Ankle, Foot, and Toe Trauma
By R. C. Schafer, DC, PhD, FICC Manuscript Prepublication Copyright 1997 Copied with permission from ACAPress
Background Ankle Instability Quick Screening of Ankle Function Gait Clues Draw Sign Talar Slide Test Lateral-Medial (Eversion-Inversion) Stability Tests Postural Distortions of the Ankle and Foot Effects of Chronic Ankle Pronation Roentgenography: Severe Ankle and Foot Injuries Heel Fractures Talus and Cuboid Fractures Classification of Ankle Fractures Fatigue Fractures of the Foot Stress Cysts of the Foot Arthrokinematics Joint Actions of the Ankle and Foot Kinesiology of the Ankle and Foot Dorsiflexion Plantar Flexion Clinical Management Electives for Ankle or Foot Strain/Sprain Commentary Ankle Trauma Contusions Peroneoextensor Spasm Disorders of the Deep Peroneal Nerve Achilles Tendon Injuries
Kohler's Disease Talar Osteochondritis Dissecans Tarsal Tunnel Syndrome Posttraumatic Spurs and Related Disorders Bowler's Spurs Football/Soccer Ankle Postural Distortions In-Toeing Out-Toeing Miscellaneous Circulatory Disturbances Circulatory Insufficiency Screening Tests Edema Volkmann's Ischemic Contracture of the Foot Erythromelalgia Black Heel Tennis Toe Articular Therapy Clinical Features Management Foot Trauma Heel Injuries Bursitis Foot Bruises and Wounds Plantar Strains Foot Sprains Toe Sprains Exostoses Heel Spur Metatarsalgia Plantar Neuroma Selected Disorders of Toes
Ankle Strains Special Concerns with Runners Trigger Point Syndromes of the Ankle Area Ankle Sprains Subtalar Arthritis
Flat Foot (Pes Planus) Ankle Fixations Ankle Subluxations Foot Fixations Foot Subluxations Toe Fixations and Subluxations References and Bibliography
The lower leg, ankle, and foot work as a functional unit. Total body weight above
is transmitted to the leg, ankle hinge, and foot in the upright position, and this force is greatly multiplied during locomotion. Thus, the ankle and foot are uniquely affected by trauma and static deformities infrequently seen in other areas of the body.
Ankle and foot injuries are common in sports, much less so in the workplace except from those caused by a fall or a dropped object. Excepting a few sports such as rowing, kite flying, and auto racing, the base of an athlete's activity is provided by the soft tissues and osseous complex of the ankle and foot. Ankle injuries in sports are close in incidence to that of knee injuries. One study shows 50% of ankle injuries during all athletics at one major college occurred in basketball. Soccer also presents a high incidence. The most common ankle injuries are bruises, muscle strains, tendon lesions, postural stress, compression syndromes, and lower tibia and fibula fractures. Bruises of the lower leg are less frequent than those of the thigh or knee, but the incidence of intrinsic strain, sprain, and stress fractures is much greater. Ankle Instability Jogging by the average citizen often strengthens the antigravity muscles at the expense of the gravity muscles --producing a dynamic imbalance unless both gravity and antigravity muscles are developed simultaneously. An anatomical or physiologic short leg as little as 1/8 inch can affect a stride and produce an overstrain in long-distance running activities. Ankle instability typically results when inversion or eversion overstress stretches or ruptures supporting ligaments. Quick Screening of Ankle Function
Bilateral screening tests for active ranges of motion can be made by toe walking to test plantar flexion and toe motion, heel walking to test dorsiflexion, lateralsole walking to test inversion, and walking on the medial borders of the feet to test eversion. To test passive subtalar inversion and eversion, stabilize the distal end of the tibia with one hand and firmly grip the heel with the active hand. Alternately invert and evert the heel. Pain during this maneuver suggests subtalar arthritis that is possibly a posttraumatic effect of an old fracture. Gait Clues Note heel strike, foot flat, midstance, and toe push-off of each extremity. When the foot slaps sharply after heel strike, weak dorsiflexors are suspect. On the other hand, fused ankles will prevent a midstance flat foot. Failure to hyperextend the foot during push-off is a sign of arthrosis. A flat-footed calcaneal gait during push-off is symptomatic of weak gastrocnemius, soleus, and flexor hallucis longus muscles. Pain in a foot during midstance may be caused by corns, calluses from a fallen transverse arch, rigid pes planus, or subtalar arthritis. Pushing off with the lateral side of the front of the foot is usually seen in disorders involving the great toe. Sharp pain on push-off is often caused by corns between the toes or by metatarsal callosities. Inability of a foot to heel strike suggests a heel spur and associated bursitis. During the swing phase, observe acceleration, midswing, and deceleration of each extremity. If the hip is flexed excessively to bend the knee and thus prevent the toe from scrapping the floor as in a steppage gait, weak ankle dorsiflexors are the usual cause. The foot will have trouble clearing the floor if the ankle dorsiflexors are weak or the knee is unable to flex properly. Draw Sign Tears of the anterior talofibular ligament produce joint instability, allowing the talus to slide forward (subluxate) on the tibia. To test for instability and subluxation of the tibia-talus articulation, place one hand on the anterior aspect of the sitting patient's lower tibia and grip the heel with your other palm. When the calcaneus and talus are pulled anteriorly and the tibia is simultaneously pushed posteriorly, the anterior talofibular ligament should not allow forward movement of the talus on the tibia. The test is positive if the talus slides anteriorly from under the cover of the ankle mortise. Sometimes the abnormal bone slide can be heard as well as felt during the manipulation. Talar Slide Test Excessive lateral or medial motion with pain indicates ligament instability and
diastasis of the distal tibiofibular articulation. The talar slide test evaluates horizontal ankle translation joint play. With the patient in either the prone or the supine position, stand to the side and face the ankle to be tested. Your cephalad hand grasps the patient's lower leg just above the malleoli and your caudad hand grasps the heel just below the malleoli. A pull is made with your upper hand on the lower leg while your lower hand pushes the patient's heel horizontally. Then a push is made with your upper hand while your lower hand pulls the patient's heel horizontally. Pain induced by these testing maneuvers suggests subtalar arthritis (eg, related to an old fracture). Lateral-Medial (Eversion-Inversion) Stability Tests Gross lateral instability results when both the anterior talofibular and calcaneofibular ligaments are torn. To test lateral stability, stabilize the patient's leg and invert the heel back and forth, noting if the talus rocks loosely in the ankle mortise. Medial instability is the result of a tear or stretch of the deltoid ligament. To test medial stability, stabilize the patient's leg and evert the heel back and forth, noting any gap at the ankle mortise. Postural Distortions of the Ankle and Foot Postural foot alterations can produce and maintain far-reaching effects both in spinal and pelvic distortions as well as distant somatic or visceral disturbances. When these changes are overlooked, symptoms referred to other parts of the body continue because their cause, being in the feet, has failed to be properly diagnosed and removed. The foot does not necessarily have to be painful to be the cause of postural imbalance and resulting nerve and muscular tensions in other parts of the body. It is well to keep in mind that a painful foot results in a protective posture and gait in which the entire neuromusculoskeletal system participates. A progressive distortion may begin in the foot and move upward or be reflected into the foot from above. Weight-bearing distortions in time may produce such symptoms as generalized fatigue, dull leg and knee aches, and back pain at any vertebral level but usually at a hypermobile joint near an area of fixation. To perceive the relationship between foot and pelvic mechanics, palpate the greater trochanters while rolling the feet medially and laterally. Femur rotation can be felt with minimal foot rotation. Effects of Chronic Ankle Pronation In-roll of the talocalcaneal articulation is a common disorder. When this is noted, remember that a weak foot is usually hypermobile. An associated chronic or recurring shin-splint syndrome often arises in the flexor group that may be isolated within the posterior tibial muscle. The most common cause of excessive
pronation is foot weakness and fatigue. The focal source may be remote in the kinematic chain. Local and Remote Effects. Abnormal ankle pronation features the superior aspect of the calcaneus tilting and rolling toward the midline, carrying the talus with it. This releases the navicular from its articulation with the talus and allows it to roll toward the midline. As the navicular is the keystone of the medial longitudinal arch, its downward subluxation results in collapse of the arch and the beginning of a progressive distortion that may extend as far as the occiput. Symptoms may occur only at the hindfoot, but a flattened arch is usually associated. Achilles Distortion. When viewed from the rear, observe the exposed Achilles tendon. Note its deviation with the inward tilting of the calcaneus. An associated tendon inflammation may be related to abduction strain, characterized by motion restriction, pain, tenderness behind the medial malleolus, and infrequently crepitus. Ankle-Lumbopelvic Biomechanical Linkage. When the arch rolls inwardly (pronates), the tibia twists, the knee strains, the femur rotates, the pelvis tilts forward, and the curves of the spine are affected. -- As the inward tilting of the foot includes the talus, which supports the tibia, unusual and downward tilting of the articulating surface of the talus produces an inward rotation of the tibia that extends onto the femur. This brings the greater trochanter forward and outward, chronically stretching the piriformis muscle. -- The piriformis inserts into the apex of the trochanter and is placed on a windlass-type stretch. As this muscle's origin is at the anterolateral aspect of the sacrum, the sacrum may be pulled into a classic subluxated anteroinferior position. In compensation, the gluteus maximus muscle contracts to resist the downward and forward pelvic tilt. Because the gluteus maximus has its origin on the outer lip of the posterior third of the iliac crest, the ilium rotates posteriorly, producing a typical pelvic distortion. -- With the sacrum thus drawn into an anteroinferior position, the vertebral body of L5 gravitates and rotates toward the low side according to Lovett's law to likely establish the beginning of a scoliosis. Thus, the biomechanical effects of pronation can be witnessed as high as the occiput. Aberrant Reflexes. The basic problem starts essentially as an inward roll of one foot or both resulting in lengthening of the foot involved with an automatic stretching of the plantar muscles. This stretching of plantar muscles is thought to produce many reflex patterns that can express themselves as sciatic pain, numbness, tingling and various other paresthesias --all of reflex origin. Abnormal Torques and Mechanoreceptor Effects. As the foot pronates and rolls inward, it produces an inward roll of the talus. This inward roll continues to have
Haglund's deformity. symptoms referred to other parts of the body continue because their cause. This principle is true throughout the skeleton. To record the effects of foot pronation. Drop a plumb line from the center of each patella. Ordinarily. inferior 2nd--4th metatarsals. Tenderness on pressure and "fiddle string" fascia that disappears when the foot is rotated to its outer border will indicate a degree of pronation in an apparently normal foot. The thigh abductors and neck flexors will usually be weak on the side of a weak iliopsoas. then repeat plantar palpation. superior 1st and 5th metatarsals. In pronation. When changes are overlooked. a tailor's bunion on the lateral 5th metatarsal head. the fibula follows suit with the torque continuing through the knee joint. and palpate the plantar fascia for tension. Rotate the foot to its outer border and the knee laterally. Do not miss checking the inside of the patient's shoes. posterocalcaneal torque. Evaluation and Mensuration. Bone design of the foot typically conforms to the habitual mechanical stress that exists at its every weight-bearing point. and a lower inner longitudinal arch will usually be found on the side of the weak iliopsoas. a foot pronation problem should be an early suspicion. the bob will be near the medial malleolus. In each case. medioinferior navicular. and flattening of the longitudinal arch. Insert an index finger under the inner longitudinal arch to a point midway under the foot. internally rotated tibia. here being in the ankle-foot complex. inferior tarsals. Each articulation is designed to allow its component parts the best possible range of motion to normal balance against gravitational force. lateral deviation of the Achilles tendon during weight bearing. Also keep in mind that the shoes worn to your office may not be those commonly worn. Other Biomechanical Effects. the bob will be in the approximate midline of the ankle. Normally. A corn at the 2nd metatarsal head. Associated foot and ankle signs include a lateroinferior cuboid. measure the amount of knee rotation by placing a mark with a skin pencil in the middle of each patella and measuring the distance between the marks. You may find that the source of pain is a small nail or thorn that has penetrated the sole of the shoe.an inward torque on the tibia. producing a sustained torque to the femur that then allows the lesser trochanter to displace backwards and laterally. if the psoas tests weak. This produces microavulsion at the trochanteric attachment of the iliopsoas muscle. side. Then roll the feet to their outer
. and back) the patient's foot posture during standing and the degree of inward pronation or outward supination. and/or bunion are typical findings. has failed to be properly diagnosed and corrected. Thus. Loading Reactions. Remove the patient's shoes and inspect (from the front. nature seeks to provide maximum strength with minimal material to support the weight above and assist the body to maintain equilibrium to the body's center line of gravity.
