The foot consists of 26 bones: 14 phalangeal, 5 metatarsal, and
7 tarsal. Toes are used to balance and propel the body. Metatarsal
Bones gives elasticity to the foot in weight bearing. Tarsal Bones
located between the bones of the lower leg and the metatarsals are
extremely important for support and locomotion.
Slide 3
Foot arches assist the foot in supporting the body weight; in
absorbing shock of weight bearing; and in providing a space on the
plantar aspect of the foot for the blood vessels, nerves, and
muscles. There are 4 arches: The metatarsal, transverse arch,
medial longitudinal arch, lateral longitudinal arch.
Slide 4
Interphalangeal Joint: located at the distal extremities of the
proximal and middle phalanges. Designed for flexion and extension.
Metatarsophalangeal Joint: Permits flexion, extension, adduction,
and abduction. Intermetatarsal Joint: Permits slight gliding
movements. Tarsometatarsal Joint: allows some gliding and
restriction of flexion, extension adduction and abduction.
Midtarsal Joint: Provides shock absorption.
Slide 5
Produce medial movements of the foot. These muscles pass behind
and in front of the medial malleolus.
Slide 6
Produce lateral movements of the foot. Muscles passing behind
the lateral malleolus are the fibularis longus and the fibularis
brevis.
Slide 7
Nerve Supply: The medial and lateral plantar nerves which are
branches of the tibial nerve, supply all of the intrinsic muscles
on the plantar surface of the foot. The deep peroneal nerve
supplies the extensor. Blood Supply: The primary blood supply for
the foot comes from the anterior tibial artery and posterior tibial
arteries.
Slide 8
Forefoot varus, forefoot valgus and rearfoot varus produce
excessive pronation or supination. The deformities will make the
foot more difficult to act like a shock absorber. The compensation
usually causes overuse injuries.
Slide 9
Appropriate Footwear; selecting an appropriate shoe is a
critical consideration in preventing a foot problem. Shoe
Orthotics; an orthotic device can be used to correct biomechanical
problems that exist in the foot and that can cause injury. Proper
foot hygiene; simple tasks such as keeping toenails trimmed,
shaving down calluses, keeping feet clean and dry can reduce a
number of problems.
Slide 10
To correctly assess the foot trainers must understand that the
foot is part of a kinetic chain that includes both the ankle and
the lower leg. History of the patients foot must also be assessed.
Observations such as if the patient is favoring the foot, walking
with a limp or unable to bear weight should be assessed. Structural
Deformities should also be observed.
Slide 11
Fracture of the Talus Symptoms: Patient often has a history of
repeated trauma to the ankle. Sharp pain during weight bearing and
complains of catching and snapping along with swelling Management:
X-ray is essential. Nonsurgical management. Protective
immobilization, and no weight bearing.
Slide 12
Symptoms and signs: occurs mostly from landing or falling from
a high place. There is usually immediate swelling and pain and an
inability to bear weight. Management: RICE must be used immediately
to minimize pain and swelling before referring the athlete to an
X-ray. With non displacement fractures immobilization and early
range of motion exercises are recommended as soon as pain and
swelling go down or is tolerated.
Slide 13
Occurs with repetitive impact during heel strike and is most
commonly found in distance runners. Symptoms and signs: weight
bearing and complaints of pain tend to continue after an exercise
stops. May not come up on X-rays so a bone scan may be the best
option. Management: for the first 2 or 3 weeks rest is important
with little as possible weight bearing on the foot. Active range of
motion exercises of the foot and ankle during rest. After 2 or 3
weeks, gradually work the athlete back into it with cushioning
shoes.
Slide 14
Occurs in the young and physically active. Symptoms and Signs:
Pain occurs at the posterior heel below the attachment of the
Achilles tendon insertion of the child or adolescent athlete.
Management: Best treated with rest, ice, stretching and
antiinflamatory medications.
Slide 15
Caused by inflammation of the bursa that lies between the
Achilles tendon and the calcaneal. Symptoms and Signs: Swelling on
both sides of the heel cord. Management: RICE and NSAIDs. The use
of ultrasound can reduce inflammation.
