Professional Documents
Culture Documents
Complaints
(ONI
EXT
T'he fbot and ankle r.r'rust provicle sllpport and shock ahsorpriur u'hilc at the s'me tirne balancirrg the bod,v. This
reqr,rires both molriiiq to adept to varvins terrain and
tbllou,ing:
first
toe
sesamoiditis
metatarsals-Morton's neurorrla,
IIleta tal'salgia,
"ciropped ntetatrsal." and stess fracnrres
lateral foot-cuboid sLrf.iuxation^ peroneal tendinitis, and lracrure of c base of the fifth mctatarsal
r
r
sirrair-t.s
-tendinitis,
bursitis, nd
fit
6ENERAT ]TRATEGY
History
tingling'
381
llerermine u'hether the patie nt had a tr,lnratic unset rr u'hcther there is an obvious overlise histon.
r l\ith
overuse)
rle te
types clf shoesu'orn, anci thc tvpe of surt:ce t re pxticnt- u,,rks or excrciscs on.
Evaluation
r l4{th traur}r, palpate fcrr points oltenilernr'ss ancl
obtain radiogr'rphs f1r the possibilin. of fra,-:turc/clis.ocation if the patient is unah,e to ber
vneight or bonv tenderncss is fbuncl.
r \\'irh ankle
r
r
n-
Management
r
r
r111rst
be
reierred
sis on preventiol.
']Lndiniris anil nrusclc strain can llc rnarraqed con-
Hindtbot 'i he
(prcvcnts t-nai n1y e.rcessive an kle dorsitlcrion ,ind Ldciuction). and (3) the crictncofihular liqarcnf (a rra jor,ttabilizcr firr ir'ersion). -l he rnedia
side of the ankle is supportcd b1' thc deltoid lig'amcnt. w'hich consists of the tibior.ravicuLr. tibitca.caneal, and anredor and posterior dbioular ligarr-rent-s.
These iganrcnts act tt)gether t(l prevellt ercessivc
evcrsjon oithc anklc (Fjsurc 1'+ 1).
Nlidfbot-.l'he rnitltarsal jolrts are the interconnections letrveen the ta-ns irnd calcneLls nd the
lnidtel'sl llones. inclurlinq tile cLrLrid. nviculr,
li4rrrncr-rt
nd cuucrfi;rms"
(II'|Pl,
382
Musculoskeletai(omPlaints
tlexible interosseous
the nklc lgainst iuversicr n(l rnterior-toposterior nrovelne,)t), (l) thc posterior talofibuhr
Iorcloot-'l
s'
section of th c tbot anrl rlefln itrons of funcf ir-,nl ( )r structr.lral devrations thar mav occur:
art jcu
ltions
up of the dist,r,
rs
Folcfbotvlrus-\\:}cn
drc fble ibot is helr.l in .rn invcrtecl position rvhile the srrbtllrr jrint is iu a neu rr:rl position, iirrefirot \i ',lrlrs occurs.'l'his detirrrlln'
occurs in rtv 9?, of the populatron.] If not conlpensctctl for. the first toe rvouLrl not each the
grc,und cluring; rllldstal-ice ncl toe-olT' Ftreioot
n-ar,s is usuallv corrtletlslitccl fbr b1'plonttior-r of
Fiure f 4-1
(A) Major Bones and Joints of the Foot (LateralView); (B) Major Bones and Joints of the Foot (Medial
Cuneiforms
Navlcila
Talocrura
joint
Me tata r'so ohalangeal
iOlnt
Medial
malleolus
Subtalar
iolnl
nlerphaiangeai
joints
Dome of talus
Head ol tailrs
Navioular
Subtalar joint
Medial
cuneiforn
Sustentaculun,
tal
Tuberosiiy of
first rnetatarsal
lnterosseous membrane
anc iiqament
Anterior
talof ibular
iigameni
Anterior
Posterior
tibiofihu ar
ligarirenl
tibiolibular
iigameni
Posterior
taiof ibular
ligarneni
Cacaneof ibular
ligamenl
Foot and Ankle [ompiaints
383
r Ilindfbot vanis-'1'he
calcrnetrs is helcl in rin invertccl position rrilire the sultlr ioirrt is irl llcrltrrli
rvith hrndfoot (rearfoot) vartrs,'lIis ls otlen ciue to
a devclo,,ntctrttl abnorrlalitl'of the tibi iIr rvlrich
rt is lrowcd ouru'ar(l (tibi r'arurl)"i'he result is thrrt
thc subtrrlar iciirrt rrl.lst mpidl,,'[)rollete thror-rgh rln
inordinarc rarrge of rrotiorr (R( ),\1) itr r ct'fbrt to
hring rhe rrleclirl colttl',lc of the t:alcanctls torr'rd ti-lc
ground durinq grttlrnrl c()llt:lct.'l'his prorltlces t:x-
tJindfirot vrlgLts-'I-lic
ertretrlitl.