a slight widening of the distal interosseous space between the tibia and fibula (indicating interosseous membrane rupture) will be found. it is always a good rule to x-ray the thoracolumbar region when a crushing fracture of a heel is found. Boehler's Angle.borders and measure the distance between the patella marks: pronation causes inward rotation of the knees. the fracture line is seldom seen. Thus. the use of Boehler's angle is recommended during roentgenographic analysis. For the normal calcaneus. In later views. For the purpose of accurate diagnosis. One report states that rupture of one or more syndesmotic ligaments occurs in more than 90% of malleolar fractures. producing an angle of 35° --40° with a second line drawn from the posterosuperior margin of the talocalcaneal joint to the superior articular margin of the calcaneocuboid joint. Fracture of the calcaneus may be obvious with a widely separated fracture line and grossly disturbed positioning of fragments or it may be quite discrete with little obvious change visible. A-P. Boehler's angle results from a line drawn first from the posterosuperior margin of the talocalcaneal joint through the posterosuperior margin of the calcaneus. Talus and Cuboid Fractures Fracture of the talus and cuboid are next in frequency to those of the calcaneus. Heel Fractures Fractures of the calcaneus are frequent. Less than 28° is considered definitely abnormal and poor position from a functional standpoint. Compression heel injuries are frequently accompanied by compression fractures in the lumbar or lower thoracic regions from force traveling up the legs to the spine. One of the more common fracture sites occurs when the talus is displaced in the ankle mortise. and oblique x-ray views are standard for evaluating possible ankle fracture. Ankle fractures are frequently associated with severe ligament injury. the posterior extension of the
. Bilateral films are helpful to rule out a trigonum.
ROENTGENOGRAPHY: SEVERE ANKLE AND FOOT INJURIES
Lateral. and sometimes tomography or stress views during inversion and eversion are required. They usually result from falls where the victim lands stiff legged on the heels. When this happens. shifting the talus and fibula laterally. Ligament injury is always present in displaced malleolar fractures. Examination should include the posterior halves of both heels.
Fractures secondary to impact of the talus are oblique and frequently comminuted. with fragments displaced inferiorly by the pull of the deltoid ligament and tearing of the anterior tibiofibular ligament. In abduction injuries. the lateral fibular cortex may be comminuted. viewed as a lucent crescent under the articular margin of the talus. abduction injuries produce transverse malleolar fractures or deltoid tears. small dorsal tibial and fibular avulsions may be noted. As with external rotation injuries. An examiner should not confuse a sharp or rough-edged fracture fragment at the posterior talus with a rounded-edged accessory ossicle (os trigonum). a torn deltoid.
Classification of Ankle Fractures
The patterns of ankle injuries can be classified according to direction of primary and secondary forces such as external rotation. The common mechanism involved in ankle injury is traumatic external rotation plus abduction. Excessive foot pronation is the usual mechanism. The interosseous ligaments are usually spared if the foot is in supination rather than pronation. The classic fracture here is an oblique fibular line directed from the anterior-inferior to the posterior-superior aspect that is frequently comminuted along the posterior cortex.talus occasionally occurring as a separate bone. while those secondary to ligamentous avulsion are typically horizontal. Fractures also commonly occur in the posterior or midportion of the talus. A small posterior malleolar fracture may result from the rotating fibula. A horizontal fracture of the medial malleolus. and diastasis is more common because the syndesmosis is ruptured. abduction. Another anatomical variation that sometimes leads to interpretative error is a separate ossification center at the base of the fifth metatarsal (usually bilateral). and a complete rupture of the syndesmosis (called a Dupuytren fracture-dislocation) are unstable injuries resulting from forceful abduction and lateral rotation. In advanced cases. These areas may be the sites of avascular necrosis. The obliquity of the fracture line is determined by the direction of force. the superior portion of the talus may show collapse of its articular margins. adduction. Comminution of the lateral cortex is usually related. As little as 1 mm of lateral displacement reduces the area of tibial-talar contact by 42%. This fibula fracture usually occurs below or within the syndesmosis but may occur above the syndesmosis if it ruptures. External Rotation Injuries. Abduction Injuries. the fracture is usually higher on the fibula and/or more oblique. associated with a deltoid tear.
. An oblique transverse fracture of the medial malleolus at or beneath the tibial articular surface may occur. When external rotation is a secondary force added to abduction. This is best seen on an A-P view because overlapping malleoli cloud the picture in lateral films. An abduction fibula fracture is typically oblique and short. and vertical compression. a high fibula fracture.
Various congenital or acquired factors such as Morton's toe. knee. similar to those seen in other weight-bearing joints (eg. Frequently associated is a vertical fracture of the medial malleolus projecting above the articular surface that is often related to a fracture of the lateral aspect of the talar dome. The condition is not common to athletes but is occasionally found in unconditioned joggers who run on hard surfaces. Fractures to the posterior margin are not common. is of the distal 4 cm of the tibia above the ankle line (Malgaine fracture). It usually occurs in the dorsiflexed foot. Vertical compression with external rotation force is more likely to produce large fragments.Anterior marginal fractures. Diagnosis is made early by exclusion and late by roentgenographic findings. -. Diastasis is not typically associated with adduction injuries. These types of fractures may occur (1) with significant vertical compression of the articular margin or (2) without vertical compression. with or without an abduction factor. Stress Cysts of the Foot Bowerman points out that chronic stress of the talus may produce marginal degenerative cysts. When the posterior articular fragment is large. may be comminuted. Adduction ankle injuries usually result in distal fibular horizontal fractures at or below the articular surface. the incidence of posttraumatic arthritis and chronic instability is high. frequently isolated. Vertical Compression Injuries. and related to high-impact forces in the direction of axial compression. The onset of symptoms may be rapid or gradual. This type of fracture. Posterior marginal fractures seldom occur as isolated injuries. a palpable callus. Rips of the anterior tibiofibular ligament are frequently associated. The second metatarsal is the site of the most common fatigue fractures found in the foot. and supramalleolar fractures. severely comminuted. the joint space near the cyst will be narrowed. -. Vertical compression injuries are subdivided by Dalinka into posterior marginal fractures.Supramalleolar fractures. hip).Adduction Injuries. warts. Usually. but not always. anterior marginal fractures. It is commonly open. but posttraumatic arthritis may result from comminution of the articular surface. This type of fracture. invariably associated with fracture of the fibula. External rotation injuries. if old. Management is similar to that for metatarsalgia: rest and support. may produce small posterior marginal fractures. and bunion may be the underlying factor in symptomatic runners.Posterior marginal fractures. Fatigue Fractures of the Foot March fractures are characterized by point tenderness and sometimes.
. -. thus the proximal fibula must also receive careful evaluation.
When the ankle is stabilized. and toes are shown in Table 1. the major joint motions of the foot are pronation. and talus. (3) midtarsal forefoot adduction (20° ) and abduction (10° ). and rotation occur. and (4) toe flexion (45° ) and extension (80° ). Most authorities consider the ankle to be formed by the tibia. leaves off and the foot begins is a matter of differing opinions. longus Peroneus tertius Plantaris
Dorsiflexion Dorsiflexion Plantar flexion. foot.ARTHROKINEMATICS
Where the ankle. foot inversion Plantar flexion Plantar flexion Plantar flexion. and Toes Spinal Segment
Muscle THE ANKLE AND FOOT Extensor digiti longus Extensor hallucis longus Flexor digiti longus Flexor hallucis longus Gastrocnemius Peroneus brevis. Muscles controlling the ankle. (2) subtalar inversion (5° ) and eversion (5° ). Joint Actions of the Ankle and Foot Normal ankle and foot movements use a combination of (1) ankle dorsiflexion (20° ) and plantar flexion (50° ). foot eversion Dorsiflexion. Muscles of the Ankle. essentially a hinge joint. Foot. Subtalar joint motion occurs about an axis that is oblique to the three axes around which usual ankle flexion-extension. supination. and toe plantar flexion. foot eversion Plantar flexion
L4-S1 L5-S1 L5-S1 L5-S2 S1-S2 L5-S1 L4-S1 L5-S1
. abduction-adduction. The foot includes all structures distal to the talus. fibula. toe dorsiflexion. Table 1.
. an allowance of a segment above and below those shown should be considered. weak foot inverter Plantar flexion.Soleus Tibialis anterior Tibialis posterior THE TOES Abductor digiti quinti Adductor hallucis Dorsal interossei Extensor digiti brevis Extensor digiti longus Extensor hallucis longus Flexor digiti Flexor hallucis brevis Flexor hallucis longus Interossei Lumbricales Plantar interossei Quadratus plantae
Plantar flexion Dorsiflexion. The spinal nerves listed here are averages and may differ in a particular patient. foot inversion
S1-S2 L4-L5 L5-S1
Small toe abduction Hallux adduction-flexion of great toe Abduction-flexion of toes 2-4 Toe extension Toe extension of lateral four toes Hallux extension Flexion of lateral toes 1st metatarsophalangeal flexion Hallux flexion 1st metatarsophalangeal flexion Flexion of toes Abduction-flexion of lateral three toes Assist flexion of lateral four toes
S1-S2 L5-S2 S1-S2 L5-S1 L4-S1 L5-S1 L5-S2 L5-S1 L5-S2 S1-S2 L5-S2 S1-S2 S1-S2
Note: Spinal innervation varies somewhat in different people.
Then push the foot into dorsiflexion and plantar flexion with the active hand. This minimal action is necessary because body weight does not fall through the center of the joint but slightly anterior to the center. pain during this maneuver suggests subtalar arthritis. Subtalar Inversion and Eversion. and supination is the result of combined plantar flexion. In the lesser toes. inversion. Fixation in this joint frequently produces a protective gait restricting push-off. KINESIOLOGY OF THE ANKLE AND FOOT Slight intermittent muscle action is involved to control normal body sway. When evaluating toe flexion and extension. extensor hallucis longus
. flexion and extension occur at the proximal and distal interphalangeal joints and the metatarsophalangeal joints. Eversion occurs about an axis running in the A-P direction of the foot. first gently test the great toe. Alternately invert and evert the heel. Adduction occurs around a vertical axis. and abduction of the foot. Ligament shortening. Flexion and Extension of the Toes. To passively test ankle dorsiflexion and plantar flexion. stabilize the heel and ankle with one hand and grip the forefoot firmly in the active hand. however. firmly stabilize the heel and hindfoot with one hand and grip the forefoot with the other hand. eversion. Again. Restricted flexion of the distal interphalangeal joint and metatarsophalangeal joint with restricted extension of the proximal interphalangeal joint are features of a hammer toe. To passively test forefoot inversion and eversion. and adduction of the foot. pain. Manipulate the forefoot medially and laterally to test passive range of motion of forefoot adduction (supination) and abduction (pronation). To test motion of the 1st metatarsophalangeal joint. Dorsiflexion and Plantar Flexion. Pronation refers to combined dorsiflexion. use the following terminology: Plantar flexion and dorsiflexion are motions about a horizontal axis (through the ankle) that lies in the frontal plane. Restricted extension of the proximal and distal interphalangeal joints and restricted flexion of the metatarsophalangeal joints are features of claw toes. stabilize the foot with one hand while the active hand flexes and extends a particular joint. or swelling commonly restricts passive manipulation of the ankle. In testing passive subtalar inversion and eversion. Most authorities. stabilize the distal end of the tibia with one hand and firmly grip the heel with the active hand.Descriptors of foot motion have yet to be standardized. Forefoot Pronation and Supination. Dorsiflexion Dorsiflexion is provided by the tibialis anterior (L4--L5). Flexion is the only motion of the great toe's proximal interphalangeal joint.
and rest. interossei. Strength of the Great Toe. Test tibialis anterior strength by applying increasing resistance when the patient attempts to dorsiflex and invert his foot. gastrocnemius (S1--S2). Stage of Acute Inflammation and Active Congestion
The major goals are to control pain and reduce swelling by vasoconstriction. peroneus tertius (L4--S1). All are supplied by the deep peroneal nerve. all the rest by the tibial nerve. protection. Resistance to plantar flexion and inversion tests the strength of the tibialis posterior muscle. flexor hallucis longus (L5--S2). Extension of the toes is governed by the extensor digiti brevis and longus. plantar interossei. If the soleus is at fault. lumbricals.(L5--S1). Palpate with the stabilizing hand the first two tendons posterior to the lateral malleolus. flexor digitorum longus (L5--S2). and tibialis posterior (L5--S1). ie. and extensor digitorum longus (L4--S1). If this can be achieved. and secondary infection by disinfection. to prevent further irritation. that of the flexor digitorum longus by offering resistance to curling toes in flexion. Limitation of the gastrocnemius or soleus muscle restricting ankle dorsiflexion can be differentiated by the ankle dorsiflexion test. and the extensor hallucis longus. oppose plantar flexion and eversion of the foot. Toe Flexion and Extension. The peroneus longus and brevis are innervated by the superficial peroneal nerve. inflammation. the gastrocnemius is the cause of the restriction. Test the strength of the flexor hallucis longus by opposing flexion of the great toe. it will not be affected by knee flexion. and flexor hallucis brevis and longus. then dorsiflex the ankle. and elevation. plantaris (L5--S1). Grasp the foot and flex the knee to slacken the gastrocnemius. Have the patient sit on the examining table with his knees flexed and relaxed. Ankle Dorsiflexion Test for Contractures. and to enhance healing
. To test the peronei. Plantar Flexion Plantar flexion is provided by the peroneus longus and brevis (L5--S1).
