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Chapter 4

Chapter 4. Clinical Assessment of Foot & Toe Injuries Part II. Student Learning Outcomes. Identify common midfoot & forefoot injuries based on their presenting history, symptoms, visual signs (inspection), & palpation findings

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Chapter 4

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  1. Chapter 4 Clinical Assessment of Foot & Toe Injuries Part II

  2. Student Learning Outcomes • Identify common midfoot & forefoot injuries based on their presenting history, symptoms, visual signs (inspection), & palpation findings • Identify special tests that might be used to evaluate these injuries • Discuss basic management strategies for dealing with these injuries • Discuss anatomical or biomechanical predisposing factors associated with these common midfoot & forefoot injuries

  3. Location of Pain: Medial Calcaneus/Medial Arch • Injuries to consider (continued from Ch. 4 Part 1) • tarsal tunnel syndrome • impingement & inflammation of the posterior tibial nerve within the tarsal tunnel

  4. History • Tarsal tunnel syndrome • Symptoms • pain, numbness, or parasthesia along medial or plantar aspectof foot • may mimic plantarfasciitis • Onset • Acute or chronic

  5. History • Tarsal tunnel syndrome • MOI • EV or PF/EV ankle injury (acute) • Forced PF (acute) • Repetitive stressassociated with pesplanus foot • Previous history of tarsal fx

  6. History • Tarsal tunnel syndrome • Possible related factors • Training surface • Distance • Shoes

  7. Inspection • Tarsal tunnel syndrome • pes planus foot • typically no swelling,discoloration, or deformity

  8. Palpation • Tarsal tunnel syndrome • Point tendernessproximal, over, and distal to the flexorretinaculum

  9. ROM • Tarsal tunnel syndrome • AROM • normal • EV may reproduce symptoms • PROM • PF & EV may reproducesymptoms • RROM • may demonstrateweakness of toe flexors

  10. Stress Tests/Special Tests • Tarsal Tunnel Syndrome • n/a

  11. Neurological Tests • Tarsal Tunnel Syndrome • Tinel’s sign • Decreased sensationover nerve distribution

  12. Management • Tarsal Tunnel Syndrome • Ice • NSAIDs • Orthotics • Surgical release (insevere cases)

  13. Location of Pain: Midfoot • Injuries to consider • fx/dislocation • sprain • strain/inflammation of tendon insertion sites • tarsal coalition

  14. Location of Pain: Midfoot • Injuries to consider • fx/dislocation • Lisfranc injury • navicular stress fx Lisfranc injury

  15. Location of Pain: Midfoot • Injuries to consider: • sprain • midtarsal joints • tarsometatarsal joints

  16. Location of Pain: Midfoot • Injuries to consider: • strain/inflammation of muscle/tendon at insertion sites • tibialis posterior • tibialis anterior • peroneal longus • peroneal brevis

  17. Location of Pain: Midfoot • Injuries to consider: • Tarsal coalition • abnormal union between two or more tarsals • bony • fibrous • Cartilaginous

  18. Location of Pain: Midfoot • Injuries to consider: • Tarsal coalition • typically presents between 3 – 16 yrs of age • 3 – 5 yrs: talonavicular coalition jt. • 8 – 12 yrs: calcaneonavicular jt. • 12 – 16 yrs: talocalcaneal jt.

  19. Location of Pain: Midfoot • Injuries to consider: • Tarsal coalition • will present clinically as a rigid pes planus • limitations in subtalar joint

  20. History **often mistaken for midfoot sprain

  21. Inspection/Observation

  22. Palpation

  23. Physical Exam

  24. Management • Midfoot fx/dislocations • Ice • Walking boot or NWB • Spring steel innersole • Surgery (when severely displaced)

  25. Management • Lisfranc fx/dislocation • Cast • NWB • Rigid orthotic • Surgery when necessary to stabilize

  26. Management • Midfoot sprain • Ice • NSAIDs • Spring steel innersole or rigid orthotic • Strengthening of intrinsic foot muscles

  27. Management • Inflammation at tendon insertion sites • Ice • NSAIDs • Stretching • Strengthening of involved musclewith emphasis on eccentrics

  28. Management • Tarsal coalition • referral to orthopedist

  29. Location of Pain: Forefoot • Injuries to consider • Fx • midshaft • avulsion • Jones’ fx • Intermetatarsal (Morton’s)neuroma • metatarsalgia

  30. History

  31. Inspection/Observation

  32. Palpation

  33. Physical Exam

  34. Management • Midshaft fx/dislocation • Ice • NSAIDs • Boot/cast • Spring steel innersole • Surgery with comminuted or displaced fx

  35. Management • avulsion fx • Boot/cast • Surgery when necessary to stabilize

  36. Management • Jones’ fx • Boot/cast – NWB • Known for nonunions • Surgery when necessary to stabilize

  37. History • Location of pain • Forefoot • between metatarsals • neuroma • intrinsic muscles • Symptoms • Burning pain • Electric shock • Dull ache • MOI • Gradual onset • Improper shoes • Forceful contraction • Stretching beyond normal limits of ROM

  38. Inspection/Palpation • Forefoot injuries • between metatarsals • neuroma • intrinsic muscles • Signs • swelling? • Palpation • Point tenderness • Compression of neuroma reproduces pain

  39. Stress/Special Tests • Forefoot injuries • between metatarsals • neuroma • intrinsic muscles • Tests • Morton’s Test • Abd/add of toes

  40. Management • Forefoot injuries • between metatarsals • neuroma • intrinsic muscles • Treatment • Ice • Anti-inflammatories • Orthotics

  41. Questions?

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