18. 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".
24. 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°
29. Basic Anatomy of the Foot and
Ankle
Three Arches enable us to absorb forces
– Transverse Arch
– Medial Longitudinal
Arch
– Lateral Longitudinal
Arch
30. 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.
31. 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.
32. 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.
33. Ligaments
Medial Side
– Deltoid Ligament-
support ligament
on medial side of
foot.
– Spring Ligament-
AKA the Plantar
Calcaneonavicular
ligament.
35. 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?
36. 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
41. 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
42. 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
43. • 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
79. • 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
80. 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
83. • 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
86. – 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
88. • Tinel’s Sign
–Tap over posterior tibial nerve
–Positive test = tingling distal to area
–Indicates presence of tarsal tunnel
syndrome
89. • Morton’s Test
– Transverse pressure applied to heads of metatarsals
– Positive test = pain in forefoot
– Indicate presence of neuroma or metatarsalgia
90. 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
91. • 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
92.
93. • 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
94. • 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
95. • 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
96. • 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
98. – 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
99. • 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
103. –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
104. • 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
109. –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
110. 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
111.
112. 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
113. • 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
114. • 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
115. • 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)
116. 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
119. TARSAL COALSION:
Painful stiff flat foot
Usually bilateral, can be
unilateral
-Stiff subtalar.
MORE COMMON:calcaneo-
navicular and subtalar.
-Request CT scan
120.
121. 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
122.
123. 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.
124. 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
125. 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.
126. 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
127. 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
128. 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
129. 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
130. 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
131. 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
132.
133. 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)
134. 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
135. 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.
137. 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
139. 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
140.
141. 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
142. 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
144. 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
145. 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
146. 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
147.
148. 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.
149. 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
150.
151.
152. 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
153. 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
154. 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
155. 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 ball of- Pad to elevate metatarsals just behind ball of
footfoot
156. 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
157.
158. 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
159. 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.
161. 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.
163. 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
164. 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
165.
166. Foot Rehabilitation
General 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
167. 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
169. Foot Rehabilitation
Flexibility
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
171. 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
172. 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
177. Neuromuscular Control Training
– Can be enhanced by training in controlled
activities on uneven surfaces or a balance board
Figure 15-5 & 6
178.
179.
180.
181. 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)
182.
183. 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
184. 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
185. 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
186. 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
