ANKLE&FOOT

Dr. TAREK NASRALA

AL AZHAR UNIVERSTY

Your Guide to Treating Foot Pain

Walking is the 2nd most common conscious function of our body next to breathing.

A person takes between

5,000 to 10,000 steps a day, depending on

their activity level.

When your feet hurt you are reminded with every step taken.

Eliminating foot pain is a challenge.

It’s pretty easy to rest your back, shoulder, arm, wrist or hand.

But to tell someone to stay off their foot, that’s not so easy.

Ankle and Foot Joints

Complex– 26 bones– ~ 30 joints– > 20 muscles

Simplification– Tarsals– Extrinsic muscles only– 9 joints

Ankle and Foot Joint Bones

Tibia Fibula Talus Calcaneus Tarsals (5) Metatarsals (5) Proximal phalanges (5) Middle phalanges (4) Distal phalanges (5)

Tibia

Fibula

Talus

Calcaneus

Tarsals

Metatarsals

Interosseus membrane

Proximal phalanges

Middle phalanges

Distal phalanges

Ankle and Foot Joints

Talocrural joint (ankle)– Uniaxial hinge

Subtalar joint– Gliding/nonaxial

Transverse tarsal joints– Gliding/nonaxial

Intertarsal joints– Gliding/nonaxial

Tarsometatarsal joints– Gliding/nonaxial

Metatarsophalangeal joints– Biaxial ball and socket

Proximal interphalangeal joints– Little toes – Uniaxial hinge

Distal interphalangeal joints– Little toes – Uniaxial hinge

Interphalangeal joint– Big toe – Uniaxial hinge

Talocrural joint

Subtalar joint

Plantar/dorsiflexion

Sagittal, ML axis

Eversion/inversion

Frontal plane AP axis

Transverse tarsal jointsIntertarsal joints

Tarsometatarsal joints

Metatarsophalangeal jointsProximal interphalangeal jointsDistal interphalangeal joints

Interphalangeal joint

Behind the trochlea is a posterior process with a medial and a lateral tubercle separated by a groove for the tendon of flexor hallucis longus.

Exceptionally, the lateral of these tubercles forms an independent bone called os trigonum or "accessory talus".

Plantar Fascia

Movements

When the body is in the erect position, the foot is at right angles to the leg

dorsiflexion consists in the approximation of the dorsum of the foot to the front of the leg, while in extension the heel is drawn up and the toes pointed downward

The range of movement varies in different individuals from about 50° to 90°

Ankle and Foot Joint Movements

Flexion/Extension– Talocrural joint (plantar/dorsiflexion)– Proximal interphalangeal joints– Distal interphalangeal joints– Interphalangeal joint– Metatarsophalangeal joints (Biaxial B+S)

Inversion/Eversion– Subtalar joint– Transverse tarsal joints

Abduction/Adduction/Circumduction– Metatarsophalangeal joints (Biaxial B+S)

Arches of the Foot

Basic Anatomy of the Foot and Ankle

Three Arches enable us to absorb forces– Transverse Arch

– Medial Longitudinal

Arch

– Lateral Longitudinal

Arch

The Three Arches Transverse Arch

– Goes across the width of the foot

– Comprised of the cuneiforms (all three), the cuboid, and the base of the fifth metatarsal.

The Three Arches Medial longitudinal arch The highest and most important arch in the

foot.

– Goes the length of the foot on the medial side.

– Comprised of the calcaneus, talus, navicular, cuneiforms and the first three metatarsals.

The Three Arches Lateral longitudinal arch The arch next to the medial one that is

flatter and lower.

– Goes the length of the foot on the lateral side.

– Comprised of the calcaneus, talus, cuboid, and the forth and fifth metatarsals.

Ligaments Medial Side

– Deltoid Ligament- support ligament

on medial side of

foot.– Spring Ligament-

AKA the Plantar Calcaneonavicular ligament.

Ligaments Lateral Side

– ATF-Anterior Talofibular Ligament

– CF-Calcaneofibular Ligament

– PTF-Posterior Talofibular Ligament

Assessing the Lower Leg and Ankle History

– Past history– Mechanism of injury– When does it hurt?– Type of, quality of, duration of pain?– Sounds or feelings?– How long were you disabled?– Swelling?– Previous treatments?

