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Foot and Ankle




T'he fbot and ankle r.r'rust provicle sllpport and shock ahsorpriur u'hilc at the s'me tirne balancirrg the bod,v. This
reqr,rires both molriiiq to adept to varvins terrain and

stabilq. to allow supported contrct anc{ pr.rsh off fronr

the grour.rd. Shock absorptior-r occurs s a result of rlc
dissipation oltfi,rces through complex movements at the
foot and ankle arrd irnposetj adaptation throrrgh tnainly
rotati<.rn in thc lou,cr extrernity at drc kne e , hip, and peivis.
Therefore, dvsfuncrion at the feet nrav have conseque ni:es

throughout the entire bod,r.. o., r.oblems rnay bc loca I

or referled; however, the need tbr lower-extrenrity colrtpensation rnay result in mc,re proxilual rain. including lorv
back pain.
As tl-re most drstai site of dre bodr,', the tbot is also corn'inon]y aff-ected bl, vascuLar tlisorilers. Arteriai rcclusive
disorders biock blood flori,. \h,ula insufficiency iu verns,
coupled rvith gravity-. may lead to a piloling effect and
vascular stasis. Neut1ogic dy,'sfirnction associted ''l,ith

metabolic neuropathies such as seen rlith dibetes is of

ten feit first distally in the feet. -['he bare tbot is c.rposed
to possible traurna and inl'ection. 'l-he .supportcd firot is
vulnerable to the pressure effcts and bionrechanical alLerations of footlvear. Wheu. cornpromised by vascular
andfur scnsory deilcits, a prtient is rn,;rc rrone to the
long-ternr collseqLrences of unnoticed rr unattcndccl lesions. Tiris js nrost ofter.r seen with the diabetic patienr"
The nrost conrlron conditions involving tl-re foc,r ntl
ankle irrc biol-ncchaical in nature an<l includc thc



halluxvalgrrs/rigidus, turftoe, gout, and


metatarsals-Morton's neurorrla,

IIleta tal'salgia,
"ciropped ntetatrsal." and stess fracnrres

medical longitudinal arch pronation/supination

eff-ects, navicular subhr-t:r ti<ln, and pl a rrta r f asciitis

lateral foot-cuboid sLrf.iuxation^ peroneal tendinitis, and lracrure of c base of the fifth mctatarsal


ankle-inver.sion and eversion

Achilles tendon/heel
pad syndrr>mc



bursitis, nd


Thc rnajoritv of fbot cornplaints arc c{uc to lack of

proper support or inappropriatc footrvcr. Points ofoverpressure or irritation titm shocs mav result rn corns rir
calluses, sesainoiditis or rggravatiotr of haitrL-rr,,r1$rs at the
tirst toe. or fat pad syndrornc at thc heel. Tight fittinq
shocs ma,u- also cause comprcssion of metatarsals or cusrl
damage to toenails (i.e., hlack toenail-"). If the tbor is
rnoiile (i.e., hvperpronatetl). lack of sr.rppor[ n]v c:tlse.

plantirr fasciiris and strain of thc tibialis posterior nd

other tencions.'l'herefbre, it is requisitc that shoes be exan.rrned and that the lbot be evaluced for anv predispo

sition to riverstrain duc to forefoor or nindfbot

br-rol't-raliues (r.e., vrrrus or valgus).

Ankle sprains re common. 'I'he rnost conrlfion are

plantar fle,xion'inversion sprains. AIthough urost in jnries
arc di,.rnissed as a -simple sprritt, rt is imrurtlnt tu r.rle out
associated injury, including various fracrures and ligarnerlt ftrptrres- Chonic arrlrle pain orinstability (or both)
is r.rot uncorrnon foLlowing' rcpcateil ankle sprains.
There fbre , it is important rrot onlv to lllanilqe thc acuter
injury but also to attempt to prevent future occurrences"
This often requiles deterrninrtion of the need.s of the
:rssociatecl activitv'or sport coupled u"ith strict dhelence
l, r :r lrr

rstlniun rell,rl,r i itnon progrenr.



Deterrnine wl-retl'rer the complaint is one of pain,

stiffrress, popping/snapping, crepitus, locking, weak-

ness, or tumbness artd


llerermine u'hether the patie nt had a tr,lnratic unset rr u'hcther there is an obvious overlise histon.

r l\ith


rle te

rrrine thc npe of act,it)-, the

types clf shoesu'orn, anci thc tvpe of surt:ce t re pxticnt- u,,rks or excrciscs on.

r l4{th traur}r, palpate fcrr points oltenilernr'ss ancl
obtain radiogr'rphs f1r the possibilin. of fra,-:turc/clis.ocation if the patient is unah,e to ber
vneight or bonv tenderncss is fbuncl.

r \\'irh ankle

sprtin. challenge firr stahiliw postcrior

to anterior (drari'cr test), intcl itrversion (latere

kle) and into eversion (nreilial anlde).



Exnrine the ratierrt's shoes nd fet iirr signs of

cxccssive wcr or'] the solc; of both shoes and feet.
When thc onsct is nontrluntatic. challenge the
musculotendinous attachments $'ltlr stretch. corrtractior-1, and a crrnbination of contracti()ir in J
stretched posrtron.
\\ lrcn trin)llll or o\ crusc is not prc:urrt. r'r' uate irt'
paticnt! foot and anklc for sri,ellinrJ and tle ibrrnin'
(bursitis, qoutl'tllphi. ostcoarthritis OA], etc.).


T)isplaci:rl or nonlicaling fr-actures

ibr medical rnanaqerne'nt.

,\k-le sprains ean be rnatragcd u.ith rnrtlriliz-tion/

nrlnipulatiorr, use of a stabilizinc l,racc or taping.
and gradual rcnrrn to r.r.eisht beanng u'ith cn.rpha-





sis on preventiol.
']Lndiniris anil nrusclc strain can llc rnarraqed con-

Hindtbot 'i he

hindf"ort in<:ludes the distal

tibiofihular ioint. In addjtion to sci'cral ligarnents.

the nvo bones are joined bv

(prcvcnts t-nai n1y e.rcessive an kle dorsitlcrion ,ind Ldciuction). and (3) the crictncofihular liqarcnf (a rra jor,ttabilizcr firr ir'ersion). -l he rnedia
side of the ankle is supportcd b1' thc deltoid lig'amcnt. w'hich consists of the tibior.ravicuLr. tibitca.caneal, and anredor and posterior dbioular ligarr-rent-s.
These iganrcnts act tt)gether t(l prevellt ercessivc
evcrsjon oithc anklc (Fjsurc 1'+ 1).
Nlidfbot-.l'he rnitltarsal jolrts are the interconnections letrveen the ta-ns irnd calcneLls nd the
lnidtel'sl llones. inclurlinq tile cLrLrid. nviculr,

nd cuucrfi;rms"

The 'ratient shouLl bc cducececl regalding lrroper

fitting of shoes rncl the speciaJ necds tbr specificr
sports reqrrircments and wpc ol fbot (res planus


(,)rthrtics rnav be a heipfur prer-entive rnesLlre

u'hen biorncchan icl alnorrnlities arc ibr.rnd, srrcl.r
as hindfbot or fbrcfbot \'rus or va gus.

Diaietic foclt problerns shouid be reibred to tire 'ri-

rrr.lrl trcrtinq lhr'.1(irll.


Terminology used to descibe fbot architecntt'c rrnd tlefbrmiry can be conhtsing. Ilsicallt, tlte foot is tlivided
ino a hindfoot, a nriclfo<.rt (nricltarsal)' arL,,l a ibretiot.
Dysliurctio in one part of dre tbot is otten accommodrtecl
or compensetcci bl, ntot'ement in ltrclther ilortion of thc
firot. Iioilor'ng is a trrie f clescrirtion oithe ]oirlts in cch



tlexible interosseous

the nklc lgainst iuversicr n(l rnterior-toposterior nrovelne,)t), (l) thc posterior talofibuhr


rnenrbrane. T1're distance beveen the bones ma1,

ll'i.len r,"'ith dorsiflexion oi the nklc, as the talus
rver.ig'es betu'een the ilrlleoli. \,Vith this nrovenrerrt
the interosseous memtrrane is stretched, causing suoerjor rrovenre nt of the rroxrnral dbiofrLrular joint
uith accornpnvil1g .xterniil rota[i<l; the olposite
'I hc talar/mallcolar joint
<ccurs u,ith plant.,rrflcuon.
is rctLrrcd to as the takcmml joint.'i-he subtalrrr
ioiut consists oithc trlus and clcneus. StaLilin rl
this rrc is pro,,iclrrd in part bv rhe ligarnent<)us sunport of the tibi nd illrLl. dorsif.lcxiol oihc ankle.
or supinalion of-rhc -ruhtaLal' joint. [.igarre]rtotts slli)port et thc nkle is rrovidecl latcrallr,bl rhree ligaments: (1) Lhe anteior tI,-rhltrlar iigarncnt (srpports

se'ativelv with tapinq supp(-)rt, gradul stretchinq,

ice, and activin. n-rodif rcatirn.

versus pes cavns).


section of th c tbot anrl rlefln itrons of funcf ir-,nl ( )r structr.lral devrations thar mav occur:

art jcu

ltions firreti.rrt is tnacle

up of the dist,r,

thc tnctatrsirl, rrretirtrsophalangeal

and interpha anecal joints.