CLINICAL MANAGEMENT ELECTIVES FOR ANKLE OR FOOT STRAIN/SPRAIN 1. Test strength of the extensor hallucis longus by resisting active dorsiflexion of the great toe with increasing pressure on the nail. adductor hallucis. compression. quadratus plantae. soleus (S1--S2). It is helpful to palpate the tibialis anterior muscle with the stabilizing hand. flexor digiti. Flexion of the toes is controlled by the dorsal interossei. it will be the same in either knee flexion or extension.
etc) Cryotherapy Cold packs Cold immersions Ice massage Vapocoolant spray Compression Pressure bandage Aircast Protection (padding) Elevation Indirect therapy (reflex therapy) Iontophoresis/phonophoresis Auriculotherapy Meridian therapy Microcurrents Spondylotherapy Mild pulsed ultrasound Pulsed alternating current Rest Bedrest Cane Crutches Foam/padded appliance Shoe orthotic Shoelift Immobilization Rigid appliance Plaster cast Indicated diet modification and nutritional supplementation. disperse coagulates and gels.
2. prevent stasis. Common electives include: Alternating superficial heat and cold Pressure bandage Protect lesion (padding) Indirect therapy (reflex therapy) Light nonpercussion vibrotherapy Passive exercise of adjacent joints
. scratches. provide rest and protection. enhance circulation and drainage. abrasions. Stage of Passive Congestion
The major goals are to control residual pain and swelling.mechanisms. maintain muscle tone. and discourage adhesion formation. Common electives include: Disinfection of open skin (eg.
3. continuous Microwave Vibromassage High-volt therapy Interferential current Spondylotherapy Mild transverse friction massage Mild proprioceptive neuromuscular facilitation techniques Rest Bedrest Cane Crutches Shoe orthotic Shoelift
. Common electives include: Mild articular adjustment technics Moist superficial heat Thermowraps Spray-and-stretch Cryokinetics (active exercise) Moderate active range-of-motion exercises Meridian therapy Alternating traction Sinusoidal current Ultrasound. Stage of Consolidation and/or Formation of Fibrinous Coagulant
The major goals are the same as in Stage 2 plus enhancing muscle tone and involved tissue integrity and stimulating healing processes.Mild surging alternating current Mild pulsed ultrasound Phonophoresis Cryokinetics (passive exercise) Meridian therapy Spondylotherapy Rest Bedrest Cane Crutches Shoe orthotic Shoelift Immobilization Shoe orthotic Plaster cast Indicated diet modification and nutritional supplementation.
causes for pain should be corrected but some local tenderness likely exists. Common electives are: Deep heat Articular adjustment technics Spondylotherapy Local vigorous vibromassage Transverse friction massage Spray-and-stretch Active range-of-motion exercises without weight bearing Negative galvanism Ultrasound.
4. Stage of Fibroblastic Activity and Potential Fibrosis
At this stage.Immobilization Shoe orthotic Semirigid appliance Indicated diet modification and nutritional supplementation.
5. Stage of Reconditioning
Direct articular therapy for chronic fixations Progressive remedial exercise Passive stretching Isometric static resistance Isotonics with static resistance Isotonics with varied resistance Plyometrics
. taut scar tissue. continuous Sinusoidal and pulsed muscle stimulation Microwave High-volt therapy Interferential current Meridian therapy Proprioceptive neuromuscular facilitation techniques Rest Bedrest Cane Crutches Shoe orthotic Shoelift Shoe orthotic Indicated diet modification and nutritional supplementation. and area fibrosis and to prevent atrophy. The major goals are to defeat any tendency for the formation of adhesions.
It is especially common after cross-country runs. and jumping account for chronic ankle and foot stress. The incidence of ankle contusions without sprain is highest in hockey from stick and puck blows. In many sports. Peroneoextensor Spasm Peroneoextensor spasm produces a spastic flat foot that is painful at the lower lateral leg and ankle. fast running with sudden stops.Aerobics Indicated diet modification and nutritional supplementation. a dressing. metabolic disturbances. Other sites of related fatigue fractures include the calcaneus. focal infections. and degenerative changes as a result of kicking the ball with the dorsum of the foot. In addition. Spasm in eversion may become marked and indicate an eversion subluxation. and an elastic ankle bandage or strap for 1--3 days. Trauma is but one of the causes. Management consists of standard muscle techniques. elevation. Epiphyseal separations are more common than fractures as the ligaments attach to the epiphysis. but dorsiflexion and inversion are restricted. and femur. Resumed activity should be safeguarded with a protective pad for 2--3 weeks. spurs. quick changes of position. Often overlooked are fatigue fractures of the 2nd metatarsal and fibula. passive peroneal
. the segments of the foot and ankle must be flexible enough (free of fixation) to accommodate to different surfaces yet be stiff enough to provide the required torque for locomotion. Ankle Contusions Ankle bruises are usually bone bruises that readily respond to cold. Ankle Trauma Note: The area of greatest weakness in children during ankle trauma is at the growth plate.
As disruption of the mechanics of the kinematic chain can lead to pathologic function. the foot and ankle must ideally combine a complex series of controlling forces and integrate to meet the demands of static and dynamic situations. tibia. being the final links in the human axial kinematic chain and those approximating the supporting surface. roentgenography shows bony spurs of the anterior or dorsal talus. and contracted plantar fascia may be involved. There is little or no area tenderness. About a third of the time in professional basketball players. tarsal navicular. Soccer players especially present with chronic ankle strains/sprains.
To detect a rupture of the Achilles tendon. and strapping for 8--12 days. Grasp the center of the leg with both hands and apply strong pressure so that the calf muscles are squeezed against the tibia and fibula. elevation.stretching. and the extensors of the great toe may be weak. If the Achilles tendon is ruptured. If during this action the head of the 1st metatarsal offers little or no pressure against your thumb. Management.Thompson's test. leg or ankle tendinitis. and the Achilles tap test. rest. and the arch disappears. These signs of nerve compression should not be confused with an anterior compartment syndrome of the lower leg. Thompson's test. peritendinitis. and progressive mobilization and strengthening. The patient is placed prone and the knee is flexed to a right angle. especially the soleus portion. Place the patient supine with the lower limbs extended in a relaxed position. Decreased sensation manifests between the 1st and 2nd toes. the test is positive for peroneus longus paralysis (L4--S1). Duchenne's Test for Peroneal Paralysis. and carefully monitored graduated active exercises.
Achilles Tendon Injuries
A painful Achilles tendon is frequently associated with plantar fascitis. Normally. Place your thumb on the plantar aspect of the head of the 1st metatarsal on the involved side. Tenderness will be found on the anterior aspect of the ankle where the deep peroneal nerve becomes superficial. -. the foot will plantarflex slightly. All involve the plantar flexion reflex. Then firmly squeeze the middle third of the calf. tendon rupture. interferential therapy. have the patient kneel on a chair with the feet extended over the edge. and instruct the patient to plantar flex the foot. The deep peroneal nerve can become compressed at the anterior ankle by shoes that are too tight or tightly laced. Clinical Tests. if not. with cold. Treatment is similar to that for any acute strain. This test is a common variant of Thompson's test. There are three common tests to evaluate the integrity of the Achilles tendon: Simmond's test. Disorders of the Deep Peroneal Nerve Induced Deep Peroneal Nerve Compression. or local inflammation. Simple avoidance of tightly fitted or laced shoes will correct the disorder if that is the cause. this squeeze will not cause the normal plantar flexion response.Simmond's test. -. a ruptured Achilles tendon is suggested.
. ultrasound. Severe peronei tendovaginitis is difficult to manage and sometimes requires referral for tendovaginotomy. compression. the medial border of the foot dorsiflexes while the lateral border plantar flexes.
and crepitation should be sought. when excessive force is applied to a previously injured or diseased tendon. but ankle weakness produces a flat-footed gait. a rupture of the Achilles tendon should be suspected. but the sulcus may be hidden by a blood clot. This may not be true. The common cause of Achilles overstress can usually be traced to overuse. tenosynovitis. one encircles the instep at the center of the longitudinal arch. If pain is induced or the normal plantar flexion reflex of the foot is absent. and Thompson's test is usually positive. The site of tear is invariably about 2 inches above the attachment of the tendon at the heel. Signs of tenderness. The calf muscles retract to a higher position than normal. Complete separation is characterized by sharp pain. but not always. tenderness. and the tenderness is often more severe than that found with complete rupture. and disability. Achilles rupture may occur even if the patient can extend the foot against resistance. Because of the great tensile strength of the healthy Achilles tendon. restricted ankle motion. often accompanied by perception of an abrupt "thud" at the site. With the patient prone. The onset of achillodynia in Achilles tendinitis is insidious and almost always the result of chronic overstress of calf muscles. The prominent Achilles tendon inserts firmly into the calcaneus and is formed by the common tendon of the gastrocnemius and soleus muscles. The sharp pain soon subsides. a tendon deficit is usually palpable. There are burning pain. a partial tear features acute pain during activity that persists until stress can be avoided. Rupture or tear results in lack of push-off during gait. and passive ankle dorsiflexion aggravates the pain. Passive dorsiflexion is restricted. The soleus and gastrocnemius test weak during weight bearing. direct violence during stretch.
. A tender swelling is noted when the site is palpated. however. Less common than complete rupture.Partial tear. or a poorly placed injection. The Achilles tendon is tapped with a reflex hammer about an inch above its insertion at the heel. dry crepitus.Achilles tap test. The patient will be unable to stand on the ball of the foot. -. Achilles Strains. Thompson's test may be positive or negative. swelling. When activity is resumed. impossible. Achilles Tendinitis. Proper taping can be described in three steps: (1) Two anchors of 3-inch-wide tape are applied.-. Thompson's test is negative. The cause of Achilles tendinitis can sometimes be traced to tape or a support applied too tightly over the tendon. severe pain returns. and the onset of symptoms is usually sudden. The onset of a complete rupture is always sudden. femoral or calcaneus fractures invariably occur before the tendon ruptures. severe swelling. -. Achilles Rupture. the patient's knee is flexed to a right angle. Plantar flexion is usually. A tender gap in the tendon is reliable evidence.Complete rupture.
