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Terms in this set (68)

* acute injuries must be differentiated from injuries with a relatively slow onset

• History
- quick assessment to determine type of injury and its history
-questions pg.496

• Observation
- observe the patient to determine the following:
- pg. 496

- looking for structural deformities
~ estbalish a position of subtalar neutral
~ prone with a distal third of the leg hanging off the end of the table
~ draw a line in the middle
~ palpate

- shoe wear patterns
~ pronation: front of the running shoe under the 2nd metatarsal
~ supination: lateral boarder of the shoe

* key to inspection is observation of the heel counter and the forefoot

• palpation
used to determine pain sites, swelling, deformities and evaluation of circulation
- pg. 497 bondy landmarks that should be palpated

- pulse
~ to ensure that there is proper blood circulation to the foot, the pulse is measured at the posterior tibial and dorsalis pedis arteries

• special test
- movement assessment: intrinsic and extrinsic foot muscles should be assesed for pain and ROM during active, passive and resistive isometric movement
- morton's test: supine position, transverse pressure is applied to the heads of the metatarsals, causing sharp pain in the forefoot (pain may indicate presence of metatarsalgia or neuroma)
- neurological assessment: reflexes and cutaneous distribution should be tested ( the Achilles tendon should elicit a response)
- tinel's sign test: tapping over the posterior tibial nerve will produce a tingling distal to that area (numbness, tingling, and parasethesia may indicate the presence of tarsal tunnel syndrome)
1) fractures of the talus
• etiology: fracture of the dome of the talaus
• symptoms and signs: history of repeated trauma to the ankle, pain from weight-bearing, complains about catching, snapping and swelling
• management: x-ray is essential; nondisplaced=nonsurgical management; protective immobilization with non-weight-bearing, progressing to full weight bearing, strengthening and full ROM in ankle, maybe surgery to remove loose bodies

2) fracture of the calcaneus
• etiology: occurs due to landing after a jump or fall from a height
• symptoms and signs: immediate swelling and pain, inability to bear weight
• management: RICE immediately before referring athlete to get an x-ray

3) calcaneal stress fracture (among the most common in the lower extremity)
• etiology: occurs with repetitive impact during heel striek and is more prevalent among distance runners
• symptoms and signs: weight bearing on heel during running has increased pain (but pain stops after exercise), may fail to appear during x-ray so a bone scan maybe better diagnostic tool
• management: rest, active ROM exercise of foot and ankle; non-weight-bearing cardiovascular exercise (pool running)

4) Apophysitis of the calcaneus (server's disease)
• etiology: occurs in young physically active patients, traction injury at the apophysis of the calcaneus where the achilles tendon attaches
• symptoms and signs: pain occurs at the posterior heel and occurs during vigorous activity and does not continue at rest (pain)
• management: rest, ice, stretching and antiinflammatory meds

5) Retrocalcaneal Bursitis (exostosis - Haglund's deformity)
• etiology: inflammation of the bursa from the pressure and rubbing of the heel counter of a shoe(chronic and develops gradually)
• symptoms and signs: pain from palpating the bursa, some swelling on both sides of the heel cord
• management: RICE plus NSAIDs, ultrasound can reduce the inflammation, stretching of achilles tendon (possibly larger shoes with a wider heel cushion)

6) heel contusion
• etiology: stop and go response or a change from horizontal to vertical movement; main function of the tissue heel pad is to sustain hydraulic pressure through fat columns (usually lateral side)
• symptoms and signs: serve pain in the heel unable to withstand stress of weight bearing; warmth and redness over the tender area
• management: should not bear weight on the heel for at least 24-hours, RICE and NSAIDs, when pain subsides moderate activity with a heel cup or protective doughnut (should wear shock absorbant footwear)

7) Cuboid subluxation
• etiology: pronation and trauma prominent causes (complains about midfoot sprain)
• symptoms and signs: pain along the 4th and 5th metatarsals as well as over the cuboid; pain increases after standing non-weight-bearing for a while
• management: restore the cuboid to is natural position, use an orthotic to help support it in its proper position