Observations– Postural deviations?– Genu valgum or varum?– Is there difficulty with walking?– Deformities, asymmetries or swelling?– Color and texture of skin, heat, redness?– Patient in obvious pain?– Is range of motion normal?

Palpation– Begin with bony landmarks and progress to

soft tissue– Attempt to locate areas of deformity, swelling

and localized tenderness

EXAMInspection.

Palpation.

Movements.

Special tests.

INSPECTION

1- ERECT POSITION.

2-SUPINE POSITION.

INSPECTION OF THE PATIENT’S GAIT:

Evaluation of the walking cycle

GAIT ANALYSIS

Gait cycleGait cycle

Heel strike

Foot flat

Toe off

Biomechanics of Normal Gait

• 2 phases: stance or support phase & swing or recovery phase

– Stance: initial contact at heel strike and ends at toe off

– Swing: time immediately after toe off, leg moved from behind body to a position in front of body in preparation of heel strike

Foot at stance phase

– Shock absorber to impact forces at heel strike and adapt to uneven surface

– At push off functions as rigid lever to transmit explosive force

– Lateral aspect of calcaneus with subtalar joint in supination to forefoot contact on medial surface of foot and subtalar joint pronation• Pronation distributes forces to many

structures

• Foot begins to re-supinate and returns subtalar joint to neutrally 70 to 90 % of support phase

• Foot becomes rigid and stable to allow greater amount of force at push off

Trendelenburg gait

Tip-toe walking

Foot drop walking

Spastic gait

Intoeing/Out toeng gait

Antalgic gait

SPECIAL PATHOLOGIES:

INTOING GAIT:

-Internal femoral torsion: exaggerated anteversion.

-Internal tibial torsion.

-Forefoot adduction.

Inspection in standing position

: POSTERIOR HEEL STANDING

FOOT SHAPE

ALL THE TOES SHOULD BE IN GROUND CONTACT IN W.B.(stability of the foot on the ground)

INSPECTION: of the L.L

Any asymmetry of length, rotational problem, or mal alignment of the lower limbs.

INSPECTION:

- Deformity, swelling, skin changes, muscle wasting, asymmetry of length, abnormal position….

INSPECT ALL ARROUND

INSPECTION:

PLANTAR SKIN

callosity

Palpation:

Bone and joints

Soft tissues

Anatomical landmarks:

-Medial malleolus, lateral malleolus, Achilles tendon, calcaneal tuberosity, peroneal tendon, tibialis posterior tendon, tibialis anterior tendon, plantar fascia, base of 5th metatarsal, 1st MP joint, metatarsal heads……..etc

Ankle Landmarks

PALPATION:

Tenderness, swelling, deformity….

Knowing the anatomy:

MOVEMENTS:

Ankle: -dorsiflection -plantarflection.

Subtalar: -inversion -eversion.

Midtarsal: -pronation -supination

Tarso-metatarsals: move the metatarsals one by one.

Toes:

Ankle movements:

MOVEMENT: SUBTALAR:

MOVE THE HEEL:

Inversion---eversion

Midtarsal supination

Move the metatarsals one by one

MOVEMENTS:

IMPORTANCE OF THE BIG TOE (running, jumping)

Problem of hallux rigidus

EXAMINATION OF THE SHOES

Special tests

• The anterior draw tests the ATFL

• Test should be done with the ankle in 10o-20o

plantar flexion

• Low loads

79

Test for the ATFL

MOB TCD

Percussion and compression tests• Used when fracture is suspected• Percussion test is a blow to the tibia, fibula or heel to create

vibratory force that resonates w/in fracture causing pain• Compression test involves compression of tibia and fibula

either above or below site of concern

Thompson test• Squeeze calf muscle, while foot is extended off table to test

the integrity of the Achilles tendon

Positive tests results in no movement in the foot

Homan’s test• Test for deep vein thrombophlebitis• With knee extended and foot off table, ankle is moved into

dorsiflexion

• Pain in calf is a positive sign and should be referred

Compression Test Percussion Test

Homan’s Test Thompson Test

• Ankle Stability Tests– Anterior drawer test

• Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarily

• A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point

– Talar tilt test• Performed to determine extent of inversion or eversion injuries• With foot at 90 degrees calcaneus is inverted and excessive motion indicates

injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments

• If the calcaneus is everted, the deltoid ligament is tested

Anterior Drawer Test Talar Tilt Test

Anterior Drawer Test

Talar Tilt TestBump Test

– Kleiger’s test• Used primarily to determine extent of damage to the deltoid ligament and

may be used to evaluate distal ankle syndesmosis, anterior/posterior tibiofibular ligaments and the interosseus membrane

