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

internally rotated tibia. and flattening of the longitudinal arch. You may find that the source of pain is a small nail or thorn that has penetrated the sole of the shoe. Loading Reactions. Each articulation is designed to allow its component parts the best possible range of motion to normal balance against gravitational force. This produces microavulsion at the trochanteric attachment of the iliopsoas muscle. side. the bob will be near the medial malleolus. In pronation. superior 1st and 5th metatarsals. Normally. posterocalcaneal torque. A corn at the 2nd metatarsal inward torque on the tibia. Haglund's deformity. and a lower inner longitudinal arch will usually be found on the side of the weak iliopsoas. the bob will be in the approximate midline of the ankle. a tailor's bunion on the lateral 5th metatarsal head. has failed to be properly diagnosed and corrected. Remove the patient's shoes and inspect (from the front. Bone design of the foot typically conforms to the habitual mechanical stress that exists at its every weight-bearing point. Thus. and back) the patient's foot posture during standing and the degree of inward pronation or outward supination. Insert an index finger under the inner longitudinal arch to a point midway under the foot. symptoms referred to other parts of the body continue because their cause. Do not miss checking the inside of the patient's shoes. To record the effects of foot pronation. lateral deviation of the Achilles tendon during weight bearing. then repeat plantar palpation. Other Biomechanical Effects. Evaluation and Mensuration. 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 roll the feet to their outer . and palpate the plantar fascia for tension. here being in the ankle-foot complex. 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. if the psoas tests weak. When changes are overlooked. Associated foot and ankle signs include a lateroinferior cuboid. inferior 2nd--4th metatarsals. Also keep in mind that the shoes worn to your office may not be those commonly worn. 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. Ordinarily. the fibula follows suit with the torque continuing through the knee joint. a foot pronation problem should be an early suspicion. and/or bunion are typical findings. medioinferior navicular. producing a sustained torque to the femur that then allows the lesser trochanter to displace backwards and laterally. This principle is true throughout the skeleton. In each case. inferior tarsals. Drop a plumb line from the center of each patella. Rotate the foot to its outer border and the knee laterally.

They usually result from falls where the victim lands stiff legged on the heels. and oblique x-ray views are standard for evaluating possible ankle fracture. For the purpose of accurate diagnosis. a slight widening of the distal interosseous space between the tibia and fibula (indicating interosseous membrane rupture) will be found. Talus and Cuboid Fractures Fracture of the talus and cuboid are next in frequency to those of the calcaneus. Ligament injury is always present in displaced malleolar fractures. One of the more common fracture sites occurs when the talus is displaced in the ankle mortise. the posterior extension of the . In later views.borders and measure the distance between the patella marks: pronation causes inward rotation of the knees. it is always a good rule to x-ray the thoracolumbar region when a crushing fracture of a heel is found. and sometimes tomography or stress views during inversion and eversion are required. Heel Fractures Fractures of the calcaneus are frequent. the use of Boehler's angle is recommended during roentgenographic analysis. Thus. the fracture line is seldom seen. Boehler's Angle. ROENTGENOGRAPHY: SEVERE ANKLE AND FOOT INJURIES Lateral. Ankle fractures are frequently associated with severe ligament injury. Boehler's angle results from a line drawn first from the posterosuperior margin of the talocalcaneal joint through the posterosuperior margin of the calcaneus. One report states that rupture of one or more syndesmotic ligaments occurs in more than 90% of malleolar fractures. Examination should include the posterior halves of both heels. Less than 28° is considered definitely abnormal and poor position from a functional standpoint. Bilateral films are helpful to rule out a trigonum. When this happens. 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. 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. 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. A-P. For the normal calcaneus. shifting the talus and fibula laterally.

adduction. Fractures also commonly occur in the posterior or midportion of the talus. A horizontal fracture of the medial malleolus. the lateral fibular cortex may be comminuted. Comminution of the lateral cortex is usually related. In advanced cases. the superior portion of the talus may show collapse of its articular margins. This fibula fracture usually occurs below or within the syndesmosis but may occur above the syndesmosis if it ruptures. a torn deltoid. associated with a deltoid tear. Another anatomical variation that sometimes leads to interpretative error is a separate ossification center at the base of the fifth metatarsal (usually bilateral). This is best seen on an A-P view because overlapping malleoli cloud the picture in lateral films. the fracture is usually higher on the fibula and/or more oblique. Abduction Injuries. In abduction injuries. 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. When external rotation is a secondary force added to abduction. abduction. abduction injuries produce transverse malleolar fractures or deltoid tears. Fractures secondary to impact of the talus are oblique and frequently comminuted. These areas may be the sites of avascular necrosis. As with external rotation injuries. while those secondary to ligamentous avulsion are typically horizontal. An abduction fibula fracture is typically oblique and short. and diastasis is more common because the syndesmosis is ruptured. and a complete rupture of the syndesmosis (called a Dupuytren fracture-dislocation) are unstable injuries resulting from forceful abduction and lateral rotation. The interosseous ligaments are usually spared if the foot is in supination rather than pronation. viewed as a lucent crescent under the articular margin of the talus. Excessive foot pronation is the usual mechanism. small dorsal tibial and fibular avulsions may be noted. An oblique transverse fracture of the medial malleolus at or beneath the tibial articular surface may occur. The obliquity of the fracture line is determined by the direction of force. The common mechanism involved in ankle injury is traumatic external rotation plus abduction. An examiner should not confuse a sharp or rough-edged fracture fragment at the posterior talus with a rounded-edged accessory ossicle (os trigonum). and vertical compression. with fragments displaced inferiorly by the pull of the deltoid ligament and tearing of the anterior tibiofibular ligament. A small posterior malleolar fracture may result from the rotating fibula. Classification of Ankle Fractures The patterns of ankle injuries can be classified according to direction of primary and secondary forces such as external rotation. . External Rotation Injuries.talus occasionally occurring as a separate bone. As little as 1 mm of lateral displacement reduces the area of tibial-talar contact by 42%. a high fibula fracture.

Fractures to the posterior margin are not common.Supramalleolar fractures. The condition is not common to athletes but is occasionally found in unconditioned joggers who run on hard surfaces. frequently isolated. Vertical compression with external rotation force is more likely to produce large fragments. anterior marginal fractures. Vertical Compression Injuries.Adduction Injuries. similar to those seen in other weight-bearing joints (eg. Fatigue Fractures of the Foot March fractures are characterized by point tenderness and sometimes. and supramalleolar fractures. invariably associated with fracture of the fibula. This type of fracture. Stress Cysts of the Foot Bowerman points out that chronic stress of the talus may produce marginal degenerative cysts. It usually occurs in the dorsiflexed foot. Vertical compression injuries are subdivided by Dalinka into posterior marginal fractures. the incidence of posttraumatic arthritis and chronic instability is high. The second metatarsal is the site of the most common fatigue fractures found in the foot. a palpable callus. -. Adduction ankle injuries usually result in distal fibular horizontal fractures at or below the articular surface. but not always. hip). thus the proximal fibula must also receive careful evaluation. -. is of the distal 4 cm of the tibia above the ankle line (Malgaine fracture). These types of fractures may occur (1) with significant vertical compression of the articular margin or (2) without vertical compression.Posterior marginal fractures. knee. and related to high-impact forces in the direction of axial compression. may be comminuted. It is commonly open.Anterior marginal fractures. the joint space near the cyst will be narrowed. This type of fracture. Management is similar to that for metatarsalgia: rest and support. may produce small posterior marginal fractures. -. When the posterior articular fragment is large. Rips of the anterior tibiofibular ligament are frequently associated. severely comminuted. warts. . and bunion may be the underlying factor in symptomatic runners. Usually. Various congenital or acquired factors such as Morton's toe. but posttraumatic arthritis may result from comminution of the articular surface. Diastasis is not typically associated with adduction injuries. with or without an abduction factor. Posterior marginal fractures seldom occur as isolated injuries. External rotation injuries. 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. if old. Diagnosis is made early by exclusion and late by roentgenographic findings. The onset of symptoms may be rapid or gradual.

Table 1. Most authorities consider the ankle to be formed by the tibia. supination. foot inversion Plantar flexion Plantar flexion Plantar flexion. the major joint motions of the foot are pronation. foot. leaves off and the foot begins is a matter of differing opinions. longus Peroneus tertius Plantaris Major Functions Dorsiflexion Dorsiflexion Plantar flexion. When the ankle is stabilized. and toe plantar flexion. and rotation occur. The foot includes all structures distal to the talus. (2) subtalar inversion (5° ) and eversion (5° ). foot eversion Dorsiflexion. and toes are shown in Table 1. abduction-adduction. Muscles of the Ankle. and Toes Spinal Segment Muscle THE ANKLE AND FOOT Extensor digiti longus Extensor hallucis longus Flexor digiti longus Flexor hallucis longus Gastrocnemius Peroneus brevis. Joint Actions of the Ankle and Foot Normal ankle and foot movements use a combination of (1) ankle dorsiflexion (20° ) and plantar flexion (50° ). essentially a hinge joint. Subtalar joint motion occurs about an axis that is oblique to the three axes around which usual ankle flexion-extension. and (4) toe flexion (45° ) and extension (80° ). Muscles controlling the ankle. foot eversion Plantar flexion L4-S1 L5-S1 L5-S1 L5-S2 S1-S2 L5-S1 L4-S1 L5-S1 . Foot.ARTHROKINEMATICS Where the ankle. and talus. toe dorsiflexion. (3) midtarsal forefoot adduction (20° ) and abduction (10° ). fibula.

an allowance of a segment above and below those shown should be considered.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. weak foot inverter Plantar flexion. . 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. thus.

