the foot chapter 17. foot anatomy 26 bones 7 tarsal 5 metatarsal 14 phalanges 38 joints 4...
TRANSCRIPT
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The FootChapter 17
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Foot Anatomy 26 Bones
7 Tarsal 5 Metatarsal 14 Phalanges
38 Joints 4 Arches
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Toes
• Designed to give wider base for balance and for propelling the body forward
• First toe has 2 phalanges the remaining toes have 3
• Sesamoids under the first metatarsal (in the flexor hallucis tendon) assist with reducing pressure in weight bearing, increase the mechanical advantage of the flexor tendons of the great toe, act as sliding pulleys for tendons
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Sesamoid Bones 2 (medial and lateral) Under great toe Functionpulley, increase leverage of
tendons that control great toe
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Metatarsals
• Five bones that lie between and articulate with the tarsals and the phalanges
• Ligamentous arrangement gives elasticity to the foot in weight bearing
• MTP joints permit hinge action of phalanges
• First metatarsal functions as the main weight bearing support during walking and running
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Tarsals
• Calcaneous– Largest tarsal bone; supports the talus and shapes
the heel
– Main functions: convey the body weight to the ground and serves as attachment of Achilles Tendon and plantar structures
• Talus–Situated above the calcaneous; consists of
the body, neck and head–Trochlea articulates with the medial and
lateral malleoli to form the ankle joint
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Tarsals
• Navicular– Anterior to the talus on the medial aspect of the foot– Articulates with the three cuneiform bones
• Cuboid– On the lateral aspect of the foot– Articulates posteriorly with the calcaneous and
anteriorly with the fourth and fifth metatarsals• Cuneiforms
– Three cuneiforms located between the navicular and the base of the three metatarsals on the medial aspect of the foot
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Bones of the Foot
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Bones of the Foot
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Bones of the Foot
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Tarsal Bones
Talus Calcaneus Navicular Cuboid Cuniforms
Medial Intermediate Lateral
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Metatarsals & Phalanges
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Regions of the Foot
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Arches of the Foot
• Arches provide support in weight bearing, absorb shock, and provide space on plantar surface of blood vessels, nerves, and muscles
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Foot Arches
Functions1. Support body weigh in an economical fashion2. Absorb the shock of weight bearing3. Provide a space on the plantar aspect of foot for
blood vessels, nerves, and muscles
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Arches of the Foot
– Lateral Longitudinal Arch• On outer aspect of the foot, formed by the
calcaneous, cuboid and fifth metatarsal bone
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Medial Longitudinal Arch
• Highest of 3 arches of foot
• Calcaneus, Talus, Navicular, Cuniforms & 1st three metatarsals
• Supports—– Ligaments:
• Spring ligament
• Plantar fascia
– Tendons:• Tibialis posterior
• Tibialis anterior
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Lateral Longitudinal Arch
• Lower and flatter• Calcaneus, Talus,
Cuboid, 4th & 5th metatarsals
• Supports—– Ligaments:
• Short plantar ligament• Plantar fascia
– Tendons:• Peroneus longus
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Arches of the Foot
– Transverse Arch• Extends across the cuboid, and the internal
cuneiform• Protects the soft tissue and increases foot mobility
– Medial Longitudinal Arch• Originates on medial border of the calcaneous and
extends forward to the distal head of the first metatarsal
• Main supporting ligament = plantar calcaneonavicular ligament (spring ligament)
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Transverse Arch
• Cuniforms, Cuboid, & 5th metatarsal
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• Thick white band of fibrous tissue originating from the medial tuberosity of the calcaneus and ending at the proximal heads of the metatarsals
• Work with ligaments to support arches during weigh bearing and downward forces
Plantar Fascia
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Joints of the Foot
Tibiotalar Talocrural Subtalar Talonavicular Calcaneocubiod Metarsocunieform
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Joints of the Foot
Metatarsophalangeal Joint
Proximal Interphalangeal Joint
Distal Interphalangeal Joint
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Joints of the Foot
– Tarsometatarsal Joint• Formed by junction of the bases of the metatarsal
bones with the cuboid and all three cuneiforms – allows for some gliding
• Also known as the Lisfranc’s joint
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Joints of the Foot
– Interphalangeal Joint• Designed for flexion and extension• Reinforced by collateral ligaments
– Metatarsophalangeal Joint• Condyloid type joints permitting flexion, extension,
adduction and abduction
– Intermetatarsal Joint• Sliding joints: include two sets of articulations
