Gait Pattern                            Swelling

Ecchymosis                             Bunions

Caluses                                  Claw Toes

Hallux Valgus                         Shoes

Redness                                 Deformities

Corns                                     Blisters

Hammer Toes                         Achilles Tendon Align

Medical Longitudinal Arch         Pes Cavus - high arch

Pes Planus - Rigid - Flat Arch    Metatarsal Arch

Pes Planus - Supple - Appears to have arch when non weight bearing

Foot - Medial Bony Palpation

1st MTP

1st Metatarsal

1st Cuneiform

Navicular

Head of Talus

Sustenaculum Tali

Foot Medial Soft Tissue

Spring Ligament

Flexor Hallucis Longus

Flexor Digitorum Longus

Tibialis Posterior

5th Metatarsal

Base of 5th Metatarsal - Styloid Process

Cuboid

Peroneal Tubercal

Lateral malleoulus

Metatarsal

2nd and 3rd Cuneiform

Toes - Rays

Dome of Talus

Extensor Hallucis Longus

Extensor Digitorum Longus

Inferior Extensor Retinaculum

Sinus Tarsi

Extensor Digitorum Brevis

Metatarsal Heads

Sesamoid Bones

Calcaneus

Medial Calcaneal Tubercle

Plantar Fascia

Intedigital Neuroma

MTP Extension

PIP Extension

MTP Flexion

PIP Flexion

MTP Extension - Extensor Hallucis Longus

MTP - Flexion - Flexor Hallucis Longus

Foot Valgus Test

MTP/IP

Testing MCL

stabilize bone proximal to the joint; grasp distal to the joint near the mid-shaft

attempt to move the distal bone laterally

this opens up joint on the medial side

+ increased laxity and pain

Foot Varus Test

MTP/IP

Tests LCL

+ increased laxity and pain

stabilize proximal to joint

grasp distal to the joint near mid-shaft

attempt to move the distal bone medially

this opens the joint on the lateral side

• Tests deep transverse ligament, metatarsal interosseus ligament
• Patient is sitting foot relaxed
• grasp metatarsal head and 2nd met; thumb on dorsal, index finger on plantar. Attempt to move up and down or distract
• + increased glide and pain

• Tests hyperpronation
• patient is sitting with feet on floor
• mark prominant aspect on the navicular
• find subtalar neutral, make a mark on the card that indicates distance from the floor
• have athlete stand
• remeasure the distance of navicular from the floor
• + navicular drops more than 10 mm

• Tests Metatarsal Fracture
• Patient is sitting, foot relaxed
• Place one hand around proximal foot/ankle to stabilize
• grasp metatarsal head of bone to be tested and push proximally
• + pain, crepitus

• Tests Morton's Neuroma
• Patient is sitting, leg extended, foot relaxed
• Place one hand around met. heads and squeeze, hold for 1-2 min
• + pain, tingling, numbness

• L4 - Medial Side of foot
• L5 - dorsal side of foot
• S1 - Lateral Foot, posterior low leg

• Dorsal Pedal Artery
• Capillary Nail Bed Refill

26 bones

14 phalangeeal

5 metatarsal

7 tarsal

2 sesamoid bones

• Under the 1st metatarsal
• Assist in reducing pressure in weight bearing
• increase the mechanical advatange of the flexor tendons of the great toe
• act as sliding pulleys for tendons

• 5 bones that lie between and articulate with the tarsals and phalanges
• ligamentous arrangement gives elasticity to the foot in weight bearing
• MTP joints permit hinge action of phalanges
• 1st MTP fx as the main wt bearing support during walking and running

• largest tarsal bone
• supports talus and shapes the heel
• main fx; convey the body wt to the ground and serves as attachment of Achillies Tendon and plantar structures

• Above calcaneous
• Consists of; body, neck and head
• Trochlea articulates with medial and lateral malleoli to form ankle jt.
• Dorsiflexion is limited due to talus being narrower posteriorly than anteriorly

• Anterior to the talus on medial aspect of the foot
• Articulates with the 3 cuneiform bones