'l'hc close-pac[<ccl position tiir rrost oi the loot


supination s,jth the ercelltiou rif the llha'anges, riclr

are close-packe d rn extension. Supinatirir' involr.cs trrpl'rnar rnor.-en-rent ol aclcltrction. -rlrrrtartlexron, and in
vcrsiort. Prolation involves a triplanar rrrr)\,ernent ll.itt.enr
o{ abtlction, dorsiflerion, and er.'ersion, These tnovclnent pattems crlr occur indcpenderrtlv in the fbot and rre
ofte n r:ourpens,ltorv to ech other. For cxrnplc, suptnrtion in thc hindfiot r1a1' [s conrpcnsaterd b' pronrtirrn rrr
the firreliot.


drc fble ibot is helr.l in .rn invcrtecl position rvhile the srrbtllrr jrint is iu a neu rr:rl position, iirrefirot \i ',lrlrs occurs.'l'his detirrrlln'
occurs in rtv 9?, of the populatron.] If not conlpensctctl for. the first toe rvouLrl not each the
grc,und cluring; rllldstal-ice ncl toe-olT' Ftreioot
n-ar,s is usuallv corrtletlslitccl fbr b1'plonttior-r of

Fiure f 4-1

(A) Major Bones and Joints of the Foot (LateralView); (B) Major Bones and Joints of the Foot (Medial

View); (C) Major Ligaments of the Ankle Joint (LateralView)



Me tata r'so ohalangeal





Dome of talus

Head ol tailrs

Subtalar joint



Tuberosiiy of
first rnetatarsal

lnterosseous membrane
anc iiqament

talof ibular




tibiofihu ar


taiof ibular


Cacaneof ibular

Foot and Ankle [ompiaints


the subtaLar joint, tttalorte thts clinicaljv similar to

pes lianus (flattcnetl nretiil kineitudinai rrcll)-

li'orcfbrt val4rs--\\'hen the firrelrrlt is ireid irr n

cvcrtcd position whilc the strbtal'.rr ioint is in a ncutml position, lbletoot valgus occurs. '['his detbrmiqlc,ccurs in *4.8 lo of a svnrpttltttauc ptrpul:rtiorr'l
'lhc rnicltarsrrI ioint ntust supinrtc in nn eftort to
bring thc tourtir urd fillh nctltrlrsl her-is trr the
glound. This rvill casc the fbot to apptrar hi.-h
archecl (pcs carus') dr.rring ambuiatrou.

r Ilindfbot vanis-'1'he

calcrnetrs is helcl in rin invertccl position rrilire the sultlr ioirrt is irl llcrltrrli
rvith hrndfoot (rearfoot) vartrs,'lIis ls otlen ciue to
a devclo,,ntctrttl abnorrlalitl'of the tibi iIr rvlrich
rt is lrowcd ouru'ar(l (tibi r'arurl)"i'he result is thrrt
thc subtrrlar iciirrt rrl.lst mpidl,,'[)rollete thror-rgh rln
inordinarc rarrge of rrotiorr (R( ),\1) itr r ct'fbrt to
hring rhe rrleclirl colttl',lc of the t:alcanctls torr'rd ti-lc
ground durinq grttlrnrl c()llt:lct.'l'his prorltlces t:x-

cessive torque in ttle fcot end lower

tJindfirot vrlgLts-'I-lic


calr:ane rrs is

hcl.l in


cve rtcd position ri'hiJe thc sulltalar joint is in netr

tralrvith nrncltoot (rcarlbot) r'algr-rs 'lhe rnajor tlilficulry* rvith this p<tsitiorr is lack of stbilitl' :rt heel

coll tact.

E,-luinus (trllipes equirrus)--Sinrplr: put. this rs .r t'cstriction o r-lorsiflexicn t the talrcnirl joint.,\Iost

r[ten this is cl,-le to conrracture of tlle so]eus or qrlstrocncm irts; h ou'ever, ti evcloptn ett ta I or :r cqurretl
clltriage to the tlus tnr' also creatc this prtl:'lern.

Piantarflexed first rr.v-Ncirrnally thc inctrtar-sal

heds arc in aligntnent ilt the nansvet'sc planc u'hen
thev are clorsitlexed. \'\'hen the flrst metatrsal lrcatl
is lorvcr, thc qre at toe is in colltict wilh the grourrtl
'ri.hile Lhe othcr rnctatarsal heads are not, lcadrng to
biomecirtnicrl problern sirnirr to tltrlt in lore fbot vl1lus. 'I'his problcrrt is assotriri.eti rvith rr hig-h
,tl,h.',1 (cs t,tvttsl iool.


urin g haif .rf tb c loot-11t phasc, thr: lirrt rnust rltt: t1' t te

thc grountl rcectloII lorcc llr.l ccottl:ltotlatc to tlitler

cnt terrain. 'l'his is accorrlrlishe cl throLrgir a "urr crsel
joint" r'cactioII at thc subtalar ioint. -l'hc talus is cr'crtcrl
by intcrnal rot1iL)n of the tibta, unJocklng lhe rrtidtarsal,

tllocalcancrl ioint rnd (rrexting pr()Iration" \ssocirted

rrith this interttill rot:]lio1r is l'lcriorr ot'thc k.ncc. Thc
colLrtination o1'thcse ctiotrs lreips ttl dissiplte grrunrl
ftrccs. E-rtern:ll rot:rtioir crlll\es tlle opposite eflcct rf ta-rrr itrvcrsjtn

rnrl thc coilsc(ltrcnt ligicf iocked posltion of

f hc subta ir nr I rtl i r I t:rl ' ioi rlt conrpi el { t loc' LcIre1,
tlonavicul ar, nrl crr I c:rltettcrrlloid ioin ts) rlele rtn I Ilcs
nrolclnclr I rf n'Lost of tll e tlot' i lor' evcr. th c nleclirrl seg-

rcntconsislinq of tl-re flrst mett;lt'sal llld tlrst {-llrrt-itornl

gene railv lllo\-t-s il-l e directlon rlpprlsitc thrt of thtr l'est if
'['htrt-fbre, c\:L:1r lvhe II tht hircltilot is structhe lbot.
ttt'i,r' non]ll i, c()irtllcltsati()ll s lll v rcstl t frol'll a lrl ttrnr:rlities oi thc lorelc,ot. Iirrrel:oclt v,tnrs rtrrplics tht tlc
rne rl jri firrctirc,t (thc lirst toc lll pill'ticLlirr) docs llot coll
tilct thc ground unless the f.rot l)rollrtcs to llring it dox n'
'l his is citlletl cotrlpetts:tteti lore[<rtt t':lt tts. l:' rcfirtrt
r-'rlg,.rs has tlte oppttsitc eflect. rvith thc ilrst rrrcttilrs1 ill

.,,,rtr.r *ith

tht-,l rrithorrt colrt'.1ct of the {Lfth rrci

firrrrtlr trtetntars ls.

\lrrscle flnctron,tcross tltt tot and anklc is qrtite ctntu'eie,hr
ricx durirre tnbrrltiott \\'ithotrt refcretlce to
hearir-rg, the dorsiflexr,'ts oftrirc fiot/nkle rg'the tibilis

rior ltttl

pcttttLe rts tcl-tirr (sec

|'iuurc 13-J)' 'l'he

atltl brevis rntl the

rlirt-rtarflexors rc thc pcroncus lotlgus
is prinrlriir'
titrilis postcriot', lJ.r'crsion
titrirlis aL',
clue to the perotte
tcrtor attrl

Irrcllt l)ettenrs: howcvtt. hc fbot liLrtctions lntrrc irt -t

tnplallr ntocic. Iironr the strrnclpoirtt oi snbtalrr joint
pronition and sulirLatictr, tentlons tllilt pass metiiaIlI trr
thc subtalr joint,:xis rrc strpinltors. incJuding tlie crtcnsor hllucis longtrs, e xtcllsoi' ilieitor:Lr-r trtrqls, ttb.