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Joints of the Foot
– Subtalar Joint• Articulation between the talus and calcaneous• Allows for inversion, eversion, pronation, and
supination• In weight bearing pronation refers to combined
movement of talar plantarflexion and adduction and calcaneal eversion
• In weight bearing supination refers to combined movement of talar dorsiflexion, abduction and calcaneal inversion
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Regions of Foot
Forefoot Metatarsals Phalanges
Midfoot Navicular Cuboid 3 Cuniforms
Hindfoot Calcaneus Talus
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Foot Movements
Dorsiflexion Plantar Flexion Pronation
Inversion Eversion Supination
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Muscles of FootIntrinsic Muscles• Relate to specific body
part or bone
• Flexor hallucis longus• Flexor hallucis brevis• Flexor digitorum longus• Extensor digitorum longus• Abductor hallucis• Abductor digiti minimi• Tibialis posterior
Extrinsic Muscles
• Muscle outside a body part, organ, or bone
• Gastrocnemius
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Muscles of Foot
• Dorsiflexion:
• tibialis anterior, extensor digitorum longus, extensor hallucis longus and peroneus tertius
• Tom, Dick and Harry
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Muscles of the Foot
• Plantarflexion:
• Gastrocnemius, soleus, plantaris, peroneus longus, peroneus brevis, tibialis posterior, flexor hallucis longus and flexor digitorum longus
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Muscles of the Foot
• Inversion:
• Tibialis posterior, flexor digitorum longus, flexor hallucis longus, tibialis anterior and extensor hallucis longus
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Muscles of the Foot
• Eversion:
• Peroneus longus, peroneus brevis, peroneus tertius and extensor digitorum longus
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Muscles of the Foot
–Hallucis muscles move the great toe
–Digitorum muscles move digits 2-5
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Muscles of the Foot
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Muscles of the Foot
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Muscles of the Foot
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Structural Derformities
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Pes Planus
• Flat foot• Associated with excessive
pronation• Multiple causes:
– Lack of shoe support– Weak muscles
• Pain & weakness in medial longitudinal arch• Calcaneal eversion• Navicular bulging• Flattening of arch
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Pronators• Prolonged pronation one of
major causes of stress injuries
• Prolonged pronation does not allow the subtalar joint to resupinate, thus there is less power for push-off
• Injuries occurring from excessive pronation include: stress fractures of the second metatarsal, plantar fasciitis, posterior tibial tendonitis, achilles tendonitis, tibial stress syndrome and medial knee pain
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Pes Cavus
• aka Clawfoot, hollow foot
• Associated with excessive supination
• Shock absorption poor
• General foot pain and metatarsalgia common
• Abnormally short Achilles tendon
• Calluses ball and heel
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Supinators• Excessive supination at
heel strike does not allow subtalar joint to unlock – foot remains rigid
• Foot cannot absorb ground reaction forces efficiently
• Injuries seen include: inversion ankle sprains, tibial stress syndrome, peroneal tendonitis, IT band friction syndrome and trochanteric bursitis
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Shoe Wear Patterns
• Excessive Pronation– Wear out front of shoe
under 2nd metatarsal
• Excessive Supination– Wear out lateral border of
shoe
• Common Misconception– Wearing out the back
lateral corner of the shoe means you pronate
– This is normal wear pattern
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Selecting Appropriate Footwear
Pronators• need stability and
firmness to reduce excess motion
• (need board lasted, straight lasted shoe, with good rearfoot control)
Supinators• need cushioning
and flexibility as foot is too rigid
• (need slip lasted or combination lasted, curve lasted shoe)
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Selecting Appropriate Footwear
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Gait
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Common Injuries
of the Foot
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Assessment of the Foot
HOPS
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Assessment of the Foot
–Obtain a thorough history
–Observation
–Look for structural Deformities (bunions, check for forefoot varus/valgus deformities, check for rearfoot varus/valgus deformities, flexibility of first ray)
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Look at shoe wear patterns
Pronators
• wear out the front of the shoe under the second metatarsal
• All have excessive wear on the lateral heel due to heel strike
Supinators
• wear out the outside of the shoe
• All have excessive wear on the lateral heel due to heel strike
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Assessment of the Foot
Palpation• Palpate Bones and Soft tissue
structures
Special Tests• Tinel’s sign: tap over the
