altered gait (walks on outside of foot)
Management includes manipulation and mobilization (caution if spurs) referral for orthotics avoid flexible shoes
Claw toes
hyperextension of the metatarsophalangeal joint and hyperflexion of the proximal and distal interphalangeal joints
often accompanies pes cavus
Management includes
padding
appropriate shoes
manipulation and mobilisation of the foot and ankle
HAMMER TOES
hyperflexion of the proximal interphalangeal joint
some extension of the metatarsophalangeal joint, often at the 2nd toe
Management includes
Best prognosis when hammer toe treated in childhood
Later treatment includes padding, appropriate shoes, splinting, surgery
Manipulation and mobilisation
MORTON’S FOOT
2nd metatarsal is longer that the first (approximately 20% of the population)
associated with pronation-related injuries
Management
Advise to wear proper fitting shoes
Mobilisation and manipulation as needed
Muscle rehabilitation
PLANTAR FASCIITIS
the most common cause of painful feet
women > men
Associated with excessive pronation and lowered longitudinal arch or pes cavus
prolonged tensile stress on the periosteum may lead to the development of a bony spur
a spur may also develop in the insert of the Achilles tendon to the superior part of the calcaneus (dancer’s heel)
Tenderness over the medial aspect of heel and plantar fascia
Increased when first rising, decreased with activity tight Achilles tendon frequently associated
PLANTAR FASCIITIS
Management Osseous mobilisation and manipulation Achilles and plantar fascia stretching Heel pads, cushion and taping (e.g. tear drop taping) Acupuncture Night splints NSAIDs When acute, wear a shoe with a small heel (flat shoes aggravate symptoms)
MORTON NEUROMA
fusiform swelling on the interdigital nerve following chronic compression by the metatarsal heads, most commonly between the 3rd and 4th metatarsal heads
Women > men
Sharp shooting forefoot pain +/- numbness in the interdigital space distal to the neuroma
relieved by removing the shoe
Management
Shoes with soft sole, wide toe box with pad
Osseous mobilsation and manipulation
Acupuncture
METATARSALIGIA
Tenderness under the 2nd and 3rd (occasionally 3rd and 4th) metatarsal heads following collapse of the transverse metatarsal arch
callus often develops under the foot
chronic foot biomechanical dysfunction, changes in weight bearing from the heel and 1st metatarsal to the 2nd to 4th metatarsals
associated with prolonged standing on a hard surface, pes planus, pregnancy, hallux valgus, high-heeled shoes, pes cavus, short gastrocnemius and poor footwear
change of shoes, especially to a higher heel often triggers the condition
Tx: osseous mobilisation and manipulation as needed, footwear advice