• With lower leg stabilized, foot is rotated laterally to stress the deltoid

– Medial Subtalar Glide Test• Performed to determine presence of excessive medial translation of the

calcaneus on the talus• Talus is stabilized in subtalar neutral, while other hand glides the

calcaneus, medially• A positive test presents with excessive movement, indicating injury to

the lateral ligaments

Kleiger’s Test Medial Subtalar Glide Test

• Tinel’s Sign–Tap over posterior tibial nerve

–Positive test = tingling distal to area

–Indicates presence of tarsal tunnel syndrome

• Morton’s Test– Transverse pressure applied to heads of metatarsals – Positive test = pain in forefoot– Indicate presence of neuroma or metatarsalgia

Neurological Assessment

• Reflexes – Tendon reflexes should elicit a response – Achilles reflex should be assessed for the foot

• Sensation– Cutaneous distribution of nerves must be tested– Sensation can be tested by running hands over all

surfaces of foot and ankle

• Functional Tests

– While weight bearing the following should be performed

• Walk on toes (plantar flexion)

• Walk on heels (dorsiflexion)

• Hops on injured ankle

• Start and stop running

• Change direction rapidly

• Run figure eights

• Medial Tibial Stress Syndrome (Shin Splints)– Cause of Injury

• Pain in anterior portion of shin

• Stress fractures, muscle strains, chronic anterior compartment syndrome, periosteum irritation

• Caused by repetitive microtrauma

• Weak muscles, improper footwear, training errors, varus foot, tight heel cord, hypermobile or pronated feet and even forefoot supination can contribute to MTSS

• May also involve, stress fractures or exertional compartment syndrome

• Shin Splints (continued)– Signs of Injury

• Diffuse pain about distomedial aspect of lower leg• As condition worsens ambulation may be painful, morning pain and stiffness

may also increase• Can progress to stress fracture if not treated

– Care• Physician referral for X-rays and bone scan• Activity modification• Correction of abnormal biomechanics• Ice massage to reduce pain and inflammation• Flexibility program for gastroc-soleus complex• Arch taping and orthotics

• Shin Contusion– Cause of Injury

• Direct blow to lower leg (impacting periosteum anteriorly)

– Signs of Injury• Intense pain, rapidly forming hematoma w/ jelly like consistency• Increased warmth

– Care• RICE, NSAID’s and analgesics as needed• Maintaining compression for hematoma (which may need to aspirated) • Fit with doughnut pad and orthoplast shell for protection

• Compartment Syndrome– Cause of Injury

• Rare acute traumatic syndrome due to direct blow or excessive exercise

• May be classified as acute, acute exertional or chronic

– Signs of Injury • Excessive swelling compresses muscles, blood supply and

nerves• Deep aching pain and tightness is experienced• Weakness with foot and toe extension and occasionally

numbness in dorsal region of foot

Figure 15-20

– Care• If severe acute or chronic case, may present as medical

emergency that requires surgery to reduce pressure or release fascia

• NSAID’s and analgesics as needed Avoid use of compression wrap = increased pressure

• Surgical release is generally used in recurrent conditions– May require 2-4 month recovery (post surgery)

• Conservative management requires activity modification, icing and stretching

– Surgery is required if conservative management fails– Return to activity after surgery , light activity,10 days later

• Achilles Tendonitis– Cause of Injury

• Inflammatory condition involving tendon, sheath or paratenon• Tendon is overloaded due to extensive stress• Presents with gradual onset and worsens with continued use• Decreased flexibility exacerbates condition

– Signs of Injury• Generalized pain and stiffness, localized proximal to calcaneal

insertion, warmth and painful with palpation, as well as thickened

• May progress to morning stiffness

Achilles Tendinitis

Achilles TendinopathyAchilles Tendinopathy

Imaging Imaging

– Care• Resistant to quick resolution due to slow

healing nature of tendon

• Must reduce stress on tendon, address structural faults (orthotics, mechanics, flexibility)