Ciait is often divi<lecl irrtct n itsilatcr,r su'ing rlnrl a

'I'he slnce phasc is cliviclcr.l intL) (rontact'
stancr' p,hrse.
rnidstance, and propulsion sulrphases.'l-he tirre spe Irt in
cach pl'rase is dcpendent olr rvhct.het rn ilrdivid.rl is rv;llkir.ra, j<-rguire, or runnitrg. \\ith walking, thc stancc phasc
'I'he corltact Ird
is arprtrxinLate lr'2'l(, of the totirl rrycle.

nd ttlerors lrtrJ Llrcis lotlqr'rs

ilis artcrior
"tnd P,steriot',
irrl dipitorunt l,n{us. T'1osc lrtrlscle tctlilorls thrlt llass larcrtllv tr> rhc sLrlrtalr joint rrxis l'c llronrtors. rncludille' tl-le
thr ee per-or-reel Iltusclcs.'l'hc pe lLrrlcus lorlg,-Ls lllilv ilct rs
erther r pr.)n'Jtor or'.t suplnltot-lsecl orl tlre posrtion tlf
the iirst nrcttarsal.
At he c colrtaLrt, l-ltost ]o11'cr lcg ttllrscles lllllLLluJl (c'['hcse includc
cell icall\.'t() cle cclcrrltc ilrposcd pronaflol1.

propLrlsion suirphases acco'.rnt fbr- 2 -5') of rhi: stzrl)ce Phase

each, $'ith thc remining 50"/o of tirue spelrl in tltt: rn
stancc subphasc.l i\ tresic descriptltln of tht lliotrrech'nics of u'alkine and rtrnninQ rna,v hclp erplaill the rrrrpat t

the tililis tntef iol atld rostcrior, Lr.\tellsot lrallrrt,is lorrqus

group. Tiris
nil di gttor,rtrr,,rnci Lhe solc trs/gastroctret tir'rs
strltcel' 1rv
fu rrction i ntlircctll- :rctr rts il sLloc
the 1odl' lld whcn

lhat propcrh, lirnctioning iet have on the lorvcr c'rtretrities and the rest of the bodlthe split seconcl contact rvltetr
tl'rc ioot lerrvts
tire hei first touches the
dre grour-rd at tot-oft. IrnmediatcLy
Support is ttccded




splilrts.+ I)urir-rq ttlitlsttrcc thtre is rt tlLrrt lutri:tiotr ot

,rrr-rv n,.,r.l"s Lrasccl c)n thc suhpirse of lnitlstance !'l'lv
,,, n,i,lr,.r,ra". the tibiaLis postcrior ''trti s''lcus act ecccntriclly tr.1 irt thc Jttcr rl-rasc thev ctitltract cr)nt'ctltri
.a.l1t'tL sr-rpin'"tte t1e subt:rlr rr'l rnidtarstl ioi.rrts lrr tlrc

early rnidstance phase, the roe flexors aiso fire ecccnrri

cally, assisting rhe tibirlis posterior and soleils in decelerrting fbru'ard rnovement of the trbia. Durng push-off
(propuisir.ln) all ol the rntrinsic ioot muscles rrct tc stabilie the foot iring concentricaliy. The peroneus lorrsrts
fire-s concerltricall-v to plantartlex the first ra-v, as does the
flexor dirlirorrrri loneus. Othcr first roe r.nuscles fire eccr: icallv Ic assist in stabilizing the frrst nretatarstiljoint.

r}'re cornplairrI to the ank1e, Intdfoot, or

forefoot and rhen ieternine u,hether-it is alrrerior.
posrerior, rnedial, 0r ltte ral"


Clarifi the mechanisnr if traumatrc.

Planrarflexion/inversior iniurv tr, the nkleConsider inuersion ankle


ain rvirh in.ilrn' to tirt:

irnterior taloflbular, celcreo6lular. aiid (rarely)

pclsterior talofrbulal iiqaments.


I)crsiilexi onieversion urjr"r v to tire nllle--Ilversion

ankle splains tear thc cleltoid lrgament anrl are ofre n as.(,citerl wirh drslo, t,orr.
iniury xt Lhe ankle u,irh lbot fixed lski booi
rlpe initrv)-Consider distal ibial anrl fi[rul:rr ]acmre or diasrsis.
SudCen dorsiilexion ol the first roe- lirrf toe is a
sprain of tire rst &f't'P joint; the r:rposite mecha
rusm occurs wirh sencl toe.

Carefui rluestioning of the patient durinq dre iristorv takingcan point to the diagnosis (lhble la-l)
Clarifi' rhe n?e o[conrPlainr.

the complaint one oipain, stiffiress, Iooseness,

creptus, deforluq,, or a cornlrinarion of compl;rints?




History Questions for FootlAnkle Complaints

0id you in.[ure your foot?

lnvenjon rtr el,ersion s0rin,s1rrn,

Sprain yourankle?

Invenion s0rain iikeiy with lieral oarn;

Twist ankle with foot planted?

Pos-.ible disral

frrt u re


with meoiai pain

ltbial or llbular frrture or


Did your big toe get forced


5udden outside foot pain with

Posible ruooid sublux[ion or

pushin g-off (e.9., jumpin g)?

Acute onset of pain with no

Rherm,rtord cr iiy,i I ire




Frclure ol toe

Heel pain landingfiom a.iump?


Heel pain assNiated

Rheumroid rthiti5

with hand pain?

with sacroil-

iac or low bark pan?

Gradual onset offirst toe pain?



vaigus, hailui r qidu:,

sel rnordtis

Gradual onset of pain in other

parts ofthe foot?

!tress iciure, relron,




metalrsal frcture (fi ft h)

Stubbed toe and still painful?

Heel pain associated

plantar fu>riitrs

toe (capsular prin of flnt MTP


pd rritti0n, b0ne

Reiter': syncrome or alk,viosing

spondyl itis

Sudden pain n arch?

Plantr fscirtis

Hurt more when you pull your big

Hallur rigidus

toe bark?
ls your big toe deviated out?
Pain on tfie bottom ofyour big toe?


Stand for long periods oftime on


Haliux valgus (ssociated bunion)


hard surtaresor run a lotofmiles?

Pain on bottom

ofball offoot?

Droppeo metatarial l)ubluxti0n) 0r

Pain worse

Numbnessand tingling in foot?


vr "lr 1,



teidigill errri

>.: Jr ,i i-.,'r-

with tight



Associated with low badr pain?

Nen,e root

0n bottom ofyourfoot?


ln between your toes?

interdigti neurtis

tunnel syndrome


Er: delltieniy

lr.r: i'illt mrtalarri phalanqeal

toot and Ankle (ornPlaints


"Stubbing" the toe (especially the iifth toe


Consider splair.r or lrctureLateral toot pain with push-off while

Consider cu loid

su b

ura t.ion

r l{ee[ pain when ]anding



ld nretrrursa l ftlcnu'e.



(A) i.ateral Aspect of Arrkle and Foot;

(B) Medial Aspect of Ankle and Foot; (C) Dorsal ,Aspect

Ankle and Foot.

trorn a jurnp-Consider

lat pad irrjtation and hone bruise to the calcaneus;

when excessrve force is applied, a clcaneal frac-

nire is possible.
Determire whether the mechanisn is one of overuse.

In wliat position does the patient work? Does rhe

Miht 'pe oI footwear does the pritiertr u,ear ?

lJnsupporrir.e [o<>twear I ltiws firot sprai r.r/strai n,
high heels fi;r'cr the trcs into the toe box rrnd llou'
shortening of the i\chilles te ndrn.

patiellt strnd or waik on hrd surfaces?

r if the pltient

is an atltlete. deterrriine the tr';irring

pro[Jrarx, running surlace, and wpe olshoe.

Arc e demailds of rhe sport or actiut-r'nratched b1'

rhe shoe design? Cie,rts n-,ay provide supp{)r't nr
some setLings :rnd in others anchor the foot, crrusing in jurv; higli-rp shoes mai, pnrvide son,.e nkle
st.ririlin in some spor:ts while )imitii'rg neecied motion in others.

I-{ow often does the adrlete replace iris or he r shoes?

For high-ler.eJ activiry e verv 4 to (r mond'is n.rav be
best; at the veiv leasr, evety 9 r-nonths.

Detennine rvhether the padent has a current or past hisrrr-v/ .liagnosis of rhe fi>orlnkle complaint or other relateci disorclers.

r i\re rhere associared

k>q, b:rck, Pelvis, i'rir,

complai nts or" diagnoses

or ltnee

Does the patient irave gout, diabetes, arterial insufficiencl,, varicose veins, or timiljal pre.lisposirr()r] t() hallur r';tlpus:

Pain L.oclizatir.n The following rre possibie r:'.luses

o localiz-rion (Iiigure l4-2, A to C, and

r>f parn based

-Ilble 1'1..l),


M'I'I, joinr


\cute tre u mir tic-turf oe, sesaroiti i tis

2. Non traunra tic--l'ra lux va lgus, hallux ri3idus,


me tararsal

1, Acute traumaric-transversL' fiones) frrrcrure,

ar,ulsion fl acrure , spir'al fr:acture

2, Nonuumac-" brei"is insertiorrl telldirritis, lselin's disease (tmction apophysitis)



. Acute trautrtatic-


['lusruloskeletal [omplaints


iioe See'lable


2 i-,r

e:tplrrtrcn 01'rrutnber!




Foot and Ankle Pain Localization

Perrtneu: iongiri nd brevri iend0i\,srjrl rter,ri


Anlerior trbrolrbuiai irgairenl

Dia5i5i5 \.^/lih


ci ;trurture:

Peoi're | tend initi5

pi)5!ble suc ted dmqe

1o i.

