Foot & Toes Flashcards
What are the 2 functions of the foot?
- “Loose bag of bones”
~ loading
~ unlock
~ pronation - “Rigid lever”
~ Unloading
~ lock
~ supination
Rear foot bones
- Talus
- Calcaneus
Mid foot bones
- Navicular
- Cuneiforms
~ Medial (1)
~ Intermediate (2)
~ Lateral (3) - Cuboid
Forefoot & toes
- 5 metatarsals
- 14 phalanges
~ proximal
~ middle
~ distal
How does Functional Loading relate to gravity?
Succumbing to gravity, absorbing force, deceleration
Functional Unloading in regards to gravity…
Overcoming gravity, generating force, acceleration
What kind of muscle contraction is occurring during Loading/Pronation?
Eccentric
What kind of muscle contraction is occurring during Unloading/Supination?
Concentric
When describing motions…
we are describing what the distal bone is doing relative to the proximal bone
Subtalar Joint
- Articulation between talus & calcaneus
- Calcaneus relative to talus
- Classic movements: Inversion and Eversion
Loading; “Loose bag of bones”, Planes of Motion
STJ -
Frontal Plane: Eversion
Sagital Plane: Plantar Flexion —> Dorsiflexion
Transverse Plane: Abduction
MTJ -
Frontal Plane: Inversion
Sagital Plane: Dorsiflexion
Transverse Plane: Abduction
Unloading; “Rigid Lever”, Planes of Motion
STJ -
Frontal Plane: Inversion
Sagital Plane: Dorsiflexion —> Plantar Flexion
Transverse Plane: Adduction
MTJ -
Frontal Plane: Eversion
Sagital Plane: Plantar Flexion
Transverse Plane: Adduction
Midtarsal Joint
- Joins the rear foot to the mid foot
- 2 joints
~ Talonavicular: head of talus &
navicular
~ Calcaneocuboid: calcaneus & cuboid
Relationship between the STJ & MTJ in regards to loading & unloading
- Loading of the STJ (evert) causes the MTJ to unlock (“loose bag of bones”) & become hypermobile
- Unloading of the STJ (invert) causes the MTJ to lock (“rigid lever”) & become hypomoble
Poor Pronator
- STJ inverts instead of everts during loading
- STJ doesn’t load well causing the MTJ to not load well
Poor Supinator
- Excessive STJ eversion
- STJ loads excessively and may cause the MTJ to load excessively
Plantar Fascia
- Thick band of connective tissue
~ Originates from the medial calcaneal
tubercle
~ Inserts into the plantar surface of all
phalanges - Primary support for longitudinal arch
Plantar Fascia: Windlass Effect
- Extension of the toes at MTP joint during the propulsive phase of gait (functional unloading)
- Shortens the distance between the calcaneus and metatarsals to elevate the medial longitudinal arch and invert the calcaneus
Along with the windlass effect, what causes unloading to occur?
Concentric muscle contraction
Tarsometatarsal Joints, also known as…
- Lisfranc’s joint
- Joins the mid foot and the forefoot
~ Cuneiforms 1-3 & Cuboid
~ Metatarsal bones 1-5 - Motions
~ Dorsal and plantar glide (up & down)
Intermetatarsal Joints
- Proximal
~ Bases of the metatarsals - Distal
~ Heads of the metatarsals - Motions
~ Dorsal & plantar glide (up & down)
Metatarsophalangeal Joints
- Joins the metatarsals & toes
- Motions
~ Sagittal: flexion/extension
~ Frontal: Rotation
~ Transverse: abduction & adduction
Interphalangeal Joints
- Joins phalanges to toes
- 1 on the 1st digit (IP)
- 2 on the 2nd-5th digit (DIP & PIP)
- Motions
~ Flexion & extension
Intrinsic Muscles of the Foot
- Very small muscles grouped into four layers
- Superficial
- Middle
- Deep
- Interosseous
Superficial Muscle
Contains the primary toe abductors & secondary flexors
Middle Muscle
Contains the quadratus plantae which when contracted changes angle of pull for Flexor Digitorum Longus
Deep Muscle
Contains the secondary flexors of the 1st & 5th toes
Interosseous Muscle
Contains dorsal & plantar interossei
Extrinsic Muscles of the Foot
- Muscles that originate outside the foot in the lower leg and insert on the foot
- Flexor Hallucis Longus
- Flexor Digitorum Longus
- Extensor Hallucis Longus
- Extensor Digitorum Longus
- Peroneus Tertiaus
- Peroneus Brevis
- Peroneus Longus
- Tibialis Anterior
- Tibialis Posterior
When describing the “action” of muscles…
you’re describing what the muscle does in space.