• 3 cuneiforms located btw navicular and base of 3 metatarsals on medial aspect of foot

• provide support in wt bearing
• absorb shock
• provide space on plantar surface to blood vessels, nerves and muscles

• extends across the cuboid and the internal cuneiform
• protects soft tissue and increases foot mobility

• originates on medial border of calcaneous and extends forward to distal head of 1st metatarsal
• main supporting lig. - plantar calcanounavicular lig/spring lig
• tendon of the post. tibialis muscle helpts to support the spring ligament

• On outer aspect of foot
• formed by the calcaneous, cuboid and 5th metatarsal bones

• thick white band of fibrous tissue
• orginates on medal tubercle of calcaneous and ends at proximal head of metatarsal
• supports foot against downward forces

• designed for flexion and extension
• reinforced by collateral ligaments

• Condyloid type joint
• permits flexion, extension, adduction and abduction

• sliding joitns
• include 2 sets of articulations

• formed by junction of the bases of the metatrsal bones with cuboid and all 3 cuneiforms
• allows for some gliding
• known as Lisfranc's joint

• articulation btw talus and calcanous
• allows for inversion, eversion, pronation and supination
• wt. bearing pronation refers to combine movement of talar plantarflexion and adduction of calcaneal eversion
• wt. bearing supicantion refers to comvined movement of talar dorsiflexion, abduction and calcaneal inversion

• consists of calcaneocuboid and talonavicular joint
• directly related to subtalar joint
• if subtalar joint is pronated, midtarsals become hypermobile
• if subtalar joint is supinated then the midtarsal joint is hypomobile

• Tibialis Anterior
• Extensor digitorum longus
• Extensor digitorum hallucis longus
• Peroneus Tertius

• Gastrocnemius
• Soleus
• Plantaris
• Peroneus Longus
• Peroneus Brevis
• Tibialis Posterior
• Flexor Hallucis Longus
• Flexor digitoum longus

• Tibialis Posterior
• Flexor digitorum longus
• flexor hallucis longus
• Tibialis anterior
• extensor hallucis longus

• Peroneus longus
• peroneus brevis
• peroneus tertius
• extensor digitorum longus

• Flexor digitorum longus
• quandrratus plantar

• lubricales
• interossei

• abductor hallucis
• abductor digit quanti
• lumbricales
• interossei

• extensor digitorum longus
• extensor hallucis longus
• extensor digitorum brevis

• tibial nerve supplies muscles on back of leg and plantar aspect of foot
• common peroneal nerve supplies: front of the leg and foot
• blood supply: anterior and posterior tibial arteries

• starts with initial heel strike on ground and ends with toe off
• 60% of total gait cycle
• 5 periods: initial contact, loading response, mid stance, terminal stance and pre-swing

• 60% stance phase
• time btw toe-off and subsequent initial contact of non-wt.bearing
• divided into 3 phases: initial swing, mid swing and terminal swing

• prolonged pronation major cause of stress injuries
• cuboid loses it mechanical advantage as pulley
• peroneus longus tendon no longer stablizes the first ray
• prolonged pronation does not allow subtalur joint to resupinate less power for push off

• Stress Fracture of 2nd Metatarsal
• Plantar fasciitis
• Posterior tibial tendonitis
• Achillies tendonitis
• Tibial Stress syndrome
• medial kneww pain

• at heel strike does not allow subtalar joint to unlock - foot remain rigid
• cuboid becomes hypomobile - increasing tension on peroneus longus tendon
• foot cannot absorb ground reaction forces efficiently

• inversion ankle sprain
• tibial stress syndrome
• peroneal tendonitis
• IT band friction syndrome
• Trochanteric bursitis

History

Observation

Palpation

Special tests

History

Inspection

Palpation

Special Tests

Mechanism

Acute or Chronic

Pain - type and location

Previous History

Sounds - snap, crack, pop

Signs/Symptoms - Sign - something you can see

Symptom - something they tell you

• uneven wear patterns on shoes
• callus formation - skin thickness
• blisters - bulla formation
• corns - hard and soft formations
• toes supernumerary digit, overlapping
• Bunions 1st/5th MP
• Claw Toes excesive flexion
• Hallux Valgus turned away from midline