Slide 16
Seen mostly in sports that have a sudden stop and go response
or a sudden change from horizontal to vertical movement. Symptoms
and Signs: Severe pain in the heel, unable to withstand the stress
of weight bearing. Management: No bearing weight on heel for 24
hours, RICE, and wear shock absorbent footwear.
Slide 17
Pronation and trauma have been reported to be prominent causes
of cuboid subluxation. Symptoms and Signs: Pain in the 4 th and 5
th metatarsals as well as over the cuboid. Often pain in the heel
area as well. Management: Cuboid manipulation is done to restore
the cuboid to the natural position. Orthotic helps support it.
Slide 18
Symptoms and Signs: Complaints of pain and paresthesia are
typical, along the medial and plantar aspects of the foot.
Management: Antiinflamatory modalities.
Slide 19
Pes planus is associated with excessive foot pronation and may
be caused by a number of factors, including a structural forefoot
varus deformity, shoes that are too tight or trauma that weakens
supportive structures. Symptoms and Signs: Pain or a feeling of
weakness or fatigue in the medial longitudinal arch. Management:
Arch support with an orthotic.
Slide 20
Etiology: Pes Cavus refers to a foot that has an arch that is
higher than normal. Symptoms/Signs: Shock absorption is poor, thus
problems include general foot pain, metatarsalgia, &
hammertoes. Management: If problems occur, orthotic should be
constructed using lateral wedge. Stretching of the Achilles tendon
and the plantar fascia is helpful
Slide 21
Etiology: Abnormally short first metatarsal, thus the second
toe appears to be longer than the great toe. Weight bearing becomes
uneven, with more weight now on the second metatarsal. Not an
injury but can develop into one. Symptoms/Signs: Symptoms are those
of stress fractures in general. Management: If there are no
problems, nothing should be done. If problems occur, an orthotic
with a medial wedge would be helpful.
Slide 22
Etiology: Caused by subjecting the musculature of the foot to
stress produced by repetitive contact with hard surfaces. There is
a flattening or strain to the longitudinal arch. Symptoms/Signs:
Pain is experienced only during running or jumping. The pain
usually appears just below the posterior tibialis tendon.
Management: RICE followed by therapy and reduction of weight
bearing.
Slide 23
Used to describe pain in the proximal arch and heel. The
function of the plantar fascia is to assist in maintaining the
stability of the foot and in securing the longitudinal arch
Etiology: Tension develops in the plantar fascia during the
extension of the toes and during depression of the longitudinal
arch as a result of weight bearing Symptoms/Signs: pain in the
medial heel, and eventually moves to central portion of plantar
fascia. Management: Extended period of treatment. Orthotic therapy
useful. Taping may reduce symptoms. Should engage in Achilles
tendon stretching, and stretch the plantar fascia.
Slide 24
Etiology: Can be caused by inversion and plantar flexion of the
foot, by direct force, or repetitive stress. Most common acute
fracture to the diaphysis at the base of the fifth metatarsal.
Symptoms/Signs: Immediate swelling and pain over the fifth
metatarsal. Healing is slow. Injury has a high nonunion rate.
Nonunion fractures heal with cartilage between the bone fracture.
Management: Use of crutches with no immobilization, progressing to
full weight bearing as pain subsides.
Slide 25
Etiology: Most common metatarsal stress fractures involve the
shaft of the second metatarsal. Symptoms/Signs: Over 2-3 week
period, dull pain begins to occur during exercise, then progresses
to pain at rest. Usually occurs when patients increase the
intensity or duration of their exercise. Management: Partial weight
bearing and 2 weeks of rest. Return to running should be very
gradual.
Slide 26
Etiology: Bunion occurs at the head of the first metatarsal.