5i, r formatron from prevcus

Itlo!5er]u5 menbralt


.4nler oi'riofrbular I grnrenl

inversrcn ankie sprr




nkle injury; talat

5cr tissue [rom


previoui ankle sprarns

Proneus lertrus or exlen50r rendinli5

oI slirturel

peioneal nerve

[altreolibr,lr lqamenl, preioneal ten,jcn: nd


lnver:ion ank


ipratn r-ritir pcisible


5nappinq prroneal tenions drslocatlng due l0 retiniu-

ligari:elt cr

lum loosenml,:i rupluie

Strin of extensor digitonrm brevi:


iate iiqamerlt

ietinr Lrlunl



Iuboid lubluxlion

Iirbord sirblurairon

trnsvene (Joresl lrcture



rnn l/TP loini




Lrre o I p


Subtuinecus nd reii'ccknel briiae,


Iilor! bunion


Achilles tendinitis


(hronir bursitis,pump bump raured

Haglund's protes




irlati0n f0m

Ruciure oltibiaris posteror iendon

lrbia is po:terro' lendinitis; trbral nei've r0mp'essi0r

Deltoid lrgament

[versrcn nkle silrin

Ligameni sprain from overpronalion

iiviculr tuberrle

!econd;ry to rversion spr n,sitir uxlton

Subluxi jon; arressory navrcular,iarsal toalition

Iibilil nleloi tendon


rbialis posterior'tendon,

Dorsei lirst

Athille: trndcr:


5trels kclirre

fiettnJ ircture





libil nerve

fom llntrflerrcn



iuritoe (lLyotrexltn5r0nt.r !Jnd be lyoerflexion


Haliux rigidus

luryioloint rpiule





frrt,re cr sel,lroiditi;


(aplriar sprrrl

tre,(;rDrr liirr<t \1lPo,rr




[xterni bunion assocraled lvrlh hallux valgus;goul


Plntar fsciin

[]rneus,it pd

(iint.l frtluit

tal pad syndrome or inilmrnt10n asso(laled with

Metirsal heads

ir,1et1r;i sr.lbluxt rcn

i4orlont neuroma;subluxation

inierdig tai rpace

lnterdigitai neunr,l

lnterdigital neuritrs


[1etirsJl fr{turr,

rheumal0id arthrti5 and Reiterb syndr0me



/hie lee




l4-2 foritliztronof numbtied


b uxl 0n5

[aLxular spi'airr, talar subiurli0r, i'etinicul.lm s0rin


(apsular spiain, talar subluxtron, retinaculum sprain


r:-i n te rd i gi ta l neuro ma (ber*,ee n

sectud and rhird interspaces), Freiber-g's (sec,l,d uiet trsal;, rtr ess Frcnrrc

2, lrirntr-aurnatic

accessor), naviculrrr, Kohler's

isease, navi cri I ar su bluxati r,rrr, stress i'ractrtre,
plarrllr fa>critrs

lrJon tra i,rria li


Stress lrartures,

1, Acute trarlmatic-- kacrrre, ruprure of plaritar
fascia, navicular sublrxation



. Acute tlr

" I\ir )tl'a um

u ma


c-*-cu ltoi


e. cuLroid su

biuxa ti



pe rtltleus

lrrevis tentlinriis

ool anC Ani<le



1. Acute traumrtic-fl'xctut'c. suillr-xatior-r
2. Norrtraumatic talat' exostctsis, anterior. ribial
nerve compression, sublnxation


1. Acute traInLic-Achilles rtrpture, Achillcs tendin itis
2. Noir trautrla tic-purnp bu rrp. Achillcs tend initis, cnca I ltursttis, blistcrs

painiul. InairiIit1'to dorsitle-r t1re nhle inclicates primrrilv

dlria lis anrerior (l-l- t,5 ) u'cakness rtr' Pcrlrap,* il'riri l itv tc;
clorsi|ex the toes (e.rtcnsor tligitontnr) or tire Lrig toe (tx
teilsor hallucis longus, t,5). The physicai e xatrtnrtiot.t
shoulil ticus on ditferentiatirrq berrvecr.r Irerve roo[ allcl
periphcral ncrvc d'lnraqe. Iliiilin'to rise up t.ltlto thc tt,cs
is suggestivc of S 1 nen c r(x)t invoivellrcrlt. esper-:ilh' rvl rcri
nonparntul. ( )thcr r:are possiitilities are rul)ture of thc tib
ialis prtsterior in n cldcrh' pltictlt or a pa ticrlt rlidr rheunlit
toirl rthritis (Ii.A), or {ch il les tcnd,-,tt in n ath rctc.

I i)lanttr

. Acutc taurnatic-calcalrcal frcruc, bortc bruise

2. Nontrarrnratic-fht pad sr.ntlrorne. plantar flsciitis, subiuxetiotr,
Ti'r unr

atic'.rnd Ovcruse

Seve r'.s dlscase

I rr]


\'\'i th clirect [ra u I llil

Instabilin lnstabilin is pt'irnlrilv ll ankle-r.:lated

cornplaint. It is irrrportant r iletcrtille hr nttllrhcl'llrl
sevcritv of :lnk1c sprair'rs itr the past. lt is also ir-nportrtr-tt
tr determrne whether footurcer lelieves this cornplaint.


Rcsrricted lntticrl-l is l.tot comrl'tolt

konl a blorv or dropping'au ()l)le ct ()n the foot, it is I u-at s

irnport:urt tr-i consic[cr ii:lctur-e ,.,f the itlpactct] boitc.

fbilt conrplaint. l'he prlrlliln ('luLlll t'clrLe l\ Jt thc first

\1-l'P loint. 'lhis is sur-tgcsti\c ol hrrllrrx rigi<1us, eslrc-

\dhen a sudden pain is fclt fbllorving landitrg on the birll

or ireel, lrcrurc sliould be suspected. Asudtlcn propulsit.r (such as quick, forceftll prrsh-ofTior a splint or lump)
rnav on occasion cause it spirai fracttlre oi the fiftl-l
rrietatars,. \,!helr tire parn is Iocated t tile first roe. it i:


iinportant to dctcrmine whctl'rel there u'as a h1,'pcrextension or'.r hrperf-lexion olthe tcie. c:rch of ii'hiclr is suqgestivc of carsr.rlar sltrain.
With anldc injun, it is alrvavs imltortent to detcrtttine

the position of the fiot: riantarflexed/inverted (


nedirl stahilizinc liearnents). It is ertrerleh itnportant to rlctermine the abiliv ot thc patient to betrr ri'cigl.rt, and the
degrcc: and onset of su'elling. Ai of tliese rrre importent
screcning questions and olrscrvations in riettrrnining the
neerl for r:rdiogr:rphic scrccning tbr fracture. (icncrallt',
the inabilitv to bear rveight associatcd u,ith sienif-icant
srvclline correlates u'itir t-he tlesree of ilarnage.
(Jverusc ir-rjuries are oftetr subtle. It is itnltortirnt ttr

stabilizinr ligrrents) or dorsiflexeci,/cvcrted


dctermine rhc npcs oishocs rvorr bv rhc paticnr ancl thc

trpes of qround srrrfaces encotrntered. It is itllpor tenl in
tlrletes to re\iieu thc specific retluirctne nts of the sport
and the abilir' of the shocs to accoltltr)odate. I lorv tllterl
<lccrs the athrete replace \\'()rn-out shcesi N1artr' overtrse
ini.ries s'ill be uncovercd as a shoe problcr, (torl fleliible
or loss or lack ofsllock absnrpticln): too soft or too har(1
a .{rorrnd sur['.rce; or, rrt the exalnitratirll-t. :rn unclerlying
r.ams/r,algus deforrritv oithe rerfbot or foretbot. If t-llere
is an underlvinq Lriorrtechanrcal pt-oLrlcnl' the rcrl'rctitir-eness anci freqtrencv of participation 'ne corne irrtportar-rt


u'he r cirrsiflerion is stiii ancl painfir.. \1'he rr thc

paticnt conrplains of ankle stiflness, it is irnportant to dr:tcnnine rn'ilether thtre is all\'ssociiltc.l reirl or cr-crinrs.
Pain suggests rttechnical irlockage frorn l,rr or- ca1cane,tl exostosis or scar tissue trctn I prcvious ankic illjrrn.. \\'hen dorsitlerion ol rlre nk]e is lirnitcd, colrtracnrrc
of the,tchilles is iikclv; hou,ever. sotrre cqltinus deiilrmi
tr.r conger-rit:rl rrtalbrr:ttior- of the tal'sal borres:trc
possible.-l his is dilltrcntitecl ttt tlte erurt thro',rgh post-f
isonie tric ettcllrpts et itt cre:rsi rt! tllovcl 1lel1t. he r:r t rrrr t
rlav also clairn that strctchir-ri
there s irtr unclerlr.itrg
posrtions icel lrlockcd, the eratnitret.should bc clirected

ties -iuc

to te.t li)r.i(cLs\r)l\ nlotlr)t) rrlrictloll\.