- Artificial
- Open chain: distal segment is not fixed
- Less functional
- Classic
When describing the “function” of muscles…
you’re describing what the muscles do when the foot is on the ground
- Natural
- Closed chain: distal segment is fixed
- More functional
Foot Type: Pes Planus
- Decreased medial arch (pronation)
- Everted heel
- Abduction of forefoot
Foot Type: Pes Cavus
- Accentuated medial arch (supination)
- Inverted heel
- Adduction of forefoot
Test for Supple Pes Planus
- Tests the severity of arch angle
- Positive Test (Supple) = Medial Arch disappears/is not present when standing, but reappears when on tippy toes
- Negative Test (Rigid) = Medial Arch disappears/is not present when standing, but does not reappear when on tippy toes
Navicular Drop Test
- Measures starting and end point of navicular
- Confirms pronated foot position
- Positive = navicular drops more than 10 mm
During weight bearing inspection how should the patient be positioned anteriorly…
- Have them march in place
- Ensure hip & trunk are not rotated: this can affect the entire kinetic chain
~ Toes should slightly be pointed out
12-18 degrees (Ficks’s angle):
anything more or less is abnormal
Metatarsal Lengths
Index Plus (“Egyptian Foot”): 1st metatarsal longer than 2nd; most common
Index Minus (Morton’s Toe or “Greek Foot”): 1st metatarsal shorter than 2nd; second most common
Index Plus-Minus (“Squared Foot”): 1st metatarsal is equal to 2nd; least common
Toe Alignment Types
- Caused by shoes
Claw Toes: Flexion contracture at PIP & DIP w/ hyperextension at MTP
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Hammer Toes: Flexion contracture at PIP & hyperextension at MTP & DIP
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Mallet Toes: Flexion contracture at DIP
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Hallux Abducto Valgus (“Bunion”)
- 1st toe is in valgus position
- Caused by narrow shoes
- MTP joint is enlarged & hypomible
- Weight bears on medial side of foot
- Limited Windlass & Flexion/Extension
During weight bearing inspection posteriorly, what kinds of things should be noticed…
- Calf Musculature
~ Girth
~ Contour - Achilles Tendon
~ Lateral
~ Medial
~ Deformity - Calcaneus
~ Inverted
~ Everted
~ Neutral
~ Shape
> “pump bump”: bursitis
During weight bearing inspection lateraly, what kinds of things should be noticed…
- Lateral longitudinal arch
- Toe Alignment
- Skin abnormalities
During weight bearing inspection anteriorly, what kinds of things should be noticed…
- Arch
~ Pronated
~ Supinated
During non-weight bearing inspection how should the patient be positioned…
- Prone
~ Distal 1/3 leg off table
~ Figure 4 - Observe for skin abnormalities on sole
Transverse Metatarsal Arch
- Shaped by metatarsals & tarsals
- Normally concave along inferior surface of metatarsals
Medial Longitudinal Arch
- Made up of calcaneus, talus, navicular, 1st cuneiform, & 1st metatarsal
- Supported by calcaneonavicular ligament & plantar fascia
- Supported by tibialis anterior, tibialis posterior, & flexor hallucis longus
Lateral Longitudinal Arch
- Made up of calcaneus, cuboid, & 5th metatarsal
- Supported by plantar fascia
- Supported by peroneus longus, peroneus brevis, & peroneus tertius
How would you know a foot is normal/neutral?
- Rearfoot (calcaneus) is in line with the lower leg (achilles & calf)
- Forefoot (met heads) is parallel to rearfoot (calcaneus)
- Forefoot (met heads) are in line to each other
Structural Deformity: Rearfoot Varus
- Rearfoot is inverted while STJ is neutral
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Rearfoot Varus Compensation
This compensation would make which muscles unhappy?
- STJ needs to EVERT in order to get the calcaneus neutral
- Increases stress on structures that provide stability
- Cause unhappy Tibialis Anterior & Tibialis Posterior muscles
Structural Deformity: Forefoot Varus
- Forefoot is inverted relative to Rearfoot while STJ is neutral
↕️ ⚫️ ⚫️ ⚫️ ⚫️ ⚫️ ↕️ ———
Structural Deformity: Dorsiflexed 1st Ray
- 1st met head is higher (dorsiflexed) than other 4 while STJ is neutral
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Forefoot Varus & Dorsiflexed 1st Ray Compensation.
This compensation would make which muscles unhappy?