Often caused by shoes. Bunionette the toe angulates toward the
fourth toe, causing an enlarged metatarsal head. In all bunions,
both the flexor and extensor tendons are malaligned, creating more
angular stress on the joint. Symptoms/Signs: During formation there
is tenderness, swelling, and enlargement of the joint. Angulation
of the toe progresses. Management: Early recognition and care can
often prevent increased irritation & deformity. 1. Wear
correctly fitting shoes 2. Wear an appropriate fitting orthotic 3.
Place a sponge rubber doughnut pad over the 1 st /5 th
metatarsophalangeal joint 4. Wear a tape splint along with a
resilient wedge placed between the great toe and 2 nd toe. 5.
Engage in daily foot exercises. Ultimately, surgery may be
necessary
Slide 27
Etiology: Two sesamoid bones lie within the flexor &
adductor tendons of the great toe. Sesamoiditis is caused by
repetitive hyperextension of the great toe Symptoms/signs: patient
complains of pain under the great toe, especially during a push off
Management: treated with orthotic devices. Decrease activity to
allow inflammation to subside
Slide 28
Etiology: pain in the ball of the foot or under 2 nd or 3 rd
metatarsal head. A heavy callus forms. One of the causes is
restricted extensibility of the gastrocnemius- soleus complex
Signs/symptoms: As the transverse arch becomes flattened and the
heads of the 2 nd, 3 rd, 4 th metatarsal bones become depressed.
Also, a cavus deformity Management: Applying a pad to elevate the
depressed metatarsal heads. Regimen of static stretching
Slide 29
Etiology: The heads of the 1 st and 5 th metatarsal bones bear
slightly more weight than the heads of 2 nd, 3 rd, & 4 th. If
the foot tends to pronate excessively, & spread abnormally
(splayed foot), fallen metatarsal arch results Symptoms/signs:
Patient has pain or cramping in metatarsal region. Point tenderness
in the area. Management: Apply pad to elevate. Pad placed in the
center just behind the ball of the foot.
Slide 30
Etiology: Located between the 3 rd & 4 th metatarsal heads
where the nerve is the thickest. With the collapse of the
transverse arch of the foot, it stretches metatarsal ligaments
which then compresses the digital nerves & vessels.
Symptoms/signs: Burning paresthesia and pain in the forefoot.
Hyperextension of the toes can increase the symptoms. Management:
Bone scan often necessary. Use a pad. Shoe selection is important
for treatment.
Slide 31
Etiology: Sprains of the phalangeal joints of the toes are
caused often by kicking an object. Joint is extended beyond normal
range of motion (jamming), or toe is twisted. Symptoms/signs: Pain
immediate & intense but generally short lived. Immediate
swelling/discoloration. Stiffness & residual pain may last
several weeks. Management: RICE. Buddy taping the injured toe to
the adjacent toes.
Slide 32
Etiology: Results in a sprain of the metatarsophalangeal joint.
Typically occurs on turf since shoes for artificial turf allow more
dorsiflexion of the great toe. Symptoms/signs: Pain & swelling.
Pain is exacerbated when patient tries to push off the foot.
Management: Shoes with steel or other materials added to the
forefoot help stiffen them. Tape, ice, ultrasound. Important to
rest injury until the toe is pain free.
Slide 33
Etiology: usually occur by kicking an object, stubbing toe, or
being stepped on. Dislocation is less common than fractures.
Symptoms/signs: Immediate intense pain. Swelling &
discoloration. Management: Toe dislocations should be reduced by a
physician. Buddy taping injured toe to adjacent toes usually
provides sufficient support.
Slide 34
Etiology: Caused by the proliferation of bony spurs on the
dorsal aspect of the 1 st metatarsophalangeal joint, resulting in
impingement. Its a degenerative arthritic process. Symptoms/signs:
Great toe is unable to dorsiflex. Forced dorsiflexion increases
pain. Weight bearing is on the lateral aspect of the foot.
Management: Stiffer shoe with larger toe box. Antiinflammatory
medication. Osteotomy(surgically removing piece of bone) to remove
mechanical obstruction to dorsiflexion
Slide 35
Etiology: Flexion contractures in the toes. Caused by wearing
shoes that are too short over a long period of time Symptoms/signs:
In all 3 conditions the MP, PIP, or DIP joints can become fixed.
