Foot Injury
-
Upload
arun-tamilvanan -
Category
Documents
-
view
215 -
download
2
Transcript of Foot Injury
![Page 1: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/1.jpg)
More than you ever wanted to know about the foot
MAJ Joel L. ShawSports Medicine
24 May 2007
![Page 2: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/2.jpg)
Overview
• Describe foot and ankle joints• Joint actions during running• Related pathology• How to prescribe running shoes
![Page 3: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/3.jpg)
Foot function
• 1. Accept vertical forces during heel strike• 2. Absorb and dissipate these forces across
a flexible mid- and forefoot during pronation
• 3. Provide propulsion as the foot becomes a rigid lever with resupination and toe-off
![Page 4: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/4.jpg)
Articulations
• Subtalar• Talocalcaneonavicular• Calcanealcuboid• Midtarsal• Tarsometatarsal• Metatarsophalangeal• Interphalangeal
![Page 5: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/5.jpg)
Subtalar
• Triplanar – Supination vs. Pronation
• Bones: inferior talus, superior calcaneus• Alternating concave-convex facets limit
mobility• Ligaments- talocalcaneal, interosseous
talocalcaneal, cervical
![Page 6: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/6.jpg)
Subtalar joint
• Supination– Inversion by calcaneus– Abduction by talus. – Dorsiflexion by talus
• Talar abduction causes external rotation of the tibia
• Position of most stability
![Page 7: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/7.jpg)
Subtalar joint
• Pronation– Eversion by calcaneus– Adduction by talus– Plantarflexion by talus
• Talar adduction causes internal rotation of the tibia– May increase Q angle
• Increased flexibility and shock absorption
![Page 8: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/8.jpg)
Subtalar joint
• Clinical significance– Mobility– Shock absorption– Stability
![Page 9: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/9.jpg)
Midtarsal joint
• Functional joint- includes talonavicular and calcaneocuboid joint
• Triplanar supination/pronation- primarily DF/PF and abd/add
• Navicular- highest point of medial arch
![Page 10: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/10.jpg)
Midtarsal joint
• Assist pronation/supination of the subtalar joint
• Maintain normal weight bearing forces on the forefoot
• Control/communication between rear foot and forefoot
![Page 11: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/11.jpg)
Metatarsophalangeal joint
• Biplanar- mostly dorsiflexion/plantarflexion with 10 degrees of abduction/adduction
• Dorsiflexion- allows body to pass over foot while toes balance body weight during gait
• Plantarflexion- allows toes to press into ground for balance during gait
![Page 12: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/12.jpg)
First ray
• Functional joint• Bones- Navicular, 1st Cuneiform, 1st
Metatarsal• Plantarflexion at late stance to assist 1st
MTP dorsiflexion• Peroneus longus and abductor hallicus
brevis muscles
![Page 13: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/13.jpg)
Plantar fascia
• Causes tension along the arch• Supination facilitated as arch heightened• Windlass effect
![Page 14: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/14.jpg)
Windlass effect
• Webster’s: machine for pulling a rope around a drum. Pulley system to lift anchor in a boat.
![Page 15: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/15.jpg)
Windlass effect
• Tension in the aponeurosis secondary to toe extension elevates the arch by acting as a pulley around which the aponeurosis is tightened.
![Page 16: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/16.jpg)
Ligaments
• Spring ligament– Tension wire which helps maintain arch– Helps rigidity during propulsion
• Long plantar ligament• Plantar aponeurosis• Short plantar ligament
![Page 17: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/17.jpg)
Function of arches
• Stability– Distribution of weight
• Mobility– Dampens shock of weight bearing– Adaptation to changes in support surfaces– Dampening of superimposed rotations
![Page 18: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/18.jpg)
Running gait
• Stance phase– 40% of gait cycle– 2 phases
• Absorption• Propulsion
• Swing phase– 60% of gait cycle– 2 phases
• Initial swing (ISW)- 75%
• Terminal swing (TSW)- 25%
![Page 19: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/19.jpg)
Running gait
• Double float• Stride length• Step length• Cadence
• Velocity=stride length x cadence
![Page 20: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/20.jpg)
Running gait
• Kinematics vs. Kinetics– Kinematics- motion of joints independent of
forces that cause the motion to occur– Kinetics- study of forces that cause movement,
both internally and externally• Internal- muscle forces• External- ground reactive forces
![Page 21: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/21.jpg)
Ankle/foot kinematics
• Ankle joint– Dorsiflexion/plantarflexion
• Foot joints– Triplanar– Pronation and supination
![Page 22: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/22.jpg)
Running gait- ankle kinematics
• Absorption and midstance– Rapid dorsiflexion (response to increased hip
and knee flexion)– Decreased plantarflexion in running
decreased supinationcause of increased running injuries??