calr:ane rrs is
hcl.l in
.rn
coll tact.
E,-luinus (trllipes equirrus)--Sinrplr: put. this rs .r t'cstriction o r-lorsiflexicn t the talrcnirl joint.,\Iost
r[ten this is cl,-le to conrracture of tlle so]eus or qrlstrocncm irts; h ou'ever, ti evcloptn ett ta I or :r cqurretl
clltriage to the tlus tnr' also creatc this prtl:'lern.
ci
urin g haif .rf tb c loot-11t phasc, thr: lirrt rnust rltt: t1' t te
srr1trnatirin.
'
f hc subta ir nr I rtl i r I t:rl ' ioi rlt conrpi el { t loc' LcIre1,
tlonavicul ar, nrl crr I c:rltettcrrlloid ioin ts) rlele rtn I Ilcs
nrolclnclr I rf n'Lost of tll e tlot' i lor' evcr. th c nleclirrl seg-
.,,,rtr.r *ith
rior ltttl
lhat propcrh, lirnctioning iet have on the lorvcr c'rtretrities and the rest of the bodlthe split seconcl contact rvltetr
tl'rc ioot lerrvts
qrourrd
an<l
tire hei first touches the
"vhelr
ctlntact
hecl
alier
dre grour-rd at tot-oft. IrnmediatcLy
'tnd
Support is ttccded
384
fc-,r
Musculoskeletal(omPlaints
l.ocalize
spr
EVAI.UAIIO
History
Carefui rluestioning of the patient durinq dre iristorv takingcan point to the diagnosis (lhble la-l)
Clarifi' rhe n?e o[conrPlainr.
Ls
fssLt
1t;I
Sprain yourankle?
Pos-.ible disral
frrt u re
eve15ion
distasls
Turf
backward?
5udden outside foot pain with
trauma?
th
riirdes,
Frclure ol toe
Ft
Rheumroid rthiti5
with sacroil-
lia
;1.,"
sel rnordtis
t15l
5bliix
li(jn,mttirslo
plantar fu>riitrs
loint)
Plantr fscirtis
Hallur rigidus
toe bark?
ls your big toe deviated out?
Pain on tfie bottom ofyour big toe?
5esmoidrt
Stress
fcture
ofball offoot?
fleuf0m
Pain worse
l."
vr "lr 1,
1',r
l.n
teidigill errri
>.: Jr ,i i-.,'r-
with tight
shoes?
Metalar:algia
Nen,e root
0n bottom ofyourfoot?
Tarsal
interdigti neurtis
tunnel syndrome
Dibetes
Er: delltieniy
38s
su b
ura t.ion
a]
junrpirg-
ld nretrrursa l ftlcnu'e.
Figure
14-2
trorn a jurnp-Consider
nire is possible.
Determire whether the mechanisn is one of overuse.
r if the pltient
Detennine rvhether the padent has a current or past hisrrr-v/ .liagnosis of rhe fi>orlnkle complaint or other relateci disorclers.
or ltnee
Does the patient irave gout, diabetes, arterial insufficiencl,, varicose veins, or timiljal pre.lisposirr()r] t() hallur r';tlpus:
-Ilble 1'1..l),
F't'e_fbat.
l.'isr
M'I'I, joinr
i,
Filth
me tararsal
Merararsls
1
386
. Acute trautrtatic-
scress
['lusruloskeletal [omplaints
fi:rctnre
iioe See'lable
l,l
2 i-,r
e:tplrrtrcn 01'rrutnber!
of
*LE'
14-2
1
I
Ioiiis
Dia5i5i5 \.^/lih
ci.i
ci ;trurture:
1o i.
