Chapter 4Clinical 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

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

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

History

Tarsal tunnel syndrome Symptoms

pain, numbness, or parasthesia along medial or plantar aspectof foot

may mimic plantarfasciitis

Onset Acute or chronic

History

Tarsal tunnel syndrome MOI

EV or PF/EV ankle injury (acute)

Forced PF (acute) Repetitive stress

associated with pesplanus foot

Previous history of tarsal fx

History

Tarsal tunnel syndrome Possible related factors

Training surface Distance Shoes

Inspection

Tarsal tunnel syndrome pes planus foot typically no swelling,

discoloration, or deformity

Palpation

Tarsal tunnel syndrome Point tenderness

proximal, over, and distal to the flexorretinaculum

ROM

Tarsal tunnel syndrome AROM

normal EV may reproduce

symptoms PROM

PF & EV may reproducesymptoms

RROM may demonstrate

weakness of toe flexors

Stress Tests/Special Tests

Tarsal Tunnel Syndrome n/a

Neurological Tests

Tarsal Tunnel Syndrome Tinel’s sign Decreased sensation

over nerve distribution

Management

Tarsal Tunnel Syndrome Ice NSAIDs Orthotics Surgical release (in

severe cases)

Location of Pain: Midfoot

Injuries to consider fx/dislocation sprain strain/inflammation of tendon

insertion sites tarsal coalition

Location of Pain: Midfoot

Injuries to consider fx/dislocation

Lisfranc injury navicular stress fx

Lisfranc injury

Location of Pain: Midfoot

Injuries to consider: sprain

midtarsal joints tarsometatarsal joints

Location of Pain: Midfoot

Injuries to consider: strain/inflammation of muscle/tendon at

insertion sites tibialis posterior tibialis anterior peroneal longus peroneal brevis

Location of Pain: Midfoot

Injuries to consider: Tarsal coalition

abnormal union between two or more tarsals bony fibrous Cartilaginous

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.

Location of Pain: Midfoot

Injuries to consider: Tarsal coalition

will present clinically as a rigid pes planus limitations in subtalar joint

History

Location of pain

(midfoot)Symptoms Onset MOI

Fx/dislocationAcute; trauma

Dropping something on the foot; stepping in hole or on uneven ground - twisting the foot

Lisfranc fx**Acute; trauma

Dropping something on the foot; stepping in hole or on uneven ground - twisting the foot**

SprainAcute; trauma

Twisting the foot

Strain/inflammation of tendon insertion site(s)

Acute or chronic

Forceful contraction; repetitive stress

Tarsal coalition congenital n/a

**often mistaken for midfoot sprain

Inspection/Observation

Location of pain

(midfoot)

Signs

Deformity? Swelling? Discoloration?

Fx/dislocationPossible Possible Possible

Lisfranc fx Possible Common Possible

Sprain No Common Possible

Strain/inflammation of tendon insertion site(s) No Minimal if at all Typically not

Tarsal coalition

Rigid pes planus; ABD of forefoot,

medial displacement of talus; navicular

drop

No No

Palpation

Location of pain

(midfoot)

Point tenderness? Deformity? Swelling? Crepitus?

Fx/dislocationDirectly over

1 or more tarsals

Possible Possible Possible

SprainOver

involved joint

No Possible Possible

Strain/inflammation of tendon insertion site(s)

Over tendon or insertion

site

Usually notPossible, would be minimal

Possible

Tarsal coalitionOver

involved joint

Typically notTypically

notNo

Physical Exam

Location of pain

(midfoot)ROM? Stress Tests?

Special Tests?

Neurological?

Fx/dislocation n/a n/a n/a n/a

Sprain n/a

Intermetatarsal glide test

Midtarsal joint glides

Tarsometatarsal joint glides

n/an/a

Strain/inflammation of tendon insertion site(s) n/a n/a

Pain w/passive stretching of muscle/tendon;

Pain w/resisted action of muscle tendon

n/a

Tarsal coalitionMay have

limitation in IN/EV

n/a n/a n/a

Management

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

Management

Lisfranc fx/dislocation Cast NWB Rigid orthotic Surgery when necessary to

stabilize

Management

Midfoot sprain Ice NSAIDs Spring steel innersole or rigid

orthotic Strengthening of intrinsic foot

muscles

Management

Inflammation at tendon insertion sites Ice NSAIDs Stretching Strengthening of involved muscle

with emphasis on eccentrics

Management

Tarsal coalition referral to orthopedist

Location of Pain: Forefoot

Injuries to consider Fx

midshaft avulsion Jones’ fx

Intermetatarsal (Morton’s)neuroma

metatarsalgia

History

Location of pain

(forefoot) Symptoms Onset MOI

Midshaft fxPain directly over

metatarsal

Acute or chronic

(stress fx)

Acute: Getting stepped on or having something dropped onto MT; stepping in hole or onto uneven surface;

Chronic: repetitive stress, weakness of toe flexors

Avulsion fx

Most common site: styloid process of 5th MT

Pain over fracture site; may have heard/felt pop

AcuteBase of 5th MT: forceful contraction of peroneal

brevis

Jones’ fxPain over distal styloid of

5th metatarsalAcute

Force inversion with ankle in PF; landing on lateral

aspect of foot

Morton’s neuroma Pain, burning

Metatarsalgia Pain under head(s) of

metatarsals; may feel like “stepping on pebble”

Acute/chronic

Inspection/Observation

Location of pain

(forefoot)

Signs

Deformity? Swelling? Discoloration?

Midshaft fx Avulsion fx Jones’ fx

Morton’s neuroma -- Possible --

Metatarsalgia -- Possible --

Palpation

Location of pain

(forefoot)

Point tenderness? Deformity? Swelling? Crepitus?

Midshaft fx Avulsion fx Jones’ fx

Morton’s neuromaOver

neuroman/a n/a n/a

Metatarsalgia Over head of involved MT

Involved head may feel lower

than others

Minimal if present

n/a

Physical Exam

Location of pain

(forefoot)ROM?

Stress Tests?

Special Tests?Neurological

?

Midshaft fxToe flex/ext may increase pain

--Tap test; Morton’s

test --

Avulsion fx

May have limitation if motion stresses fx site

-- -- --

Jones’ fxMay be limited in EV -- Morton’s test --

Morton’s neuromaToe ext. may increase symptoms

-- Morton’s test --

MetatarsalgiaToe ext. may increase symptoms

-- -- --

Management

Midshaft fx/dislocation Ice NSAIDs Boot/cast Spring steel innersole Surgery with comminuted or

displaced fx

Management

avulsion fx Boot/cast Surgery when necessary to

stabilize

Management

Jones’ fx Boot/cast – NWB

Known for nonunions Surgery when necessary to

stabilize

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

Inspection/Palpation

Forefoot injuries between metatarsals

neuroma intrinsic muscles

Signs•swelling?

Palpation•Point tenderness•Compression of neuroma reproduces pain

Stress/Special Tests

Forefoot injuries between metatarsals

neuroma intrinsic muscles

Tests•Morton’s Test•Abd/add of toes

Management

Forefoot injuries between metatarsals

neuroma intrinsic muscles

Treatment•Ice•Anti-inflammatories•Orthotics

Questions?