• Acute - Navicular fracture
• Congenital
• Chronic - Weak musculature and lig. laxity
• Associated Problems: plantar fasciitis, Heel spurs, patellofemoral pain

• In ability to adapt to forces
• Congenital
• Associated Problems: Claw toes, metatarsal stress fx., plantar fascia rupture

Plantar Fasciitis

Onset:

Acute DF and MTP Ext

Chronic: - repeated stress, chronic in nature

abnormal biomechanics

Evaluation

pain at orgin on calcaneous

worst when getting out of bed in the AM

ROM limitations - gets better with activity

Associate Problems

exostosis - "heel spurs" abnormal bone growth

adhersions of plantar fascia

rupture of plantar fascia

Tarsel Tunnel Syndrome

Entrapment of posterior Tibial Nerve

Onset

Acute, fracture, dislocation

Chronic - pes planus, more often associated with plantar fasciitis

Evaluation

pain, burning, numbness

medial malleolus to plantar surface of foot

S/S increase with activity

Tinel's sign - radiating sensation, tingling all signs of nerve damags, gets worse with activty

Metatarsal Fracture

Onset

Acute - direct contact, overload, torque

Jones Fracture associated with inversion ankle sprains

Chronic - repeated stress

March fracture

Evaluation

Pain increase with activity

point tender, deformity, swelling

ROM limited

Long bone compression test

 Nerovascular

L4 medial foot

L5 - Dorsum of foot

S1 - Lateral foot

Vascular

dorsal pedal artery

Capillary nail bed refill

Interdigital Neruroma "Morton's Neuroma"

Entrapment of nerves btw metatarsal heads

Onset

acute - direct trauma

Evaluation

pain worse when wearing shoes

radiating pain, tingling, numbness

palpate for nodule btw. metatarsal heads

Tests

intermetatarsal glides

squeeze metatarsal head

Turf Toe

Sprain of 1st MTP joint - Injury to joint capsule, MCL, LCL

Onset

acute - direct contact

forced ROM

Evaluation

pain during pressuring

point tender, swelling, ecchymosis

Tests

Valgus

Varus

Jones Fracture

Fracture of 5th met, 1 cm styloid process

Mechanism

twisting inversion of ankle

Acute - possiblity of chronic

Palpation

Pain over middle of foot over 5th metatarsal

swelling

edema

pain increase with activity

crepitis

Phalangeal Fracture

Mechanism

direct blow

acute most Common

distal phalanz of the first

result of kicking something

Palpation

pain

point tender over phalangeals

pain with wt. or activity 

Hallux valgus

Mechanism

big toe overlap

increased ROM in extension

flatening of medial arch

wearing too pointy, cramped shoes

can appear with bunion like function

inrease pain from pressure friction

associated with pes planus

might be uncomfortable

What to do

get better fitting shoes

wedge splint btw 1st and 2nd metatarsal and tape

Hammer Toe

Permanent flexion in phalengeal toes

Mechanism

to short of shoes

flexion of proximal extension of distal

acute- after rupture of plantar fascia

chronic in nature

Palpation

blistering

effusion

callus

corns

obvious

No special tests

Functional tests

flexion contraction

Heel Spur

Mechanism

• chronic
• abnormal bone growth
• plantar fasciitis
• localized point tenderness

No special tests

X-Rays

Treatment

• Increase flexiblity
• donut pad

Metatarsalgia

pain under the 2nd/3rd metatarsal

lack of movement

tight gastroc

transverse arch flattened

shortened mid gait stance

emphasizes toe off phase, putting pressre on forefoot

History

chronic

insidious

Inspection

callus forms

fallen arch

numbness, sharp shooting pain associated with morton's neuroma

Palpation

ptt on 2nd/3rd

No special tests

Metatarsal Stress Fracture

Mechanism

results from one incident

athlete develops localized pain and swelling

pain worsens with activitiy and improves with rest

generally no history or obvious injury

sometimes not even visible on x-ray

Palaption

discrete pain

pain

swelling

Special Tests

long bone compression test

tap test

Treatment

relative or absolute rest

low impact sports

casting or bracing may be needed

period of non-wt. bearing with crutch

Ankle and Lower Leg Inspection

• Gait pattern - antalgic, external rotation
• deformity
• medial longitudinal arch
• shoes
• ecchymosis
• redness
• swelling
• achilles tendon alignent