'l'hcre are nunrertllts cle rtrzt

Superficial Complaints
tolosic cL)lnpltints of the ieet. It is iniportant hrst [t. cle

tcrrnine u'l.rethcr the patient is


Muxuloskeletl [omplaints

betic or


p.rrrant to ask ahoLlt shre tvcar. Black toenails lld othcr'

cotttpre ssive conseqrleltccs .rc conlrllon u'hen tire shoe is
too short enrl thc patie Llt is athietic. Fulrq-a infcctj,rn 1e
t\.vcen the tocs i,r colnnlrn atrd is usrralll' respollsi\-e to
trte dictions. J-he pitient shotrld lre
qucstioncd regardins shou-eriuq in pirblic lcilities, thc
cnvilonnrent of the shoes drrring xctivin' (are the shtlcs
tlade tf a rnterial tllat "lrreathes"i)' Ild hog hoU:u'cll'
thc f-cct llccome rvitlr aetrvitt. {il tnrn'he pretiisllc.'sitit.'rlt
for tiureal gro\r'th.
\\,'hen thc parter corrrplirrs gt defbnlitl,, the loction
ls oftcn patho{nomonic. r\ b:llion xt the first.\'1'tP in-


,,licates h:rllux vaigus.

m:rv be Less appreciable dirccth'

hut inrlirect,v er,ident itecanse ti-re tr:les crltch on rugs or
-I'his indicltes
hit a curb or step rvhen clilnling stairs'
neural cornpromise, especiJlll'u'hen the condition i5 rrlr-

W'eakness \\cakess


srgns,/syrnptoltls sltggcstive of rlil-,etes. Next. rr rs il'r-

Bonl'llrotnrsit.'n rt thc ntet'irlt'all

lr crostosis. llefornrin- t the
sts lfaqland's dciirrnritv (prornitrent

kle is ofterl tlue to ta


rior heel sLrgge

poster()superi()r later1 borCer of thc calc"rntus) or ir l)rlnlP

tunrp (associated t'etrr crllc'.rncal Lr u rsa )'

l{urbness and tingline on the l-,ortorn of the loor

should suggesr nerve root or peripheral nerue cor)pression.It s again important to determine wherher the parienc is diaberic. lVhen the s)mptom is on the lortorn ol
the foot, an S1 nen,e root probienr (especiaily when associated w,ith lorv back pain complaints) is likely. \V1-ren
the nunliness/ringling exrends ecross the bortoln of the
foot, trrsal ruilnel svndrotne due to poste rior'ibial nerl'e
conrpression is likelv. This is often associated rvirh iin
overpronated lrrot. !\''l"Len nutnbness occurs letween dre
toes, interdigrtai neul'itis de to tansverse (:ompresslolr
of rhe metatarsals is likelv. This


often rlue to too nar-

a shoe,


Foot Prior to e xamining thc feet, it is oten helpful to examine the parientls footwear. Tf the parient is rrr
arhlete, it is inrportant for him or her to bling in trlinLng


I-ooking at wear paerns on rhe shr,e ma)/ lle helpful. (ieneralll', he normal wear parterfl iE at rhe all of e
ibot and at the lateral heei. Excessive lateral wear at rhe
heel coupled wirh a caved-itr appearar.rce oite inside of
rhe sl'roe wor-rld suggesr pes planus, die olposite lor pes
carrrs. The inside of e shoe should be exmined to determine whether arry irre.gularities may act as frictior.t
source.s ro the slon or underlylng tendons- Check the
shoe for flexibility and shock absorption characteri-sucs.
1s *rere a finn heel counteri The fir oir,he shoe is also impont to gauge while the parient is standi-ng. Is r}e'e sufficie nt toe roorni Is rhe shoe supportive ol dre medial
Ionginrdinal arch? Does the lacing fit tr:o rightJy over the
rlus or extensor tendonsi
Nhch can be gained t}rrough observation of thc foot.
Look lor indicarlons of wear anri ter on rhe ibor. lf hese
are often cles to variotls foor delbrmities.


Clalltis or corn tormation at

tIe dorsal aspect of,re

proxmal interphalangeai (PIP) joinr is 5s wirh

borh hamrrrer toes (tiexjon deiormrry of the PIP

foint) and clrv toes (dorsal suhhr"xarion of rhe MTP

join$. A callus is alst lound at the plantar tr'TTp
joint with clarv toes. Maller toe (flexion contrilcrure o1'the distal interphal,trlgeal [DIP] ioint) causes
callus lormarion at e DIP ioint and clistal toe'


Bunion developrnent on the mediai aspect olthe rst

A4TP joint is indrcarive of h.allur valgus
Bunior development is also seen on *re fitrh il'1-i'P
joinr and is referrecl to 2s a tailork hunion r:r a
lurrionette. It is ofte n due to fbrefbot valgr:s'


forrrrh melatrsal hcads is found *'rth lorefoot vrus'

Callus fr:rmauon rnder *le frrst. second. and somenles third metatarsal heads rs fr-rund w'iti'r fbreloot



ti.nde r dre stccnd r-hrough

third or

If the patrent is corlplaining of nr"rmbness and/or tingling of e foot, a searr:h firr neuraI irritrion tegins urttr
a rest oInerv'e root inte$"ity wi dccp te ndon ref]ex testing and senson' restir)!f. The toot is pnrnarily inerr,'ateil
by the L4-SZ ner:l'e roo. If irlract. a search ibr locai ner-r,'e

irritation tocuses on the pstient's ]ocalization. lVhen

there rs nunbness/tingling on tie hottorrr o:re ftlut,
ltinel's test (tapping) of rhe posterior tibial nerve behind
the medial malleolus rnav reveal tarsai tunelslricirome.
che location of the s),rrrptorn is more in re toes (pos
'I-inel'.s test rs pe ribrnred at
sible associted motor loss),
the anterior ankle t tlte anterior ribiai branch oflhe deep
peroneal nen,e . lf the ratienr'.s s14'nptorn ertends i'orn
the medial i<neg down through e medial foot, ttqurru
widr coinplessto. at rhe adductor turtlnel or Tinells test
perlonned below the rnedial joinr line of e knee nrrv reveal sarhetri:us nerne involvettent. if scttsaliort ts cle
creased benveen the ilrst trvo toes, the deep peroneal
nerv'e is comprolltsetl. If chere is nrtlnbness I'retu'eel tlle
odrer toes, interdigrtainen'e coirpression is likelv. \&'herr
there is pain and rurnbness and dngling on Lire Lrotton
of the ball of the lbot, ral:atiort ior a neuroma betrvcen
the second and third or drird ,rnd iburdl meutarsal spaces


sirould be perfbrmed. Passive e-xtension of the toes ma,v

increase rhe complairrt, and some relief ma-v }:e provided
by passive fle"r-ion.

Deterrnination of forefcrot and rearfoot valgus and

vams is usuLl,y peribmned r.rrth rht padent proire The opposite leg is brought into flexion on the rable to neutral-

ize rotatior.t of the exanined extrernitv. The initial

positioning ol the foor is an atrempt ar iinding sulttalr
i',eurral (Figtre 1a-3). The approach is described generallv in two 'i,',tru,

1. The foot is grasped at the fourth

rrd I'ith

tnetatarsal Iieds ancl rassiverlv tlorsitlexcd unill resistence is felt' The foo is llen supinated
and pronared tultil point rs lourcl r'vhere sllghdy
rn{}re t1rover]ie nt il] e idier ,lirection r:auses dle

talus to "[]l


otre side or *re other'


is rhe r:errr:l pt,:ition.

2. The ioot is grasped at the lrurth and lti ith

mcr.rt,rrsal hcads anr-i distractcd downr'at'il tci
rentove dorsit-lexion. The fo-rt is then passive ly
lnverted and everted while the erarniner lalpates e talus *'ith *le rhurnb and middie finger.'I'here will be a pt-rint rrr *'hcir the alus rs
tclt oy borh thumh and fin{er or not at a1l i:-v cither. Tiris js he lle-ttri losltion-r
a derermiration of, rhe degree of hindlcror
varus nd vaigus can be deterrlined by cotrnectrne in
tersectillg lines rough e tibia (Achilles) and *re calcaneus. Iirhe caica,reus is rvihin 2" to 8'civaus' the
ieg-to-heel alignnrent is nr-rtnal' When the heel is inuJ.,*d, hin,lfoot varus is presenl:; rf everted, hin<lfoot

At this point

oot and Ankie



Figure ! 4-3 Neutral Position of Foot. Palpating the

talus with the index finger and thumb,the examiner
pronates and supinates the foot until the talus is felt
equally by both contacts.The fourth and fifth metatarsal
heads are then passively dorsiflexed.

ular rubelosis posrtion is markerti Dn the caf(i. 'fhe patient thel bears his or her u,eighr onto tlle k-iot anii the
distnce berweer tire ciriginal rnar-k and the mark oi the
new navicular: tlrbercle position is lneasured. (lreater
rhair atrout 1/2 in. implies a h4rerpronaterl lbot.
Ratiiographic assessment oi rhe fb'rt is dicratci.j b.v
whetller the intention is r search tbr tracrilre rr rvhcthe r
a biornechanical appreciation of the firot is desired.
Fracture is usualil' evi denr on non-'eight-beari n g vi eri''
l-l're stndard series consisLs oi an rrnteroiro,stcrior (AP
[dorsiirlantarl) vien', an o'tlieue (laterai aspect of loot etevated 30') vieu,, anci a ltera1 vjerv. On the AP vier.v, the
fire ibot and part ol riie niidioot are 'o,eil visualizecl.'[-he
olrLrque vierv gives en excelli:nt alternate perspecrir,e ofrhe
rneta ta rsals" The a lonavi cuier and calcane,;cr boiil joints

nd sius trsi are also iiern,ustratrd on this r icrr.

