Chapter 18

The Foot
Matt Weidenbach
By: Ben Hoffmann
Taylor Westbrook
 Foot Anatomy
The foot consists of 26 bones: 14
phalangeal, 5 metatarsal, and 7 tarsal.
Toes are used to balance and propel the
body.
Metatarsal Bones gives elasticity to the
foot in weight bearing.
Tarsal Bones located between the bones
of the lower leg and the metatarsals are
extremely important for support and
locomotion.
 Arches of the foot
Foot arches assist the foot in
supporting the body weight; in
absorbing shock of weight bearing;
and in providing a space on the
plantar aspect of the foot for the
blood vessels, nerves, and muscles.
There are 4 arches: The metatarsal,
transverse arch, medial longitudinal
arch, lateral longitudinal arch.
 Articulations
Interphalangeal Joint: located at the distal
extremities of the proximal and middle
phalanges. Designed for flexion and extension.
Metatarsophalangeal Joint: Permits flexion,
extension, adduction, and abduction.
Intermetatarsal Joint: Permits slight gliding
movements.
Tarsometatarsal Joint: allows some gliding and
restriction of flexion, extension adduction and
abduction.
Midtarsal Joint: Provides shock absorption.
Inversion, Abduction and Supination
Produce medial movements of the
foot.
These muscles pass behind and in
front of the medial malleolus.
 Eversion, Abduction, and Pronation
Produce lateral movements of the
foot.
Muscles passing behind the lateral
malleolus are the fibularis longus and
the fibularis brevis.
 Nerve and Blood Supply
Nerve Supply: The medial and lateral
plantar nerves which are branches of
the tibial nerve, supply all of the
intrinsic muscles on the plantar
surface of the foot. The deep
peroneal nerve supplies the extensor.
Blood Supply: The primary blood
supply for the foot comes from the
anterior tibial artery and posterior
tibial arteries.
 Structural Deformities
Forefoot varus, forefoot valgus and
rearfoot varus produce excessive
pronation or supination.
The deformities will make the foot
more difficult to act like a shock
absorber.
The compensation usually causes
overuse injuries.
 Prevention of Foot Injuries
Appropriate Footwear; selecting an
appropriate shoe is a critical consideration in
preventing a foot problem.
Shoe Orthotics; an orthotic device can be
used to correct biomechanical problems that
exist in the foot and that can cause injury.
Proper foot hygiene; simple tasks such as
keeping toenails trimmed, shaving down
calluses, keeping feet clean and dry can
reduce a number of problems.
 Foot Assessment
To correctly assess the foot trainers must
understand that the foot is part of a kinetic
chain that includes both the ankle and the
lower leg.
History of the patients foot must also be
assessed.
Observations such as if the patient is favoring
the foot, walking with a limp or unable to bear
weight should be assessed.
Structural Deformities should also be
observed.
 Recognition and Management of
specific Injuries
Fracture of the Talus
Symptoms: Patient often has a history
of repeated trauma to the ankle. Sharp
pain during weight bearing and
complains of catching and snapping
along with swelling
Management: X-ray is essential.
Nonsurgical management. Protective
immobilization, and no weight bearing.
 Fracture of the
Calcaneus
Symptoms and signs: occurs mostly from
landing or falling from a high place. There is
usually immediate swelling and pain and an
inability to bear weight.
Management: RICE must be used
immediately to minimize pain and swelling
before referring the athlete to an X-ray. With
non displacement fractures immobilization
and early range of motion exercises are
recommended as soon as pain and swelling
go down or is tolerated.
 Calcaneal stress fracture
Occurs with repetitive impact during heel strike
and is most commonly found in distance runners.
Symptoms and signs: weight bearing and
complaints of pain tend to continue after an
exercise stops. May not come up on X-rays so a
bone scan may be the best option.
Management: for the first 2 or 3 weeks rest is
important with little as possible weight bearing on
the foot. Active range of motion exercises of the
foot and ankle during rest. After 2 or 3 weeks,
gradually work the athlete back into it with
cushioning shoes.
 Apophysitis of the
Calcaneus
Occurs in the young and physically
active.
Symptoms and Signs: Pain occurs at
the posterior heel below the
attachment of the Achilles tendon
insertion of the child or adolescent
athlete.
Management: Best treated with rest,
ice, stretching and antiinflamatory
medications.
 Retrocalcaneal Bursitis
Caused by inflammation of the bursa
that lies between the Achilles tendon
and the calcaneal.