• Aggressive stretching and use of heel lift may be beneficial

• Use of anti-inflammatory medications is suggested

• Achilles Tendon Rupture– Cause

• Occurs w/ sudden stop and go; forceful plantar flexion w/ knee moving into full extension

• Commonly seen in athletes > 30 years old

• Generally has history of chronic inflammation

– Signs of Injury• Sudden snap (kick in the leg) w/ immediate pain which rapidly

subsides

• Point tenderness, swelling, discoloration; decreased ROM

• Obvious indentation and positive Thompson test

Figure 15-20

Tendoachilles Rupture

Palpate the Tendon ProneRestingPosition

– Care• Usual management involves surgical repair for serious

injuries • Non-operative treatment consists of, NSAID’s,

analgesics, and a non-weight bearing cast for 6 weeks to allow for proper tendon healing

• Must work to regain normal range of motion followed by gradual and progressive strengthening program

Retrocalcaneal Bursitis (Pump Bump)Retrocalcaneal Bursitis (Pump Bump)

• Etiology– Caused by inflammation of

bursa beneath Achilles tendon

– Result of pressure and rubbing of shoe heel counter

– Chronic condition that develops over time

• May take extensive time to resolve

– Exostosis may also develop

• Signs and Symptoms– Pain with palpation

superior and anterior to Achilles insertion

– Swelling on both sides of the heel cord

Retrocalcaneal Bursitis (Pump Bump) cont.

• Management– RICE and NSAID’s used as needed– Ultrasound can reduce inflammation– Routine stretching of Achilles– Heel lifts to reduce stress– Donut pad to reduce pressure– Possibly invest in larger shoes with wider heel

contours

• Leg Cramps and Spasms(sudden, violent, involuntary contraction, either clonic (intermittent)

or tonic (sustained)– Etiology

• Difficult to determine; fatigue, loss of fluids, electrolyte imbalance, inadequate reciprocal muscle coordination

– Signs and Symptoms• Cramping with pain and contraction of calf muscle

– Management• Try to help athlete relax to relieve cramp• Firm grasp of cramping muscle with gentle stretching will relieve acute

spasm• Ice will also aid in reducing spasm• If recurrent may be fatigue or water/electrolyte imbalance

• Gastrocnemius Strain– Etiology

• Susceptible to strain near musculotendinous attachment• Caused by quick start or stop, jumping

– Signs and Symptoms• Depending on grade, variable amount of swelling, pain, muscle disability• May feel like being “hit in leg with a stick”• Edema, point tenderness and functional loss of strength

– Management• RICE, NSAID’s and analgesics as needed• Grade 1 should apply gentle stretch after cooling• Weight bearing as tolerated; heel wedge to reduce calf stretching while

walking• Gradual rehab program should be instituted

• Stress Fracture of Tibia or Fibula– Etiology

• Common overuse condition, particularly in those with structural and biomechanical insufficiencies

• Runners tends to develop in lower third of leg, dancers middle third

• Often occur in unconditioned, non-experienced individuals

• Often training errors are involved

• Component of female athlete triad

– Signs and Symptoms• Pain more intense after exercise than before

• Point tenderness; difficult to discern bone and soft tissue pain

• Bone scan results (stress fracture vs. periostitis)

Pes planus : common 20%

-GAIT: UGLY.

-INSPECTION STANDING: HEEL, ARCH, FOREFOOT.

-LIGAMENT LAXITY

-MOVE THE HEEL AND THE 1ST METATARSAL.

-EXAMIN THE TENDO ACHILLES

-May be asymptomatic

Pes cavusHigh arch

Varus

TARSAL COALSION:

Painful stiff flat foot

Usually bilateral, can be unilateral-Stiff subtalar.