Itlo!5er]u5 menbralt
i
4
Percneurteriius,erlensoitend0ni,superlrt
ioniuito
al
subluxalion
5cr tissue [rom
rr
oI slirturel
peioneal nerve
lnver:ion ank
Exierilordrr:ltorr',]irrbrl]vrs,disialrlineui,u\iur
1,,"i'it
ligari:elt cr
Erfilr(lelr_a,rileIinjr.)lur1];!Lll\i0i'rirctlor'olilr:tl
iate iiqamerlt
ietinr Lrlunl
r..lr
r1tneu!
tuboid
Iuboid lubluxlion
Iirbord sirblurairon
9
,
I
2
1,i
14
i
1l
tI
rati
Lrre o I p
Achiir
Builil
Iilor! bunion
1,,-ialqe
Achilles tendinitis
rupture
is
prcttil
b,y
irlati0n f0m
Deltoid lrgament
iiviculr tuberrle
Sli'in
rbialis posterior'tendon,
Dorsei lirst
Athille: trndcr:
Haglund!
5trels kclirre
fiettnJ ircture
l,,4etrnlshft
1c
,\,1
lf
libil nerve
fom llntrflerrcn
Tendinit
injLrry
iorni
Haliux rigidus
luryioloint rpiule
l8
:o
l0
21
!eilmord
ieimoids
rilr
frrt,re cr sel,lroiditi;
Sesamoidits
(aplriar sprrrl
i;ia
Plrltf
lr\ii
ruplLjre
Plntar fsciin
[]rneus,it pd
(iint.l frtluit
Metirsal heads
i4orlont neuroma;subluxation
lnterdigitai neunr,l
lnterdigital neuritrs
ivietatarals;exiensorlerrdont
[1etirsJl fr{turr,
?2
2-i
24
25
Extenscrrenlinruium,r0[if
/hie lee
Figure
2.
(i0sLLip,iiu!
5Lr
b uxl 0n5
iendiniti:
rl's
2, lrirntr-aurnatic
14rdfoot.
Stress lrartures,
Medial
1, Acute trarlmatic-- kacrrre, ruprure of plaritar
fascia, navicular sublrxation
i]
J..,atera1
1
. Acute tlr
u ma
a
tr
tic--{r:rctur
c-*-cu ltoi
ii
e. cuLroid su
u
biuxa ti
tt
tt.
liluxattutt
pe rtltleus
lrrevis tentlinriis
f
{omplaints
387
Anterior
1. Acute traumrtic-fl'xctut'c. suillr-xatior-r
2. Norrtraumatic talat' exostctsis, anterior. ribial
nerve compression, sublnxation
Hirtdfoat.
Posterior
1. Acute traInLic-Achilles rtrpture, Achillcs tendin itis
2. Noir trautrla tic-purnp bu rrp. Achillcs tend initis, retrt.ca cnca I ltursttis, blistcrs
I i)lanttr
'l
atic'.rnd Ovcruse
uries
}lotion
cr'.r111'
iinportant to dctcrmine whctl'rel there u'as a h1,'pcrextension or'.r hrperf-lexion olthe tcie. c:rch of ii'hiclr is suqgestivc of carsr.rlar sltrain.
With anldc injun, it is alrvavs imltortent to detcrtttine
atcrrl
nedirl stahilizinc liearnents). It is ertrerleh itnportant to rlctermine the abiliv ot thc patient to betrr ri'cigl.rt, and the
degrcc: and onset of su'elling. Ai of tliese rrre importent
screcning questions and olrscrvations in riettrrnining the
neerl for r:rdiogr:rphic scrccning tbr fracture. (icncrallt',
the inabilitv to bear rveight associatcd u,ith sienif-icant
srvclline correlates u'itir t-he tlesree of ilarnage.