• tibia - main wt. bearing bone
• medial malleoulus
• sustentaculum tali - calcaneus - prominance on calcaneous
• navicular

• Deltoid Ligament - medial maleolus to navicular/calcaneous
• tibialis posterior tendon - behind medial maleolus and attahes to navicular
• posterior tibial artery - dig right behind medial maleolus

Ankle Palpation - Soft Tissue Lateral

• Anterior Tibialis and Tendon - pops out when plantar flex
• Sinus Tarsi
• Anterior Inferior Tibiofibular Ligament (AITF) - holds distal end of fibual and tibia together
• Peroneus Tertius Tendon - lateral to EDL - front of lateral maleolus to base of 5th
• Dorsal pedal artery

• Base of 5th Metatarsal (styloid Process)
• Cuboid
• Lateral Malleolus - distal end of fibula
• peroneal tubercle - calcaneus
• fibula

• Anterior Talofibular ligament (ATF) - talus to fibula - inversion ankle
• Calcaneofibular - (CF) - calcaneous to fibula - inversion ankle
• Poterior Talofibular - (PTF) talus to fibula - inversion ankle
• peroneus longus and brevis tendons (under 5th)
• peroneal retinaculum - holds peronues longus and brevis down

• Gastrocnemius - form Achilles tendon with soleus
• Soleus - form achilles tendon with gastroc
• Achilles Tendon
• Retrocalcaneal bursa - btw tendon and bone
• calcaneal bursa - superficial

• Plantarflexion
• eversion
• dorisflexion
• inversion

• Inversion with dorsiflexion - tests anterior tibialis
• inversion with plantarflexion - posterior tibialis
• eversion with plantarflexion - peroneus longus and brevis
• eversion with dorsiflexion - peroneus  tertius
• plantarflexion - gastrocnemius
• plantarflexion with knee flexion - soleus

Ankle Anterior Drawer

• Tests anterior talofibular
• patient is sitting, knee extended, ankle in newutral position, athlete relaxed
• Cup the bottom of the calcaneus with one hand and place the other hand on anterior tibia to stabilize. Ankle should be in neutral or slightly DF. Attempt to  pull calc toward ceiling
• +pain and laxity

Ankle Inversion Stress Test

• Tests = ATF, CF, PTF
• athlete is sitting knee extended, ankle neutral positon, athlete relaxed
• grasp plantar and lateral surfaces of the foot with one hand; place the other hand on the low leg to stabilize; passively PF then passively invert the ankle. Repeat in neutral and DF positions
• +pain and laxity

• tests deltoid ligament
• patient is sitting knee extended, ankle neutral position
• grasp the plantar and medial sufaces of foot and stabilize low leg with other hand. Passivley PF then passibely evert the ankle. Repeat in neutral and DF
• +pain and laxity

Kleiger's - External Rotation Test

• Tests - deltoid ligament and AITF ligament
• Patient is sitting knee extended, ankle in neutral position
• grasp the polantar and medial surfaces of foot with one hand stabilize low leg with other. Passivley DF and externaly rotate foot
• + pain and laxity

Squeez Test

• tests fracture in tibia and fibula
• patient sitting, knee extended ankle neutral position
• cup hands around athlete's low leg away from injury site and squeeze compress tibia and fibula
• +pain, pain away from area being compressed

Bump Test

• tests fracture in tibia, fibula and talus
• patient is sitting knee extended ankle in neutral position
• with one hand hold foot in neutral position, using heel of other hand bump on the plantar surface ofthe calcaneous
• +pain, radiating pain into the low leg