MORE COMMON:calcaneo-navicular and subtalar.-Request CT scan

Plantar fascia– Dense, broad band of connective tissue attaching proximal and

medially on the calcaneus and fans out over the plantar aspect of the foot

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

Plantar Fasciitis– “Catch all” term used for pain in proximal arch and heel– Common in athletes and nonathletes– Attributed to heel spurs, plantar fascia irritation, and bursitis

Plantar Fasciitis

Etiology– Increased tension and stress on fascia

• Particularly during push off of running phase

– Change from rigid supportive footwear to flexible footwear

– Running on soft surfaces while wearing shoes with poor support

– Poor running technique

– Leg length discrepancy, excessive pronation, inflexible longitudinal arch, or tight gastroc-soleus complex

Plantar Fasciitis cont.

Plantar Fasciitis cont.

Signs and Symptoms– Pain in anterior medial heel and along medial

longitudinal arch– Increased pain in morning

• Plantar fascia loosens after first few steps thus decreasing pain

– Increased pain with forefoot dorsiflexion

Management– Extended treatment (8-12 weeks)– Orthotic therapy is very useful

• Soft orthotic with deep heel cup

– Simple arch taping– Night splint to stretch plantar fascia– Vigorous heel cord stretching – Exercises that increase great toe dorsiflexion– NSAID’s and occasionally steroidal injection

Plantar Fasciitis cont.

Longitudinal Arch StrainLongitudinal Arch Strain

Etiology– Early season injury due

to increased stress on arch

– Flattening of foot during midsupport phase causing strain on arch

– May appear suddenly or develop slowly

Sign and Symptoms– Pain with running and

jumping– Pain below posterior

tibialis tendon accompanied by swelling

– May also be associated with sprained calcaneonavicular ligament and flexor hallucis longus strain

Longitudinal Arch Strain cont.

Management– Immediate care is RICE

• Reduction of weight bearing

– Weight bearing must be pain free– Arch taping may be used to allow pain free

walking

Apophysitis of the CalcaneusApophysitis of the Calcaneus(Sever’s Disease)(Sever’s Disease)

Etiology– Traction injury at

apophysis of calcaneus• Where Achilles tendon

attaches to calcaneous

Signs and Symptoms– Pain occurs at posterior

heel below Achilles attachment

– Pain occurs during vigorous activity

– Pain ceases following activity

Apophysitis of the Calcaneus

(Sever’s Disease) cont. Management

– Best treated with ice, rest, stretching and NSAID’s

– Heel lift could also relieve some stress

Heel ContusionHeel Contusion

Etiology– Caused by sudden starts,

stops or changes of direction

– Irritation of fat pad

– Pain often on the lateral aspect due to heel strike pattern

Sign and Symptoms– Severe pain in heel

– Unable to withstand stress of weight bearing

– Often warmth and redness over the tender area

Heel Contusion cont.

Management– Reduce weight bearing for 24 hours– RICE and NSAID’s– Resume activity with heel cup or doughnut pad

after pain has subsided – Wear shock absorbent shoes

Etiology– Exostosis of 1st metatarsal head

– Associated with…• Forefoot varus

• Wearing shoes that are too narrow or too short

• Wearing shoes with pointed toes

– Bursa becomes inflamed and thickens• Enlarges the joint and causes lateral malalignment of the great toe

• Bunionette (Tailor’s bunion) – Impacts 5th metatarsophalangeal joint – Causes medial displacement of 5th toe

Bunion (Hallux Valgus Deformity)

Bunion (Hallux Valgus Deformity) cont.

Signs and Symptoms– Initially…

• Tenderness• Swelling• Enlargement of joint

– As inflammation continues…• Angulation of the joint increases • Painful ambulation

– Tendinitis in great toe flexors may develop

Management

– Early recognition and care is critical

– Wear correct fitting shoes

– Orthotics may be used

– Padding over 1st metatarsal head with a tape splint between 1st and 2nd toe may be used

– Exercises for flexor and extensor muscles

– Bunionectomy may be necessary

Bunion (Hallux Valgus Deformity) cont.

Hallux valgus

SesamoiditisSesamoiditis

Etiology– Caused by repetitive

hyperextension of the great toe

– Results in inflammation

Signs and Symptoms– Pain under great to

• Especially during push off

– Palpable tenderness under first metatarsal head

Sesamoiditis cont.

Management– Orthotics that include metatarsal pads, arch

supports, and metatarsal bars– Decrease activity to allow inflammation to

subside

Morton’s ToeMorton’s Toe

Etiology– Abnormally short 1st

metatarsal (great toe)• 2nd toe looks longer

– More weight bearing occurs on 2nd toe as a result and can impact gait

– Stress fracture could develop

Signs and Symptoms– Possible stress fracture– Pain during and after

activity with possible point tenderness

– Positive bone scan – Callus development

under 2nd metatarsal head

Morton’s Toe cont.