To passively test forefoot inversion and eversion. KINESIOLOGY OF THE ANKLE AND FOOT Slight intermittent muscle action is involved to control normal body sway. Adduction occurs around a vertical axis. pain. Fixation in this joint frequently produces a protective gait restricting push-off. Most authorities. stabilize the heel and ankle with one hand and grip the forefoot firmly in the active hand. Alternately invert and evert the heel. eversion. extensor hallucis longus . stabilize the foot with one hand while the active hand flexes and extends a particular joint. use the following terminology: Plantar flexion and dorsiflexion are motions about a horizontal axis (through the ankle) that lies in the frontal plane. Flexion and Extension of the Toes. In the lesser toes. To test motion of the 1st metatarsophalangeal joint. Restricted flexion of the distal interphalangeal joint and metatarsophalangeal joint with restricted extension of the proximal interphalangeal joint are features of a hammer toe.Descriptors of foot motion have yet to be standardized. pain during this maneuver suggests subtalar arthritis. firmly stabilize the heel and hindfoot with one hand and grip the forefoot with the other hand. Ligament shortening. Subtalar Inversion and Eversion. Restricted extension of the proximal and distal interphalangeal joints and restricted flexion of the metatarsophalangeal joints are features of claw toes. Dorsiflexion Dorsiflexion is provided by the tibialis anterior (L4--L5). Forefoot Pronation and Supination. and supination is the result of combined plantar flexion. flexion and extension occur at the proximal and distal interphalangeal joints and the metatarsophalangeal joints. and abduction of the foot. Manipulate the forefoot medially and laterally to test passive range of motion of forefoot adduction (supination) and abduction (pronation). Again. To passively test ankle dorsiflexion and plantar flexion. In testing passive subtalar inversion and eversion. Eversion occurs about an axis running in the A-P direction of the foot. inversion. first gently test the great toe. Dorsiflexion and Plantar Flexion. Flexion is the only motion of the great toe's proximal interphalangeal joint. and adduction of the foot. stabilize the distal end of the tibia with one hand and firmly grip the heel with the active hand. Pronation refers to combined dorsiflexion. or swelling commonly restricts passive manipulation of the ankle. This minimal action is necessary because body weight does not fall through the center of the joint but slightly anterior to the center. Then push the foot into dorsiflexion and plantar flexion with the active hand. When evaluating toe flexion and extension. however.

(L5--S1). and rest. To test the peronei. to prevent further irritation. and extensor digitorum longus (L4--S1). that of the flexor digitorum longus by offering resistance to curling toes in flexion. CLINICAL MANAGEMENT ELECTIVES FOR ANKLE OR FOOT STRAIN/SPRAIN 1. all the rest by the tibial nerve. It is helpful to palpate the tibialis anterior muscle with the stabilizing hand. Stage of Acute Inflammation and Active Congestion The major goals are to control pain and reduce swelling by vasoconstriction. All are supplied by the deep peroneal nerve. Flexion of the toes is controlled by the dorsal interossei. Resistance to plantar flexion and inversion tests the strength of the tibialis posterior muscle. interossei. gastrocnemius (S1--S2). Strength of the Great Toe. and to enhance healing . If the soleus is at fault. adductor hallucis. Extension of the toes is governed by the extensor digiti brevis and longus. then dorsiflex the ankle. Test strength of the extensor hallucis longus by resisting active dorsiflexion of the great toe with increasing pressure on the nail. it will not be affected by knee flexion. inflammation. the gastrocnemius is the cause of the restriction. flexor digiti. If this can be achieved. Test the strength of the flexor hallucis longus by opposing flexion of the great toe. it will be the same in either knee flexion or extension. compression. protection. quadratus plantae. flexor digitorum longus (L5--S2). soleus (S1--S2). Grasp the foot and flex the knee to slacken the gastrocnemius. and elevation. ie. and flexor hallucis brevis and longus. plantaris (L5--S1). Ankle Dorsiflexion Test for Contractures. peroneus tertius (L4--S1). Test tibialis anterior strength by applying increasing resistance when the patient attempts to dorsiflex and invert his foot. Plantar Flexion Plantar flexion is provided by the peroneus longus and brevis (L5--S1). oppose plantar flexion and eversion of the foot. The peroneus longus and brevis are innervated by the superficial peroneal nerve. and tibialis posterior (L5--S1). Limitation of the gastrocnemius or soleus muscle restricting ankle dorsiflexion can be differentiated by the ankle dorsiflexion test. lumbricals. Toe Flexion and Extension. and the extensor hallucis longus. Palpate with the stabilizing hand the first two tendons posterior to the lateral malleolus. flexor hallucis longus (L5--S2). plantar interossei. Have the patient sit on the examining table with his knees flexed and relaxed. and secondary infection by disinfection.

2. abrasions. and discourage adhesion formation. 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. scratches. prevent stasis. maintain muscle tone. enhance circulation and drainage. 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 . Stage of Passive Congestion The major goals are to control residual pain and swelling. disperse coagulates and gels. Common electives include: Disinfection of open skin (eg. provide rest and protection.mechanisms.

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.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. 3. 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.

Stage of Fibroblastic Activity and Potential Fibrosis At this stage.Immobilization Shoe orthotic Semirigid appliance Indicated diet modification and nutritional supplementation. 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. 5. and area fibrosis and to prevent atrophy. 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. causes for pain should be corrected but some local tenderness likely exists. 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 . The major goals are to defeat any tendency for the formation of adhesions. 4. taut scar tissue.

Ankle Contusions Ankle bruises are usually bone bruises that readily respond to cold. and contracted plantar fascia may be involved. metabolic disturbances. Epiphyseal separations are more common than fractures as the ligaments attach to the epiphysis. and degenerative changes as a result of kicking the ball with the dorsum of the foot. COMMENTARY As disruption of the mechanics of the kinematic chain can lead to pathologic function. and femur. focal infections. Soccer players especially present with chronic ankle strains/sprains. tibia. but dorsiflexion and inversion are restricted. tarsal navicular. 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. a dressing. In addition. Peroneoextensor Spasm Peroneoextensor spasm produces a spastic flat foot that is painful at the lower lateral leg and ankle. Spasm in eversion may become marked and indicate an eversion subluxation. The incidence of ankle contusions without sprain is highest in hockey from stick and puck blows. quick changes of position. roentgenography shows bony spurs of the anterior or dorsal talus.Aerobics Indicated diet modification and nutritional supplementation. and an elastic ankle bandage or strap for 1--3 days. passive peroneal . Management consists of standard muscle techniques. Other sites of related fatigue fractures include the calcaneus. In many sports. fast running with sudden stops. Ankle Trauma Note: The area of greatest weakness in children during ankle trauma is at the growth plate. Often overlooked are fatigue fractures of the 2nd metatarsal and fibula. Trauma is but one of the causes. elevation. There is little or no area tenderness. the foot and ankle must ideally combine a complex series of controlling forces and integrate to meet the demands of static and dynamic situations. being the final links in the human axial kinematic chain and those approximating the supporting surface. Resumed activity should be safeguarded with a protective pad for 2--3 weeks. About a third of the time in professional basketball players. and jumping account for chronic ankle and foot stress. spurs. It is especially common after cross-country runs.

Severe peronei tendovaginitis is difficult to manage and sometimes requires referral for tendovaginotomy. if not. Achilles Tendon Injuries A painful Achilles tendon is frequently associated with plantar fascitis. There are three common tests to evaluate the integrity of the Achilles tendon: Simmond's test.Thompson's test. the medial border of the foot dorsiflexes while the lateral border plantar flexes. leg or ankle tendinitis. or local inflammation. ultrasound. Normally. . If the Achilles tendon is ruptured.Simmond's test. Management. compression. These signs of nerve compression should not be confused with an anterior compartment syndrome of the lower leg. Duchenne's Test for Peroneal Paralysis. The patient is placed prone and the knee is flexed to a right angle. this squeeze will not cause the normal plantar flexion response. Simple avoidance of tightly fitted or laced shoes will correct the disorder if that is the cause. peritendinitis. have the patient kneel on a chair with the feet extended over the edge. and the arch disappears. Tenderness will be found on the anterior aspect of the ankle where the deep peroneal nerve becomes superficial. -. the foot will plantarflex slightly. Decreased sensation manifests between the 1st and 2nd toes. the test is positive for peroneus longus paralysis (L4--S1). 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. a ruptured Achilles tendon is suggested. interferential therapy. All involve the plantar flexion reflex. Disorders of the Deep Peroneal Nerve Induced Deep Peroneal Nerve Compression. especially the soleus portion. and instruct the patient to plantar flex the foot. Place your thumb on the plantar aspect of the head of the 1st metatarsal on the involved side. To detect a rupture of the Achilles tendon. Then firmly squeeze the middle third of the calf.stretching. This test is a common variant of Thompson's test. and strapping for 8--12 days. -. Clinical Tests. and carefully monitored graduated active exercises. The deep peroneal nerve can become compressed at the anterior ankle by shoes that are too tight or tightly laced. elevation. and the Achilles tap test. Place the patient supine with the lower limbs extended in a relaxed position. tendon rupture. and the extensors of the great toe may be weak. If during this action the head of the 1st metatarsal offers little or no pressure against your thumb. with cold. and progressive mobilization and strengthening. Treatment is similar to that for any acute strain. Thompson's test. rest.