Ankle Dorsiflexion Test

• Tests- tightness in gastroc/soleus
• patient is sitting
• with athlete sitting and knee extended passively DF foot mearure PROM and repeat with knee flexed at 90
• +if less motion when knee extended - gastroc
• if less motion when knee flex - soleus

Ankle Thompson's test

• Tests Achilles Tendon Rupture
• Athlete is prone, kneww extended ankle neutral position
• squeeze belly of the calf muscles; look for motion of the ankle joint
• + no motion or decreased motion of the ankle

Ankle Homan's Test

• tests deep vein thrombophlebitis
• athlete is sitting, knee extended ankle in neutral position
• hold the athlete's low leg just slightly off the table; passively DF ankle
• + deep pain in the calf

Ankle Nurovascular - Reflexes

• S1 - Achilles tendon

Ankle Neurovascular Dermotomes

• L4 - medial low leg and foot
• L5 - anterior low leg, dorsum of foot
• S1 - posterior low leg just above the ankle, lateral foot
• S2 - posterior low leg

Ankle - Neurovascular Myotomes

• L4 - Ankle Dorsiflexion

Ankle Neurovascular Vascular

• Posterior Tibial Artery

Tibia

• longest bone in the body with exception of femur
• princpal weight bearing bone in the leg

Fibula

• joins tibia with an arthorodial articulation at the upper end just below the knee and as a syndesmotic joint at the lower end
• main function is to provide for the attachment of muscles

Tibial and fibular malleoli

• lateral malleolus extends further distally which creates stability on the lateral aspec of the ankle

Talus

• second largest tarsal and main wt. bearing bone of the articulation, rests on the calcaneous and receives the articulating surfaces of the lateral and medial malleoli

Calcaneous

• forms the hell
• attachment site for ligaments and the achilles tendon

Ankle Articulations

• superior and infrerior tibiofibular joints
• superior tibiofibular joint is diarthrotic allows for some gliding
• inferior tibiofibular joint is a fibrous articulation btw the lateral malleolus and the distal end of the tibia
• talocrual joint

Ankle Joint

• is a hinge joint ginglymus
• movements include plantarflexion and dorsiflexion

Ankle Mortise

• formed by the distal portion of tibia, lateral malleolus and medial malleolus articulating with the trochlea of the talus

Ankle Stabilizing ligaments

• tibiofibular ligament - oblique arrangment aids in diffusing the forces on the lower leg.
• Anterior and posterior tibiofibular ligaments, which hold the tibia and fibula together form the distal portion of the interosseous membrane (syndesmotic ligaments)

Ankle ligaments

• lateral ligaments
• Anterior Talo Fibular restrains anterior displacement of talus
• calcaneofibular restrains inversion of calcaneous
• posterior talofibular restrains posterior displacement of talus
• Medial Ligaments
• deltoid anterior tibiofibular, tibionavicular, tibiocalcaneal and posterior tibiotalar
• prevents abduction and eversion of the ankle and subtalar joint
• prevents eversion, pronation and anterior displacement of the talus

Ankle Joint Capsule

• encases the ankle joint, thick on the medial aspect and becomes thin at the back.

Ankle Muscle Compartments

• Divided into 4 compartments bound by heavy fascia
• anterior compartment - contains the muscles that dorsiflex the ankle and extend the toes (tibialis anterior, extensor hallucis longus, extenstors digitorum)
• Lateral Compartment - peroneus longus and brevis - evert ankle . Peroneus tertius assiss dorsiflexion, superficial branch of the peroneal nerve
• superficial posterior compartment - gastrocnemius and soleus plantarflex ankle
• deep posterior compartments - tibialiss posterior, flexor difitorum longus and flecor hallucis longus invert ankle. Posterior tibial artery

Ankle Nerve and blood supply

• major nerves of the lower leg are the tibial and common peroneal
• major arteries include the posterior and anterior tibial areteries
• primary veins conssit of popliteal, peroneal and anterior and posterior tibial veins