Symptoms and Signs: Swelling on
both sides of the heel cord.
Management: RICE and NSAIDs. The
use of ultrasound can reduce
inflammation.
 Heel Contusion
Seen mostly in sports that have a sudden
stop and go response or a sudden change
from horizontal to vertical movement.
Symptoms and Signs: Severe pain in the
heel, unable to withstand the stress of
weight bearing.
Management: No bearing weight on heel
for 24 hours, RICE, and wear shock
absorbent footwear.
 Cuboid Subluxation
Pronation and trauma have been
reported to be prominent causes of
cuboid subluxation.
Symptoms and Signs: Pain in the 4th
and 5th metatarsals as well as over
the cuboid. Often pain in the heel
area as well.
Management: Cuboid manipulation is
done to restore the cuboid to the
natural position. Orthotic helps
 Tarsal Tunnel Syndrome
Symptoms and Signs: Complaints of
pain and paresthesia are typical,
along the medial and plantar aspects
of the foot.
Management: Antiinflamatory
modalities.
 Pes Planus Foot
Pes planus is associated with excessive foot
pronation and may be caused by a number
of factors, including a structural forefoot
varus deformity, shoes that are too tight or
trauma that weakens supportive structures.
Symptoms and Signs: Pain or a feeling of
weakness or fatigue in the medial
longitudinal arch.
Management: Arch support with an
orthotic.
 Pes Cavus Foot (High Arch Foot)
Etiology: Pes Cavus refers to a foot that has an
arch that is higher than normal.
Symptoms/Signs: Shock absorption is poor, thus
problems include general foot pain, metatarsalgia,
& hammertoes.
Management: If problems occur, orthotic should
be constructed using lateral wedge. Stretching of
the Achilles tendon and the plantar fascia is
helpful
 Second Metatarsal Stress Fracture
(Mortons Toe)
Etiology: Abnormally short first metatarsal, thus
the second toe appears to be longer than the
great toe. Weight bearing becomes uneven, with
more weight now on the second metatarsal. Not
an injury but can develop into one.
Symptoms/Signs: Symptoms are those of stress
fractures in general.
Management: If there are no problems, nothing
should be done. If problems occur, an orthotic
with a medial wedge would be helpful.
 Longitudinal Arch Strain
Etiology: Caused by subjecting the musculature of
the foot to stress produced by repetitive contact
with hard surfaces. There is a flattening or strain
to the longitudinal arch.
Symptoms/Signs: Pain is experienced only during
running or jumping. The pain usually appears just
below the posterior tibialis tendon.
Management: RICE followed by therapy and
reduction of weight bearing.
 Plantar Fasciitis
Used to describe pain in the proximal arch and heel.
The function of the plantar fascia is to assist in
maintaining the stability of the foot and in securing the
longitudinal arch
Etiology: Tension develops in the plantar fascia during
the extension of the toes and during depression of the
longitudinal arch as a result of weight bearing
Symptoms/Signs: pain in the medial heel, and
eventually moves to central portion of plantar fascia.
Management: Extended period of treatment. Orthotic
therapy useful. Taping may reduce symptoms. Should
engage in Achilles tendon stretching, and stretch the
plantar fascia.
 Jones Fracture
Etiology: Can be caused by inversion and plantar
flexion of the foot, by direct force, or repetitive
stress. Most common acute fracture to the
diaphysis at the base of the fifth metatarsal.
Symptoms/Signs: Immediate swelling and pain
over the fifth metatarsal. Healing is slow. Injury
has a high nonunion rate. Nonunion fractures heal
with cartilage between the bone fracture.
Management: Use of crutches with no
immobilization, progressing to full weight bearing
as pain subsides.
Metatarsal Stress Fractures
Etiology: Most common metatarsal stress
fractures involve the shaft of the second
metatarsal.
Symptoms/Signs: Over 2-3 week period, dull pain
begins to occur during exercise, then progresses
to pain at rest. Usually occurs when patients
increase the intensity or duration of their exercise.
Management: Partial weight bearing and 2 weeks
of rest. Return to running should be very gradual.
 Bunions (Hallux Valgus
Deformities) & Bunionettes
(Tailors Bunions)
Etiology: Bunion occurs at the head of the first metatarsal. Often
caused by shoes. Bunionette the toe angulates toward the fourth
toe, causing an enlarged metatarsal head.
In all bunions, both the flexor and extensor tendons are malaligned,
creating more angular stress on the joint.
Symptoms/Signs: During formation there is tenderness, swelling,

and enlargement of the joint. Angulation of the toe progresses.

