The FootChapter 17

Foot Anatomy 26 Bones

7 Tarsal 5 Metatarsal 14 Phalanges

38 Joints 4 Arches

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

Sesamoid Bones 2 (medial and lateral) Under great toe Functionpulley, increase leverage of

tendons that control great toe

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

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

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

Bones of the Foot

Bones of the Foot

Bones of the Foot

Tarsal Bones

Talus Calcaneus Navicular Cuboid Cuniforms

Medial Intermediate Lateral

Metatarsals & Phalanges

Regions of the Foot

Arches of the Foot

• Arches provide support in weight bearing, absorb shock, and provide space on plantar surface of blood vessels, nerves, and muscles

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

Arches of the Foot

– Lateral Longitudinal Arch• On outer aspect of the foot, formed by the

calcaneous, cuboid and fifth metatarsal bone

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

Lateral Longitudinal Arch

• Lower and flatter• Calcaneus, Talus,

Cuboid, 4th & 5th metatarsals

• Supports—– Ligaments:

• Short plantar ligament• Plantar fascia

– Tendons:• Peroneus longus

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)

Transverse Arch

• Cuniforms, Cuboid, & 5th metatarsal

• 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

Joints of the Foot

Tibiotalar Talocrural Subtalar Talonavicular Calcaneocubiod Metarsocunieform

Joints of the Foot

Metatarsophalangeal Joint

Proximal Interphalangeal Joint

Distal Interphalangeal Joint

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

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

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

Regions of Foot

Forefoot Metatarsals Phalanges

Midfoot Navicular Cuboid 3 Cuniforms

Hindfoot Calcaneus Talus

Foot Movements

Dorsiflexion Plantar Flexion Pronation

Inversion Eversion Supination

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

Muscles of Foot

• Dorsiflexion:

• tibialis anterior, extensor digitorum longus, extensor hallucis longus and peroneus tertius

• Tom, Dick and Harry

Muscles of the Foot

• Plantarflexion:

• Gastrocnemius, soleus, plantaris, peroneus longus, peroneus brevis, tibialis posterior, flexor hallucis longus and flexor digitorum longus

Muscles of the Foot

• Inversion:

• Tibialis posterior, flexor digitorum longus, flexor hallucis longus, tibialis anterior and extensor hallucis longus

Muscles of the Foot

• Eversion:

• Peroneus longus, peroneus brevis, peroneus tertius and extensor digitorum longus

Muscles of the Foot

–Hallucis muscles move the great toe

–Digitorum muscles move digits 2-5

Muscles of the Foot

Muscles of the Foot

Muscles of the Foot

Structural Derformities

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

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

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

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

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

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)

Selecting Appropriate Footwear

Gait

Common Injuries

of the Foot

Assessment of the Foot

HOPS

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)

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

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

Pulse

• Posterior Tibial Artery• Medial Malleolous• Dorsalis Pedis artery• Extensor Tendon

Great Toe

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

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

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

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

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

Heel Contusion

• Irritation of the lateral aspect of the heel

• Sudden stop-and-go or sudden change in movement

Heel Contusion—Treatment

• Cold application before activity

• Ice & elevation after activity

• Absorb shock—– Heel cups– Donut pad

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.

LisFranc Injury

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

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

Plantar Fascia

• Wide, non-elastic ligamentous tissue that extends from the anterior portion of calcaneus to heads of metatarsals

• Supplies support to longitudinal arch

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

• Correct training errors• Ice• Massage• Evaluate shoes &

activity level• Arch support• Heel cup or cushion

Plantar Fasciitis—Treatment

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

Injuries to the Toes

• Sprained Toes

• Turf Toe

• Fractures and Dislocations of Phalanges

• Hallux Rigidus

• Subungual Hematoma (blood under toenail)

Turf Toe

• Great toe strain

• Hyperextension of the first MTP joint of the big toe

• Treatment:– RICE & Support– Limit movement– Turf toe taping

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

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

Prevention of Foot Injuries

• Selecting appropriate footwear

• Using shoe orthotic

• Foot hygiene

Rehabilitation of the Foot

• Towel pulls

• TheraBand®

• Marble pick-up