Plantar flexion is usually. and passive ankle dorsiflexion aggravates the pain.Achilles tap test. -. A tender swelling is noted when the site is palpated. femoral or calcaneus fractures invariably occur before the tendon ruptures. tenosynovitis. Thompson's test may be positive or negative. dry crepitus. one encircles the instep at the center of the longitudinal arch.-. when excessive force is applied to a previously injured or diseased tendon. Proper taping can be described in three steps: (1) Two anchors of 3-inch-wide tape are applied. however. . The onset of a complete rupture is always sudden. The onset of achillodynia in Achilles tendinitis is insidious and almost always the result of chronic overstress of calf muscles. The patient will be unable to stand on the ball of the foot. The calf muscles retract to a higher position than normal. and disability. Rupture or tear results in lack of push-off during gait. Thompson's test is negative. When activity is resumed. With the patient prone. restricted ankle motion. severe pain returns. tenderness. The Achilles tendon is tapped with a reflex hammer about an inch above its insertion at the heel. often accompanied by perception of an abrupt "thud" at the site. Complete separation is characterized by sharp pain. but the sulcus may be hidden by a blood clot. If pain is induced or the normal plantar flexion reflex of the foot is absent. The prominent Achilles tendon inserts firmly into the calcaneus and is formed by the common tendon of the gastrocnemius and soleus muscles. Achilles Tendinitis. and the tenderness is often more severe than that found with complete rupture. The soleus and gastrocnemius test weak during weight bearing. severe swelling. Passive dorsiflexion is restricted. The site of tear is invariably about 2 inches above the attachment of the tendon at the heel. a rupture of the Achilles tendon should be suspected. but ankle weakness produces a flat-footed gait.Complete rupture. Less common than complete rupture. Signs of tenderness. There are burning pain. The sharp pain soon subsides. direct violence during stretch. and Thompson's test is usually positive. the patient's knee is flexed to a right angle. Achilles Rupture. A tender gap in the tendon is reliable evidence. swelling. a partial tear features acute pain during activity that persists until stress can be avoided. a tendon deficit is usually palpable. The common cause of Achilles overstress can usually be traced to overuse.Partial tear. or a poorly placed injection. Achilles rupture may occur even if the patient can extend the foot against resistance. Achilles Strains. and crepitation should be sought. and the onset of symptoms is usually sudden. The cause of Achilles tendinitis can sometimes be traced to tape or a support applied too tightly over the tendon. Because of the great tensile strength of the healthy Achilles tendon. impossible. -. but not always. This may not be true.

Contrast or whirlpool baths (108° --110° F) at least twice daily. analgesic packs. tenderness. A tight or shortened Achilles tendon restricting dorsiflexion of the foot is likely in the history but unknown to the patient. and vitamin-mineral supplementation may be helpful. During the early stages. running on hard surfaces. and to the calf anchor. interferential therapy. Ischemia appears to be the triggering mechanism. 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. Management of Achilles tendinitis is extremely long and frequently disappointing. Adhesions form that bind the tendon proper to its covering. crosses the tendon. pain is felt only during initial warm-up --disappearing with exercise. A short leg walking cast may be helpful during healing. over the heel. It is good policy to check for ankle distortion in any case of Achilles tendinitis. crosses the Achilles tendon. Immobilization may be necessary during the acute stage. This disorder of unknown cause is the result of diminished lubricating fluid within the sheath of the tendon. The third strip is secured on the lateral heel. These strips are secured by semicircular horizontal strips of overlapping 2-inch tape from the ankle to the upper calf. (3) This taping is anchored by a continuous figure-8 and heel lock. Crepitus is often present. The second strap is applied on the medial heel. thus surgical decompression is considered the treatment of choice if considerable relief from conservative measures does not occur within a week. Spontaneous rupture can result if excessive force is applied against a degenerated tendon. and is attached to the medial calf just below the knee. Later. Pronation Syndrome. The . Low-heeled shoes. The valgus torque placed on the insertion of the tendon during pronation leads to overstress pain and inflammation. Bilateral heel lifts should be provided to accommodate for the fixed partial extension. Bilateral heel pads should be provided to reduce the strain on the tendons. The inflammatory reaction may be the result of an ankle pronation syndrome. Dry Sheath. The foot compensates for this lack of motion through abnormal supination of the forefoot and subtalar or hindfoot pronation.the other encircles the leg above the malleoli. rest. the pain becomes persistent and increases in severity. Some relief may be obtained by standard physiotherapy. also of 3-inch-wide tape. and restricted ankle motion. and is attached to the lateral calf just below the knee. mild swelling. (2) Three or four strips are applied from the arch anchor. Focal Stress Degeneration. and severe training schedules are causative factors in sports. Features include a burning pain during and after strenuous activity. Taping begins in slight extension with a vertical strip run from the heel up the calf to just below the knee. and heel lifts. the inability to raise the heel from the ground during weight bearing. heel-strike running events.

Achilles tenosynovitis often produces local pain increased by use. Table 2. and heel padding offer temporary relief. the onset is rapid and there is swelling. and a distinct limp. swelling is characteristic. and Thompson's test is negative. calcaneovalgus) Degenerative joint disease Fixation Peripheral vascular disease Postural foot disorder Rheumatoid arthritis Spur . 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. In chronic peritendinitis. Symptoms usually arise a day or two after injury. the onset is gradual. and a thickened nontender paratendon is palpable. and fatigue fractures. Other features include pain on motion.2. Little tenderness is associated. Ankle Strains Many ankle strains involve the peroneus or posterior tibial muscles. For differentiation. Achilles Peritendinitis. In acute peritendinitis. Somewhere in the range of motion. rest. Surgical procedures appear to be the alternative after a thorough trial of conservative measures. Of the conservative measures. a painful point in the arc is manifested. Crepitus may or may not be present. tenderness is severe. Conservative management is usually successful unless there are associated fibrosis and strictures of the paratendon. ultrasound.onset is gradual. the common causes of ankle pain are shown in Table . It is sometimes associated with palpable crepitus. Strains must be differentiated from ankle or foot sprain. Achilles Tenosynovitis. Thompson's test is negative in both acute and chronic cases. but continued vigorous activity causes relapse. tenderness. swelling may or may not be present. interferential therapy. Treat as any inflammatory tendon reaction with emphasis on hydrotherapy and ultrasound. referred trigger point pain.

K. The peronei tendons pass behind the lateral malleolus and are best palpated during active eversion and plantar flexion. While peronei tendons pass behind the lateral malleolus. Ultimately. Posterior Tibia Tendon Strain. When an associated peroneal tenosynovitis or tendovaginitis is associated with strain. An aseptic tendon inflammation is often involved after overstress. Naughton points out. improper training habits left uncorrected will render the runner susceptible to further injury. running style. pain. logical preparation is necessary because some precise kinematic interrelationships are involved. The clinical picture of posterior tibial overstress is similar to that of peronei strain and inflammation: tenderness. crepitus. Tenderness here also suggests bursitis or fracture of the styloid process in severe sprain. The peronei are the primary foot everters and help in plantar flexion. they experience recurring injuries and frustration. and training habits is necessary to adequately evaluate any runner. Consequently. motion restriction. the peroneal tubercle will be tender and thick. If stenosis of the tunnel in which the tendons run occurs. and possibly ecchymosis. However. this cycle of failed expectations and injury may prove overwhelming and compel the runner to abandon running or exercise altogether. M. A thorough investigation of the patient's biomechanics.Talar osteochondritis Tarsal tunnel syndrome Tendinitis Subluxation Tuberculosis Tumor (rare) Peronei Strain. the tendon of the posterior tibial muscle courses behind the medial malleolus. swelling of the sheath. However. The chiropractic physician can serve a pivotal role in breaking this cycle by addressing both relief and prevention. and possible ecchymosis. SPECIAL CONCERNS WITH RUNNERS Running has become an essential element in many personal fitness programs. injury history. it is characterized by acute tenderness. 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. sheath swelling. a probable squeaking crepitus on joint movement. While appropriate chiropractic intervention can obviate symptomatology. "Novice runners are frequently ill prepared to begin a sound training program and often overestimate their capabilities. It provides relatively inexpensive aerobic activity and requires no special talent or facilities." Pronation and supination are essential during gait when properly performed in .

while the supinated heel will demonstrate a varus position. A drop greater than 15 mm indicates hyperpronation. and abduction to provide flexibility. Navicular drop can also be measured to assess pronation. Supination incorporates plantar flexion. Fatigue fractures can result. The approximate midpoint of the navicular is marked with the foot in neutral. Runners with pronated ankles frequently present with shin splints. especially those related to running. eversion. and adduction. Although oversupination distortion is far less common than overpronation. these lines are normally in close alignment. Treat as a moderately severe strain/sprain. Firm sustained pressure on this trigger point sets off an aggravating ache. pronation includes dorsiflexion. 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. "The pronated foot will demonstrate a valgus heel-to-tendon alignment. It is remeasured with weight bearing. Ankle pronation/supination occur primarily at the subtalar joint. refers pain more laterally in the ankle and/or to the dorsum of the foot in the area of the 4th metatarsal bone. located in the extensor digitorum longus muscle. medial or lateral knee pain and some forms of ankle sprain. In addition. 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. and contributes to stability through joint compression. Naughton strongly recommends that evaluation of a runner should include assessing weight-bearing ankle pronation and supination. Management. heel pain from plantar fascitis. fatigue fractures. bunions. Common Oversupination Effects. If the area of pain is . a trigger area just lateral to this site. As described previously. Less pronounced overpronation is determined by drawing lines bisecting the Achilles tendon and calcaneus. This position is marked in relation to the floor. the foot excessively pronates and hyperpronation symptoms are encouraged. When weight bearing or the subtalar joint is in the neutral position. Overinversion is particularly prevalent when running on irregular surfaces. the predisposed trauma from oversupination may be harsh because the supinated foot is rigid and does not transmit force well. Thus ground reactive forces.correct sequence. for proper congruency with the ground at midstance. Runners with oversupination or who have tibial varum land on the extreme lateral borders of their feet (varus position) at heel strike. At other times." Common Overpronation Effects. inversion. 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. are inadequately dispersed.