(laIcineonaviculrr r:oa1ion (bonv brirJuing) is lest seen

on the rnedial oblique rierv.'l'he lateral vie*'is excellent

fbr vierving rlre calcaneus, talus, navicul.rr, cuboicl, frrst
cuneitbrrn. and head oithe fifth nrettasal. In addiuon
to fractures, bonY e,\ostosis rnav Le seen on the talus, calcincus, or fidi mctatarsl heail. i\lclidrinlviervs are de
signed rc r,isrralize tire ph:rianees, sesalcids, calcaneus,
rr:d t lus.

if he inrention is to obain a lror'e functional per

spective rthe lbot, u,eight-bearing films are often used.
Numerous lilres of mcnsuritior are nsed to ei'aiuarc hc
biorlechanical rclauonship otrthe foot. on drsqe l,irt s, .l
dcscrirtion oi which is bevonil thc scope


is preselrt. Through rht use of a plasuc gtrtiorle-

rer placed asairrst the metararsaj heads, the tlegree ol

fcrefoot valgus or varus should be measured.
-l-he patient can also be e-rarnineci tlom behind in thc
standing position. The angle formed by e lowcr ihird
of thc AchiLles end dre calcaneus can be detcrrnined, indicating statically a tendency tou,rcl pronarir:r-r (hindfbot valgus) or supinarion (hinclfoot verus). \}',iren the
patient is sketl to rise tnto his or hcr toes, a rnetiial longinrdinal arch shoulcl tblm. If *rere is no rch in rhis posidon, tarsai coa[non (frbrous or bony connection beoveen
arsal bones) or rupnlre of dre tibialis posterior te ndon is
likely. \iarious fbrr.:s of navicular posiriorinti testing have
been suggested. One is the Feiss line. 'i'his lile repre-

oithe rnedil mlleolus nd rhe length oithe frrst metatarsal.'1-he navicular

ruLre rosir, is risually at a point along thrs line. \4''hen the
patient stands rvith equal rveighr beveen the i-eet (abour
in. apart), rhe nacular should remain in close proxnrB'
ro dris line.'I-he f arther it rjrops away, the tnore pronated
rhe rnclividual. A simrlar test is the navicular drop tesr
(Figure l+4, A and B). A parer card is placed alongside
thc fbot rvith the padcnt not bearing weiqht. Tht n'rvic'
sents a conr)ection beu'een tlre apex


[.4usruloskeletal [omplaints

r--i this text.

Ilor.r,cver, the lnos cornnronlv,'used is the (-r'nl"i linc.'
On 'c lat,:r'al vicrv, th.e articulaion be&r'een the ralonaviculr ar,d calcaneocuboiri (L.hopartls jornt,) iorrns a conLinuous S-siral:ed [ne. A break in dre iine anterior]v at the
tlus indicates pronarion; a break posteriorly indicates

-I he

'l-he ability to bear rveigirt is an irnportant

scrcenrng m.lneuver u'ith ankle srrains. if the peuclt is
able to bear weiuht, palpanon oispecific bonv landnarks


incluiiingdre malleoLi, nacuirr, md cuboici reaswill help

hr nkie ls tesred
derennrne rhe need fbr,,qraplrs.\
prrnariiy fol subiLiry'l hree tesls are commonlv used. The
firsr is the anterior dr-arver test Frgurtr l4-iA).
is perlbrrned rvirh rhe patienr supine and thc ankle rlantarfiexer] 15" to 10".')'l his position places the rttcrior
tal,i'ibular ligemenr perpentlit:Lrlar to the dhitr. '1'he cx
rliner pulis ttrrwilrd bv srabilizing ol Lhc rnttri{.rr rlistai
ribla rvith one hanrl :urrl tire cher hand irtrlls forwarri
while cuprirrg the calcaneus 'rosterioriv. \{'hi1e analogous ro thc nterior drarver test of the kr:ce, hc r-rore
is being resed in rhe anLie.
ar inversion sprain the :1nlerior talofibLilar Iig'a'
rnerrt may be dalnageil.l-he anrerior drau'er test rvili rcveal sorne.laxi,rvhen com:ared r,ith the opposite ankle.

crllaterl ligamentr:us svstenr


Tr e liniinate stabiii-tion


the;\chiIIcs, testrngu'irh




Navcula Drop Test for Prontion. (A) I he ptent's navicrrlr tubercle is marked r;irile the patient
not bea ring weight. (8) The position is then again marked wh en the patient bea rs weight onto the foot. lf t he differenre between marks is greater thn 5z! in., the patient is probably functionally a oronator.

ri.ffiL]; . :.


Zflt. "11'1., (:,:::::::/




: ..-,.::;;t,;:!

@1r. ,:.11.1!lryg')
i."-.......... . 1/1,#.,'ffi i
: :\v ". /.,/" - //l!,//"#
:,::),: t l






14-5 (A)The Anterior DrwerTest.Witl'r the kree fiexed and the nkle flexed to 15", the exanriner stablizes
while pulling forward on the caicaneus.(B) lnversion Test for Lateral Ankle Stabiltty.

]Ilay be rlrorc se nsilive. Ithe zinin

ciorsiile.rion, dtlnrage to l.he colunstablc
l<Le is f'elt to be
ralar rilt
ligalnerlrsis iikel-v
test rs simplir air illrersion stress applicd to rl":e ankli:' Tire

the lree in



fest oosinon is srde lying wirb lhe paricnt'.s lo-rlee fleretl

90o ivith e hnds cupped r'or.rnd thc ankie, rnrlaitlrrg
an Lnversion lorcc (Figr-ire 14-5il).'lire taial tjit tesis tt'r
integrirv of lhe caicaneofiirular ligarlrent he Klergcr-test
r, ,,i..,., rion test o[ the ankle \\''itir the peent -se atcd

exalrillarion table, the non-u'cight- E'earrng ibot is

everted out to rest for'*re ntedial deltoid iigan'rent conlplex'
'.lhe stabiltzing fur-rction oi muscles
dle prcserce
of tenciinitis
ment patterns coupled v"ith stretch pattel"ns' Ns{" retchcd
sisting tJee rllovelilent pattern strtitrp' fr'.,lm the srre

p,tsion u ill L'eveal te;.ltlllIi.;s not e!'iJe Iit


rreLrtral pr''

sitior resij irg.

Dr.,rsieion/cvet-tioti--tnai-nil dte io ilie p'roneus; stt'etchi ng :ntO ,iant;lt)exlon,lj llr'erst^n rn;r
aiso incr:ease pain.


fl eri orlr'inr,e:si


in g

o): r stretth

ll:o intrP(e

cl Lhe


ciors ifl c;rl


e t i L'i:r

/cr-ersto n




Plantarilerioll/evcsiorr -nainlv clue to ti''c peroireus lonqus atlcl llrevLs: srretcl-rrng irrto llanta i'f'lex

on---main it' lue tr.l dl

ion usu


I' is nlore pa rn ft' I tllan iiorsr


Piittart'lexion/inve f-sion mairliv t-lue

ia iis rosteritlr'; stretching inro clorsrflexiol
incicase Pain '



t1''e ii-r


IootanciAnxle[onlPlairts 391

changes, yet rhese conciitjons rvould rarely present solelv

Radiographic assessnent of the ankle is prinariiv used

to l-ule out i?ssociated fracrure. A.nJ<1e injury ls extremely
conrrnon, vet olly 15 ? ol patient^s will be ibund to h ave
a iracrure. J'he authors of the srudy have estimated drat
appro-ximatelyS500 million is spent on ankle radiogr-aphs
in the Llnited States nd Canacla each vear" Accordin g to
riis study, ilrhe rules or guidelines lvere uscrd, ere could
be an cslimated savings of over $i00 million rvithout loss

heel pain. The pririraru distinction ben,een [rt pad

svndrome anci plantar fascirtis is tl're locauon of tenderness. Far pad tencierness is direcrlv in the micldle of rhe
heel. This tenderness is decreascd bv sr.ueczing the boLtorl of*re heel togethet'and pressing over [he srn tender area. Ii.v squeez-ing the heel rr.gcdrer, rhe renrainrnq
far pad is approxirnated, providing tnrre cushioning; terder:ress should c{ecrease substanrially. PLantar fa:crrs rr

of qualiry of Due to many factors including

the fear of rnalpracrice, patient demands, and habitradiographs are ordered on the majority of patients. The

painfu1 at rhe rnedil heel lecause of rhe anach.inent to the

medial tuberosrry of rhe calcaneus. Pain or tenderness

rnay be increased through passive rension. Thrs rs ccomplishcd b,v dorsifleung'e first toe and, if nor p,,sitive, adiling dorsitlerjon oi the anklc. '1'lre pain with
plantr js tfter across the botton of the foot
along rhe rneditri )onginrdinai arch.