Management– If no signs and symptoms – “don’t fix what

isn’t broken” – If associated with structural forefoot varus,

orthotics with a medial wedge would be helpful

Etiology– Development of bone spurs on dorsal aspect of first

metatarsophalangeal joint • Results in impingement • Loss of active and passive dorsiflexion

– Degenerative arthritic process involving articular cartilage and synovitis

– If restricted, compensation occurs with foot rolling laterally

Hallux Rigidus

Hallux rigidus:

O.A 1st MPJ

Hallux Rigidus cont.

Signs and Symptoms– Forced dorsiflexion causes pain– Walking becomes awkward due to weight bearing on lateral

aspect of foot Management

– Stiffer shoe with large toe box– Orthotics to increase rigidity of forefoot region within the

shoe – NSAID’s– Surgery may be requires

• Osteotomy to remove mechanical obstructions in effort to return to normal functioning

Etiology– Hammer toe

• Flexion contracture of the PIP joint, which can become fixed

– Mallet toe • Flexion contracture of the DIP joint, which can become fixed

– Claw toe • Flexion contracture of the DIP joint with hyperextension at the MP

joint

– All may be caused by wearing short shoes over an extended period of time

Hammer Toe, Mallet Toe, or Claw Toe

Hammer Toe, Mallet Toe, or Claw Toe cont.

Signs and Symptoms– The MP, DIP, and PIP can all become fixed – Swelling– Pain– Callus formation – Occasionally infection

Management– Wear shoes with more room for toes– Use padding and taping to prevent irritation– Shave calluses– Once the contracture becomes fixed, surgery will

be required to correct

Hammer Toe, Mallet Toe, or Claw Toe cont.

Overlapping ToesOverlapping Toes

Etiology– May be congenital

– May be caused by wearing shoes that are too narrow

Signs and Symptoms– Outward projection of

great toe articulation

– Drop in longitudinal arch

Overlapping Toes cont.

Management– Hammer toe: surgery is the only cure– Some modalities, such as whirlpool baths can

assist in alleviating inflammation– Taping may prevent some of the contractual

tension within the sports shoe

MetatarsalgiaMetatarsalgia

Etiology– Decreased flexibility of

gastroc-soleus complex– Typically emphasizes toe

off phase during gait– Fallen metatarsal arch

• Pes Cavus

Signs and Symptoms– Pain in ball of foot

• In the area of the 2nd and 3rd metatarsal heads

– Flattened transverse arch

– Depressing 2nd, 3rd, and 4th metatarsal bones

Metatarsalgia cont.

Management– Orthotics that elevate the depressed metatarsal

heads and/or medial aspect of calcaneus may be used

– Remove excessive callus build-up– Stretching of heel cord – Strengthening exercises for the intrinsic foot

muscles

Metatarsal Arch StrainMetatarsal Arch Strain

Etiology– Fallen metatarsal arch

• Pes Cavus

– Excessive pronation

Signs and Symptoms– Pain or cramping in

metatarsal region

– Point tenderness

– Weakness

– Positive Morton’s test

ManagementManagement- Pad to elevate metatarsals just behind - Pad to elevate metatarsals just behind ball of football of foot

Etiology– Thickening of nerve sheath of the common plantar

nerve where it divides into digital branches• Commonly occurs between 3rd and 4th metatarsal heads

where medial and lateral plantar nerves come together

– Also irritated by collapse of transverse arch of foot• Places transverse metatarsal ligaments under stretch,

compressing digital nerves and vessels

– Excessive pronation can be a predisposing factor

Morton’s Neuroma

Morton’s Neuroma cont.

Signs and Symptoms– Burning paresthesia in forefoot– Severe intermittent pain in forefoot– Pain relieved with non-weight bearing– Toe hyperextension increases symptoms

Management– Must rule out stress fracture

– Teardrop pad can be placed between metatarsal heads to increase space

• Decreases pressure on neuroma

– Shoes with wider toe box would be appropriate

– Surgical excision may be required

Morton’s Neuroma cont.