Clinical Features. Hyperextension sprain exhibits lateral. and spastic functional impairment. talus. hypermobile inversion. the most common ankle sprain. possible ecchymosis. As in knee sprains. This is especially true when the foot is plantar flexed with the heel raised from the ground. medial. ankle inversion with internal rotation. often produces an indirect tenderness in the deltoid ligament area from impaction. The lateral malleolus. Ankle Sprains: General Considerations Ankle sprains are frequently seen. In comparison to the knee. rather than at the middle of the ligament. In mild cases. little is known about the integrated biomechanical actions within the ankle and foot. After eversion sprain. and cuboid will feel prominent on palpation. the pain will be relieved only momentarily. It is less often found over the calcaneofibular ligament if stress occurs when the ankle is at a right angle. with or without avulsion. if a supination force is applied to the neutral-positioned ankle. free restricted motion. Isolated tenderness may be most acute over the anterior talofibular ligament. they involve a wide variety of damage depending on which ligaments are stretched and the degree of tear. A partial tear of the deep anterior fibers of the deltoid ligament occurs in extreme degrees of internal rotation or plantar flexion. an incomplete rupture of the fibulocalcaneal ligament may precede the total rupture of the anterior fibulotalar ligament. Most ankle strain/sprains are diffuse to some degree. tenderness. During inversion stress. this area exhibits primary tenderness with secondary tenderness from impaction on the lateral aspect. However. and fibula fractures are often associated with severe ruptures. Isolated tears are rare. ie.sprayed with a vapocoolant. Inversion Sprains The most common form of tarsotibial sprain occurs by twisting the leg in varus. The talus is usually subluxated from the ankle mortise. but spraying over the focal trigger area may abolish the pain. Dias showed complete rupture of the anterior fibulotalar ligament is the first lesion to occur in lateral ankle sprains. The ligament tears are usually at their attachments. and sometimes posterior tenderness and swelling. The local manifestations of inversion ankle sprain are mild-severe pain and swelling beneath the affected tendons and ligaments. Lateral sprain. only the lateral . which especially injures the talofibular bundle of the lateral ligament. and relieve deep tenderness in the reference zone for many hours if not permanently. 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. The stability of the complex series of joints comprising the ankle and foot is primarily maintained by an expansive network of ligaments.

Casting should be avoided unless there are severe fractures associated. interferential therapy.sulcus is filled with effusion. and active joint manipulation speed recovery and inhibit posttrauma effects. This joint widening produces instability readily leading to degenerative changes. Inadequately treated initial injuries invariably lead to chronic disorders. Management. Eversion Sprains In this less common form of ankle sprain. the greater the atrophy. check for the draw sign. Keep in mind that the greater the support. An application of hyaluronidase may be helpful in reducing tissue swelling and edema if used with iontophoresis. After 48 hours. bracing. During the stage of consolidation. moderate range of motion manipulation. Pain relief is enhanced by placing a 2. possible ecchymosis. periodic rest. active exercise (eg. swelling. moderate active exercise. During the acute stage. sinusoidal stimulation. tenderness. elevation. deep massage or vibrotherapy. and possibly elevation are also indicated. positive galvanism. Structural alignment. local moderate heat.x 2-inch gauze pad (about 1/4-inch thick) within . or ultrasonics are beneficial. Active taxing exercises should not begin until the walking gait is normal and pain free. 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. In the stage of fibroblastic activity. the fibula and tibia separate at the ankle mortise (diastasis). Local manifestations include pain. and restricted inversion mobility. and/or light ultrasound. Passive or active stretching is helpful but. low fibula bone damage is more the rule than isolated medial ligament tears because of the inherent strength of the deltoid ligament. Ankle Taping Strapping should be applied during slight eversion in lateral sprain or inversion in medial sprain. negative galvanism. and pressure strapping should be applied as soon as possible after injury to control swelling. Swelling should subside in 36 hours. eversion hypermobility. To support the diagnosis. avoid inversion in inversion sprains and eversion in eversion sprains. Ideal healing requires time and patience. and use Thompson's or an alternative test. obviously. Add peroneal muscle exercises against resistance according to patient tolerance. passive congestion may be managed by contrast baths. inversion and eversion walking). cold immersions. ultrasound. mild periodic walking is encouraged after several days of rest because functional use facilitates recovery. deep heat. light massage. gentle passive manipulation. If the inferior tibiofibular ligament tears. mild ultrasound. After strapping over a protective underwrap. heel lifts. judge lateral and medial instability. toe walking.

relieving ankle and foot fixations. The foot and leg are shaved and the foot is held at a right angle to the leg while the dressing is being applied. under the heel. methods of ankle strapping. Simplified Postinjury Taping Procedure. a lateral heel wedge is helpful in lateral instability. in which there is a valgus deformity and the long arch is flattened. avoid wrinkling the tape during application. Competitive activity must be avoided for 2--3 weeks for Grade III sprains. tape can be applied in a basketweave ankle lock. In preventive strapping for athletic activity. Successive strips are placed alternately about the leg and foot until the ankle is encased. crepitation on motion. A second strip is placed at a right angle to the first. 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. The foot usually has a "rocker bottom" shape. Preventive Strapping. Taping during stressful activity should continue for several more weeks. and possibly peroneal spasm to splint the joint. The Gibney Taping Method. leading to ischemia. Kohler's Disease The cause of avascular necrosis of the tarsal navicular is unknown. Other clinical features include heel pain aggravated during weight bearing. 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. Whatever taping method is used. but interference with the circulation to the bone. Especially protect the anterior portion of the deltoid ligament after medial sprain. When swelling has subsided or disappeared. This is one of the more time-consuming. a medial heel wedge in medial instability. A strip of 1-1/2. Underwater ultrasound. During rehabilitation. Double pads are necessary for especially heavy patients. is generally . and antivalgus exercise are helpful. passed downward over the outer malleolus. is the most important ligament to protect for lateral stability. tenderness over the sinus tarsi.or 2-inch-wide adhesive tape is placed against the outer aspect of the leg. Subtalar Arthritis Subtalar arthritis is a posttraumatic joint inflammation that often follows calcaneal fracture. During application. and the ankle shows no ligamentous tear.the longitudinal arch before taping. but stable. Semicircular strips of tape are used about the anterior foot and leg to retain the dressing. which runs from the distal fibula to the talus. the strips begin from the inside and run under the foot to the outside to hold the heel slightly everted when lateral instability exists. Vitamin C and manganese glycerophosphate appear to be helpful during rehabilitation. the anterior talofibular ligament. Weight-bearing can then be resumed. It also allows for swelling without constriction.

In the . misdiagnosis can occur as the result of vasospasm produced by a lumbosacral subluxation syndrome. swelling of the navicular bone. a posttraumatic scar or adhesion. If symptoms and signs do not improve within a logical course of conservative therapy. Reossification should be completed in 2--3 years if the area is protected from injury. and a painful limp. and invariably increased by activity and usually worse in the evening.thought to be involved. tenderness. arthritic changes. During initial treatment. restricted motion due to a scar or contracture. infrequently radiating as high as the buttocks. Check for something that might inhibit local circulation such as a subluxation-fixation syndrome. When the neurovascular bundle is percussed. 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. chronic ankle swelling following activity. a positive Tinel's sign is typically elicited with radiating pain. A sensory loss is usually found on the inferior aspect of the heel and/or the sole of the foot. The pain is typically referred along the posterior tibial nerve. ankle motion restriction. better. TTS is characterized by burning pain and paresthesia (eg. or something leading to a deformed heel or foot. Parasympathetic fibers have not been found in the extremities but sympathetic fibers are widespread and especially innervate the arterioles. Spontaneous recovery often occurs. and a painful limp. Weight-bearing irritation must be avoided during the healing process. Talar Osteochondritis Dissecans A small area of necrotic bone on the articular surface of the talus (usually the medial aspect) develops in this disorder. Just as an upper thoracic lesion may produce carpal tunnel symptoms. a short walking cast is often applied for about 2 months. tingling) in the toes and plantar surface that may radiate up the back of the leg. a space-occupying lesion. but the initial trauma may not be remembered. and this can be aided by a short walking cast or. depending on which branch of the nerve is most involved. a firm brace. surgical referral should be considered to possibly remove necrotic bone. The cause may be a subluxation syndrome. etc. which is often the consequence of trauma. postural weakness. Deep palpation posterior to the medial malleolus finds tenderness or aggravates pain in the sensory distribution of the nerve. It is easily confused with an ankle sprain that stubbornly refuses to heal. The typical onset is near the age of 5 and features variable degrees of local pain. Diagnosis is confirmed by roentgenography. 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.