(Jverusc ir-rjuries are oftetr subtle. It is itnltortirnt ttr
(r
modifiers.
ties -iuc
388
Muxuloskeletl [omplaints
betic or
h,ts
over-the-coultter
W'eakness \\cakess
dia
rs
a shoe,
Examination
Foot Prior to e xamining thc feet, it is oten helpful to examine the parientls footwear. Tf the parient is rrr
arhlete, it is inrportant for him or her to bling in trlinLng
The
I-ooking at wear paerns on rhe shr,e ma)/ lle helpful. (ieneralll', he normal wear parterfl iE at rhe all of e
ibot and at the lateral heei. Excessive lateral wear at rhe
heel coupled wirh a caved-itr appearar.rce oite inside of
rhe sl'roe wor-rld suggesr pes planus, die olposite lor pes
carrrs. The inside of e shoe should be exmined to determine whether arry irre.gularities may act as frictior.t
source.s ro the slon or underlylng tendons- Check the
shoe for flexibility and shock absorption characteri-sucs.
1s *rere a finn heel counteri The fir oir,he shoe is also impont to gauge while the parient is standi-ng. Is r}e'e sufficie nt toe roorni Is rhe shoe supportive ol dre medial
Ionginrdinal arch? Does the lacing fit tr:o rightJy over the
rlus or extensor tendonsi
Nhch can be gained t}rrough observation of thc foot.
Look lor indicarlons of wear anri ter on rhe ibor. lf hese
are often cles to variotls foor delbrmities.
shoes.
r
r
CaLIus
lormadon
lgus.
third or
If the patrent is corlplaining of nr"rmbness and/or tingling of e foot, a searr:h firr neuraI irritrion tegins urttr
a rest oInerv'e root inte$"ity wi dccp te ndon ref]ex testing and senson' restir)!f. The toot is pnrnarily inerr,'ateil
by the L4-SZ ner:l'e roo. If irlract. a search ibr locai ner-r,'e
Ii
rrd I'ith
tnetatarsal Iieds ancl rassiverlv tlorsitlexcd unill resistence is felt' The foo is llen supinated
and pronared tultil point rs lourcl r'vhere sllghdy
rn{}re t1rover]ie nt il] e idier ,lirection r:auses dle
talus to "[]l
ofl'to
-l'hrs
At this point
[omPlaints
389
ular rubelosis posrtion is markerti Dn the caf(i. 'fhe patient thel bears his or her u,eighr onto tlle k-iot anii the
distnce berweer tire ciriginal rnar-k and the mark oi the
new navicular: tlrbercle position is lneasured. (lreater
rhair atrout 1/2 in. implies a h4rerpronaterl lbot.
Ratiiographic assessment oi rhe fb'rt is dicratci.j b.v
whetller the intention is r search tbr tracrilre rr rvhcthe r
a biornechanical appreciation of the firot is desired.
Fracture is usualil' evi denr on non-'eight-beari n g vi eri''
l-l're stndard series consisLs oi an rrnteroiro,stcrior (AP
[dorsiirlantarl) vien', an o'tlieue (laterai aspect of loot etevated 30') vieu,, anci a ltera1 vjerv. On the AP vier.v, the
fire ibot and part ol riie niidioot are 'o,eil visualizecl.'[-he
olrLrque vierv gives en excelli:nt alternate perspecrir,e ofrhe
rneta ta rsals" The a lonavi cuier and calcane,;cr boiil joints
valg-Lrs
390
[.4usruloskeletal [omplaints
supination.
-I he
Ankle
With
Tr e liniinate stabiii-tion
1-rom
the;\chiIIcs, testrngu'irh
Figure
14-4
-lhe
Navcula Drop Test for Prontion. (A) I he ptent's navicrrlr tubercle is marked r;irile the patient
not bea ring weight. (8) The position is then again marked wh en the patient bea rs weight onto the foot. lf t he differenre between marks is greater thn 5z! in., the patient is probably functionally a oronator.
is
ri.ffiL]; . :.
,,:
;::;;:
:'!i.W,,ji.
\.t
: ..-,.::;;t,;:!
@1r. ,:.11.1!lryg')
*d.-...Ltffi1
i."-.......... . 1/1,#.,'ffi i
: :\v ". /.,/" - //l!,//"#
:,::),: t l
-:l:"ie""*:
-.,/#
.:.,.#
rcrgry.ffiE
ffi#ffi
;-ffi.Y,S$ffi
ffi
14-5 (A)The Anterior DrwerTest.Witl'r the kree fiexed and the nkle flexed to 15", the exanriner stablizes
tibja
while pulling forward on the caicaneus.(B) lnversion Test for Lateral Ankle Stabiltty.
the
Figure
the lree in
9(i'of
t.lexii.)n
iiot
rreLrtral pr''
l)orsi
fl eri orlr'inr,e:si
rlterl
in g
o): r stretth
ll:o intrP(e
cl Lhe
ilrto
rLl
e t i L'i:r
/cr-ersto n
rn
Ii
).rill.