There may be blistering, pain, swelling, callus formation, and
occasionally infection. Management: Wear footwear with more room
for the toes. Use of padding and protective taping. Once
deformities become fixed, surgical procedures that involve
straightening the toes and maintaining position using Kirshner Wire
is necessary.
Slide 36
Etiology: Congenital, or improperly fitting footwear.
Symptoms/signs: Outward projection of the great toe or a drop in
the longitudinal or metatarsal arch. Management: Surgery.
Therapeutic modalities like whirlpool bath help alleviate
inflammation. Taping
Slide 37
Etiology: Toe being stepped on, dropping object on toe, or
kicking an object. Blood that accumulates is likely to produce
extreme pain & loss of nail. Symptoms/signs: Bleeding into the
nail may be immediate or slow. Bluish purple color, and gentle
pressure on the nail exacerbates pain. Management: Ice pack applied
immediately. Elevation. Within next 12-24 hrs physician should
drill hole to release pressure.
Slide 38
Managing injuries to the foot often require that the patient be
non weight bearing for some period of time. No running activities
so its necessary to substitute alternative conditioning activities.
Ex: running in a pool, working on upper extremity ergometer.
Continue in strengthening & flexibility exercises as allowed by
the injury.
Slide 39
Anterior/posterior calcaneocuboid glides are used for
increasing adduction and abduction. Anterior/posterior
cuboidmetatarsal glides. Used for increasing the mobility of the 5
th metatarsal. Anterior/posterior tarsometatarsal glides decrease
hypomobility of the metatarsals Anterior/posterior talonavicular
glides increase adduction and abduction. Anterior/posterior
metatarsophalangeal glides. The anterior glides increase extension
and the posterior glides increase flexion.
Slide 40
Restoring full range of motion following various injuries to
the phalanges is important. Critical to engage in stretching
activities in the case of plantar fasciitis. Also stretch
gastrocnemiussoleus complex for number of injuries
Slide 41
Strength exercises can be done with a variety of resistance
methods including rubber tubing, towel exercises, and manual
resistance. Strengthening muscles involved in foot motion: o Write
alphabet in the air with toes pointed o Patient picks up small
objects (ex. Marbles) with toes o Ankle is circumducted o Gripping
and spreading the toes. o Towel exercises
Slide 42
Neuromuscular control in the foot is the single most important
element dictating movement strategies within the kinetic chain
Exercises for reestablishing neuromuscular control in the foot
should include a variety of walking, running, and hopping involving
directional changes performed on varying surfaces. Exercise sandals
are excellent for increasing muscle activation in the foot and
lower leg
Slide 43
Foot Orthotics and Taping Orthotics are used to control
abnormal compensatory movements of the foot. The orthotic provides
a platform of support so that soft tissues can heal properly
without undue stress. 3 types of Orthotics: 1. Pads or soft
orthotics. These soft inserts are advocated for mild overuse
syndromes. 2. Semirigid orthotics are prescribed for athletes who
have increased symptoms. Made of flexible thermoplastics, rubber,
or leather 3. Functional or rigid orthotics are from made from hard
plastic Orthotics for Correcting Excessive Pronation Supination For
structural forefoot varus deformity, orthotic should be rigid type
and should have a medial wedge under the 1 st metatarsal. For more
comfort add a small wedge Structural forefoot valgus deformity in
which the foot excessively supinates, orthotic should be semirigid
and have a lateral wedge under the head of the 5 th metatarsal. For
more comfort add a small wedge Structural rearfoot varus deformity,
the orthotic should be semirigid and have a wedge under the medial
calcaneus and a small wedge under the head of the 1 st
metatarsal.
Slide 44
Non weight bearing Partial weight bearing Full weight bearing
Walking -Normal -Heel -Toe -Side step / shuffle slides Logging
-Straightaways on track -Walk turns -Jog complete oval of track
Short sprints Acceleration/deceleratio n sprints Carioca Hopping
-Two feet -One Foot -Alternate Cutting jumping hopping on
command