These commonly occur from chronic stress to the talonavicular ligament in sports requiring constant speed. Recurrent trauma is usually involved. tarsal tunnel syndrome is suggested. They also have a significant incidence in professional bowlers (bowler's spurs). With the patient prone and the knee flexed to a right angle. tenosynovitis. Conservative care is often frustrating when activity is continued. percuss the posterior tibial nerve as it passes behind the lateral malleolus. This may be traced to effects of chronic subluxation with ankle pronation. An early priority is to find the cause of the compression. and maintained for 1--2 minutes. scar or adhesion formation. Football/Soccer Ankle This disorder consists of traumatic osteitis that is sometimes confused with chronic sprain. tennis. but referral for surgery to remove spurs or loose bodies may be required. Tinel's Foot Test. venous engorgement. An increase in foot pain signifies tarsal tunnel syndrome or a similar circulatory deficit. A temporary medial heel wedge or heel seat is often beneficial in relieving traction from the nerve by slightly inverting the heel. Ankle Tourniquet Test. referral for exploratory surgery should be considered. Management. valgus deformity of the foot. the spur becomes constantly irritated by forced ankle flexion. 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. jumping. and soreness aggravated by kicking the ball. Cold packs. cool immersions. If this induces paresthesias in the foot. minimal swelling.chronic stage. There are general ankle pain. or vapocoolant sprays are helpful during the acute stage. POSTTRAUMATIC SPURS AND RELATED DISORDERS Two common posttraumatic abnormalities are talonavicular spurs and narrowing of the subtalar joint. and rapid changes in direction such as seen in basketball. but the joint surfaces are . Deep heat and graduated exercises bring good results. Progression into osteoarthrosis is a common complication. inflated slightly above the patient's systolic blood pressure. Roentgenography shows new bone formation on the margins of the inferior articular surface of the tibia. If symptoms fail to respond some to conservative care in 7 days. intrinsic foot weakness and claw toes develop that restrict extension. soccer. Once formed. and field hockey. A sphygmomanometer cuff is wrapped around the suspected ankle. etc. They sometimes arise in nurses and orderlies who must quickly travel long hard hallways repetitively during their shift.

An everted heel and flat arch . The ankle mortise normally faces 15° externally. If internal tibial torsion exists. especially in children. If not. is often the product of excessive internal rotation of the tibia. Conservative care incorporating rest and graduated active exercises will usually suffice.not involved as in osteoarthrosis. Metatarsus Varus Sign. Excessive toe-in. habitually sleeping with the feet turned inward may be the cause. the spurs must be removed surgically. If there is toe-in and the patellae face forward (as is normal). an internal contracture of the hip will usually be found. This abnormal position is called the toe-in sign. characterized by a markedly posterior position of the lateral malleolus relative to the medial malleolus. This is often caused by a fixed point at either end of the tibia. The lateral border of the foot will appear convex and the medial border concave if there is metatarsus. it faces anteriorly or internally. Mercier states that an internal rotation deformity exists at the hip when internal rotation exceeds external rotation by more than 30° . Note the posture of the relaxed bare foot. and the lateral malleolus will be posterior to the medial malleolus. POSTURAL DISTORTIONS In-Toeing Internal Tibial Torsion. about 20° --30° of external tibial torsion is present. the lateral malleolus will be anterior to its medial mate. Common points of fixation are at the malleoli in the ankle or the tibial tubercle below the knee joint. In infants. To confirm a suspicion of internal tibial torsion. Out-Toeing There are three common causes of external lower extremity rotation and outtoeing: -. In normal adults. Internal femoral torsion is found if the patellae are marked with a skin pencil and these points are observed during gait. but in internal tibial torsion. There will be toe-in. Internal Femoral Torsion.External tibial torsion. and there will be excessive anteversion of the femur in metatarsus varus. Grasp the malleoli with your thumb and index finger. the patellae will face medially. have the patient sit on a table with the relaxed knees flexed at 90° . the focal deformity will be distal to the knee. The tibial tubercle will palpate as if it is directed straight anterior. The patient sits on a table with the knees flexed at 90° . and determine the position of the ankle joint.

Soft-tissue shortening or adhesions at the hip or retroversion of the femur (external torsion).are commonly associated. or an inflammatory lesion. then rotate weight to outer border and repeat test. If this is the cause. -. Edema is usually greatest in the front of the leg. John Palo reports in personal correspondence that both in-toeing and outtoeing are seen in young. Tenderness frequently accompanies edema from any cause. Trauma or local disease is the usual cause for unilateral swelling. Tenderness along the transverse arch is common in aseptic necrosis from a circulatory disturbance. then release pressure quickly. Note the venous filling time on the dorsum of the foot at this time. squatted with feet in the toed-in position. To evaluate the capillary filling time of the toes. "Children who watch much TV. Dr. In infants. habitually sleeping supine with the feet turned outward or the constant use of excessively wide diapers may be the cause. or genu valgum. or acute arterial occlusion may result in lower extremity edema. Blanching time is delayed in cases of pronation and arch weakness due to circulatory interference. Normal color should return within 6-10 seconds. Children who watch much TV. venous disease.Flat feet. squatted with feet in a toed-out position will be found walking with toed-out pronated feet. top of the foot. Unilateral edema may be due to thrombosis of a vein. If the pulse is absent in a limb. Apply finger pressure to the medial dorsal area of the foot and note time for the white spot to disappear. -. external rotation of the femur will be much greater than internal rotation. will be found walking with toed-in supinated feet. squatting television viewers. Venous disease is the most common cause of pitting on pressure." MISCELLANEOUS CIRCULATORY DISTURBANCES Circulatory Insufficiency Screening Tests Skin color normally darkens in the weight-bearing position. check the most distal palpable pulse and auscultate for an audible bruit suggesting the site of obstruction. A temporary reversal of their habitual foot position while watching television helps to reverse the distorting process. pressure of tumors in the pelvis. and back of the thigh. compress a selected toe until it blanches white. Edema Lymphatic obstruction. . An elevated pink foot that markedly deepens in color in the standing position suggests arterial insufficiency or vascular disease. Collapsed veins should fill within 12 seconds on standing. calcaneovalgus.

an absolute cause cannot be found (angioneurotic. Other evidences of insufficient arterial blood supply (eg. gangrene) may coexist. trichinosis. The attacks are aggravated by heat and not by cold as with Raynaud's disease. nephritis. and swollen. The contracture is the result of impairment of or injury to a major artery or innervating nerve. In sports. Muscle swelling or prolonged spasm within a fascia-encased compartment and ischemia-enhanced edema may cause or contribute to the disorder. In Raynaud's disease. Tibial fracture leading to embolism or thrombosis may be involved when this type of contracture is seen in the leg and foot. vibromassage). It may also be due to neuritis. The anterior compartment of the leg is tightly bound and has difficulty in expanding to compensate for increased internal pressure. galvanism. Management. intermittent claudication. tender. and other less common causes of deficient local circulation. The long flexors of the toes primarily exhibit the effects of inadequate nutrition. conservative rehabilitative procedures should be directed to enhancing circulation and softening of fibrotic tissues (eg. Volkmann's Ischemic Contracture of the Foot This condition (postischemic fibrosis) may appear in either the lower or upper extremity. hereditary types). the digits are cold and painless or numb. cyanotic. cramps. cancer complications. . and painful. or another source of local inflammation. anemia. The resulting necrosis leads to fibrosis and contracture. ultrasound. Prolonged cast pressure or tourniquet applications may be involved. essential. The patient kicks off the bed clothes from his feet at night because of warm burning sensations. varicose veins. painful. it is most often associated with tennis. basketball. cirrhotic liver. Erythromelalgia Red neuritis of the extremities is common in the feet. badminton.Nontraumatic bilateral edema is due to uncompensated heart lesions (primary or secondary from lung disease). obesity. and soccer. Such attacks are probably akin to the condition of "hot feet" often seen in the arteriosclerosis of elderly people. The toes (or fingers) are red. clubbing. deep heat. hot. Diagnosis depends on the history and the examination of the remainder of the body. lymphatic disorders. neuritis. but the disorder is frequently asymptomatic. The tissues below the blockage are cool. Once the cause has been determined and corrected. Heel pain following activity is the common complaint. Black Heel Pigmented areas on the back of the heel secondary to petechial hemorrhage are sometimes seen. In some cases. flatfoot. mobilization.

atrophic. Generally. 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. plantar strains) than a rigid fallen arch. Clinical Features There may or may not be changes in the sole print (a useful record). the feet of the same patient may vary in size and design to an amazing degree. Related pain may be local in the arch or extend to the medial malleolus. joint stiffness. . congenital tarsal abnormalities. Valgus or eversion of the heel and abduction of the forefoot are usually associated. The cause is thought to be from sudden stops. but many cases are symptomless. congenital. a "flat foot" results from a breaking down or weakening of the normal medial longitudinal arch of the foot. or lumbar area. and peroneal muscle spasm. One foot may have a strong arch and be in a straight-line position while the other foot is flattened and toed-out. usually horizontal. a rigid high arch will cause more problems (eg. quick changes of direction. There may be pain and tenderness near the attachment of the ligaments and often higher up on the leg. The "arches" of the feet serve more like springs than they do rigid mechanical arches. But contrary to popular belief. disability during gait. spina bifida occulta. loss of spring in the step. In addition. the disorder is easily confused with the splinter hemorrhages consequential to subacute bacterial endocarditis after a recent illness. or cerebral palsy. A postural flattened arch must be differentiated from that associated with benign hypotonia. A patient with an apparently short leg often has a greater pronation or inward roll on that leg. When the arch flattens. excessive eversion during weight bearing. 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. under the toenails (tennis toe). and the severe forward motion of the body that propels the long toes against the front of the inside shoe.Tennis Toe A chronic complaint of pain in one or more of the longer toes is frequently associated with hemorrhage. If the hemorrhage is longitudinal in a nonathlete. The cause may be traumatic. or the effect of obesity or ill-fitting shoes. and the arch may be lessened. spastic flat foot. There is usually a pronated gait. hip. the head of the talus drops downward and medially from under the navicular and stretches the tibialis posterior and spring ligament. knee. obliterating the longitudinal arch and forming a callus under the talar head.