Management: Early recognition and care can often prevent

increased irritation & deformity.

1. Wear correctly fitting shoes
2. Wear an appropriate fitting orthotic
3. Place a sponge rubber doughnut pad over the 1 st/5th
metatarsophalangeal joint
4. Wear a tape splint along with a resilient wedge placed between
the great toe and 2nd toe.
5. Engage in daily foot exercises. Ultimately, surgery may be
necessary
 Sesamoiditis
Etiology: Two sesamoid bones lie within the flexor
& adductor tendons of the great toe. Sesamoiditis
is caused by repetitive hyperextension of the
great toe

Symptoms/signs: patient complains of pain under

the great toe, especially during a push off

Management: treated with orthotic devices.

Decrease activity to allow inflammation to subside
 Metatarsalgia
Etiology: pain in the ball of the foot or under 2nd or
3rd metatarsal head. A heavy callus forms. One of
the causes is restricted extensibility of the
gastrocnemius-soleus complex

Signs/symptoms: As the transverse arch becomes

flattened and the heads of the 2nd, 3rd, 4th
metatarsal bones become depressed. Also, a
cavus deformity

Management: Applying a pad to elevate the

depressed metatarsal heads. Regimen of static
stretching
 Metatarsal Arch Strain
Etiology: The heads of the 1st and 5th metatarsal
bones bear slightly more weight than the heads of
2nd, 3rd, & 4th. If the foot tends to pronate
excessively, & spread abnormally (splayed foot),
fallen metatarsal arch results

Symptoms/signs: Patient has pain or cramping in

metatarsal region. Point tenderness in the area.

Management: Apply pad to elevate. Pad placed in

the center just behind the ball of the foot.
 Mortons Neuroma
Etiology: Located between the 3rd & 4th metatarsal
heads where the nerve is the thickest. With the
collapse of the transverse arch of the foot, it
stretches metatarsal ligaments which then
compresses the digital nerves & vessels.

Symptoms/signs: Burning paresthesia and pain in

the forefoot. Hyperextension of the toes can
increase the symptoms.
Management: Bone scan often necessary. Use a
pad. Shoe selection is important for treatment.
 Injuries to the Toes
Sprained Toes
Etiology: Sprains of the phalangeal joints of the
toes are caused often by kicking an object. Joint is
extended beyond normal range of motion
(jamming), or toe is twisted.

Symptoms/signs: Pain immediate & intense but

generally short lived. Immediate
swelling/discoloration. Stiffness & residual pain
may last several weeks.
Management: RICE. Buddy taping the injured toe
to the adjacent toes.
 Great Toe Hyperextension
Etiology: Results in a sprain of the
metatarsophalangeal joint. Typically occurs on turf
since shoes for artificial turf allow more dorsiflexion
of the great toe.

Symptoms/signs: Pain & swelling. Pain is

exacerbated when patient tries to push off the foot.

Management: Shoes with steel or other materials

added to the forefoot help stiffen them. Tape, ice,
ultrasound. Important to rest injury until the toe is
pain free.
 Fractures and Dislocations of the
Phalanges
Etiology: usually occur by kicking an object,
stubbing toe, or being stepped on. Dislocation is
less common than fractures.

Symptoms/signs: Immediate intense pain.

Swelling & discoloration.

Management: Toe dislocations should be reduced

by a physician. Buddy taping injured toe to
adjacent toes usually provides sufficient support.
 Hallux Rigidus
Etiology: Caused by the proliferation of bony spurs on
the dorsal aspect of the 1st metatarsophalangeal joint,
resulting in impingement. Its a degenerative arthritic
process.

Symptoms/signs: Great toe is unable to dorsiflex.

Forced dorsiflexion increases pain. Weight bearing is
on the lateral aspect of the foot.

Management: Stiffer shoe with larger toe box.