Crepitus is often present. Spontaneous rupture can result if excessive force is applied against a degenerated tendon. rest. crosses the tendon. Later. tenderness. Ischemia appears to be the triggering mechanism. These strips are secured by semicircular horizontal strips of overlapping 2-inch tape from the ankle to the upper calf. Taping begins in slight extension with a vertical strip run from the heel up the calf to just below the knee. Bilateral heel lifts should be provided to accommodate for the fixed partial extension. and is attached to the medial calf just below the knee. mild swelling. Contrast or whirlpool baths (108° --110° F) at least twice daily. heel-strike running events. Some relief may be obtained by standard physiotherapy. the inability to raise the heel from the ground during weight bearing. Bilateral heel pads should be provided to reduce the strain on the tendons. running on hard surfaces. crosses the Achilles tendon. During the early stages. and heel lifts. A short leg walking cast may be helpful during healing. thus surgical decompression is considered the treatment of choice if considerable relief from conservative measures does not occur within a week. Management of Achilles tendinitis is extremely long and frequently disappointing. and is attached to the lateral calf just below the knee. This disorder of unknown cause is the result of diminished lubricating fluid within the sheath of the tendon. The valgus torque placed on the insertion of the tendon during pronation leads to overstress pain and inflammation. The inflammatory reaction may be the result of an ankle pronation syndrome. the pain becomes persistent and increases in severity. Focal Stress Degeneration. pain is felt only during initial warm-up --disappearing with exercise. and severe training schedules are causative factors in sports. Features include a burning pain during and after strenuous activity. The common site of central-tendon degeneration is at the midpoint between the musculotendinous junction and insertion of the Achilles tendon: the site of poorest blood supply in the tendon. Immobilization may be necessary during the acute stage. Adhesions form that bind the tendon proper to its covering.the other encircles the leg above the malleoli. and to the calf anchor. Pronation Syndrome. Low-heeled shoes. The third strip is secured on the lateral heel. also of 3-inch-wide tape. and restricted ankle motion. The
. The second strap is applied on the medial heel. (3) This taping is anchored by a continuous figure-8 and heel lock. interferential therapy. (2) Three or four strips are applied from the arch anchor. over the heel. The foot compensates for this lack of motion through abnormal supination of the forefoot and subtalar or hindfoot pronation. and vitamin-mineral supplementation may be helpful. Dry Sheath. analgesic packs. It is good policy to check for ankle distortion in any case of Achilles tendinitis. A tight or shortened Achilles tendon restricting dorsiflexion of the foot is likely in the history but unknown to the patient.
onset is gradual. and a thickened nontender paratendon is palpable. the onset is rapid and there is swelling. For differentiation. Somewhere in the range of motion. swelling is characteristic. and heel padding offer temporary relief. ultrasound. Treat as any inflammatory tendon reaction with emphasis on hydrotherapy and ultrasound. rest. Strains must be differentiated from ankle or foot sprain. Table 2. Of the conservative measures. the onset is gradual. In chronic peritendinitis. Little tenderness is associated. swelling may or may not be present. Achilles tenosynovitis often produces local pain increased by use. In acute peritendinitis. It is sometimes associated with palpable crepitus. interferential therapy. calcaneovalgus) Degenerative joint disease Fixation Peripheral vascular disease Postural foot disorder Rheumatoid arthritis Spur
. Achilles Peritendinitis. Surgical procedures appear to be the alternative after a thorough trial of conservative measures. Other features include pain on motion. Thompson's test is negative in both acute and chronic cases. Symptoms usually arise a day or two after injury. and a distinct limp. Achilles Tenosynovitis. Crepitus may or may not be present. and Thompson's test is negative.2. and fatigue fractures. the common causes of ankle pain are shown in Table . tenderness is severe. tenderness. referred trigger point pain. a painful point in the arc is manifested. Conservative management is usually successful unless there are associated fibrosis and strictures of the paratendon. but continued vigorous activity causes relapse. Common Causes of Ankle Pain Acute Pain Arthritis/synovitis Bone bruise Contusion Dislocation Fracture Osteomyelitis Strain/sprain Subluxation Chronic Pain Acquired Flatfoot Congenital fault (eg. Ankle Strains Many ankle strains involve the peroneus or posterior tibial muscles.
SPECIAL CONCERNS WITH RUNNERS Running has become an essential element in many personal fitness programs. The peronei tendons pass behind the lateral malleolus and are best palpated during active eversion and plantar flexion. M. While appropriate chiropractic intervention can obviate symptomatology. Consequently. If stenosis of the tunnel in which the tendons run occurs. sheath swelling. While peronei tendons pass behind the lateral malleolus. the peroneal tubercle will be tender and thick. swelling of the sheath. When an associated peroneal tenosynovitis or tendovaginitis is associated with strain. the tendon of the posterior tibial muscle courses behind the medial malleolus. An aseptic tendon inflammation is often involved after overstress. a probable squeaking crepitus on joint movement. logical preparation is necessary because some precise kinematic interrelationships are involved. running style. it is characterized by acute tenderness. pain. However.Talar osteochondritis Tarsal tunnel syndrome Tendinitis
Subluxation Tuberculosis Tumor (rare)
Peronei Strain. A thorough investigation of the patient's biomechanics. it is especially important to focus upon these aspects in the novice runner where relatively minor changes and recommendations may deter further injury and disappointment. this cycle of failed expectations and injury may prove overwhelming and compel the runner to abandon running or exercise altogether. improper training habits left uncorrected will render the runner susceptible to further injury. The clinical picture of posterior tibial overstress is similar to that of peronei strain and inflammation: tenderness. However. Posterior Tibia Tendon Strain. they experience recurring injuries and frustration. injury history. and training habits is necessary to adequately evaluate any runner. Naughton points out." Pronation and supination are essential during gait when properly performed in
. Ultimately. Tenderness here also suggests bursitis or fracture of the styloid process in severe sprain. crepitus. The peronei are the primary foot everters and help in plantar flexion. "Novice runners are frequently ill prepared to begin a sound training program and often overestimate their capabilities. motion restriction. K. and possible ecchymosis. and possibly ecchymosis. It provides relatively inexpensive aerobic activity and requires no special talent or facilities. The chiropractic physician can serve a pivotal role in breaking this cycle by addressing both relief and prevention.
Management. and adduction. eversion. Common Oversupination Effects. bunions. Runners with oversupination or who have tibial varum land on the extreme lateral borders of their feet (varus position) at heel strike. The approximate midpoint of the navicular is marked with the foot in neutral. located in the extensor digitorum longus muscle. a trigger area just lateral to this site. Trigger Point Syndromes of the Ankle Area A trigger point in the upper anterolateral aspect of the leg within the tibialis anticus muscle is frequently the cause of pain referred chiefly to the front of the ankle and big toe. pronation includes dorsiflexion. these lines are normally in close alignment. while the supinated heel will demonstrate a varus position. A drop greater than 15 mm indicates hyperpronation. Although oversupination distortion is far less common than overpronation. refers pain more laterally in the ankle and/or to the dorsum of the foot in the area of the 4th metatarsal bone. In addition. Navicular drop can also be measured to assess pronation. This position is marked in relation to the floor. "The pronated foot will demonstrate a valgus heel-to-tendon alignment. especially those related to running. medial or lateral knee pain and some forms of ankle sprain. inversion. Thus ground reactive forces. It should also be noted that the heel pain associated with plantar fascitis may also be found in the supinated foot because plantar fascia in the high-arched foot acts as a windlass to produce traction irritation at fascial insertions. Runners with pronated ankles frequently present with shin splints.correct sequence. If the area of pain is
. for proper congruency with the ground at midstance. At other times. Supination incorporates plantar flexion. When weight bearing or the subtalar joint is in the neutral position. and abduction to provide flexibility. Ankle pronation/supination occur primarily at the subtalar joint. Fatigue fractures can result. Overinversion is particularly prevalent when running on irregular surfaces. It is remeasured with weight bearing. fatigue fractures. the foot excessively pronates and hyperpronation symptoms are encouraged. Less pronounced overpronation is determined by drawing lines bisecting the Achilles tendon and calcaneus. Treat as a moderately severe strain/sprain. Naughton strongly recommends that evaluation of a runner should include assessing weight-bearing ankle pronation and supination. are inadequately dispersed. heel pain from plantar fascitis. the predisposed trauma from oversupination may be harsh because the supinated foot is rigid and does not transmit force well. Firm sustained pressure on this trigger point sets off an aggravating ache." Common Overpronation Effects. and contributes to stability through joint compression. She describes that degrees of pronation and supination can be easily determined because the longitudinal arch of a truly overpronated foot is absent on weight bearing and a medial bulge is prominent. As described previously.
with or without avulsion. The local manifestations of inversion ankle sprain are mild-severe pain and swelling beneath the affected tendons and ligaments. and sometimes posterior tenderness and swelling. the mechanism of injury is a first-class lever joint amplifying the external force (five or six times) above the resistance limit supplied by the bones and ligaments. In mild cases. ankle inversion with internal rotation. A partial tear of the deep anterior fibers of the deltoid ligament occurs in extreme degrees of internal rotation or plantar flexion. ie. rather than at the middle of the ligament. and cuboid will feel prominent on palpation.sprayed with a vapocoolant. the pain will be relieved only momentarily. Most ankle strain/sprains are diffuse to some degree. possible ecchymosis. they involve a wide variety of damage depending on which ligaments are stretched and the degree of tear. Lateral sprain. However. but spraying over the focal trigger area may abolish the pain. Hyperextension sprain exhibits lateral. Clinical Features. As in knee sprains. talus. Inversion Sprains The most common form of tarsotibial sprain occurs by twisting the leg in varus. Isolated tenderness may be most acute over the anterior talofibular ligament. tenderness. an incomplete rupture of the fibulocalcaneal ligament may precede the total rupture of the anterior fibulotalar ligament. The stability of the complex series of joints comprising the ankle and foot is primarily maintained by an expansive network of ligaments. and fibula fractures are often associated with severe ruptures. The ligament tears are usually at their attachments. free restricted motion. and spastic functional impairment. After eversion sprain. if a supination force is applied to the neutral-positioned ankle. Ankle Sprains: General Considerations Ankle sprains are frequently seen. which especially injures the talofibular bundle of the lateral ligament. the most common ankle sprain. Dias showed complete rupture of the anterior fibulotalar ligament is the first lesion to occur in lateral ankle sprains. and relieve deep tenderness in the reference zone for many hours if not permanently. medial. only the lateral
. In comparison to the knee. This is especially true when the foot is plantar flexed with the heel raised from the ground. Isolated tears are rare. During inversion stress. It is less often found over the calcaneofibular ligament if stress occurs when the ankle is at a right angle. little is known about the integrated biomechanical actions within the ankle and foot. this area exhibits primary tenderness with secondary tenderness from impaction on the lateral aspect. hypermobile inversion. often produces an indirect tenderness in the deltoid ligament area from impaction. The lateral malleolus. The talus is usually subluxated from the ankle mortise.
deep heat. and use Thompson's or an alternative test. moderate range of motion manipulation. obviously. bracing. elevation. During the stage of consolidation. inversion and eversion walking). After 48 hours. sinusoidal stimulation. and restricted inversion mobility. Structural alignment. Passive or active stretching is helpful but. Local manifestations include pain. If the inferior tibiofibular ligament tears.sulcus is filled with effusion. Pain relief is enhanced by placing a 2. check for the draw sign. After strapping over a protective underwrap. swelling. positive galvanism. Eversion Sprains In this less common form of ankle sprain. heel lifts. An application of hyaluronidase may be helpful in reducing tissue swelling and edema if used with iontophoresis. mild ultrasound. During the acute stage. gentle passive manipulation. cold immersions. Keep in mind that the greater the support. the greater the atrophy. eversion hypermobility. Management. Inadequately treated initial injuries invariably lead to chronic disorders. or ultrasonics are beneficial. ultrasound. negative galvanism. moderate active exercise. Acute traumatic arthritis of the ankle following severe sprain can be produced by rupture or stretching of the ligaments of the joint by direct or indirect violence unless appropriate rehabilitation measures are taken. Casting should be avoided unless there are severe fractures associated. interferential therapy. periodic rest. Ideal healing requires time and patience. low fibula bone damage is more the rule than isolated medial ligament tears because of the inherent strength of the deltoid ligament.x 2-inch gauze pad (about 1/4-inch thick) within
. possible ecchymosis. mild periodic walking is encouraged after several days of rest because functional use facilitates recovery. Swelling should subside in 36 hours. tenderness. active exercise (eg. avoid inversion in inversion sprains and eversion in eversion sprains. and pressure strapping should be applied as soon as possible after injury to control swelling. Active taxing exercises should not begin until the walking gait is normal and pain free. To support the diagnosis. and possibly elevation are also indicated. Ankle Taping Strapping should be applied during slight eversion in lateral sprain or inversion in medial sprain. judge lateral and medial instability. passive congestion may be managed by contrast baths. the fibula and tibia separate at the ankle mortise (diastasis). In the stage of fibroblastic activity. toe walking. and/or light ultrasound. This joint widening produces instability readily leading to degenerative changes. light massage. Add peroneal muscle exercises against resistance according to patient tolerance. deep massage or vibrotherapy. local moderate heat. and active joint manipulation speed recovery and inhibit posttrauma effects.