re am of phvsicians rvho designed rhe Ottawa Ankle ruies

found that t}e only consistent (sensitive and specific) histc;ry and exanrinarion finding's [hat wcre relevnt were
pain in the malieolar region and elrher (J) tenderness ar
either malleoius or (2) the inabilitl, to ler weight irnmediately after rhe injury or in rhe ernergenc.y- room.
For he micl-fbot, rhe relevanr findings were p:rir in the
urid-foot area and either (1) tenderness at the lase oIrhe
fifLl-r rnctatarsal, (2) tenderness at the navicu[ar, or (3) the
inabiliry to bea r w eight immediate jy after thc injur.v' ,-,r in
the emergelcy room.
No significanr acrures rvere missed rvhen Lhese rules
rvere usecl ar t$'9 12jg hospital enrergencv deparulents
or ourpauent clinics evaluating over 2,300 adults. A signif:cnt fracru-re is defied es Brerter than J mm in bredtlr.
Manl' 5r1 rnalleolar tip fracmres do not require casng

Radrographic exanrinetion is *'arranred if there is

trar.ura suclr as landing on the ieet, ii the patient is an
adolescent (Sever's disease), or iI there is a history of
rheumatoid drsease. Racliographs for pl:r.ntar fascrius are
usually misieading of the appear'nce of a heel
spr,rr. The heel spur is ialselv accused of [-,erng the cause
of ihe rarient! pain. Resoluticn oi pain rvithout changes

in tire spur is rhe usualcourse oievenr.;.lr is believed rhlt

the spur is a consequenct cif:lantat fasciaL tensrotr rather
tha.n a cause

of planrar fsciius.


or pinning.
Ilesearchers in a recent stuclv used a modified version

of rhe Ottarva Rules, called dre "Buf[a]o" Rule, r]iat

srvrtched rhe site of tenderness from the posterior bor
ders of rhe rllaieoii to the rnidline away lrom iigarnent attacbments ro avoid false-positive responses.l2 Of I51



Traumatic lnjury
l,{ost fl'acrLrres of the frrot and nkie should be re^
ierred for reductirr arcl rrsting. some e-rccpons

patients, there u.'er-e clinically sign itlcant lractures.

Sensivirv fo the alkle rvas l009zo, ,"virh a speciflciry of
40o/o;specificiry lor loot lractures was79o/o. There were
no lalse-negadve re sult-s. Potential reductior.r in anl<le Xrirys \4'r',s 4%; for foot x-rays ttwasT9on. Standard vreu's
include an AP, a laterrl, and a morlise view (AP wi 20"
of internl rotatron of e ibot). Suess riews rnay be indicated when there i-. a need to distinguish berweer a
single-ligairent and a two-ligamenr injury. The ular ril

include slall, nondisplaced :lv-ulsion {ractules at

the fifth metatarsal c laterai maller'lus (period of
immobilization rnay be nee,led) anci most toe iractures. ri'hich can be bLrddy-taped tor 2 to J iveeks.
Sprains oirhe I4TP capsules can he ntanaged wirir
a:rrri1:riate r:rping, nuld mobiliz:ltion, and suppori

Ankle sprains are rna:raged basecl on rhe degree of

iniun. Even hrll-hgarnent r.l)ptule (third degree)
car Lre inanagecl consenativelyu'i a castand grad-

is rhe degree oftopenrng betu,een rhe ubia and talus rvhen

srressed into inversion as vieu'ed on n AP vierv. More
dlan i0o of tilt inclicates in jurv to the anterior talofii-riar
and calcaneofihular ligalnenrs (posive predicnve vaiue be-

rween E,5% and 99%).ll The irortise vieu, is lieiphrl in

revealing rsteochondrai fr'cr,re of rhe talus (seen less
clearlv on the srraig'ht AP vien') ad cliastasis due tc, inferosseous memlrane rupfure beni'een the tibia ad fibula.



is between

The prin.rary clif{rendal of plantar heel prr

plantar [asciius ancl fat pad syldlorne ln pa-

tients u,ith a [risron of rheurnatoid conciitions, radiographs may prove helpful in detecting ciraracttrlstic


lvlusculcrskeletal (omplaints

uated return to weigirr bearing and actrvitt, althoush

corlangernent or preoLrs erpcrience is suqgestcd
prior: to lollowing rhis approach .Table l4-l).

Overuse and/or Biomechanical lnjury

Overuse iniuries are often treared slrrlpt{)rnacall,v-.

rvirh ict:, tnvofascial srretcLriitg, nd modihcation
of .rcriyiry; long erln lnanage rrr.ent inclr-rdes rnodificaf;on of lctlru,ear, terrain, nairtenance of prt'per
access'Jry lnor'ion, tuncdon'1 tra ininf of suPl)ot1rr''c
nuscles frcusing on ccceurrl( ur collccntn'-: neecis'
and possibrle pre.scriptior, of orthcc sripport'



Ankle lnversion Sprain Rehabilitation



ol Sr,;ellin,thsderresed;soireidtelnocssi[le xie rit,,,rlh nversron sire,-..

Laterlanke:v''e rnq sdependeni

,jeqree oiinjur'y,r;rn nd
in:1brirt'l l,lund,ih







1!ir)ion 5!ie)5.

lkie nver-

:ion lies;rdiogpir to ilie oui

lrci ie


fied,;ie ilreilinq ,rno p,i n,avoio





[uii weiqhi berin,

lhe rst 0frflrt,.he! dnc


thr rlie.ior
f/ lnderl'tinll pie,j:iroii 0fs,










1lidomerrtrenoleviderl0 I"r0erliyaieliir0i0rroii::Li,ii!,drrI'

rup- rd]oqrAD,h.

rr; ..;[trigil;eiiitg thittf iieet

metall5;i), btlirr{"}le itqaiireni

trie,0r:iorel {enlon


Prli wri!lht

;rleinJl Strppuii

bernqposlible;rtLjur fui ,oreighlcearrnr'riiholltlilcel,no

nextstagen(ludingapproxi- toninivrellinganpin,1-ld'ii.

swell ngevrdenl.[ull






mate time needed


Ea:ea on ihe de0ree ci


iirOr iib Ct(menl


tlr o tibil

(cptoute sstsl



1)elerirne reed ior n,

ii,:nel i'id




4,1;r:l nq

p0!rii0l 0[ rnjrirt-d0i!i' exr0ri

eversir:i',) my



3-5 rllcay


[rr 2U


( hoirr rn


eftrr erlivit';iombrnlro





bei,r,,etn),rest,elevailon,Till5or souni/E[1Si]Utir'.r;,1-i!

(hrgh-vclt galvanrc


80 - 12C llz wlth rte for 20






-)x'si aai)

Air-\giiIt0r()penrJibneytypecf,:ntrle Air-5plinlloi!ale

r,',ialkrn.; wilf l0 Lru(hilq onlv
calsrve R0lvi



cr .l n brlot spiint, iru ti



cf graduai'r.reight bearlrrr;
S/.i'5 iruaio be,un ',,!ith lhe plre0i

irguir oi-elqhielasili0n{lqe!Lr00crt

wened oli (rutihes a foer i ^ 7

'r' rth 'ra

ikinq il r ecelsa ry,

)iloril Jrivir

la pin,.