Plantarilerioll/evcsiorr -nainlv clue to ti''c peroireus lonqus atlcl llrevLs: srretcl-rrng irrto llanta i'f'lex
ion usu
il
to
l-l
e'iorl'
t1''e ii-r
rLla)'
al"o
IootanciAnxle[onlPlairts 391
of planrar fsciius.
l+
or pinning.
Ilesearchers in a recent stuclv used a modified version
CI
MANAGEMENI
Traumatic lnjury
l,{ost fl'acrLrres of the frrot and nkie should be re^
ierred for reductirr arcl rrsting. some e-rccpons
The
Heel
is between
tients u,ith a [risron of rheurnatoid conciitions, radiographs may prove helpful in detecting ciraracttrlstic
392
lvlusculcrskeletal (omplaints
TASLT
Il*3
(riteria
a::::
:::::::
:a
:a
::
a:::E#*w
Nrweliirg.niilii(iqpii.
1!ir)ion 5!ie)5.
lkie nver-
Goals
nearing
ilil
Pioqre:s
thrcuqh
thr rlie.ior
f/ lnderl'tinll pie,j:iroii 0fs,
?rotriocectiveiv:ibrirr
sup-
:r!ie
ier-i
pori(Atr-Spllint,tpirg,orbiale)
{01!i0trtp1n{"Niihagte:ilrerprlit
cllriiy.
tonrerns
Po::iblrfitureriflibie,lrbrl,ialu5,
1lidomerrtrenoleviderl0 I"r0erliyaieliir0i0rroii::Li,ii!,drrI'
rup- rd]oqrAD,h.
disirtitrcn
trie,0r:iorel {enlon
Reguirementsforprogressionto
Prli wri!lht
;rleinJl Strppuii
nextstagen(ludingapproxi- toninivrellinganpin,1-ld'ii.
swell ngevrdenl.[ull
Abiet0bln(e0,1celegnln0prlrr
RCllil-]c.]5
oneielwilhoul
p.ttn,
l,uteli:
Manipuiationlmobilization
rntury,0tner,li
[.rcer;i
tlr o tibil
(cptoute sstsl
nrav
adlrilmrn{
t;i;r
crrlr,
t,rioiil.
4,1;r:l nq
Modalities
1rt
3-5 rllcay
::i:l
[rr 2U
min!es
( hoirr rn
ice
eftrr erlivit';iombrnlro
ulii-
l{-e
dher
i]ili'Jii!
bei,r,,etn),rest,elevailon,Till5or souni/E[1Si]Utir'.r;,1-i!
[lv'15
(hrgh-vclt galvanrc
at
Externalbrace,supp6rt,et(.
ior
6I
mirutei
-)x'si aai)
Air-\giiIt0r()penrJibneytypecf,:ntrle Air-5plinlloi!ale
ir
r,',ialkrn.; wilf l0 Lru(hilq onlv
calsrve R0lvi
t,l0rn,q,
Roillflexibility
n,ini
fu1ild
u0bii{e,plieni
d,iyl
cf graduai'r.reight bearlrrr;
S/.i'5 iruaio be,un ',,!ith lhe plre0i
irguir oi-elqhielasili0n{lqe!Lr00crt
)iloril Jrivir
la pin,.
ior
es
teted;p05ti50rietrl(ielxailfip-
apci0arh.
prcath lo ttrelchrnq
pen-chain
exercise
neuirI.
isoreiril:
a{
enr.1-ianqflitlo
patiensrside-ly ng:trar,-tht
tai-res
le,;
tle0!
b(luaiLli!
0osed-rhainexecise l.lone.
5qLrt5.
pro prioceptive
.l,re
training
toui [ing w rh
r.u
tt h
ir:e
T[ltis
ap
Pi0q restirrrr i0
piliti0n'ldp,ingcrlrlpp0rtlls!e
:ropriccepiive:i
Associatedbiomechanical
witi
items
,nulll.