relieving ankle and foot fixations. tenderness over the sinus tarsi. passed downward over the outer malleolus. and making firm upward pressure against the arch by traction as the remainder of the strip is applied to the inner aspect of the leg. crepitation on motion. avoid wrinkling the tape during application. tape can be applied in a basketweave ankle lock. It also allows for swelling without constriction. Preventive Strapping. which runs from the distal fibula to the talus. In preventive strapping for athletic activity. When swelling has subsided or disappeared. is generally
. This is one of the more time-consuming. under the heel. Kohler's Disease The cause of avascular necrosis of the tarsal navicular is unknown. a lateral heel wedge is helpful in lateral instability. methods of ankle strapping. Weight-bearing can then be resumed. A strip of 1-1/2.the longitudinal arch before taping. the strips begin from the inside and run under the foot to the outside to hold the heel slightly everted when lateral instability exists. Successive strips are placed alternately about the leg and foot until the ankle is encased. Vitamin C and manganese glycerophosphate appear to be helpful during rehabilitation. Semicircular strips of tape are used about the anterior foot and leg to retain the dressing. The foot usually has a "rocker bottom" shape. Simplified Postinjury Taping Procedure. Double pads are necessary for especially heavy patients.or 2-inch-wide adhesive tape is placed against the outer aspect of the leg. in which there is a valgus deformity and the long arch is flattened. Underwater ultrasound. a medial heel wedge in medial instability. leading to ischemia. Taping during stressful activity should continue for several more weeks. During application. and the ankle shows no ligamentous tear. The Gibney Taping Method. Whatever taping method is used. and possibly peroneal spasm to splint the joint. During rehabilitation. but stable. Competitive activity must be avoided for 2--3 weeks for Grade III sprains. Other clinical features include heel pain aggravated during weight bearing. beginning on the outer aspect of the foot over the cuboid bone and passing on the medial side of the foot over the internal cuneiform bone. Subtalar Arthritis Subtalar arthritis is a posttraumatic joint inflammation that often follows calcaneal fracture. the anterior talofibular ligament. and antivalgus exercise are helpful. is the most important ligament to protect for lateral stability. Especially protect the anterior portion of the deltoid ligament after medial sprain. but interference with the circulation to the bone. A second strip is placed at a right angle to the first. The foot and leg are shaved and the foot is held at a right angle to the leg while the dressing is being applied.
a space-occupying lesion. but the initial trauma may not be remembered. When the neurovascular bundle is percussed. ankle motion restriction. tenderness. which is often the consequence of trauma. swelling of the navicular bone.thought to be involved. Check for something that might inhibit local circulation such as a subluxation-fixation syndrome. Spontaneous recovery often occurs. Weight-bearing irritation must be avoided during the healing process. and invariably increased by activity and usually worse in the evening. tingling) in the toes and plantar surface that may radiate up the back of the leg. depending on which branch of the nerve is most involved. A sensory loss is usually found on the inferior aspect of the heel and/or the sole of the foot. Tarsal Tunnel Syndrome Tarsal tunnel syndrome (TTS) is a nerve compression syndrome of the neurovascular bundle (especially the posterior tibial nerve) that lies under the medial malleolus. a posttraumatic scar or adhesion. or something leading to a deformed heel or foot. It is easily confused with an ankle sprain that stubbornly refuses to heal. Reossification should be completed in 2--3 years if the area is protected from injury. better. a firm brace. Diagnosis is confirmed by roentgenography. The cause may be a subluxation syndrome. In the
. The pain is typically referred along the posterior tibial nerve. TTS is characterized by burning pain and paresthesia (eg. arthritic changes. a positive Tinel's sign is typically elicited with radiating pain. misdiagnosis can occur as the result of vasospasm produced by a lumbosacral subluxation syndrome. and a painful limp. The typical onset is near the age of 5 and features variable degrees of local pain. surgical referral should be considered to possibly remove necrotic bone. Just as an upper thoracic lesion may produce carpal tunnel symptoms. chronic ankle swelling following activity. Talar Osteochondritis Dissecans A small area of necrotic bone on the articular surface of the talus (usually the medial aspect) develops in this disorder. During initial treatment. Parasympathetic fibers have not been found in the extremities but sympathetic fibers are widespread and especially innervate the arterioles. Deep palpation posterior to the medial malleolus finds tenderness or aggravates pain in the sensory distribution of the nerve. a short walking cast is often applied for about 2 months. infrequently radiating as high as the buttocks. and a painful limp. and this can be aided by a short walking cast or. postural weakness. The onset is gradual and usually occurs during adolescence or early adulthood and features point tenderness over the talus when the foot is plantar flexed. If symptoms and signs do not improve within a logical course of conservative therapy. etc. restricted motion due to a scar or contracture.
Management. and rapid changes in direction such as seen in basketball. With the patient prone and the knee flexed to a right angle. valgus deformity of the foot. and field hockey. jumping. If this induces paresthesias in the foot. but the joint surfaces are
. soccer. or vapocoolant sprays are helpful during the acute stage. Recurrent trauma is usually involved. venous engorgement. Roentgenography shows new bone formation on the margins of the inferior articular surface of the tibia. tennis. Deep heat and graduated exercises bring good results. minimal swelling. referral for exploratory surgery should be considered. scar or adhesion formation. If symptoms fail to respond some to conservative care in 7 days. Once formed. Ankle Tourniquet Test. They also have a significant incidence in professional bowlers (bowler's spurs). tarsal tunnel syndrome is suggested. An increase in foot pain signifies tarsal tunnel syndrome or a similar circulatory deficit. Cold packs. An early priority is to find the cause of the compression. percuss the posterior tibial nerve as it passes behind the lateral malleolus. Progression into osteoarthrosis is a common complication. Tinel's Foot Test. inflated slightly above the patient's systolic blood pressure. etc. tenosynovitis. Conservative care is often frustrating when activity is continued. POSTTRAUMATIC SPURS AND RELATED DISORDERS Two common posttraumatic abnormalities are talonavicular spurs and narrowing of the subtalar joint. the spur becomes constantly irritated by forced ankle flexion. There are general ankle pain. They sometimes arise in nurses and orderlies who must quickly travel long hard hallways repetitively during their shift. intrinsic foot weakness and claw toes develop that restrict extension. and maintained for 1--2 minutes.chronic stage. but referral for surgery to remove spurs or loose bodies may be required. Bowler's Spurs Degenerative changes or fracture may result in spur formation of the posterior talus that may irritate the posterior margin of the tibia's inferior articular surface. These commonly occur from chronic stress to the talonavicular ligament in sports requiring constant speed. This may be traced to effects of chronic subluxation with ankle pronation. A temporary medial heel wedge or heel seat is often beneficial in relieving traction from the nerve by slightly inverting the heel. A sphygmomanometer cuff is wrapped around the suspected ankle. and soreness aggravated by kicking the ball. Football/Soccer Ankle This disorder consists of traumatic osteitis that is sometimes confused with chronic sprain. cool immersions.
and determine the position of the ankle joint. characterized by a markedly posterior position of the lateral malleolus relative to the medial malleolus. Grasp the malleoli with your thumb and index finger.not involved as in osteoarthrosis. the lateral malleolus will be anterior to its medial mate. The patient sits on a table with the knees flexed at 90° . If not. the spurs must be removed surgically. Mercier states that an internal rotation deformity exists at the hip when internal rotation exceeds external rotation by more than 30° . In infants. If internal tibial torsion exists. Metatarsus Varus Sign. An everted heel and flat arch
. have the patient sit on a table with the relaxed knees flexed at 90° . and there will be excessive anteversion of the femur in metatarsus varus. Internal femoral torsion is found if the patellae are marked with a skin pencil and these points are observed during gait. Excessive toe-in.
In-Toeing Internal Tibial Torsion. the patellae will face medially. The ankle mortise normally faces 15° externally. but in internal tibial torsion. especially in children. Common points of fixation are at the malleoli in the ankle or the tibial tubercle below the knee joint. it faces anteriorly or internally. the focal deformity will be distal to the knee. habitually sleeping with the feet turned inward may be the cause. about 20° --30° of external tibial torsion is present. There will be toe-in. Out-Toeing There are three common causes of external lower extremity rotation and outtoeing: -. and the lateral malleolus will be posterior to the medial malleolus. This abnormal position is called the toe-in sign. Note the posture of the relaxed bare foot.External tibial torsion. This is often caused by a fixed point at either end of the tibia. Internal Femoral Torsion. Conservative care incorporating rest and graduated active exercises will usually suffice. To confirm a suspicion of internal tibial torsion. If there is toe-in and the patellae face forward (as is normal). an internal contracture of the hip will usually be found. The lateral border of the foot will appear convex and the medial border concave if there is metatarsus. In normal adults. The tibial tubercle will palpate as if it is directed straight anterior. is often the product of excessive internal rotation of the tibia.
check the most distal palpable pulse and auscultate for an audible bruit suggesting the site of obstruction. squatting television viewers. A temporary reversal of their habitual foot position while watching television helps to reverse the distorting process. squatted with feet in the toed-in position. Trauma or local disease is the usual cause for unilateral swelling. Blanching time is delayed in cases of pronation and arch weakness due to circulatory interference. Tenderness along the transverse arch is common in aseptic necrosis from a circulatory disturbance. To evaluate the capillary filling time of the toes. or genu valgum. John Palo reports in personal correspondence that both in-toeing and outtoeing are seen in young. Children who watch much TV. will be found walking with toed-in supinated feet. or an inflammatory lesion. If this is the cause. calcaneovalgus. An elevated pink foot that markedly deepens in color in the standing position suggests arterial insufficiency or vascular disease. top of the foot." MISCELLANEOUS CIRCULATORY DISTURBANCES Circulatory Insufficiency Screening Tests Skin color normally darkens in the weight-bearing position. squatted with feet in a toed-out position will be found walking with toed-out pronated feet. then release pressure quickly. Edema is usually greatest in the front of the leg. -. Dr. venous disease. Normal color should return within 6-10 seconds. and back of the thigh. Apply finger pressure to the medial dorsal area of the foot and note time for the white spot to disappear. -.Soft-tissue shortening or adhesions at the hip or retroversion of the femur (external torsion). Venous disease is the most common cause of pitting on pressure. Collapsed veins should fill within 12 seconds on standing. external rotation of the femur will be much greater than internal rotation. then rotate weight to outer border and repeat test.
. or acute arterial occlusion may result in lower extremity edema. In infants. habitually sleeping supine with the feet turned outward or the constant use of excessively wide diapers may be the cause. Edema Lymphatic obstruction. compress a selected toe until it blanches white. If the pulse is absent in a limb. pressure of tumors in the pelvis. Note the venous filling time on the dorsum of the foot at this time. "Children who watch much TV. Tenderness frequently accompanies edema from any cause. Unilateral edema may be due to thrombosis of a vein.are commonly associated.Flat feet.
Black Heel Pigmented areas on the back of the heel secondary to petechial hemorrhage are sometimes seen. basketball. and swollen. trichinosis. The long flexors of the toes primarily exhibit the effects of inadequate nutrition. anemia. cramps. Muscle swelling or prolonged spasm within a fascia-encased compartment and ischemia-enhanced edema may cause or contribute to the disorder. Other evidences of insufficient arterial blood supply (eg. lymphatic disorders. flatfoot. Once the cause has been determined and corrected.Nontraumatic bilateral edema is due to uncompensated heart lesions (primary or secondary from lung disease). Diagnosis depends on the history and the examination of the remainder of the body. The contracture is the result of impairment of or injury to a major artery or innervating nerve. ultrasound. It may also be due to neuritis. cirrhotic liver. or another source of local inflammation. badminton. The patient kicks off the bed clothes from his feet at night because of warm burning sensations. varicose veins. clubbing. conservative rehabilitative procedures should be directed to enhancing circulation and softening of fibrotic tissues (eg. deep heat. The attacks are aggravated by heat and not by cold as with Raynaud's disease. The tissues below the blockage are cool. vibromassage). neuritis. Erythromelalgia Red neuritis of the extremities is common in the feet. nephritis. The anterior compartment of the leg is tightly bound and has difficulty in expanding to compensate for increased internal pressure. Management. painful. Such attacks are probably akin to the condition of "hot feet" often seen in the arteriosclerosis of elderly people. cancer complications. obesity. In some cases. Volkmann's Ischemic Contracture of the Foot This condition (postischemic fibrosis) may appear in either the lower or upper extremity. Tibial fracture leading to embolism or thrombosis may be involved when this type of contracture is seen in the leg and foot. intermittent claudication.
