Foot Complex Flashcards
Common Deformities:
Clubfoot
- Congenital deformity resulting in an unusual twisted position of the foot (typically inwards & upwards)
- Etiology is unknown, may involve multifactorial genetic & environemnt cayses
One cause is thought to be due to intauterine malposture (posutral clubfoot) - Flexible Type: able to move footback into “normal” position - serial casting - progressive INC ROM to normal
- Rigid Type: Complicated surgery - tendon relocation/ soft tissue/ bony
Most common form is Congenital Talipes Equinovarus (CTEV)
- Ankle: PF
- Rearfoot: Varus
- Midfoot: Adduction, supination
Inverted, PF position > walking on lateral borders of their feet & heels are off the ground
Common Deformities: Pes Cavus
(2)
- Longitudinal arches are accentuated w/ abnormally short mm on the sole of the foot > may lead to lateral arch abnormalities
- Leads to rigid foot w/ poor ability to adapt to stress & absorb shock
Can lead to shin splints OR plantar fasicosis - stress # @ heel = poor shock absorption > forces need to go somewhere & structures will give elsewhere
Common Deformities: Pes Planus
(2)
- Medial longitudinal arch is reduced
- Relatively common & often causes no problems - frequently blamed
Everybody has a flat foot until they are 2 yo - begin to develop arch when walking
Tx: Tape an arch onto foot to see if it impacts pain
- orthotics
- lifts
Common Deformities: Hallux Rigidus (Limitus)
(2)
- Extension of great toe is limited
- Due to OA of 1st MTP joint
Common Deformities: Hallux Valgus
(3)
- Great toe deviated towards center of the foot (MT head deviates medial)
- Common causees include tight pointed shoes & hereditary factors (common in women d/t heels & tight shoe boxes)
- Medial side of MT head develops callus, thickended bursa, and exostosis = bunion
Tx:
- Toe wedge - helps hold it out of valgus position
- Proper footwear
- Mobilization
- Intrinsic foot mm strengthen
Common Deformities: Toes
(3)
Claw Toe:
- Hyperextension of MTP & flexion of PIP/DIP
- Callus under MTP (plantar side) d/t lots of pressure - more contact with bottom of foot
Hammer Toe:
- Extension of MTP & flexion of PIP (DIP may be flexed, neutral, or extended)
- Area of pressure: Top of PIP joint
Mallet Toe:
- Flexion of DIP
- Area of pressure: Top of DIP joint & tip of toe
BE AWARE of the areas of pressure
Plantar Fasciosis
Plantar Fascia = a band of connective tissue that runs from the medial tibercle of the calcaeous to the head of the metatarsals
Plantar Fasciosis = an overuse injury of the plantar fascia which results in pain at its attachment at the calcaneus
Plantar Fasciosis: Etiology
(Risk Factors)
(8)
Pes Planus
- INC strain on plantar fascia, especially at calcaneous as it tires to maintain a stable arch at heel/ toe-off > taking an already stretched fascia & now putting more stress on it w/ great toe extension > stretching it even more > excessive load it may not be prepared for > irritate it
Pes Cavus
- Poor at shock absorption - adapted to become shorter & thicker > INC stress going into toe off > fascia is getting stretched > tight fascia you are pulling against - may lead to some degeneration
Excessive walking or running
- Capacity < load
Prolonged weight-bearing activities
- Loaded position for a long time
Obesity
- Excessive load
DEC Ankle dorsiflexion
- Compensate to get push off > often will pronate > stretch or hyper mobility in great toe EXT
Tight calf muscles
- Same mechanism as DEC ankle DF
Non-supportive footwear
- Especially w/ pes planus
Plantar Fasciosis:
Special Test
1
Windlass
Patient stands on stool w/ toe sticking off edge & PT puts great toe into EXT
Could just have patient stand on floor
(+) = pain in insertion of plantar fascia on calcaneus
WINDLASS MECHANISM =
Toe-off > big toe goes into EXT > plantar fascia tightens > brings all the bones of the foot into a congruent position = strong strcutral position > attentuates & lifts arch > creates a rigid foot > now foot is ready for PUSH-OFF
Plantar Fasciosis:
S/S
(5)
- Insidious onet (likely not traumatic)
- WORSE in the morning & may decrease w/ activity - HALLMARK
- Increase pain when activity is recommenced after period of inactivity (inactive & foot mm have relaxed & shortened & then walking stretches & irritates fascia)
- Tenderness on medial calcaneal tubercle which may extend into medial longitudinal arch
- May present with antalgic gait
May NOT do TOE OFF - painful but more likely toe off in TRUE plantar or heelstrike
Plantar Fasciosis:
Interventions
PT Management:
- Activity modification
- Soft tissue mobilization (plantar fascia & calf)
- Stretching (plantar fascia & calf)
- Strengthening (instrinsic foot mm)
Help support the medial longitudinal arch so there is less stress through plantar fascia
-Taping - helps accenuate arch - rigid tape (KIN tape will not work)
- Orthotics, insoles, heel pads - help cushion the heel
- Night splints / Strassberg sock - DF position over night - stretch (will not shorten overnight = less sensitive in the morning)
- Cryotherapy
- Iontophoresis (not used in canada)
Driven tropical medication through the skin via electrical current (looks like a TENS machine w/ pads but they have medication on them)
- Extracorpeal Shock Wave Therapy (ESWT) - mixed results
Medical Management:
- NSAIDS
- Corticosteriod injection
another use: if fascosis is so bad - CHRONIC & nothing works - some ppl get repeated injections into heel > can help dec strength/ weaken connective tissue > actually trying to weaken & blow out/snap PF & disconnect it = no pain as a result
- Plantar fasciotomy
Plantar Fasciosis:
DDx
(3)
Fat pad contusion
- More common in ppl w/ fat pad atrophy - lack of cushion
- PAIN: posterior-lateral (compared to PF which is medial)
- MOI: bruise - high impact on heel or excessive heel strike
- Tx: offload & cushion (get gel pads)
Calcaneal Stress Fracture:
- More common in someone w/ PES CAVUS - every heel stroke/contact = PAIN
Ie military - onfantry population
- TX: similar to tibial stress #
Lateral Plantar nerve entrapment (extension of posterior tibial nerve)
- 1st branch of lateral nerve is associated with heel pain
- Not going to present as a typical neuropathy - sensation wont tell you anything - not typical
- SLR may help with differential Dx
Morton’s Neuroma
Description & Etiology (4)
Thickening of fibrous tissue leading to entrapment of digital nerve of the foot
- Usually, the digital nerve of 3rd & 4th tpes (between metatarsals of these two)
- Also known as Mortons’ metatarsalgia or interdigital neuroma
Etiology (RF):
Essentially things that are compressing the metatarsal heads together OR areas the nerves may be
1. Narrow shoes
2. High heels - MTP extension- DEC transverse arch - that noramlly INC space in b/t BUT big toe EXT = MT heads are dropping down & DEC arch
3. Metatarsal injury - inflammation or # cause ossication = encoarches into the area where the nerve is
4. Dropped transverse arch - makes MT closer together - lose psace b/t MT
Morton’s Neuroma:
Special Test
1
Morton’s Test
Push sides of foot together (medial - lateral pressure) “compressing” these areas
(+) = reproduction of pain or S/S
Morton’s Neuroma:
S/S
(3)
- Pain between MT heads
- May have associated paresthesia
- Wrose w/ walking (especially PUSH off > MTP extention > dropping of arch), running, and w/ high heeled or narrow shoes (compression of MT heads)