'"v]qhl-t
i nq P f ra ie!
onBAfr'-'i''vobhlelborri;lilw
a0unir,0llil0liallleStrlpli0n5h0LiiC
he
0e
rf,-rtnreC
iiOeened ne'-essary
uriih srade
PNfipronriOteptire nt,],5lr
atrlriallon
iniuriet
to
e]imi'
l1]c:tl,t:l|{1:11'"rrq
[ompiint-c
393
ci
is
de
p and
fiim to pro-
Preventive Management
be reviewed (see Fiqure l4'').'f'he crrrn:ron-h,uscr,-i rer-rrrirrclogy ard nlexlrns fnr shr:e consrnrcl-ion are es [ollo$,s:
'l-he shalk
r l'he
r 'i'he
shoe shoLrld l.,e long e nough to evoiri comoith.r roc.c f ihe enci ,f tl'e ,:c Lrox.
prcss.r()il
I l
'I-he moiti r-rpi:n i,"'hich ihe shoc is consmctd is rcferred to -( thc iasr. l'her:c lirc essuntialll, tr,.,o rypcs,
srrargh r iasr ancl clrn'etJ hrt."I'l-,c sraight last is better
design trr ihe pronrrecl tbot. The curl,ed hsr clesign is ior
14-6 Components of a Well r\4ade Shoe.rhe heel rounter should fit st-,curely (lt rnay be
necessary to balance Flaglund's Deformity wlth felt),and its bisectron should be verticl io the supFigure
Shank
A
5or, e: T Micf-,a ud, i oo O r.hot:" a n<t Ai'rter { or rns
,;schusefts
394
Musculoskeletal ComPlalnts
oi icn:e
weight bea rin g.'lhe non-we ial'rt-treari rr g clst p r()ponents clajm that rhe fbot is castetj rri rhe neurai "perfect" "losition and th:rr the wpe c:i othotic ald the
[eesurements used in the prescriprion a]iow lor more
inciivirlualiz.ed approaches through the use oiforefoot
anrj rearioot postrns. Alsi, if dre individual has ex.,*osis,
bunions, or o*ier alnoru.ialiries, the orthotic can ie nrorj
ified to acconrrnodate.
There are generally nvo types olposrilrg, rearfoot and
forefoot. A rear toot var-us irn:dirl) posr is used to control or linrit the calcneal eversiorr anri associatecl internal rotdon oii: ubir shordy after ireel strilie. (Jf course,
the oppositt principle ls usecl th"r'earfo,t valgus (iaterai)
posting; ir is used to evert the clcaneus 'nd there lore
bring'the subtala:: jou'lt closr:r to the oprirral neutral po sltlon. For-e[<)ot var-us rnal' be cottrpensateC for" hv a neciial post, rvhereirs forr:ibot valgus is best supiror"teci by a
iateral post"'I'his is particularly helrFLri rvhen rerfoot
cornpensaLion occlrrs to ccommodate for friefoor al,rrorrna l ities. l{eel l i fts are occasicn a ) l-v used ibr' plobl e ms
irrvolving the Achilles renclon. 1,'ire n the ,\chille". ten
clon is trght, it ma1, x1ggnt the efiect ol re alibot prolr
lems. The use of a heei iift (3 t<,r rrul) rnl'decrease the
tension ol the Achiiles and Jrereioi'e its el"f'ect on rerfoot
motion. A partial heel lih, referred to s a nerjialor latera) r.vedge, mr, also be used ternpollrilv s r iirst'rt tcr
iest the leasibilin, of posting or patients who are I'eluct3nt to llurchrse the more erpensive cstecl orthouc.
Figure l
lt-7
Algorithms
suride n cnse o foot 1t,rin,
nontraLrmiic or insiclious onset of tbot pain,;rnd irl:ual
airkle sprain evaluation are presentetl in Figtres 14-8 to
i+
10.
Types of Shoe Construction (A) Board-lasted shoe. iB) Slip-lasted shoe .(C) Combination iast shoe.
,,:''.-.
BC
A
5ourCe:'t. lichaud, Fcot OthoS:
ComPlaints 395