. mobilization. an absolute cause cannot be found (angioneurotic. it is most often associated with tennis. In Raynaud's disease. tender. cyanotic. hot. and soccer. In sports. The toes (or fingers) are red. the digits are cold and painless or numb. galvanism. Heel pain following activity is the common complaint. but the disorder is frequently asymptomatic. hereditary types). Prolonged cast pressure or tourniquet applications may be involved. The resulting necrosis leads to fibrosis and contracture. and painful. essential. gangrene) may coexist. and other less common causes of deficient local circulation.
There may be pain and tenderness near the attachment of the ligaments and often higher up on the leg. quick changes of direction. atrophic. Valgus or eversion of the heel and abduction of the forefoot are usually associated. spina bifida occulta. usually horizontal. A postural flattened arch must be differentiated from that associated with benign hypotonia. If the hemorrhage is longitudinal in a nonathlete. and the severe forward motion of the body that propels the long toes against the front of the inside shoe. joint stiffness. plantar strains) than a rigid fallen arch. under the toenails (tennis toe). The "arches" of the feet serve more like springs than they do rigid mechanical arches. the disorder is easily confused with the splinter hemorrhages consequential to subacute bacterial endocarditis after a recent illness. One foot may have a strong arch and be in a straight-line position while the other foot is flattened and toed-out.
FLAT FOOT (PES PLANUS)
The human foot is normally held in an arched position only by the power of the muscles acting coordinately the instant weight is borne. the head of the talus drops downward and medially from under the navicular and stretches the tibialis posterior and spring ligament. Related pain may be local in the arch or extend to the medial malleolus. Generally. or cerebral palsy. and peroneal muscle spasm. loss of spring in the step. The cause may be traumatic. The cause is thought to be from sudden stops. congenital. But contrary to popular belief. a "flat foot" results from a breaking down or weakening of the normal medial longitudinal arch of the foot. or lumbar area. and the arch may be lessened. spastic flat foot. knee. but many cases are symptomless. Clinical Features There may or may not be changes in the sole print (a useful record). A patient with an apparently short leg often has a greater pronation or inward roll on that leg. In addition. excessive eversion during weight bearing. the feet of the same patient may vary in size and design to an amazing degree. disability during gait.
.Tennis Toe A chronic complaint of pain in one or more of the longer toes is frequently associated with hemorrhage. hip. congenital tarsal abnormalities. or the effect of obesity or ill-fitting shoes. This is anticipating that there is nothing to hinder the bones of the arch from taking their normal position and that the Achilles tendon is not pathologically short. obliterating the longitudinal arch and forming a callus under the talar head. a rigid high arch will cause more problems (eg. When the arch flattens. There is usually a pronated gait.
This is usually secondary to a motion-restricting hindfoot arthritis or a tarsal disorder. A longitudinal arch that is dropped in both the standing and nonweight-bearing position is rigid and may be aggravated by arch supports. forefoot abduction. pain and tenderness over the peroneal tendons or in the hindfoot. Rigid Flatfoot. On the contrary. When distress is produced by a flexible flatfoot. but during weight bearing. Check for foot pronation that may be associated with a fallen arch but is a separate deviation. he found most flattened arches on the side of the long leg. Physical signs include a painful limp. the fallen arch would correct itself in a few days. A rigid flatfoot is frequently caused by protective peroneal spasm leading to contractures. the forefoot pronates and abducts. and wear of the patient's shoes. quality. When associated with a shortened Achilles tendon. restricted and painful midtarsal and subtalar motion. Compensatory Flatfoot. When symptoms appear. Note the existence of hammer toes or marked deviation of the large toe toward the midline of the foot (hallux valgus). and possibly mild swelling. It cannot be passively or actively reduced in a nonweight-bearing position. the influence of a flattened arch on femoral height does not usually exceed a millimeter. On the other hand. the typical symptoms are foot pain. Flexible Flatfoot. Common complaints associated with a rigid flatfoot are stiffness. a longitudinal arch that is absent in the weight-bearing position but present in the nonweight-bearing position may be
. His studies showed that while most deficiencies in femur height are of several millimeters. A hypermobile foot that flattens on weight-bearing is usually a hereditary state that may or may not produce symptoms. but Gillet has not found this to be the case. burning sensations.A convex medial border of the foot (when viewed from above) is a sign of an extremely flattened arch. If either of these theories is true. an arch support or a heel wedge on the side of the long leg would be contraindicated. they usually do so gradually during adolescence. and pain aggravated by forefoot adduction and inversion. A flexible flatfoot appears normal when examined in a nonweight-bearing position. pelvis. Management Free any subluxation-fixations in the spine. heel eversion results and a pronation syndrome follows. and lower extremities. passive dorsiflexion is limited when the heel is inverted. The supposition is that such a fallen arch is a product of the hip of the long leg rotating outward (producing foot eversion) to cause the line of force to fall more medially over the arch and/or is an innate biomechanical attempt to reduce the discrepancy in functional limb length. the medial longitudinal arch disappears. If the Achilles tendon is tight. A lowered longitudinal arch might be thought to be a common cause of a physiologic short leg. Note fit. and a mild genu valgum (knock-knee) or internal tibial torsion may be present. and fatigability. When a heel lift was added to the short side. heel eversion.
Added to this stress is the effect of unyielding surfaces. A tabulation of the common causes of foot pain is shown in Table 3. Even minor traumatic disturbances can greatly inhibit optimal performance. FOOT TRAUMA It is not uncommon that the foot is caught between forces from both above and below. One study showed that while 99% of all feet are normal at birth. 8% develop troubles by the first year of age. Common Causes of Foot Pain Rearfoot Pain Achilles strain Achilles tendinitis Apophysitis Bursitis Fracture Plantar fascitis Spur Midfoot Pain Fixation Flat-foot syndrome Fracture Forefoot Pain Cellulitis Corn Degenerative arthritis Toe Pain Blister Corn Dislocation Fixation Fracture Hallux rigidus Hallux valgus Hallus varus Hammer toe Osteochondritis Peripheral vascular
Kohler's disease Fixation Plantaris rupture Sprain/strain Subluxation Subtalar arthritis Tarsal coalition Freiberg's disease Gout Metatarsalgia Morton's neuroma Peripheral neuropathy Phlebitis Plantar neuroma
. Table 3. the force on the supporting foot is about three times body weight. 41% at age 5.aided by longitudinal arch supports. and 80% by age 20. When running on a level surface. This increases to four times body weight during downhill runs. strengthening exercises and orthoses for chronic flexible flatfoot syndromes offer only palliative comfort and little curative value. In general.
Then check the calcaneal bursa situated between the insertion of Achilles tendon and the skin. Foot Bruises and Wounds
. A pronated ankle is often involved. often leading to spurs. This is especially common in track where the shoes are often heelless. Runner Fascitis. Chronic cases. Treat as any bursitis. hurdlers). Both of these bursae are subject to inflammation from pressure or friction from poorly fitting shoes (especially football shoes with their heavy counters). The area will be tender and often feel thick and boggy. Heel cups are helpful in prevention and during healing. Special care must be taken not to confuse heel bursitis with avulsion of the Achilles insertion. During nonactivity. Lift the skin away from the tendon with one hand while palpating anterior to the tendon. Management. This is an inflammatory reaction caused by prolonged dynamic traction of the plantar aponeurosis. Bursitis Palpate the area of the retrocalcaneal bursa located between the anterior surface of the Achilles tendon and the top of the heel. and granulation tissue. Prolonged stress from heavy heel landings displaces the fat pad and ruptures the fibrous septa under the calcaneus. especially at fiber insertions into the calcaneus. jumpers. Heel bruises are seen affecting the plantar surface of the os calcis. may require surgical excision of new bone. low-cut shoes and heel padding throughout the counter area are recommended to avoid recurrent swelling. Examine the area of the medial tubercle lying on the medial plantar surface of the calcaneus. and ultrathin (eg. long-distance runners. flexible. This usually longterm stretch of the fascia can result in pain and chronic inflammatory reactions leading to heel spurs. heelless sandals or slippers are recommended.disease Plantar wart Subluxation Synovitis Strain/sprain Subluxation
Heel Injuries Palpate the dome of the calcaneus from above plantarward. and check for spurs in adults or signs of epiphysitis in children. A common cause of heel pain in runners is plantar fascitis. During activity. necrotic fibers.
osteomyelitis. ultrasound. In acute cases. Callosities. tetanus. Contusions and Abrasions. Palpable stiff cords or nodules within the fascia suggest consequences of chronic plantar fascia spasm. or acute arthritis of the foot. like contractures. or cleat wounds. especially on the heel. With early suspicions. True plantar fascitis is rare. the plantar aponeurosis should feel smooth and without areas of tenderness. or plantar warts tender to pinching. During recovery. and ultrasound. A bone bruise affecting the 2nd or 3rd metatarsal head. elevation. Check thoroughly for possible cuboid or navicular subluxation. local heat. and sometimes the transverse arch. Some degree of swelling may be felt. foot stubs. trigger point therapy. In spite of proper care. It is usually the result of chronic pronation. Puncture Wounds. The typical clinical picture of plantar strain primarily exhibits pain during running due to plantar-fascial stretch. Clinical Features. Tight plantar fascia raises the longitudinal arch. During palpation. It is common in track and the result of running with full weight onto some small. and insert near the metatarsal heads. A puncture wound of the sole of the foot presents a special problem. and rest. Padding. should be worn as long as tenderness persists. spray across the sole. fascial tears from dorsiflexion overstress. mobilization. referral should be made for debridement and/or antibiotics. Bone Bruises. often specially designed. Tenderness is found just distal to the calcaneal tubercles. but when it occurs. Most foot contusions can be traced to a dropped object. A blow to the lateral ankle occasionally dislocates the peronei tendons anteriorly from their normal position behind the malleolus. Adjunctive care consists of cold packs during elevation and compression. Dupuytren's contractures tender under deep pressure. are tender to pressure but not to pinching. A temporary longitudinal arch support (or taping) and crutches are
. it is often confused with sprain of the spring ligaments in the arch. some may develop cellulitis. Management. and deep vibromassage may be applied to relieve related soreness. compression. but calcification may appear on later films. is called a "stone bruise" in athletics. which are later followed by vibromassage. Plantar Strains The strong bands of plantar fascia have their origin at the medial tubercle of the calcaneus. contrast baths. Early roentgenographs are negative. a slight degree of ecchymosis and severe tenderness may be at attachments. hard object without adequate protection.Initial treatment must be quick to minimize bleeding and swelling through cold. or associated with calcaneal fatigue fractures.