[ontrne iiri'citiliQ w1h ircf i',oineiri(



prcath lo ttrelchrnq



lvlilcj rsonrelro i""


il0r flexicr I atiii iiibrnq exercrle: ioi'.]oi; lle;lrrr:

ndeversiOn;cltiveirNldiqciil nda\eritr-'e i:liPl'it^'lt li




patiensrside-ly ng:trar,-tht



icr peronea : .n'J hic


rliti w".-leggeolorrar:esnohil loeriieirl t,n:l tts, tdtr.t

0osed-rhainexecise l.lone.


pro prioceptive



toui [ing w rh


tt h


(onsiCer weiq l-rt lie; rinq



Pi0q restirrrr i0







i nq P f ra ie!


ilrQi' '!i'rr l;i in;

[heikorrekrleis0if]tpbdullcr!; 5hr-ieslunoLliCtort0'lrrqrJlrl ''lrlfrrii'irrir'-l





iiOeened ne'-essary

n0 su/eliillg hd! ctrrease0 enorl';h

for tlstinE

uriih srade

PNfipronriOteptire nt,],5lr





;rrc t'tr'; 'Q


toot anrl Ankle



Sress ficrures can be m,rn,rged li'imrnobilization

u,itl-r non-ra' bearing f'or 2 ro weeks, derenciing
()n actiliry levei; aeroiic conciitioniirs rlray L.:e con-

tinued with nol)-\1'eight*bearing ;lctivities {e.q,

pool running').

p1,s1,g nranagement i'or alkle sprarns includes

isornctric tr-ainir.rq of the peror-ieals, hip a'Lrd,-rctors,
and i b i alis an ter"i ol r'i th srretchin g o f the Achilles;
plr)irrro( cp rivc :.r'-r in i : g usi i r,: t.r rin g. rr n rli,rcr'p
tive neuromuscuir f:iciIirtion (PNi!') techlio res,
or'Lr.rJncc cxeicises with blirnce bornl-s.

Paie cil'-rcatior-r rcgarding pioi.rer seiecrior

shoes rrnd irxrt l-rt,gir:ne is an


ilnrotant tool ly rvhich

to alord iutur e pr,rbiems.


fur in-clcpth disclrssion oishoe clesign anci l)rescrrptron

beironri rhe score of this tex; however', some basrcs cr

-l-he hcel counter-shoLrld ir,r


p and

fiim to pro-

vrde sta bilitt anci cr-rshioning.

Preventive Management

be reviewed (see Fiqure l4'').'f'he crrrn:ron-h,uscr,-i rer-rrrirrclogy ard nlexlrns fnr shr:e consrnrcl-ion are es [ollo$,s:

'l-he shalk

shr-rLilr,i ire str-ong;lncl shoulrJ not del.)rm

wi.,h we iqht bez'rrirrg (rhe shank rcprcsents tlre pr-rrtion ol'r dre bottorn of rhe shoe iirt ct-rrespond-s to
rhe nredral lon ginrd ii'raj rrt: h).

r l'he

toe [ox .should be enola-h to avord

comprcssion of thc rncti.,ra rsa ls.

r 'i'he

shoe shoLrld l.,e long e nough to evoiri comoith.r roc.c f ihe enci ,f tl'e ,:c Lrox.


I l

Lr-qerl ;1 2 -spo:-tin[ ct]\'rty: he siroe should be

sp"'ciil(r tr tllc sport.

'I-he moiti r-rpi:n i,"'hich ihe shoc is consmctd is rcferred to -( thc iasr. l'her:c lirc essuntialll, tr,.,o rypcs,
srrargh r iasr ancl clrn'etJ hrt."I'l-,c sraight last is better
design trr ihe pronrrecl tbot. The curl,ed hsr clesign is ior

14-6 Components of a Well r\4ade Shoe.rhe heel rounter should fit st-,curely (lt rnay be
necessary to balance Flaglund's Deformity wlth felt),and its bisectron should be verticl io the supFigure

portingsurface.(Poorqualitycontro oftenallowsforanasymrnetricalheel counterthatiseitherin

verted or everted relative to the table tcp; see (A).Also, the sirank should be able to !'esi!I forceful
com p ressio n w thou t deform i ng (B), a nd it sh ou ld be a ng led i n s uch a way th a t ,h en tn e h ee I sea t i:
compressed (C), the planiar forefcot lifts no more tfian fevv nrillimeters (D). (AP instability is present if the forefcot rfts rore than this,)-lhe toe box sould provide ample space so s not to ccm
press a dorsorredil or lateral burrion" lf the patient complains tirat his or her foot is slidirrg forward
on the orthotic (whch often r:ccurs when heel lifts are used), a strip of adhesive feit may be placed
alonq the undersirrface of the lngue that gently presses tlre foot posterioriy nto thi: orthtic,
thereby preventing slippage arrd irlproving control.


5or, e: T Micf-,a ud, i oo O" a n<t Ai'rter { or rns



Musculoskeletal ComPlalnts

oi icn:e

r'.'a ii'e Foci Cort',

)24,A lrcjl ,I i',1i'lhucl, i'jeu',tcn

a foreloor angle d medialll,. This shoe design is betrer fbr.

the siipinated foot and./or those r,irh hallux valgrs. Ther-e

are generalll, three rvpes of lasr construciionj (1) rhe

b,:ard-lasted shoe, (2) e slip-lasted shoe, and (3) the
:ornlination last shoe (Figre l4-7). l\4ren a pailenr's
ib,:t rs,-severely pronatcd, rhe boarci-lasteci shcie is usualli,
best because oIt]re suppor-t prolrded b-v a irard hbrous nrateriaI placed on the iiner s:r'fce of tie shoe. The sliplasted shoe is constucted by stitchirg the uDier into a
one-piece moccasin and ien glLring it to the sole. Tis
provides a iighter, rrore f'lexlble si'roe; hor.veve ii has less
stabiliqr. This shoe constructiou is probabl.v betrcr i'or
dre fiot. "lhe cornbination last shoe conirines a
board-lasted hee I with a slip lasred ibleloot, the best oi
horh rvorlds.'lhis shoe constr-ucLion is best fbr those with
reartbot varus or rnild pronators.
r\ prescripnon fol'or-t-horics rs oiten grven to rhe paucnr
u'irh fbot par..{ or-*ronc is a cievrce that is usualll'placed
in rhe shoe to accommodte ior biornechanical abnornraliries or tc cushion painlul ares. The biomechanical
ordoc can Le constructecl accordiug to individual need
or purchasecl as an off-the-sheliproduct. The rype. olorrouc is oftelr based on thr:.seriousness or complc.titt ,:ithe problerr-r nd the panent\ bilitv to Jlurchase the product. The three cornmorl r1.J)es oi custon.rized orthotics
re the non-weigirt-bearing, castecl orthotic; the nonweishr" bearin g, vacu um- a pp lied c-'r-thr:tic;

nd rhe wei gli t-

belring foam in.rpression orthotic. There is much

weight bea rin g.'lhe non-we ial'rt-treari rr g clst p r()ponents clajm that rhe fbot is castetj rri rhe neurai "perfect" "losition and th:rr the wpe c:i othotic ald the
[eesurements used in the prescriprion a]iow lor more
inciivirlualiz.ed approaches through the use oiforefoot
anrj rearioot postrns. Alsi, if dre individual has ex.,*osis,
bunions, or o*ier alnoru.ialiries, the orthotic can ie nrorj
ified to acconrrnodate.
There are generally nvo types olposrilrg, rearfoot and
forefoot. A rear toot var-us irn:dirl) posr is used to control or linrit the calcneal eversiorr anri associatecl internal rotdon oii: ubir shordy after ireel strilie. (Jf course,
the oppositt principle ls usecl th"r'earfo,t valgus (iaterai)
posting; ir is used to evert the clcaneus 'nd there lore
bring'the subtala:: jou'lt closr:r to the oprirral neutral po sltlon. For-e[<)ot var-us rnal' be cottrpensateC for" hv a neciial post, rvhereirs forr:ibot valgus is best supiror"teci by a
iateral post"'I'his is particularly helrFLri rvhen rerfoot
cornpensaLion occlrrs to ccommodate for friefoor al,rrorrna l ities. l{eel l i fts are occasicn a ) l-v used ibr' plobl e ms
irrvolving the Achilles renclon. 1,'ire n the ,\chille". ten
clon is trght, it ma1, x1ggnt the efiect ol re alibot prolr
lems. The use of a heei iift (3 t<,r rrul) rnl'decrease the
tension ol the Achiiles and Jrereioi'e its el"f'ect on rerfoot
motion. A partial heel lih, referred to s a nerjialor latera) r.vedge, mr, also be used ternpollrilv s r iirst'rt tcr
iest the leasibilin, of posting or patients who are I'eluct3nt to llurchrse the more erpensive cstecl orthouc.

emoonal debare as to the best wav to cast thc feet. The

forrrr impression orthotic supporters claim that it rs a

"function1" orrhotic uiving an rndiviciul trnpression oi patienr's foot in a closed-packed posrtion, The argument againsr *us approach is drat rhe f-ee t are cdsied in alr
inrperfect posrtion and llowed to spla,and elongate wrth

Figure l


suride n cnse o foot 1t,rin,
nontraLrmiic or insiclious onset of tbot pain,;rnd irl:ual
airkle sprain evaluation are presentetl in Figtres 14-8 to

Algorithms fbr traurratic or



Types of Shoe Construction (A) Board-lasted shoe. iB) Slip-lasted shoe .(C) Combination iast shoe.



5ourCe:'t. lichaud, Fcot OthoS:

and Ctlter i.c:rrnsf CCttetvAiivtlcrtf CAre.

126,(9 1997.i \,1iii.rirrl,i'ie''lt.tu1.1::iiintrseTl:!

ioot and Ankie

ComPlaints 395