Antiinflammatory medication. Osteotomy(surgically
removing piece of bone) to remove mechanical
obstruction to dorsiflexion
Hammer Toe, Mallet Toe, & Claw Toe
Etiology: Flexion contractures in the toes. Caused by
wearing shoes that are too short over a long period of
time

Symptoms/signs: In all 3 conditions the MP, PIP, or DIP

joints can become fixed. There may be blistering, pain,
swelling, callus formation, and occasionally infection.
Management: Wear footwear with more room for the
toes. Use of padding and protective taping. Once
deformities become fixed, surgical procedures that
involve straightening the toes and maintaining
position using Kirshner Wire is necessary.
 Overlapping Toes
Etiology: Congenital, or improperly fitting
footwear.

Symptoms/signs: Outward projection of the great

toe or a drop in the longitudinal or metatarsal
arch.

Management: Surgery. Therapeutic modalities like

whirlpool bath help alleviate inflammation. Taping
 Blood Under the Toenail(Subungual
Hematoma)
Etiology: Toe being stepped on, dropping object on
toe, or kicking an object. Blood that accumulates
is likely to produce extreme pain & loss of nail.

Symptoms/signs: Bleeding into the nail may be

immediate or slow. Bluish purple color, and gentle
pressure on the nail exacerbates pain.

Management: Ice pack applied immediately.

Elevation. Within next 12-24 hrs physician should
drill hole to release pressure.
 Foot Rehabilitation
General Body Conditioning
Managing injuries to the foot often require that
the patient be non weight bearing for some period
of time.
No running activities so its necessary to
substitute alternative conditioning activities. Ex:
running in a pool, working on upper extremity
ergometer. Continue in strengthening & flexibility
exercises as allowed by the injury.
 Joint Mobilization
Anterior/posterior calcaneocuboid glides are used
for increasing adduction and abduction.
Anterior/posterior cuboidmetatarsal glides. Used
for increasing the mobility of the 5th metatarsal.
Anterior/posterior tarsometatarsal glides decrease
hypomobility of the metatarsals
Anterior/posterior talonavicular glides increase
adduction and abduction.
Anterior/posterior metatarsophalangeal glides.
The anterior glides increase extension and the
posterior glides increase flexion.
 Flexibility
Restoring full range of motion following various
injuries to the phalanges is important. Critical to
engage in stretching activities in the case of
plantar fasciitis. Also stretch gastrocnemiussoleus
complex for number of injuries
 Muscular Strength
Strength exercises can be done with a variety of
resistance methods including rubber tubing, towel
exercises, and manual resistance.

Strengthening muscles involved in foot motion:

o Write alphabet in the air with toes pointed
o Patient picks up small objects (ex. Marbles) with
toes
o Ankle is circumducted
o Gripping and spreading the toes.
o Towel exercises
 Neuromuscular Control
Neuromuscular control in the foot is the single
most important element dictating movement
strategies within the kinetic chain
Exercises for reestablishing neuromuscular control
in the foot should include a variety of walking,
running, and hopping involving directional
changes performed on varying surfaces.
Exercise sandals are excellent for increasing
muscle activation in the foot and lower leg
Foot Orthotics and Taping
Orthotics are used to control abnormal compensatory
movements of the foot.
The orthotic provides a platform of support so that soft tissues
can heal properly without undue stress.
3 types of Orthotics:
1. Pads or soft orthotics. These soft inserts are advocated for
mild overuse syndromes.
2. Semirigid orthotics are prescribed for athletes who have
increased symptoms. Made of flexible thermoplastics, rubber,
or leather
3. Functional or rigid orthotics are from made from hard plastic
Orthotics for Correcting Excessive Pronation Supination
. For structural forefoot varus deformity, orthotic should be rigid type
and should have a medial wedge under the 1 st metatarsal. For more
comfort add a small wedge
. Structural forefoot valgus deformity in which the foot excessively
supinates, orthotic should be semirigid and have a lateral wedge under
the head of the 5th metatarsal. For more comfort add a small wedge
. Structural rearfoot varus deformity, the orthotic should be semirigid
and have a wedge under the medial calcaneus and a small wedge
under the head of the 1st metatarsal.
 Functional Progression for the Foot
Non weight bearing Short sprints
Partial weight bearing Acceleration/decelerati
Full weight bearing on sprints
Walking Carioca
-Normal Hopping
-Heel -Two feet
-Toe -One Foot
-Side step / shuffle slides -Alternate
Logging Cutting jumping
-Straightaways on track hopping on command
-Walk turns
-Jog complete oval of
track