Subungual Hematoma

Etiology– Direct pressure

– Dropping an object on toe

– Kicking another object

– Repetitive shear forces on toenail

Signs of Injury– Accumulation of blood underneath toenail – Likely to produce extreme pain – May result in loss of toe nail

Management– RICE immediately

• Reduces pain and swelling– Relieve pressure within 12-24 hours

• Lance or drill nail• Must be sterile to prevent infection

Subungual Hematoma cont.

Metatarsalgia

Tunnel behind medial malleolus– Osseous floor – Roof composed of flexor retinaculum

Etiology– Any condition that compromises tibialis posterior,

flexor hallucis longus, flexor digitorum, and tibial nerve, artery, or vein

– May result from previous fracture, tenosynovitis, acute trauma, or excessive pronation

Tarsal Tunnel SyndromeTarsal Tunnel Syndrome

Tarsal Tunnel Syndrome cont.

Signs and Symptoms– Pain and paresthesia along medial and plantar

aspect of foot– Motor weakness and atrophy may result– Increased pain at night – Positive Tinel’s Sign

Management• NSAID’s and anti-inflammatory modalities• Orthotics• Possibly surgery if condition is recurrent

Foot RehabilitationGeneral Body Conditioning A period of non-weight

bearing is common, therefore alternative means of conditioning must be introduced– Pool running

– Upper body ergometer

General strengthening and flexibility should be included as allowed by injury

Progression to Weight Bearing If unable to walk without a limp, crutch or

cane walking should be utilized Poor gait mechanics will impact other joints

within the kinetic chain– Could result in additional injuries

Progress to full weight bearing as soon as tolerable

Foot Rehabilitation

Foot Rehabilitation

Joint Mobilizations Can be very useful in normalizing joint motions

Foot RehabilitationFlexibility Must maintain or re-

establish normal flexibility of the foot– Full range of motion is

critical for normal function Stretching of the plantar

fascia and Achilles tendon is very important

Strengthening Writing alphabet Picking up objects Ankle circumduction Gripping and

spreading toes Towel gathering Towel Scoop

Foot Rehabilitation

Neuromuscular Control Critical to re-establish because it is the

single most important element dictating movement

Muscular weakness, proprioceptive deficits, and ROM deficits challenge the athlete’s ability to maintain center of gravity without losing balance

Foot Rehabilitation

Foot Rehabilitation

Neuromuscular Control cont. Must be able to adapt to

changing surfaces– Involves highly integrative and

dynamic process that utilizes multiple neurological pathways

Proprioception and kinesthesia is essential in athletics

Figure 15-4

Neuromuscular Control Training– Can be enhanced by training in controlled

activities on uneven surfaces or a balance board

Figure 15-5 & 6

Taping and Bracing– Ideal to have athlete return w/out taping and bracing– Common practice to use tape and brace initially to enhance

stabilization– Must be sure it does not interfere with overall motor performance

Functional Progressions– Severe injuries require more detailed plan– Typical progression initiated w/ partial weight bearing until full

weight bearing occurs w/out a limp– Running can begin when ambulation is pain free (transition from pool

- even surface - changes of speed and direction)

Return to Activity– Must have complete range of motion and at least

80-90% of pre-injury strength before return to sport– If full practice is tolerated w/out insult, athlete can

return to competition– Must involve gradual progression of functional

activities, slowly increasing stress on injured structure

– Specific sports dictate specific drills

Footwear– Can be an important factor in reducing injury– Shoes should not be used in activities they were not made

for

Preventive Taping and Orthoses– Tape can provide some prophylactic protection– However, improperly applied tape can disrupt normal

biomechanical function and cause injury– Lace-up braces have even been found to be effective in

controlling ankle motion

Select a rigid shoe for pronators Select a flexible shoe with additional cushioning for

supinators Other considerations:

– Midsole design: controls motion along medial aspect of foot

– Heel counters: controls motion in rearfoot– Outsole contour and composition– Lacing systems – Forefoot wedges

Appropriate Footwear

Keep toenails trimmed correctly Shave down excessive calluses Keep feet clean Wear clean socks and shoes that fit

correclty Keep feet as dry as possible

– Prevents development of athlete’s foot

Foot Hygiene