Foot & Toe Evaluation

Foot Anatomy

26 Bones Rearfoot Calcaneus, Talus Midfoot 3 Cuneiforms, Cuboid, Navicular Forefoot 5 Metatarsals, 14 Phalanges, 2 Sesamoids

Ankle mortise tibia, fibula, talus

Reference: Starkey, C. (2002). Evaluation of Orthopedic & Athletic Injuries, p. 89.

Rearfoot

Provides stability & shock absorption during initial stance phase Lever arm for Achilles tendon during plantarflexion Talus no muscles attach to it Calcaneus - Calcaneal tubercle posterior side - Sustentaculum tali medial side - helps support the talus flexor hallicus longus - passes through the medial groove - Peroneal tubercle lateral side

Subtalar joint inferior talus/superior calcaneus

Rearfoot

Reference: Primal Pictures, 2001

Midfoot

Shock absorber Medial longitudinal arch Navicular tuberosity Tibialis posterior insertion

Reference: Primal Pictures, 2001

Forefoot

Lever during pre-swing phase Metatarsals proximal base, body, distal head Phalanges MTP, PIP, DIP, IP joints Plantar fascia

Forefoot

Reference: Primal Pictures, 2001

Metatarsophalangeal Joints
Classified as condyloid-type joints Great toe metatarsophalangeal (MP) joint flexes 45 & extends 70 MP joints of the four lesser toes

40 of flexion 40 of extension also abduct & adduct minimally

Joints

Great toe interphalangeal (IP) joint flexes from 0 of full extension to 90 of flexion Proximal interphalangeal (PIP) joints in lesser toes flexes from 0 extension to 35 flexion Distal interphalangeal (DIP) joints flexes 60 & extend 30 Much variation from joint to joint & from person to person

Terminology

Intrinsic muscles m. contained within the foot Extrinsic muscles m. originating from lower leg or femur Supination inversion + adduction + plantarflexion Pronation - eversion + abduction + dorsiflexion Inversion movement of the plantar aspect of the calcaneus
toward the midline of the body

Eversion movement of the plantar aspect of the calcaneus

away from the body Dorsiflexion flexion of the ankle, pulling the foot & toes toward the tibia

Plantarflexion extension of the ankle, pointing the foot &

toes

Ray series of bones formed by the MT & phalanges

Pronation
combination of ankle

dorsiflexion, subtalar eversion, & forefoot abduction (toe-out)

Movements of Foot

Supination
combination of ankle

plantar flexion, subtalar inversion, & forefoot adduction (toe-in)

Eversion
turning ankle & foot

outward; abduction, away from midline; weight is on medial edge of foot

Inversion
turning ankle & foot

inward; adduction, toward midline; weight is on lateral edge of foot

Movements of Toes

Toe flexion
movement of toes

toward plantar surface of foot

Toe extension
movement of toes

away from plantar surface of foot

Intrinsic Muscles of the Foot

All originate & insert within the foot

Extensor

digitorum brevis - dorsum of foot

Remainder are

in a plantar compartment in 4 layers on plantar surface of foot

Intrinsic Muscles of the Foot

First (superficial) layer: Abductor hallucis, flexor digitorum brevis,

abductor digiti minimi (quinti) Second (middle) layer: Quadratus plantae, lumbricales (4)

Intrinsic Muscles of the Foot

Third (deep) layer: Flexor hallucis brevis, adductor hallucis, flexor digiti

minimi brevis Fourth (deep) layer: Dorsal interossei (4), plantar interossei (3)

Intrinsic Muscles of the Foot

Grouped by location Medial - attach to great toe proximal phalanx

Abductor hallucis & flexor hallucis brevis - medially Adductor hallucis - centrally beneath metatarsals
Beneath the foot Quadratus plantae, 4 lumbricales, 4 dorsal interossei, 3 plantar interossei, flexor digitorum brevis Dorsal compartment Extensor digitorum brevis