burning sensations. It cannot be passively or actively reduced in a nonweight-bearing position. the fallen arch would correct itself in a few days. If either of these theories is true. they usually do so gradually during adolescence. a longitudinal arch that is absent in the weight-bearing position but present in the nonweight-bearing position may be . When distress is produced by a flexible flatfoot. the medial longitudinal arch disappears. and a mild genu valgum (knock-knee) or internal tibial torsion may be present. A hypermobile foot that flattens on weight-bearing is usually a hereditary state that may or may not produce symptoms. Physical signs include a painful limp. When associated with a shortened Achilles tendon. he found most flattened arches on the side of the long leg. If the Achilles tendon is tight. passive dorsiflexion is limited when the heel is inverted. On the other hand. His studies showed that while most deficiencies in femur height are of several millimeters. and fatigability. heel eversion.A convex medial border of the foot (when viewed from above) is a sign of an extremely flattened arch. Note fit. A lowered longitudinal arch might be thought to be a common cause of a physiologic short leg. heel eversion results and a pronation syndrome follows. 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. and pain aggravated by forefoot adduction and inversion. Rigid Flatfoot. quality. pain and tenderness over the peroneal tendons or in the hindfoot. 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. This is usually secondary to a motion-restricting hindfoot arthritis or a tarsal disorder. and lower extremities. the influence of a flattened arch on femoral height does not usually exceed a millimeter. A flexible flatfoot appears normal when examined in a nonweight-bearing position. Note the existence of hammer toes or marked deviation of the large toe toward the midline of the foot (hallux valgus). the forefoot pronates and abducts. and wear of the patient's shoes. When symptoms appear. the typical symptoms are foot pain. Check for foot pronation that may be associated with a fallen arch but is a separate deviation. but during weight bearing. Compensatory Flatfoot. Management Free any subluxation-fixations in the spine. and possibly mild swelling. A rigid flatfoot is frequently caused by protective peroneal spasm leading to contractures. but Gillet has not found this to be the case. Common complaints associated with a rigid flatfoot are stiffness. restricted and painful midtarsal and subtalar motion. pelvis. Flexible Flatfoot. an arch support or a heel wedge on the side of the long leg would be contraindicated. On the contrary. When a heel lift was added to the short side.

aided by longitudinal arch supports. A tabulation of the common causes of foot pain is shown in Table 3. This increases to four times body weight during downhill runs. and 80% by age 20. strengthening exercises and orthoses for chronic flexible flatfoot syndromes offer only palliative comfort and little curative value. FOOT TRAUMA It is not uncommon that the foot is caught between forces from both above and below. Table 3. In general. 41% at age 5. One study showed that while 99% of all feet are normal at birth. the force on the supporting foot is about three times body weight. When running on a level surface. 8% develop troubles by the first year of age. Added to this stress is the effect of unyielding surfaces. 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 . Even minor traumatic disturbances can greatly inhibit optimal performance.

and check for spurs in adults or signs of epiphysitis in children. This usually longterm stretch of the fascia can result in pain and chronic inflammatory reactions leading to heel spurs. This is especially common in track where the shoes are often heelless. Heel bruises are seen affecting the plantar surface of the os calcis. flexible. Then check the calcaneal bursa situated between the insertion of Achilles tendon and the skin. may require surgical excision of new bone. and granulation tissue. Treat as any bursitis. The area will be tender and often feel thick and boggy. A pronated ankle is often involved. Prolonged stress from heavy heel landings displaces the fat pad and ruptures the fibrous septa under the calcaneus.disease Plantar wart Subluxation Synovitis Strain/sprain Subluxation Heel Injuries Palpate the dome of the calcaneus from above plantarward. often leading to spurs. During nonactivity. heelless sandals or slippers are recommended. long-distance runners. especially at fiber insertions into the calcaneus. Lift the skin away from the tendon with one hand while palpating anterior to the tendon. A common cause of heel pain in runners is plantar fascitis. Both of these bursae are subject to inflammation from pressure or friction from poorly fitting shoes (especially football shoes with their heavy counters). hurdlers). Heel cups are helpful in prevention and during healing. and ultrathin (eg. During activity. Bursitis Palpate the area of the retrocalcaneal bursa located between the anterior surface of the Achilles tendon and the top of the heel. Special care must be taken not to confuse heel bursitis with avulsion of the Achilles insertion. necrotic fibers. Management. Chronic cases. Foot Bruises and Wounds . Runner Fascitis. This is an inflammatory reaction caused by prolonged dynamic traction of the plantar aponeurosis. jumpers. 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.

Adjunctive care consists of cold packs during elevation and compression. Management. and rest. Tight plantar fascia raises the longitudinal arch. fascial tears from dorsiflexion overstress. is called a "stone bruise" in athletics. A temporary longitudinal arch support (or taping) and crutches are . hard object without adequate protection. A puncture wound of the sole of the foot presents a special problem. especially on the heel. Some degree of swelling may be felt. a slight degree of ecchymosis and severe tenderness may be at attachments. and deep vibromassage may be applied to relieve related soreness. Palpable stiff cords or nodules within the fascia suggest consequences of chronic plantar fascia spasm. should be worn as long as tenderness persists. and ultrasound. foot stubs. like contractures. which are later followed by vibromassage. In spite of proper care. Padding. or plantar warts tender to pinching. Contusions and Abrasions. Dupuytren's contractures tender under deep pressure. mobilization. The typical clinical picture of plantar strain primarily exhibits pain during running due to plantar-fascial stretch. compression. Puncture Wounds. During palpation. trigger point therapy. often specially designed. or cleat wounds. Early roentgenographs are negative. it is often confused with sprain of the spring ligaments in the arch. local heat. A bone bruise affecting the 2nd or 3rd metatarsal head. Tenderness is found just distal to the calcaneal tubercles. are tender to pressure but not to pinching. contrast baths. With early suspicions. In acute cases. spray across the sole. Plantar Strains The strong bands of plantar fascia have their origin at the medial tubercle of the calcaneus. or acute arthritis of the foot. Most foot contusions can be traced to a dropped object. tetanus. but calcification may appear on later films. but when it occurs. Check thoroughly for possible cuboid or navicular subluxation. elevation. Clinical Features. referral should be made for debridement and/or antibiotics. the plantar aponeurosis should feel smooth and without areas of tenderness. True plantar fascitis is rare. During recovery. or associated with calcaneal fatigue fractures. It is common in track and the result of running with full weight onto some small.Initial treatment must be quick to minimize bleeding and swelling through cold. some may develop cellulitis. Bone Bruises. It is usually the result of chronic pronation. A blow to the lateral ankle occasionally dislocates the peronei tendons anteriorly from their normal position behind the malleolus. and insert near the metatarsal heads. Callosities. ultrasound. osteomyelitis. and sometimes the transverse arch.

and ultrasound in water. Symptoms of medial aching pain and tenderness deep within the plantar arch commonly arise after prolonged running when soft shoes are worn. Spring Ligament Sprain. Pain and swelling may be severe. what may . extending for many years. swelling over the calcaneocuboid area. passive mobilization of the entire foot. Rearfoot Sprain. Forefoot Sprain. Talar subluxations and restrictions are often related. and great disability. Differentiation must be made from plantar fascitis. which is found farther posterior and usually more acute. with distal neurologic effects. Correct any fixation-subluxations isolated and apply general sprain management with emphasis on rest. There is immediate severe pain. The cause in some cases can be traced to a low-grade tarsal synovitis from poor foot support on hard ground during strenuous activity. Toe Sprains The most common toe sprain is that of the great toe. Chronic low arches do not seem to be a precipitating factor. especially at the metatarsophalangeal joint as the result of forced plantar flexion or dorsiflexion. Sideward sprains rarely occur. featuring progressive pain with minimal swelling in the rear half of the foot during and following activity. Treatment is usually by surgery (exostectomy). Overstress of the plantar calcaneonavicular ligament is often associated with navicular subluxation. and orthotics improving foot support are helpful. Rearfoot sprains are usually chronic in nature. Calcaneocuboid sprain is usually produced by forceful internal rotation of the foot on the talonavicular joint when the foot is inverted. Exostoses Bony overgrowths infrequently form at the head of a metatarsal. but bone tenderness or crepitus is absent.helpful during initial healing. contrast baths. avulsion of the insertion of the tibialis posterior features acute styloid tenderness. As a consequence of severe eversion or inversion strain. Disability is severe because weight-bearing is predominantly on the hallus. Sprains of the other toes are managed similar to finger sprains. An ache and tenderness under the 2nd and 3rd metatarsal heads are often the result of postural stress. Foot Sprains Calcaneocuboid Sprain. During rehabilitation. However. especially the 1st metatarsal. Management. intrinsic exercises. This can be a chronic strain that can set up a subtle pathobiomechanical complex. arch strapping.