Ankle Functional Anatomy

• ankle is a stable hinge joint dome of talus articulating with distal ends of tibial and fibula
• medial or lateral displacement of talus prevented bu malleoli
• talus is wider anteriorly than posteriorlu most stable position of the ankle is in dorsiflexion
• ankle ROM ranges fom 10 dorsiflexion to 50 of plantarflexion
• normal gait requires at least 20 of plantarflexion and 10 of dorsiflexion with knee extended

Malleolar Avulsion Fraction

vs

Eversion Ankle Sprain

• deformities, ptt and crepitis

Syndesmotic Ankle Sprain

Mechanism

external rotation of tibia, eversion, dorsiflexion

usually associated with an eversion or inversion sprain

Inspection

swelling

ecchymosis

Palpation

pain at distal tib-fib

ROM

AROM, PROM, RROM painfull

Stress Test

Kleigers

Inversion

Eversion

Low Leg Fracture

Mechanism

direct blow

excessive force

Inspection

deformity

loss of fx

crepitis

Palpation

radiating pain

crepits

Stress Test

bump test

squeeze test

Low Leg stress facture

Mechanism

microtrauma

insidious

Inspection

no deformity

swelling only in advanced stages

loss of fx

Palpation

localized pain

ROM

Very little change

Stress Test

Bump Test

Stress Fracture

vs.

Shin Splints

• Stress fracture - roximal distal 1/3
• shin splints - medial side of tibia
• Palpation - pain location and nature of the pain
• ROM - weakness depeding on what muscle is effected
• No stress test

Shin Splint Grading Scale

1. pain after activity
2. pain after and during activity
3. pain before, during and after activity

Achilles Tendonitis

Mechanism

chronic - inscidious

acute - direct blow, friction

results of ankle sprain

Inspection

swelling

tightness in calf

predisspoing factors

ankle dorsiflextion test

redness

Palpation

ptt

creptitis

heat

ROM

AROM - PF and DF pain

PROM - DF pain and weakness

RROM - PF pain and weakness

Achilles Tendon Rupture

Mechanism

acute - forceful contraction

chronic - result of many mirco traumas

rare in young people

Inspection

deformity - feel ball of calf

ptt

ROM

remeber the toe flexes

ARROm - limited PF

RROM - weakness in RL

Stress Test - thompson's

Compartment Syndrome

Mechanism

acute - direct blow

chronic - exertional

Inspection

swelling

red, shiney

drop foot

Palpation

ptt on leg

tight and hard

distal pulses weak

ROM

depends on compartment

PROM - lateral - eversion

RROM - deep inversion

Treatment

do not wrap and refer to DR

Peroneal Nerve Injury

Mechanism

fibual frac

 contusion

entrapment

varus force

Palpation

ptt at fibula head

radiating pain

tingling, numbness

Neurological

Sensory - decresed at anterior and lateral foot and low leg

ROM

AROM/RROM - limited to DF, eversion and toe extension

Retrocalcaneal Bursitis

Mechanism

• Chronic - no pervious injury
• swellnig on both sides of heel in front of achilles tendon

Palpation

• ptt on Achilles tendon

ROM

• going to hurt to stretch PF and DF

No special tests

Anterior Posterior Talotibial Exostosis

bony outgrowth off talus/tibia where they connect

Mechanism

• chronic - takes months/years
• may have had a sprain
• hurts when they walk

Inspection

• affect gait pattern - toe off
• feel it and might see it
• pain with most movements

ROM

• eversion, PF
• Anterior limited dorsiflexion

No special tests

Achilles Tendon Tenosynovitis

Mechanism

• tendonitis
• inflammation of the sheath
• chronic
• feel grinding and snowball crepitis

Palpation

• ptt and crepitis

ROM

• pain with PF and Df

No special tests

Anterior Ankle Luxation

Mechanism

• acute
• complete disruption of joint
• blow pushes it one way or another
• anterior - foot moves forward compared to leg
• posterior foot moves backward - heel longer

Inspection/Palpation

• can't walk
• obvious deformity
• effusion and edema

No ROM

Treatment

• Immobilize and transport
• Check distal pulses