![Page 23: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/23.jpg)
Running gait- foot kinematics
• Subtalar motion determined by muscular activity and ground reactive forces
• Midtarsal motion determined by subtalar position
![Page 24: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/24.jpg)
Running gait- midtarsal joint• Calcaneus/talus
supination– Increase midtarsal
obliquity– Lock joint– “Rigid lever”– During propulsion and
ISW
• Calcaneus/talus pronation– Parallel midtarsal
joints– Increased ROM– “Mobile adapter”– Mid stance
![Page 25: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/25.jpg)
O'Connor FG, Wilder RP: Textbook of Running Medicine, McGraw Hill Companies, 2001. Page 13.
Axis of transverse tarsal joint
![Page 26: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/26.jpg)
Running gait- foot kinematics
• Absorption– Pelvis, femur, tibia internally rotate– Eversion and unlocking of subtalar joint– Pronation of midtarsal joints
• Allows mobility and shock absorption.• Able to adapt to ground surface.
– Plantar fascia- relax medial arch
![Page 27: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/27.jpg)
Running gait- foot kinematics
• Propulsion– Pelvis, femur, tibia externally rotate– Inversion/locking of subtalar joint– Supination of forefoot– Plantar fascia- increase medial arch stability
and invert heel– Metatarsal break- promote hindfoot inversion
and external rotation of leg
![Page 28: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/28.jpg)
Running gait- foot kinetics
• External forces- ground reactive forces– Vertical- 3-4 times body weight– Fore-aft- 30% of body weight– Medial-lateral- 10% of body weight– Newton’s third law
• Internal forces- muscle forces
![Page 29: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/29.jpg)
External forces
• Foot strike pattern– Forefoot Midfoot Rearfoot
![Page 30: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/30.jpg)
Rearfoot striker• 80% of runners• Initial contact- posterolateral foot• Center of Pressure (COP)
– Outer border of rear footprogresses along lateral borderthen across forefoot medially toward 1st and 2nd metatarsal head
![Page 31: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/31.jpg)
Midfoot strikers
• Most other runners• Initial contact- midlateral border of foot• COP
– Lateral midfootprogresses posteriorly (corresponds to heel contact)rapidly moves to the medial forefoot
![Page 32: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/32.jpg)
Evaluation of running injuries
• Training log• Shoe examination• Arch appraisal• Gait analysis• Running shoe
prescription
![Page 33: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/33.jpg)
Training log
• Weekly mileage• Transition point• Increase in distance or intensity• Increase in mileage >10% per week• Change in terrain or running surface
![Page 34: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/34.jpg)
Shoe examination
• Current running shoes– Age (days and miles)– Replacement frequency– New brand or model? (change biomechanics)
![Page 35: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/35.jpg)
Shoe examination
• Outsole wear– Lateral heel vs. inside heel vs. lateral sole
• Midsole wear– Heel counter tilt– Midsole wrinkling, tilt, or decomposition
![Page 36: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/36.jpg)
Shoe wear
• Based on foot strike pattern, initial contact, and center of pressure
• Neutral gait– Wear on lateral aspect of heel– Uniform wear under the toes
![Page 37: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/37.jpg)
Shoe wear
• Overpronator– Excessive wear on medial portion of heel and
forefoot
• Underpronator– Excessive wear on lateral heel– Wear on entire lateral portion of the outersole
![Page 38: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/38.jpg)
Arch appraisal
• Standing arch contour
• “Wet test”• Static
evaluation=running evaluation?
![Page 39: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/39.jpg)
Biomechanical function
• Required functions of locomotion– Adaptation– Shock absorption– Torque conversion– Stability– Rigidity
![Page 40: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/40.jpg)
Biomechanical assessment
• Video gait analysis• Always base on running gait, not arch
height• Evaluate shoe wear
![Page 41: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/41.jpg)
Gait analysis
• Behind- location of heel strike, foot motion during single stance, foot engaged at push-off
• Side- gastroc-soleus flexibility, great toe dorsiflexion
• Treadmill-based analysis• Force plate analysis
![Page 42: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/42.jpg)
Neutral gait
• Level Heel Throughout Gait Cycle
• 90 Degree Medial Angle Throughout Gait Cycle
![Page 43: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/43.jpg)
Intrinsic abnormalities
• Pes cavus- abnormal supination• Pes Planus- abnormal pronation
![Page 44: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/44.jpg)
Supination
• Normal– Late stance phase– Provides rigidity,
support, propulsion– Facilitates lower leg
external rotation
• Abnormal– Minimal pronation at
subtalar joint– Little drop of medial
longitudinal arch
![Page 45: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/45.jpg)
Abnormal supination- signs
• Lateral Leaning Foot Surface Placement
• Inflexible Foot• Callus- 1st and 5th
metatarsal heads• Clawing of 4th and 5th
digits
![Page 46: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/46.jpg)
Abnormal supinators
• Stable and rigid foot• Lacks flexibility and
adaptability
• Poor gastroc-soleus flexibility– Achilles tendonitis– Plantar fasciitis
• Poor shock absorption– Tibial and femoral
stress fractures
![Page 47: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/47.jpg)
Pronation
• Normal– Early in stance phase– Provides flexibility,
adaptability and shock absorption
– Facilitates lower leg internal rotation
• Abnormal– Continues throughout
stance phase
![Page 48: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/48.jpg)
Mild Overpronation- signs
• Slightly Greater than 90 Degree Angle Throughout Gait Cycle
• Medial Leaning Foot Surface Placement
• Some Ankle Instability/ unstable position
![Page 49: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/49.jpg)
Severe overpronation- signs
• Significant Medial Leaning of Surface Foot
• Great Instability• Excessive internal
tibial rotation• Increased medial
stress
![Page 50: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/50.jpg)
Overpronators
• Patellofemoral pain• Popliteal tendonitis• Posterior tibial tendonitis• Achilles tendonitis• Plantar fasciitis• Metatarsal stress fracture
•
![Page 51: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/51.jpg)
Arch Height Will Produce Different Levels of Flexibility
• Normal feet:– are flexible as they grip the ground and become stiff at
push off
• Flat feet:– are flexible as they grip the ground and remain flexible
at push off
• High arched feet– are inflexible and do not adjust to terrain well, but
provide a good base for push off.