constant pain only during weight bearing. and there is abnormal weight balance and distribution. neuroma. A metatarsal crescent can be applied to the sole of the shoe or a felt pad placed just behind the plantar . Surgery is reported to be the treatment of choice. and tendon avulsions. In metatarsalgia. Signs and Symptoms. the procedure is painless.appear to be a bony overgrowth during palpation (a knuckle-like prominence) is actually a metatarsocuneiform subluxation that can be demonstrated by roentgenography. subluxations. Strunsky's Test. especially between the 2nd and 3rd metatarsals. Metatarsalgia Morton's syndrome (metatarsalgia) produces pain near the proximal end of one or more of the three outer toes. After mobilizing all fixated joints from the foot to the hip. Minor conditions can be aided by heel pads and any taping procedure that supports the arches of the foot. but trauma from the surgery may set the stage for further periosteal reactions and other surgical complications. Differentiation must be made from postural strains. Management. exostoses. corns. march fractures. In addition. This test is designed essentially for the recognition of lesions of the metatarsal arch. Use a shin splint taping procedure in acute cases. Pain results if there is an inflammatory lesion in the metatarsal arch. An osseous triad consists of (1) a 1st metatarsal bone that is shorter than the 2nd. and (3) posteriorly displaced sesamoids. The clinical picture includes a distinct limp. there are toe pain. and transverse arch support. foot fatigue. the foot is pronated and the arch flattened. adjunctive care includes ultrasound in water. and pronation complaints that are often associated with plantar callous patterns. Under normal conditions when the toes are grasped and quickly flexed. The cause is attributed to chronic traction of the plantar fascia on calcaneal periosteum. Management. tenderness increased in dorsiflexion. Morton's Test. (2) hypermobility at the naviculocuneiform and medialand inter-cuneiform articulations. padding beneath the tongue of the shoe. Heel Spur A heel spur typically forms at the inferomedial aspect of the calcaneus. and intermetatarsal neuroma. and mild swelling along the medial aspect of the os calcis or plantar fascia attachments at the calcaneal tuberosity. deep vibromassage (many trigger points will be found). 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. transverse pressure across the heads of the metatarsals induces sharp pain. There also is hypertrophy of the 2nd metatarsal joint. bunion.

Check for short shoes. The sesamoid enlarges. Claw Toes. Hypertrophy of the nerve sheath develops. Increased pronation causes a lax peroneus longus tendon. 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. and there is an accompanying digital artery disorder. Plantar Neuroma A rare cause of metatarsalgia is Morton's neuroma --painful round "beads" found between the heads of the 1st through 4th metatarsals.metatarsal heads involved. Whenever a bunion is found. check the ankle for hyperpronation. An adventitious bursa forms that often becomes tender and inflamed. Predisposing factors include forceful plantar flexion of the metatarsal joint. In either case. An early sign is the formation of callosities over the dorsal surface of the toes. Shoe irritation and concomitant bursal inflammation produce the painful bunion. pes cavus. which is ridiculous. forefoot . feature flexed proximal and distal interphalangeal joints and hyperextended metatarsophalangeal joints. Selected Disorders of Toes Bunion. The patient should be advised to lace the foreshoe loosely. Claw toes. and the soft tissues on the lateral aspect of the great toe enlarge. Hammer Toe. on the tips of the toes. a short metatarsal. Bunions are especially common in hyperpronated runners and women who habitually wear sharp-pointed shoes. Graduated tiptoe walking and walking on the lateral edge of the foot are helpful during rehabilitation. the object is to slightly lift the stressed joints during weight bearing. and on the plantar surface under the metatarsal heads. A hammer toe presents fixed flexion of the proximal interphalangeal joint with hyperextension of the metatarsophalangeal and distal interphalangeal joints. It is usually singular and associated with a callosity on top of the proximal interphalangeal joint. especially between the 3rd and 4th. This laxity from hyperpronation allows the metatarsal to adduct. Shooting distal pains and sometimes periods of numbness are severe but quickly relieved when the shoeless foot is rested. Shoe salesmen often measure foot length in nonweightbearing. Roentgenographs are negative. Poorly responding cases may require referral for specialized attention. usually associated with pes cavus. They are thought to be the effect of excessive foot rolling where the plantar nerve is chronically impinged on taut fascia or bone. which attaches to the first metatarsal and typically exerts a lateral pull. The disorder is rare in athletics but must be differentiated from postural strains and tendon avulsions producing forefoot pain and plantar tenderness.

and stand or squat facing the patient. rest. navicular. medial tilt. ultrasound in water. The key structure within the ankle is the talus. ARTICULAR THERAPY According to an arbitrary anatomical classification. A mallet toe is a distal interphalangeal joint flexion contracture that usually occurs in the smaller toes. and cuboid bones. strapping. which superiorly supports the weight of the tibia. Deep palpation within the flexor hallucis brevis tendon may locate the two sesamoids where signs of sesamoiditis develop. Mallet Toe. This is a subtle motion to perceive but necessary for complete evaluation of joint motion in the ankle. the midfoot consists of the cuneiform. Suggested techniques are described below. Restricted Ankle Mortise Long-Axis Extension. 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 . Sesamoid necrosis under the head of the 1st metatarsal in the flexor hallucis longus tendon may show roentgenographic signs. Similar to a hinge joint. Sesamoiditis. The plantar surface of the patient's uninvolved extremity should be placed above your knee for stability. of Ontario. MD. It is less common than a hammer toe. Progressive exercises may be started immediately after the acute stage has subsided. Only a slight amount of rotation is normally allowed. developed a world-wide reputation in the 1930s treating a broad range of human ailments by doing nothing more than adjusting the cuboid. laterally articulates with the nonweight-bearing fibula. The only motions of joint play to be evaluated within the ankle mortise are longaxis extension and A-P glide. trauma. adjustment of subluxations. William Locke. and inferiorly rests primarily on the anterior two-thirds of the calcaneus. Passive mobilization of fixated joints. talar rock on the calcaneus. the forefoot is composed of the five metatarsals and phalanges. or pronation imbalance. and improved footwear are beneficial. and lateral tilt are the primary considerations. the ankle mortise is designed essentially to allow plantar flexion and dorsiflexion. and the hindfoot (rearfoot) includes the talus and calcaneus. sole padding.valgus. long-axis extension. Within the subtalar joint. Place the patient in the supine position with the feet at the end of the table. Ankle Fixations Two major areas of likely joint restriction exist in the ankle area: above and below the talus.

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). With your cephalad hand. and stand or squat facing the patient. 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. With the doctor-patient positions and contacts the same as described above for evaluating subtalar rock. This procedure is similar to that described above for evaluating ankle mortise longaxis extension except that the contacts are applied at a lower level. This motion refers to A-P movement of the talus between the malleoli. 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 plantar surface of the patient's uninvolved extremity should be placed above your contralateral knee for stability. noting the subtalar motion elicited under your index fingers. Restricted Subtalar Long-Axis Extension. Place the patient in the supine position with the feet at the end of the table. Care must be taken to avoid pressure against the malleoli during this maneuver. Restricted Ankle Mortise A-P Glide. In this position. alternately dorsiflex and plantar flex the patient's foot by rotating your hands upward and downward. Restricted Subtalar Medial and Lateral Tilt.posteriorly and your thumbs are centered over the anterior aspect of the tibiotarsal joint. Restricted Subtalar Rock. With your caudad hand. In this position. with your thumb laterally and your fingers on the medial surface of the patient's ankle. Stand or sit facing perpendicular to the patient's ankle. you will be able to elicit ankle mortise A-P glide by alternately pushing downward and pulling upward with your active (cephalad) hand. . Apply traction and simultaneously note the degree of joint play perceived by your thumbs. grasp the patient's lower leg anteriorly just above the malleoli. An alternative method to evaluate posterior glide of the talus on the tibia uses the same doctor-patient positions described above. Apply traction and note the degree of joint play perceived by your thumbs. alternately invert and evert the patient's ankle by rotating your hands clockwise and counterclockwise to evaluate subtalar medial and lateral tilt. 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. grasp the anterior surface of the patient's ankle just below the malleoli. With this procedure.

a history of inversion sprain that occurred with plantar flexion. The major features associated with a lateral subluxation of the talus are a history of inversion ankle sprain. 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. To correct the mechanical displacement. To make the articular correction. and sit at the foot of the table (facing the patient). The patient is placed supine. Sit at the foot of the table. Lateral Talus Subluxation. Your lateral stabilizing hand supports the patient's heel. facing the patient. To make the correction. Indications of an anterior talus subluxation include pain and tenderness at the anterior aspect of the ankle. while your medial hand grasps the anterior surface of the tarsals. and tenderness of the anterior talofibular ligament. To adjust. and take a double-thumb contact on the lateroanterior aspect of the involved talus. and excessive postural pronation during weight bearing. 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. Your third fingers should make specific contact over the anterior aspect of the involved talus. facing the patient. The doctor-patient position is the same as described above. Your lateral hand grips the calcaneus. pain anterior to the lateral malleolus. Subluxation of the talus medioinferiorly is often found in association with eversion ankle sprain exhibiting tenderness at the deltoid ligament. Place the third finger of your lateral contact hand over the anteromedial aspect of the involved talus with your thumb on the plantar . roentgenographic signs of exostosis of the dorsal talonavicular articulation. slightly invert the foot. Stand at the foot of the table. and simultaneously make a short. place the patient supine. 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. There is an alternative procedure.Ankle Subluxations Anterior Talus Subluxation. 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. apply traction. Internally rotate the patient's leg. Medial-Inferior Talus Subluxation. place the patient supine. excessive postural pronation during weight bearing. Apply pressure with your double-thumb contact. The corrective maneuver for this subluxation is essentially the opposite of the adjustment for a lateral talus. sharp pull toward yourself to correct the malposition.