posterior tibial nerve – numbness, tingling and paresthesia may indicate tarsal tunnel syndrome
• Morton’s Test: Transverse pressure on metatarsal heads causing sharp pain in forefoot, may indicate presence of neuroma or metatarsalgia
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Pulse
• Posterior Tibial Artery• Medial Malleolous• Dorsalis Pedis artery• Extensor Tendon
Great Toe
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Injuries to the Tarsal Region
• Fractures of the Talus• Fractures of the Calcaneous• Calcaneal Stress Fracture• Sever’s Disease (Apophysitis of the Calcaneous)• Retrocalcaneal Bursitis• Heel Contusion• Cuboid Subluxation• Tarsal Tunnel Syndrome
• Lisfranc Injury (Tarsometatarsal Fracture/Dislocation
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Fractures & Stress Fractures
• Impair ability to perform competitively
• NWB
• More swelling & pain than ligament sprain
• Point tenderness present
• Obvious deformity often present
• Usually occur acutely; result of traumatic episode
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Sever’s Disease
• Traction injury at the apophysis of the calcaneus where the Achilles tendon attaches
• Young, physically active athletes– Comparable to Osgood-Shlatter’s disease (at
tibial tubercle of knee)
• Pain occurs during vigorous activity and does not continue during rest
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Retrocalcaneal Bursitis
• Swelling of the bursa at the back of the calcaneus under the Achilles tendon
• S/sxs: – Pain in heel– Painful to touch– Pain worse when
rising on toes– Red, warm skin over
back of heel
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Heel Spur
• Bony growth on calcaneus
• Causes painful inflammation
• Aggravated by exercise
• As foot flattens, plantar fascia is stretched & pulled where it attaches to calcaneus
calcaneus reacts by
forming spur of bony material
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Heel Contusion
• Irritation of the lateral aspect of the heel
• Sudden stop-and-go or sudden change in movement
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Heel Contusion—Treatment
• Cold application before activity
• Ice & elevation after activity
• Absorb shock—– Heel cups– Donut pad
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LisFranc Injury
• Tarsometatarsal fracture/dislocation
• The midfoot will be affected if the bones are broken (fractured) or the ligaments are torn (ruptured). Injuries can vary, from a simple injury that affects only a single joint to a complex injury that disrupts multiple different joints and includes multiple fractures.
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LisFranc Injury
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Injuries to Metatarsal Region
• Pes Planus Foot • Pes Cavus Foot• Longitudinal Arch Sprain• Plantar Fasciitis• Metatarsal Stress Fracture• Hallux Valgus Deformity (Bunion)• Sesamoiditis• Metatarsalgia• Morton’s Neuroma
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Jones Fracture
• Fracture to the diaphysis at the base of the 5th metatarsal
• Repetitive stress, direct force, or inversion and PF of foot
• Healing slow; high nonunion rate
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Plantar Fascia
• Wide, non-elastic ligamentous tissue that extends from the anterior portion of calcaneus to heads of metatarsals
• Supplies support to longitudinal arch
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Plantar Fasciitis
• Strain/irritation of the plantar fascia
• Caused by:– Overuse– Unsupportive footwear– Tight Achilles tendon– Running on hard
surfaces– Chronic irritation
• Pain, tenderness on bottom of foot near heal (especially in am)
• Untreated will lead to:– Bone imbalance– Heel spurs– Muscle strains– Shin splints
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• Correct training errors• Ice• Massage• Evaluate shoes &
activity level• Arch support• Heel cup or cushion
Plantar Fasciitis—Treatment
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Arch Sprains
• Ligaments stretch, thus fail to hold bones of foot in position
• When arch weakened, it cannot absorb shock normally
• Causes:– Overuse– Overweight– Fatigue– Training on hard
surfaces– Non-supportive shoes– Shoes in poor
condition
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Injuries to the Toes
• Sprained Toes
• Turf Toe
• Fractures and Dislocations of Phalanges
• Hallux Rigidus
• Subungual Hematoma (blood under toenail)
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Turf Toe
• Great toe strain
• Hyperextension of the first MTP joint of the big toe
• Treatment:– RICE & Support– Limit movement– Turf toe taping
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Blisters
• Occur on any part of body where there is friction
• Most common on feet or heels
• Treatment Goals: – Relieve pain– Keep from enlarging– Avoid infection
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Blisters—Treatment
• Wash area thoroughly• Use sterile blade to
cut small hole in blister
• Squeeze out clear fluid
• Do not remove skin
• Prevention:– Wear work gloves– Break in new skin– Petroleum jelly/skin
lube– Adhesive bandage
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Prevention of Foot Injuries
• Selecting appropriate footwear
• Using shoe orthotic
• Foot hygiene
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Rehabilitation of the Foot
• Towel pulls
• TheraBand®
• Marble pick-up
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