Central location

Lateral attach on lateral aspect of base of 5th

phalange proximal phalanx

abductor digiti minimi, flexor digiti minimi brevis

Intrinsic Muscles of the Foot

Grouped by action 4 muscles act on great toe

abductor hallucis - abduction of great toe & assists flexor hallucis brevis in flexing great toe at MP joint adductor hallucis - adduction of great toe extensor digitorum brevis - extension of great toe at MP joint

4 lumbricales flexors of the 2nd, 3rd, 4th, & 5th phalanges at MP joints quadratus plantae flexors of 2nd, 3rd, 4th, & 5th phalanges at DIP joints 3 plantar interossei adductors & flexors of proximal phalanxes of 3 rd, 4th, & 5th phalanges 4 dorsal interossei abductors & flexors of 2nd, 3rd, & 4th phalanges MP joints flexor digitorum brevis nd rd th th flexes middle phalanxes of 2 , 3 , 4 , & 5 phalanges extensor digitorum brevis extends great toe & 2nd, 3rd, 4th phalanges at MP joints 5th toe muscles abductor digiti minimi abducts proximal phalanx flexor digiti minimi brevis flexes proximal phalanx

Lateral Foot & Ankle

Reference: Primal Pictures, 2001

Medial Foot & Ankle

Reference: Primal Pictures, 2001

Extrinsic Muscles of the Foot

Extensor hallucis longus (EHL) Extensor digitorum longus (EDL) Flexor hallucis longus (FHL) Flexor digitorum longus (FDL) Triceps Surae (Gastrocnemius, Soleus, Plantaris) Peroneus longus, brevis, tertius Tibialis anterior Tibialis posterior
Starkey, Ch. 4, Table 4-2, p. 92-95

Neurovascular

Nerves
Tibial n.

medial side Lateral & Medial Cutaneous branch (comes from Peroneal n.) lateral side

Vascular
Tibial a. Dorsalis Pedis

pulse

Reference: Primal Pictures, 2001

Lateral Cutaneous Distribution

Peach Sural N. Purple Lat. Plantar N. Yellow Superficial Peroneal N.

Reference: Primal Pictures, 2001

Medial Cutaneous Distribution

Light Green Saphenous N. Yellow Superficial Peroneal N. Dark Pink Tibial N. (Medial Calcaneal

branches)

Dark Green Medial Plantar N.

Reference: Primal Pictures, 2001

Dermatome Distribution
Green L4 Pink L5 Salmon S1

Reference: Primal Pictures, 2001

Ligaments in foot & ankle maintain arches Two longitudinal arches

Arches

Medial longitudinal arch -

Transverse arch

extends from calcaneus bone to talus, navicular, 3 cuneiforms, and proximal ends of 3 medial metatarsals Lateral longitudinal arch extends from calcaneus to cuboid and proximal ends of 4th & 5th metatarsals
extends across foot from 1st

metatarsal to the 5th metatarsal

Evaluation of the Foot

History

What happened? (MOI) Where is the pain? When did it happen? (onset) Has it happened before? What does it feel like? Pain scale (1-10) What type of surface? How old are the shoes? Type of pain Unusual noises/sensations

Observation

Toes, Arches Forefoot & Rearfoot Valgus/Varus, Pronation/Supination Calluses, blisters, warts, etc. Appearance Bilateral comparison Color Deformity Edema, Swelling Gait Infection Weight bearing vs. nonweight bearing Shoe wear pattern

Evaluation of the Foot

Palpation

Stress Tests

Start away from the point of pain Palpate bony & soft tissue structures Medial structures Lateral structures Dorsal structures Plantar structures Crepitus Heat Swelling Rigidity Deformities Softness

ROM tests (AROM, PROM, RROM-strength)

Alignment Ligament & Capsular tests Fracture tests Neurological tests Other special tests

Assessment & Plan

What injury have you evaluated? What are you going to do with this injury?

Common Injuries

Retrocalcaneal bursitis Heel contusion Arch strains Plantar fasciitis Fractures Bunion Know the signs & symptoms of these injuries

Sesamoiditis Mortons neuroma Sprained toes Turf toe Fractures & dislocations