talus-navicular. The metatarsophalangeal joint of the great toe is a common site. Proximal Metatarsal A-P Glide. cuneiform-cuboid. apply traction with your stabilizing hand to separate the calcaneus from the talus while simultaneously making a medial to lateral torque maneuver toward yourself. intermetatarsal fixations and costospinal subluxations. intercuneiform. With your active hand. metatarsal fixation and C3--C7 fixations. cuneiform-navicular or cuboid-calcaneus and lumbar fixations. and stand or squat facing the patient. While holding these contacts. Partial or complete fixations are also found at the cuneiform-metatarsal. alternately pull upward and push downward with your active hand to elicit proximal metatarsal glide. especially where plantar flexion is restricted. Grasp the patient's foot with your stabilizing cephalad hand so that you have firm contact on the cuneiforms and cuboid. 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. cuboid-metatarsal. Distal Metatarsal A-P Glide. and talus fixations and L5 fixations. Foot Fixations The bony complex of a foot (about 27 articulations) is a common site of single or multiple fixations. With doctor-patient positions the same as described above. With your lateral . Place the patient in the supine position with the feet at the end of the table. Fixation of the distal phalangeal joints is not common but those joints more proximal are. Keep in mind that a high stiff arch that does not reduce much during weight bearing is just as abnormal as a flattened arch. Proximal Metatarsal Rotation. navicular-cuboid. To make the adjustment.surface of the patient's foot. The joint plays to always evaluate for possible fixations are of the midfoot (proximal metatarsal) and forefoot (distal metatarsal) A-P glide and rotation. Hindfoot mobility has been evaluated indirectly during the evaluation of ankle mortise and subtalar mobility. 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. Several authorities agree with this observation. He felt that the cause of many frequently recurring fixations in the spine or pelvis can be traced to fixations in the feet. Gillet's studies showed a distinct relationship between phalangeal fixations and upper cervical fixations. stand or sit facing perpendicular to the patient's foot. cuneiform-navicular. Your stabilizing hand supports the heel. With the patient in the supine position. Gillet looked to the feet as the functional base of the spine. The intermetatarsal ligaments are frequently shortened. and talus-cuboid articulations. metatarsal-tarsal fixations and thoracic fixations.

The most obvious signs of an anterior calcaneus subluxation are excessive supination and pes cavus during weight bearing. With your lateral hand. excessive pronation during weight bearing. and fibula by grasping the posterior ankle with a web contact. facing the involved limb. 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. and a history of inversion or eversion ankle . thus alternately producing distal metatarsal flexion and extension. alternately push with one hand while pulling with the other hand. place the patient prone with the involved knee flexed. To correct the displacement. clasp the head of the 4th metatarsal in a similar manner. while your cephalad hand stabilizes the patient's talus. Continue to evaluate A-P glide between each digit by moving your contacts medially over the distal 4th and 3rd metatarsals. With the doctor-patient positions and contacts the same as described above. Your caudad hand contacts the anterior plantar aspect of the involved calcaneus with a web contact. and pain located inferior and slightly posterior to the medial malleolus. To correct malposition. With your medial hand. Distal Metatarsal Rotation. cup the patient's heel and apply firm pressure against the posterior aspect of the calcaneus. To adjust. grasp the anterior aspect of the patient's involved ankle with your fingers and place your thumb firmly against the distal plantar calcaneus. With your medial hand. Anterior Calcaneus Subluxation. Foot Subluxations Posterior Calcaneus Subluxation. An inferomedial subluxation of the navicular is typically associated with medial longitudinal arch pain. place the patient prone. Inferomedial Navicular Subluxation. 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. Both hands must act simultaneously. excessive pronation during weight bearing. tibia. working in unison. and 2nd and 1st metatarsals. apply pressure with your contact hand against the heel and simultaneously make a short sharp thrust directed from the anterior to the posterior.hand. Subluxation of the calcaneus posteriorly is usually associated with tarsal tunnel syndrome. Stand at the foot of the table. grasp the head of the 5th metatarsal anteriorly with your index finger and posteriorly with your thumb. 3rd and 2nd metatarsals. rotation is evaluated by trying to move one metatarsal hand over and under its neighbor by rotating your contact fingers clockwise and counterclockwise. To evaluate A-P glide between the 5th and 4th metatarsals distally. Stand on the side of involvement.

place the patient prone with the involved knee slightly flexed. and simultaneously make a thrust directed medially with the stabilizing palm against your contact thumb. While maintaining this contact.sprain. stand closer to the patient so the patient's foot is held between your thighs. To reposition the displacement. Lateral Cuboid Subluxation. Stand at the foot of the table on the side of involvement. and excessive pronation during weight bearing. take a pisiform contact over your contact fingers. 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. lateral longitudinal arch pain and tenderness. Make pisiform pressure over your contact thumb with your cephalad hand. To correct the malposition. apply traction by thigh pressure. and simultaneously make a thrust toward the floor with a drooping motion aided by bending your knees. With your cephalad hand. To reposition. To adjust. 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. Locate the plantar aspect of the cuboid. apply traction and simultaneously thrust obliquely lateral toward the floor. apply traction. Lateral subluxation of the cuboid (Locke's basic concern) is usually associated with a history of inversion sprain. 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. To correct the malposition. A contact is made with the thumb of your medial hand with the fingers wrapping around the anterior aspect of the foot for support. Stand at the foot of the table facing laterally oblique to the involved limb. with your fingers wrapping around the lateral aspect of the foot. The typical clinical picture of an inferior cuboid subluxation is lateral longitudinal arch pains and excessive pronation or supination during weight bearing. Locate the plantar aspect of the cuboid. the doctor-patient positions are the same as described above. and assume a crouching position. . A contact is made with the pisiform of your cephalad hand. stand at the foot of the table centered to the involved limb. Grasp the patient's anterior ankle with your medial hand so your thumb is on the lateral aspect of the cuboid. place the patient supine. 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. and face the patient. To make the correction. To correct the malposition. place the patient prone. With an alternative technic.

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. 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. Your fingers. a history of ankle sprain. a history of inversion sprain resulting in a 1st metatarsal displaced superiorly. a history of plantar forefoot pain. with your fingers extending around to support the anterior aspect of the foot. In this adjustment. Apply a double-thumb contact on the involved inferior tarsal or proximal metatarsal bone. To correct the malposition. place the patient supine. remove any foot inversion or eversion present. pronation syndrome with superior 1st and 5th metatarsals. Inferior Distal Metatarsal Subluxation. and excessive supination during weight bearing. To adjust the prone patient. and face the patient. Face the patient. 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. Inferior Tarsal or Proximal Metatarsal Subluxation. Face the patient. thumbs. slightly flex the patient's knee. To adjust the supine 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. To correct the malposition. and excessive pronation or supination during weight bearing. Stand at the foot of the table. The major features of either a superior tarsal or proximal metatarsal subluxation are pain on the dorsum of the foot. Stand at the foot of the table. the patient is placed supine. To apply a corrective adjustment. and simultaneously apply a sharp pull toward yourself to move the subluxated bone caudally. To correct the malposition. and face the patient. apply traction with firm contact pressure. and excessive pronation during weight bearing. wrists.Superior Tarsal or Proximal Metatarsal Subluxation. centered at the involved side. 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. The features of either an inferior tarsal or proximal metatarsal subluxation are arch pain. and elbows must work in unison. the involved foot is placed at a right angle to the leg. Stand at the foot of the table. centered at the involved side. apply steady plantar flexion to the foot and simultaneously make a snapping thrust with your contact thumbs directed toward the floor. Stand at the foot of the table.

stabilize the patient's foot with one hand while your active hand flexes and extends the joint. 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. Once overt structural joint changes have occurred. Stand at the foot of the table. With your medial contact hand. With the thumb and index finger of your lateral stabilizing hand. Hallux Valgus. stiffness. Evaluate the integrity of the abductor hallucis and the muscles involved in excessive pronation. In other toes. and limited motion of the 1st metatarsophalangeal joint. Restricted flexion of the distal interphalangeal and metatarsophalangeal joints and restricted extension of the proximal interphalangeal joint are features of a hammer toe. The involved muscles become ineffective in maintaining abduction. adjustments have little benefit except to slow progression. Stubborn cases may require referral for surgery (phalangeal osteotomy). flexion and extension occur at the proximal and distal interphalangeal joints and the metatarsophalangeal joints. In adjusting. 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. contrast baths. The 1st metatarsal becomes fixed in abduction and the hallux subluxates laterally. remove any foot inversion or eversion present. facing the patient and centered to the involved limb. apply traction to the phalanges. This disorder is characterized by pain. Flexion is the only motion of the great toe's proximal interphalangeal joint. place the patient supine. Apply traction. and make a short pull toward your body. the abductor hallucis becomes deformed in lateral displacement beneath the metatarsal head.extend around the medial aspect. Toe Fixations and Subluxations Restricted Toe Mobility. . remove the valgus deviation. Restricted movement in this joint frequently produces a protective gait restricting push-off. In evaluating toe flexion and extension. To correct the malposition. Incidence is higher in females during youth but higher in males during adulthood. Your lateral stabilizing hand grasps the wrist of your contact hand for support. To test mobility of the 1st metatarsophalangeal joint. and simultaneously make a short thumb thrust cephalad to move the subluxated bone superiorly. In time. first test the great toe. and a rigid insole are helpful. tenderness. Manual foot and toe mobilization. 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. grasp the phalanges of the involved metatarsal. Hallus Rigidus. Be especially gentle in mobilizing this joint. This is a state of lateral deviation of the great toe.

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