and orthotics improving foot support are helpful. especially the 1st metatarsal. Sideward sprains rarely occur. Calcaneocuboid sprain is usually produced by forceful internal rotation of the foot on the talonavicular joint when the foot is inverted. avulsion of the insertion of the tibialis posterior features acute styloid tenderness. Talar subluxations and restrictions are often related. especially at the metatarsophalangeal joint as the result of forced plantar flexion or dorsiflexion. Pain and swelling may be severe. Disability is severe because weight-bearing is predominantly on the hallus. Toe Sprains The most common toe sprain is that of the great toe. which is found farther posterior and usually more acute. contrast baths. what may
. Correct any fixation-subluxations isolated and apply general sprain management with emphasis on rest. Symptoms of medial aching pain and tenderness deep within the plantar arch commonly arise after prolonged running when soft shoes are worn. Management. passive mobilization of the entire foot. Chronic low arches do not seem to be a precipitating factor. Exostoses Bony overgrowths infrequently form at the head of a metatarsal. An ache and tenderness under the 2nd and 3rd metatarsal heads are often the result of postural stress. extending for many years. and ultrasound in water. with distal neurologic effects. Rearfoot sprains are usually chronic in nature. Sprains of the other toes are managed similar to finger sprains. Foot Sprains Calcaneocuboid Sprain. swelling over the calcaneocuboid area. Differentiation must be made from plantar fascitis. and great disability. Spring Ligament Sprain. Forefoot Sprain. This can be a chronic strain that can set up a subtle pathobiomechanical complex. arch strapping. Rearfoot Sprain. intrinsic exercises. Treatment is usually by surgery (exostectomy). featuring progressive pain with minimal swelling in the rear half of the foot during and following activity. As a consequence of severe eversion or inversion strain. Overstress of the plantar calcaneonavicular ligament is often associated with navicular subluxation. During rehabilitation.helpful during initial healing. The cause in some cases can be traced to a low-grade tarsal synovitis from poor foot support on hard ground during strenuous activity. There is immediate severe pain. However. but bone tenderness or crepitus is absent.
exostoses. corns. Minor conditions can be aided by heel pads and any taping procedure that supports the arches of the foot. It is especially debilitating in track and almost always associated with compression of the foot by tight shoes pinching the external plantar nerves between the metatarsal bones. In addition. but trauma from the surgery may set the stage for further periosteal reactions and other surgical complications. Morton's Test. and pronation complaints that are often associated with plantar callous patterns. Management. and mild swelling along the medial aspect of the os calcis or plantar fascia attachments at the calcaneal tuberosity. there are toe pain. The clinical picture includes a distinct limp. bunion. foot fatigue. and tendon avulsions. Heel Spur A heel spur typically forms at the inferomedial aspect of the calcaneus. constant pain only during weight bearing. padding beneath the tongue of the shoe. Signs and Symptoms. The cause is attributed to chronic traction of the plantar fascia on calcaneal periosteum. Under normal conditions when the toes are grasped and quickly flexed. and there is abnormal weight balance and distribution. In metatarsalgia. There also is hypertrophy of the 2nd metatarsal joint. and (3) posteriorly displaced sesamoids. adjunctive care includes ultrasound in water. Management. A metatarsal crescent can be applied to the sole of the shoe or a felt pad placed just behind the plantar
. Metatarsalgia Morton's syndrome (metatarsalgia) produces pain near the proximal end of one or more of the three outer toes. Surgery is reported to be the treatment of choice. and transverse arch support. This test is designed essentially for the recognition of lesions of the metatarsal arch. march fractures. neuroma.appear to be a bony overgrowth during palpation (a knuckle-like prominence) is actually a metatarsocuneiform subluxation that can be demonstrated by roentgenography. An osseous triad consists of (1) a 1st metatarsal bone that is shorter than the 2nd. and intermetatarsal neuroma. especially between the 2nd and 3rd metatarsals. Differentiation must be made from postural strains. the procedure is painless. After mobilizing all fixated joints from the foot to the hip. (2) hypermobility at the naviculocuneiform and medialand inter-cuneiform articulations. subluxations. tenderness increased in dorsiflexion. deep vibromassage (many trigger points will be found). Use a shin splint taping procedure in acute cases. transverse pressure across the heads of the metatarsals induces sharp pain. the foot is pronated and the arch flattened. Pain results if there is an inflammatory lesion in the metatarsal arch. Strunsky's Test.
Poorly responding cases may require referral for specialized attention. It is usually singular and associated with a callosity on top of the proximal interphalangeal joint. Predisposing factors include forceful plantar flexion of the metatarsal joint. The sesamoid enlarges. This laxity from hyperpronation allows the metatarsal to adduct. and the soft tissues on the lateral aspect of the great toe enlarge. the object is to slightly lift the stressed joints during weight bearing.metatarsal heads involved. on the tips of the toes. The disorder is rare in athletics but must be differentiated from postural strains and tendon avulsions producing forefoot pain and plantar tenderness. especially between the 3rd and 4th. Check for short shoes. Bunions are especially common in hyperpronated runners and women who habitually wear sharp-pointed shoes. A hammer toe presents fixed flexion of the proximal interphalangeal joint with hyperextension of the metatarsophalangeal and distal interphalangeal joints. A bunion is a progressive effect of prolonged hallux valgus where the great toe displaces laterally with rotation about the long axis so that the nail faces medially. Claw toes. The patient should be advised to lace the foreshoe loosely. usually associated with pes cavus. Whenever a bunion is found.
Selected Disorders of Toes
Bunion. and on the plantar surface under the metatarsal heads. An early sign is the formation of callosities over the dorsal surface of the toes. An adventitious bursa forms that often becomes tender and inflamed. Plantar Neuroma A rare cause of metatarsalgia is Morton's neuroma --painful round "beads" found between the heads of the 1st through 4th metatarsals. Hammer Toe. pes cavus. and there is an accompanying digital artery disorder. Increased pronation causes a lax peroneus longus tendon. which is ridiculous. Shooting distal pains and sometimes periods of numbness are severe but quickly relieved when the shoeless foot is rested. forefoot
. In either case. Shoe salesmen often measure foot length in nonweightbearing. They are thought to be the effect of excessive foot rolling where the plantar nerve is chronically impinged on taut fascia or bone. Hypertrophy of the nerve sheath develops. a short metatarsal. check the ankle for hyperpronation. Graduated tiptoe walking and walking on the lateral edge of the foot are helpful during rehabilitation. which attaches to the first metatarsal and typically exerts a lateral pull. Claw Toes. Shoe irritation and concomitant bursal inflammation produce the painful bunion. Roentgenographs are negative. feature flexed proximal and distal interphalangeal joints and hyperextended metatarsophalangeal joints.
developed a world-wide reputation in the 1930s treating a broad range of human ailments by doing nothing more than adjusting the cuboid.
According to an arbitrary anatomical classification. rest. and the hindfoot (rearfoot) includes the talus and calcaneus. Similar to a hinge joint. ultrasound in water. Mallet Toe. This is a subtle motion to perceive but necessary for complete evaluation of joint motion in the ankle. Sesamoiditis. William Locke. Sesamoid necrosis under the head of the 1st metatarsal in the flexor hallucis longus tendon may show roentgenographic signs.valgus. Progressive exercises may be started immediately after the acute stage has subsided. adjustment of subluxations. Passive mobilization of fixated joints. laterally articulates with the nonweight-bearing fibula. the forefoot is composed of the five metatarsals and phalanges.
Two major areas of likely joint restriction exist in the ankle area: above and below the talus. It is less common than a hammer toe. The plantar surface of the patient's uninvolved extremity should be placed above your knee for stability. Restricted Ankle Mortise Long-Axis Extension. Within the subtalar joint. The only motions of joint play to be evaluated within the ankle mortise are longaxis extension and A-P glide. medial tilt. and improved footwear are beneficial. which superiorly supports the weight of the tibia. navicular. the midfoot consists of the cuneiform. of Ontario. Encircle the ankle mortise at the level of the malleoli with the thumb and index fingers of each hand so your index fingers are interlaced and firmed against the Achilles tendon
. the ankle mortise is designed essentially to allow plantar flexion and dorsiflexion. Only a slight amount of rotation is normally allowed. A mallet toe is a distal interphalangeal joint flexion contracture that usually occurs in the smaller toes. and cuboid bones. long-axis extension. or pronation imbalance. strapping. Deep palpation within the flexor hallucis brevis tendon may locate the two sesamoids where signs of sesamoiditis develop. talar rock on the calcaneus. and lateral tilt are the primary considerations. trauma. Place the patient in the supine position with the feet at the end of the table. MD. and stand or squat facing the patient. and inferiorly rests primarily on the anterior two-thirds of the calcaneus. The key structure within the ankle is the talus. Suggested techniques are described below. sole padding.
Restricted Subtalar Medial and Lateral Tilt. Place the patient in the supine position with the feet at the end of the table. With your caudad hand. noting the subtalar motion elicited under your index fingers. In this position. Apply traction and note the degree of joint play perceived by your thumbs. In this position. and stand or squat facing the patient. With the doctor-patient positions and contacts the same as described above for evaluating subtalar rock. This motion refers to A-P movement of the talus between the malleoli. Restricted Subtalar Rock. alternately invert and evert the patient's ankle by rotating your hands clockwise and counterclockwise to evaluate subtalar medial and lateral tilt. An alternative method to evaluate posterior glide of the talus on the tibia uses the same doctor-patient positions described above. Restricted Subtalar Long-Axis Extension. With this procedure. your cephalad hand grasps the underside of the patient's distal leg and applies an upward pressure while your caudad hand on the anterior surface of the patient's ankle just below the malleoli exerts a downward force. Place the patient supine with the hip and knee on the involved side flexed and the foot at a right angle to the leg (resting on the heel). Care must be taken to avoid pressure against the malleoli during this maneuver. you will be able to elicit ankle mortise A-P glide by alternately pushing downward and pulling upward with your active (cephalad) hand. Restricted Ankle Mortise A-P Glide. This procedure is similar to that described above for evaluating ankle mortise longaxis extension except that the contacts are applied at a lower level. alternately dorsiflex and plantar flex the patient's foot by rotating your hands upward and downward. with your thumb laterally and your fingers on the medial surface of the patient's ankle. grasp the patient's lower leg anteriorly just above the malleoli. The plantar surface of the patient's uninvolved extremity should be placed above your contralateral knee for stability.posteriorly and your thumbs are centered over the anterior aspect of the tibiotarsal joint. With your cephalad hand. Apply traction and simultaneously note the degree of joint play perceived by your thumbs.
. grasp the anterior surface of the patient's ankle just below the malleoli. Stand or sit facing perpendicular to the patient's ankle. Encircle the involved subtalar area with the thumb and index fingers of each hand so that your index fingers are interlaced and firmed against the heel and your thumbs are centered over the anterior aspect of the talonavicular and talocuboid joints. The doctor-patient positions are the same as described above except that your hand contact is reversed so your thumbs are firmed against the apex of the longitudinal arch of the patient's involved limb and your fingers are wrapped around the anterior surface of the ankle so your index fingers are centered over the talonavicular joint anteromedially and the talocuboid joint anterolaterally.
and simultaneously make a short. The patient is placed supine. The doctor-patient position is the same as described above. and sit at the foot of the table (facing the patient). Interlock your fingers across the anterior aspect of the involved ankle with your thumbs placed on the plantar surface of the patient's foot and your elbows moderately flexed. Apply pressure with your double-thumb contact. Place the 3rd and 4th finger of your medial contact hand over the anterolateral aspect of the involved talus with your thumb on the plantar surface of the patient's foot. excessive postural pronation during weight bearing. and take a double-thumb contact on the lateroanterior aspect of the involved talus. while your medial hand grasps the anterior surface of the tarsals. The major features associated with a lateral subluxation of the talus are a history of inversion ankle sprain.Ankle Subluxations
Anterior Talus Subluxation. To adjust. To make the articular correction. apply traction with your stabilizing hand to separate the calcaneus from the talus while simultaneously applying a lateral-to-medial torque maneuver by bringing the fingers of your active hand medially while thrusting laterally with the web between your thumb and 1st finger. Subluxation of the talus medioinferiorly is often found in association with eversion ankle sprain exhibiting tenderness at the deltoid ligament. slightly invert the foot. Your third fingers should make specific contact over the anterior aspect of the involved talus. Your lateral stabilizing hand supports the patient's heel. roentgenographic signs of exostosis of the dorsal talonavicular articulation. Place the third finger of your lateral contact hand over the anteromedial aspect of the involved talus with your thumb on the plantar
. Internally rotate the patient's leg. and excessive postural pronation during weight bearing. Lateral Talus Subluxation. Indications of an anterior talus subluxation include pain and tenderness at the anterior aspect of the ankle. apply traction to separate the calcaneus and talus while simultaneously snapping your wrists and elbows inferiorly in a scooping fashion to move the talus from the anterior to the posterior. To make the correction. and tenderness of the anterior talofibular ligament. Sit at the foot of the table. facing the patient. To correct the mechanical displacement. place the patient supine. pain anterior to the lateral malleolus. apply traction. sharp pull toward yourself to correct the malposition. Stand at the foot of the table. a history of inversion sprain that occurred with plantar flexion. Medial-Inferior Talus Subluxation. The corrective maneuver for this subluxation is essentially the opposite of the adjustment for a lateral talus. There is an alternative procedure. place the patient supine. facing the patient. Your lateral hand grips the calcaneus.
and talus-cuboid articulations. metatarsal-tarsal fixations and thoracic fixations. He felt that the cause of many frequently recurring fixations in the spine or pelvis can be traced to fixations in the feet. To make the adjustment. With your lateral
. intercuneiform. The joint plays to always evaluate for possible fixations are of the midfoot (proximal metatarsal) and forefoot (distal metatarsal) A-P glide and rotation. especially where plantar flexion is restricted.surface of the patient's foot. and talus fixations and L5 fixations. alternately pull upward and push downward with your active hand to elicit proximal metatarsal glide. The intermetatarsal ligaments are frequently shortened. Hindfoot mobility has been evaluated indirectly during the evaluation of ankle mortise and subtalar mobility. Proximal Metatarsal A-P Glide. Keep in mind that a high stiff arch that does not reduce much during weight bearing is just as abnormal as a flattened arch. metatarsal fixation and C3--C7 fixations. With doctor-patient positions the same as described above. With your active hand. cuneiform-navicular or cuboid-calcaneus and lumbar fixations. Distal Metatarsal A-P Glide. Fixation of the distal phalangeal joints is not common but those joints more proximal are. talus-navicular. and stand or squat facing the patient. Your stabilizing hand supports the heel. With the patient in the supine position.