![Page 52: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/52.jpg)
Running Shoe Design• In an attempt to minimize injuries, running
shoes need to provide:– Cushioning
– Motion Control
– Support
![Page 53: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/53.jpg)
Anatomyof the Running Shoe
Outersole
Uppers
Midsole
Midsole
![Page 54: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/54.jpg)
Anatomy of the Running Shoe
Tongue
Toebox
Lacing systemHeel notch
Heel counter
![Page 55: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/55.jpg)
Anatomy of the Running Shoe
Flex GroovesFlex Grooves
Split HeelSplit Heel
![Page 56: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/56.jpg)
Anatomy of the Running Shoe Last (Curvature)
Straight, Semi-curved and Curved
![Page 57: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/57.jpg)
Anatomy of the Running Shoe
• Lasts (Shoe Template) – Board – Slip– Combination
• If you cannot remove insole, remove shoe…it is of poor quality
![Page 58: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/58.jpg)
Stabilizing Features
Support is added to the inside or medial portion of the heel to counteract the foot rolling inward (pronation)
![Page 59: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/59.jpg)
Running Shoe Selection
• The three basic types of running gait based on ankle biomechanics are: over-pronation, neutral and underpronation
• Shoes should be bought to accommodate your running gait, not your arch height!
![Page 60: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/60.jpg)
Shoe prescription
• High arch- curve-lasted, cushion shoe
• Flat arch- motion control or stability shoes with firm midsoles and straight to semi-curved lasts
• Neutral arch- cushion or stability shoe
![Page 61: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/61.jpg)
Orthotics
• Effectiveness– Gross, et al. 90% with symptom improvement– Schere. 81% with complete symptoms relief– Blake and Denton. Reduced pain associated
with plantar fasciitis by 80%.
![Page 62: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/62.jpg)
Orthotics
• Motion control– Control excessive pronation
• Shock absorption• Pressure relief in specific area
– Plantar heel or great toe metatarsophalangeal• Redistribution of forces away from area
– Metatarsal pad for metatarsalgia/Morton’s neuroma
![Page 63: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/63.jpg)
Orthotics
• Adjunct to rehab and training modification• Return athlete to full function• Prevent further injury• Functional orthoses
– Alter foot function– Guide foot through stance phase– Promote biomechanical efficiency
![Page 64: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/64.jpg)
Orthotics
• Start with soft temporary orthotic• Over-the counter prefabricated devices
– Most athletes report improvement
• Incomplete improvementcustom orthotic
![Page 65: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/65.jpg)
High arch orthotic
• Dropped forefoot• Plantarflexed first metatarsal and forefoot
valgus• Decreased subtalar range of motion• Plantarflexed first ray, unstable cuboid• Peroneal cuboid syndrome
![Page 66: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/66.jpg)
Pronated foot orthotic
• Flat medial arch• Unstable rearfoot and excessive motion of
plantar calcaneal fat pad• Weak plantarflexion of first metatarsal head
and weak “windlass” effect
![Page 67: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/67.jpg)
Common mistakes
• Only looking at standing gait• Failure to evaluate various needs of
different runners• Need of different orthoses for running and
everyday activity
![Page 68: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/68.jpg)
Summary
• Understand normal foot biomechanics- pronation vs. supination
• Evaluate with functional arch and shoe wear• Signs of abnormal arch• Match shoes and orthotics to running
alignment- correct shoes and over-the-counter inserts first
![Page 69: Foot Injury](https://reader036.fdocuments.in/reader036/viewer/2022070603/577ccf091a28ab9e788eb89c/html5/thumbnails/69.jpg)
Questions??
•