- STJ needs to EVERT in order to get Forefoot & 1st ray in neutral
- Increases stress on structures that provide stability
- If calcaneus unable to evert, foot will be more rigid because the MTJ would have to evert to compensate for STJ
- Cause unhappy Tibialis Anterior & Tibialis Posterior
Structural Deformity: Forefoot Valgus
- Forefoot is everted relative to Rearfoot while STJ is neutral
↕️ ⚫️ ⚫️ ⚫️ ⚫️ ⚫️ ↕️ ———
Structural Deformity: Plantarflexed 1st Ray
- 1st met head is lower (plantarflexed) than other 4 while STJ is neutral
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Forefoot Valgus & Plantarflexed 1st Ray Compensation
- MTJ needs to INVERT in order to get lateral portion of Forefoot on the ground
- OR - - STJ needs to INVERT/STAY INVERTED to to get lateral portion of Forefoot on the ground
~ Happens if there’s not enough MTJ
motion
~ Foot isn’t a good shock absorber
~ Muscles become shortened & more
prone to tendinitis - Increases stress on structures that provide stability
Why would someone take a pulse in the foot?
Dislocations can cause lack of blood flow to the foot
AROM Testing
- MTP Joint
~ Flexion: 35-45 degrees
~ Extension: 75-85 degrees - STJ
~ Inversion: 20 degrees
~ Eversion: 4-5 degrees
Neurological Assessment
- Lower Quarter Screen
- Tinel’s Sign
~ Tibial Nerve palpitation
~ Increased or new neurological
symptoms into heel & plantar aspect
of foot
Normal/Neutral Foot: Rearfoot, Arch, & Forefoot positions
Rearfoot: Vertical
Arch: Normal
Forefoot: Straight
Pronated Foot: Rearfoot, Arch, & Forefoot positions
Rearfoot: Everted
Arch: Flat
Forefoot: Abducted
Supinated Foot: Rearfoot, Arch, & Forefoot positions
Rearfoot: Inverted
Arch: High
Forefoot: Adducted
What are the common signs & symptoms for a fracture?
- Loss of function
- Deformity
- Point tenderness
Intermetatarsal Joint Ligaments
- Proximal & Distal
- Supported by Dorsal, Plantar, & Transverse Ligaments
- Resists dorsal & plantar glide
Intermetatarsal Glide Test
- Positive test indicated by “pain” & increased glide compared to opposite foot
Metatarsalphalangeal & Interphalangeal Joint Ligaments
- Supported by collateral ligaments
- Resists Varus (adduction) & Valgus (abduction)
MTP & IP (Valgus & Varus) Testing
- Positive test indicated by increased Varus or Valgus compared to opposite foot
Which way does Varus & Valgus stretch ligaments?
Varus: Laterally
Valgus: Medially
Tarsometatarsal Joint Ligaments
- Supported by dorsal & plantar ligaments
- Resists dorsal & plantar gliding
Tarsometatarsal Glide Test
- Positive test indicated by “pain” & increased glide compared to opposite foot
Talus Fracture
- Usually not a gross fracture, but instead a fragment or chip in the dome of Talus
- Cause:
~ Forceful inversion, eversion, or
rotation; forces dome of Talus into
Ankle mortise (Tibia & Fibula) - Signs & Symptoms:
~ Pain when weight bearing
~ “Catching” or “snapping”
~ Tenderness with palpitation - Management:
~ Very important to pay attention to
complaints
~ Difficult to find on X-Ray
~ Self limiting
~ No cast; can make it worse or stiff and
can take to long to RTP
Sever’s Disease or Apophysitis of the Calcaneus
- Inflammation of the attachment of Achilles to Calcaneus
- Common in children
- Cause:
~ Excess stress or tension - Signs & Symptoms:
~ Pain just below attachment
~ Swelling over attachment - Management:
~ RICE
~ Stretching
~ Heel lift: causes plantarflexion
(shortening of Achilles)
Apophy means…
Tendon attachment to bone
Retrocalcaneal Bursitis or “Pump Bump”
- Inflammation of bursa between Achilles and Calcaneus
- Cause:
~ Pressure from heel counter of shoe
~ Tight calf/tendon
~ Excess friction - Signs & Symptoms:
~ Pain with activity & palpitation
~ Swelling - Management:
~ RICE
~ Stretching
~ Heel lift: reduces strain on tendon &
bursa; distributes pressure of bursa
~ Donut heel pad
~ Change of shoes
Cuboid Subluxation
- Cuboid displaces in plantar direction
- Cause:
~ Abnormal foot type that keeps foot
pronated too long or too much
~ Trauma to lateral side of foot
~ Stairs - Signs & Symptoms:
~ Pain along 4th & 5th metatarsals &
over Cuboid
~ Possible referred pain on heel: lateral
or medial - Management:
~ Manipulation