The bony complex of a foot (about 27 articulations) is a common site of single or multiple fixations. cuneiform-navicular. stand or sit facing perpendicular to the patient's foot. Grasp the patient's foot with your stabilizing cephalad hand so that you have firm contact on the cuneiforms and cuboid. navicular-cuboid. Partial or complete fixations are also found at the cuneiform-metatarsal. cuboid-metatarsal. cuneiform-cuboid. Gillet looked to the feet as the functional base of the spine. grasp the patient's foot so that your thumb and index fingers are around the proximal aspect of the bases of the patient's metatarsals. Gillet's studies showed a distinct relationship between phalangeal fixations and upper cervical fixations. While holding these contacts. These empirical findings are awaiting further confirmation. evaluate rotary motion of the proximal metatarsals by rolling your contact hand into pronation and supination so that the patient's foot is rotated medially and laterally. intermetatarsal fixations and costospinal subluxations. apply traction with your stabilizing hand to separate the calcaneus from the talus while simultaneously making a medial to lateral torque maneuver toward yourself. Proximal Metatarsal Rotation. Place the patient in the supine position with the feet at the end of the table. The metatarsophalangeal joint of the great toe is a common site. Several authorities agree with this observation.
hand. grasp the anterior aspect of the patient's involved ankle with your fingers and place your thumb firmly against the distal plantar calcaneus. Distal Metatarsal Rotation. and a history of inversion or eversion ankle
. and 2nd and 1st metatarsals. The adjustment is made with a snapping force by the thumb of the contact hand superiorly while the stabilizing hand rotates the calcaneus toward your body. To correct malposition. Both hands must act simultaneously. To correct the displacement. excessive pronation during weight bearing. cup the patient's heel and apply firm pressure against the posterior aspect of the calcaneus. With your medial hand. apply pressure with your contact hand against the heel and simultaneously make a short sharp thrust directed from the anterior to the posterior. and fibula by grasping the posterior ankle with a web contact. Subluxation of the calcaneus posteriorly is usually associated with tarsal tunnel syndrome. Anterior Calcaneus Subluxation.
Posterior Calcaneus Subluxation. place the patient prone. Stand at the foot of the table. Gross screening of forefoot rotational mobility can be evaluated by stabilizing the patient's heel with one hand while your contact hand grasps the patient's forefoot and performs a figure-8 maneuver by supinating and pronating your forearm. To adjust. Stand on the side of involvement. working in unison. With your medial hand. Your caudad hand contacts the anterior plantar aspect of the involved calcaneus with a web contact. The most obvious signs of an anterior calcaneus subluxation are excessive supination and pes cavus during weight bearing. An inferomedial subluxation of the navicular is typically associated with medial longitudinal arch pain. place the patient prone with the involved knee flexed. excessive pronation during weight bearing. With your lateral hand. Inferomedial Navicular Subluxation. Continue to evaluate A-P glide between each digit by moving your contacts medially over the distal 4th and 3rd metatarsals. To evaluate A-P glide between the 5th and 4th metatarsals distally. 3rd and 2nd metatarsals. With the doctor-patient positions and contacts the same as described above. tibia. rotation is evaluated by trying to move one metatarsal hand over and under its neighbor by rotating your contact fingers clockwise and counterclockwise. and pain located inferior and slightly posterior to the medial malleolus. grasp the head of the 5th metatarsal anteriorly with your index finger and posteriorly with your thumb. alternately push with one hand while pulling with the other hand. while your cephalad hand stabilizes the patient's talus. clasp the head of the 4th metatarsal in a similar manner. thus alternately producing distal metatarsal flexion and extension. facing the involved limb.
While maintaining this contact. apply traction by thigh pressure. place the patient supine. Lateral Cuboid Subluxation. The typical clinical picture of an inferior cuboid subluxation is lateral longitudinal arch pains and excessive pronation or supination during weight bearing. To make the correction. Locate the plantar aspect of the cuboid. To correct the malposition. the doctor-patient positions are the same as described above. and simultaneously make a thrust directed medially with the stabilizing palm against your contact thumb. To reposition. and excessive pronation during weight bearing. and face the patient. Grasp the patient's anterior ankle with your medial hand so your thumb is on the lateral aspect of the cuboid. With an alternative technic. To adjust. Your stabilizing hand is placed palm up against the lateral ankle so the thumb of the contact hand is between the thenar and hypothenar pads of the stabilizing hand. Grasp the anterior surface of the patient's foot with your caudad hand so your 2nd and 3rd fingers are hooked over the inferomedial aspect of the navicular. and assume a crouching position. place the patient prone. Stand at the foot of the table facing laterally oblique to the involved limb. Stand at the foot of the table on the side of involvement. place the patient prone with the involved knee slightly flexed. Lateral subluxation of the cuboid (Locke's basic concern) is usually associated with a history of inversion sprain. take a pisiform contact over your contact fingers. apply traction to the patient's forefoot with your stabilizing hand with emphasis on the 5th metatarsal and simultaneously make a short sharp thrust toward the floor. The patient's anterior foot rests in the palm of your caudad stabilizing hand. Inferior Cuboid Subluxation. A contact is made with the pisiform of your cephalad hand. with your fingers wrapping around the lateral aspect of the foot.sprain. and simultaneously make a thrust toward the floor with a drooping motion aided by bending your knees. To correct the malposition. To correct the malposition. stand at the foot of the table centered to the involved limb. Locate the plantar aspect of the cuboid. With your cephalad hand. stand closer to the patient so the patient's foot is held between your thighs. To reposition the displacement. Make pisiform pressure over your contact thumb with your cephalad hand. Subluxations of the cuboid are one of the most frequent subluxations found in the foot and frequently involved in a wide variety of noxious reflex manifestations.
. apply traction. lateral longitudinal arch pain and tenderness. apply traction and simultaneously thrust obliquely lateral toward the floor. A contact is made with the thumb of your medial hand with the fingers wrapping around the anterior aspect of the foot for support.
wrists. Grasp the patient's involved foot with your medial hand so the inferiorly subluxated bone is under your thumb and your fingers
. A distal metatarsal bone subluxated inferiorly is commonly associated with excessive callus formation across the metatarsal heads. and excessive supination during weight bearing. Stand at the foot of the table. To adjust the supine patient. Face the patient. Your fingers. Stand at the foot of the table. To correct the malposition.Superior Tarsal or Proximal Metatarsal Subluxation. apply steady plantar flexion to the foot and simultaneously make a snapping thrust with your contact thumbs directed toward the floor. To correct the malposition. Your medial hand is interlaced over the contact hand so the third finger is on top of the contact hand's third finger and the thumb is firmed against the plantar surface. and excessive pronation or supination during weight bearing. remove any foot inversion or eversion present. Stand at the foot of the table. a history of inversion sprain resulting in a 1st metatarsal displaced superiorly. centered at the involved side. Face the patient. centered at the involved side. Inferior Tarsal or Proximal Metatarsal Subluxation. apply traction with firm contact pressure. To correct the malposition. In this adjustment. apply steady plantar flexion of the forefoot by finger pressure toward your body and simultaneously make a quick short adjustment by thrusting your thumb contacts cephalad by snapping your elbows forward. The major features of either a superior tarsal or proximal metatarsal subluxation are pain on the dorsum of the foot. To adjust the prone patient. Grasp the lateral aspect of the patient's involved foot with your lateral hand so the superiorly subluxated bone is under the proximal or medial phalanx of your third finger and your thumb can stabilize the plantar surface of the patient's foot. Apply a double-thumb contact on the involved inferior tarsal or proximal metatarsal bone with your fingers extending around to stabilize the anterior aspect of the involved foot. pronation syndrome with superior 1st and 5th metatarsals. slightly flex the patient's knee. The features of either an inferior tarsal or proximal metatarsal subluxation are arch pain. and simultaneously apply a sharp pull toward yourself to move the subluxated bone caudally. the patient is placed supine. Apply a double-thumb contact on the involved inferior tarsal or proximal metatarsal bone. with your fingers extending around to support the anterior aspect of the foot. and elbows must work in unison. place the patient supine. and excessive pronation during weight bearing. To apply a corrective adjustment. Inferior Distal Metatarsal Subluxation. a history of plantar forefoot pain. Stand at the foot of the table. a history of ankle sprain. the involved foot is placed at a right angle to the leg. and face the patient. thumbs. and face the patient.
Toe Fixations and Subluxations
Restricted Toe Mobility. With the thumb and index finger of your lateral stabilizing hand. Restricted flexion of the distal interphalangeal and metatarsophalangeal joints and restricted extension of the proximal interphalangeal joint are features of a hammer toe. remove any foot inversion or eversion present. Be especially gentle in mobilizing this joint. Keep in mind that restricted extension of the proximal and distal interphalangeal joints and restricted flexion of the metatarsophalangeal joints are features of claw toes. The involved muscles become ineffective in maintaining abduction. grasp the involved great toe with your 3rd and 4th fingers extended along the plantar and medial aspect of the foot and your thumb placed against the anterior aspect of the involved joint.extend around the medial aspect. In time. grasp the phalanges of the involved metatarsal. adjustments have little benefit except to slow progression. Hallus Rigidus. apply traction to the phalanges. With your medial contact hand. stabilize the patient's foot with one hand while your active hand flexes and extends the joint. The 1st metatarsal becomes fixed in abduction and the hallux subluxates laterally. and make a short pull toward your body. place the patient supine. To correct the malposition. contrast baths. and simultaneously make a short thumb thrust cephalad to move the subluxated bone superiorly. remove the valgus deviation. In other toes. Once overt structural joint changes have occurred. Incidence is higher in females during youth but higher in males during adulthood. Hallux Valgus. Restricted movement in this joint frequently produces a protective gait restricting push-off. and a rigid insole are helpful. In adjusting. the abductor hallucis becomes deformed in lateral displacement beneath the metatarsal head. Evaluate the integrity of the abductor hallucis and the muscles involved in excessive pronation. This is a state of lateral deviation of the great toe. This disorder is characterized by pain. Stubborn cases may require referral for surgery (phalangeal osteotomy). usually found in conjunction with a hypermobile pronated foot and the wearing of pointed-toed shoes producing abuse to the medial aspect of the front foot. Apply traction. tenderness. stiffness. first test the great toe. Manual foot and toe mobilization. Your lateral stabilizing hand grasps the wrist of your contact hand for support. Flexion is the only motion of the great toe's proximal interphalangeal joint. In evaluating toe flexion and extension. flexion and extension occur at the proximal and distal interphalangeal joints and the metatarsophalangeal joints. Stand at the foot of the table.
. and limited motion of the 1st metatarsophalangeal joint. facing the patient and centered to the involved limb. To test mobility of the 1st metatarsophalangeal joint.
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