~ Correct abnormal foot mechanics
Tarsal Tunnel Syndrome
- Tarsal tunnel is formed by the medial malleolus and flexor retinaculum
- Contains:
~ Tibialis Posterior, Flexor Digitorum, &
Flexor Hallucis Longus Tendons
~ Tibial artery, vein, & nerve - Cause:
~ Any event or condition that causes
compression of structures (Tibial
Nerve) inside tunnel
> Mechanical
> Inflammatory - Signs & Symptoms:
~ Pain & paresthesia into plantar side of
foot - Management:
~ Control inflammation; prevent further
inflammation
~ May need surgery to cut connective
tissue to allow for more space for
structures
Tinel’s Sign
- Tap behind malleolus
- Positive test indicated by worsening pain or paresthesia
Lisfranc Injury
- Dorsal dislocation of the base of metatarsal
~ Typically seen in 1st or 2nd metatarsal
~ Fracture often occurs - Cause:
~ Hyper-planterflextion of Forefoot with
axial load (foot on ball & force comes
from top) - Management:
~ Identify & fixate bones
~ Casting may not be effective (foot
stays in bad alignment) , but instead
screws & plates will
~ Surgery may be best option
Arch Strains
- Strain of the INTRINSIC muscles of the foot
- Cause:
~ Increased/excessive loading
~ Abnormal foot type - Signs & Symptoms:
~ Pain during weight bearing
~ Pain below Tibialis Posterior Tendon
~ Pain in metatarsal region - Management:
~ RICE
~ Arch Taping
~ Orthotic Device/Pad: can cause more
pain in early stages
Plantar Fasciitis
- Inflammation of plantar fascia
- Cause:
~ Change in footwear
~ Change in activity
~ Abnormal foot type
~ Leg length discrepancy: shorter legs
needs to compensate causing poor
mechanics affecting the kinetic chain
~ Calf tightness: pulls on plantar fascia - Signs & Symptoms:
~ Pain in anterior & medial heel
~ Pain in fascia
~ Increased pain in the morning or after
long periods of sitting
~ Increased pain when toes & ankle are
Dorsiflexed/extended - Management:
~ Identify cause and correct it
~ Shoe insert/pad for abnormal foot
type
~ Add height to shoe for leg length
discrepancies
~ Support & increased flexibility in calf
If a patient doesn’t display the common signs & symptoms of a fracture, you should follow the…
Ottawa Rules
- Used to determine if a fracture is present or not and if a patient should be referred for an X-Ray
- Areas to assess
~ Lateral & Medial Malleolus to 6cm
proximally
~ Over Navicular
~ Base of 5th metatarsal
~ Inability to weight bear or take 4 steps
Jones Fracture
- Fracture to the base of 5th Metatarsal
- Cause:
~ Forceful inversion
~ Direct blow - Signs & symptoms:
~ Swelling
~ Point tenderness
~ Complaints of lateral pain & ankle
sprain: palpate 5th metatarsal - Management:
~ Refer
~ Fixate with screws & plates - Not every fracture to the 5th metatarsal is a Jones Fracture, it needs to be at the base
Sesamoiditis
- Inflammation is the Sesamoids of great toe
- Cause:
~ Excessive loading
~ Repetitive hyperextension of great toe - Signs & symptoms
~ Pain under 1st metatarsal head
~ Compensation will occur by weight
bearing on lateral side - Management:
~ RICE
~ Pads & supports to take stress off
Sesamoids
> needs to be placed behind Met
heads to alleviate pressure
Turf Toe
- Sprain of 1st Metatarsal Phalangeal Joint
- Cause:
~ Excess 1st MTP dorsiflexion/extension:
(plantar side) more common
~ Excess 1st MTP plantarflexion/flexion:
(dorsi side) - Signs & symptoms:
~ Pain
~ Swelling
~ Unable to properly push off during
gait - Management:
~ RICE
~ Prevent excess movement (temporary)
> Tape, Splint, & Heel Inserts
• Limits motion affecting Windlass
Intermetatarsal (Interdigital) Neuroma
- Entrapment of the interdigital nerve between the met heads
- Cause:
~ Morton’s Toe or foot: Valgus of 2nd
toe
~ Foortwear
~ Foot mechanics - Signs & symptoms:
~ Pain & paresthesia on adjacent toes
that may radiate up leg
~ Compression may reproduce pain and
result in a click sound called Mulder’s
Click (scar tissue)
Morton’s Neuroma
Nerve entrapment between 3rd & 4th metatarsals
Heel Spur
Bony outgrowth at medial Calcaneal Tubercle (exostosis)
- Cause:
~ Excessive pulling of plantar fascia or
Achilles
March Fracture
Stress fracture
Styloid Fracture of 5th Metatarsal
Avulsion fracture at peroneus brevis attachment