8) tarsal tunnel syndrome
• etiology: tenosynovitis, previous fractues, excessive pronation, or any acute trauma can cause this
• symptoms and signs: pain and paresthesia along medial and plantar aspects of the foot, increased pain at night, tinel's sign tested positive, motor weakness and atrophy
• management: antiinflammatory med and other antiinflammatory modalities; appropraite orthotic to correct excessive pronation, surgery if it becomes a recurrent symptoms

9) tarsometatarsal fracture/dislocation
• etiology: uncommon injury that can cause long-term disability
• symptoms and signs: relatively subtle; pain and inability to bear weight, swelling and tenderness over the dorsum of the foot,
• management: fist recognize the injury, restoring alignment, maintaing stability
1) Pes Planus Foot (Flatfoot)
• Etiology: associated with excessive foot pronation; may be caused by structural forefoot varus deformity, shoes that are too tight, trauma, overweight, excessive exercise from server pounding of foot
• Symptoms and Signs: pain, weakness/fatigue of the medial longitudinal arch, possible calcaneal eversion, bulging navicular bone, flattening of the medial longitudinal arch
• Management: if pain then a constructed orthotic design to correct excessive pronation, adding an arch support taping for arch support (if no pain do not try to correct the flatness of the medial arch)

2) Pes Cavus Foot (High Arch Foot)
• Etiology: associated with excess supination
• Symptoms and Signs: shock absorption is poor, pain and hammer toes are seen, forefoot valgus deformity, abnormal shortening of the Achilles tendon, due to abnormal distribution of body weight heavy calluses develop on the ball and heel of the foot
• Management: if no pain do not try to correct, if pain then orthotic lateral wedge to help with forefoot valgus deformity, stretching achilles tendon and plantar fascia

3) Second Metatarsal Stress Fracture
• Etiology: 2nd metatarsal is longer than the 1st metatarsal, more weight is often bearing on the 1st metatarsal but with the 2nd one being longer it has more weight-bearing
• Symptoms and Signs: pain during and after activity, and an area of tenderness, callus likely to form under the second metatarsal
• Management: no pain do not do anything, if pain then an orthotic medial wedge

4) Longitudinal Arch Strain
• Etiology: increased stress produced by repetitive contact with hard surfaces
• Symptoms and Signs: pain during running or jumping, swelling and tenderness, possible sprain of calcaneonavicular ligament or strain of the flexor hallucis longus tendon
• Management: RICE immediately therapy and reduction of weight bearing, arch taping tech No. 1 or 2 might help with pain-free weight bearing

5) Plantar Fasciitis
• Etiology: (heel pain) heel spurs, plantar fascia irritation, bursitis; tension develops in the plantar fascia and is increased when on the ball of the foot, trauma could occur from poor running technique, possible causes leg length discrepancy, excessive pronation of subtarar joint, inflexibility of the longitudinal arch, and tightness of gastrocnemius-soleus unit
• Symptoms and Signs: pain in anterior medial heel, pain increases after waking in the morning or adding weight-bearing after sitting for a while
• Management: orthotic therapy (soft instead of hard) orthotic with deep-heel cup, arch/alternative tapping, achilles tendon stretching and exercises of the plantar fascia in the arch

6) Jones fracture
• Etiology: caused by inversion and plantar flexion of the foot by direct force or repetitive stress (most common fracture is the diaphysis at the base of the 5th metatarsal)
• Symptoms and Signs: swelling and pain (over 5th metatarsal), healing is a slow and frustrating process
• Management: crutches with no immobilization, to gradually adding weight-bearing as pain lessens, electric or ultrasonic bone-growth stimulator will promote healing

7) Metatarsal Stress Fractures
• Etiology: most common metatarsal stress fracture (involves the shaft of the 2nd metatarsal often referred to as a march fracture ( occurs in runners who have suddenly changed patterns of training)
• Symptoms and Signs: 2-3 dull pain begins during exercise and then progresses to pain during rest
• Management: bone scan is the best way to detect a stress fracture, orthotic that corrects excessive pronation, 3-4 activity then 2 weeks rest

8) Bunions (Hallux Valgus Deformities) and Bunionettes (Tailor's Bunions)
• Etiology: most common and painful deformities, occurs at the head of the first metatarsal, first ray tends to splay outward putting pressure on the first metatarsal head, often caused by shoes that are pointed, to narrow, or to short
• Symptoms and Signs: tenderness, swelling, enlargement of the join, inflammation
• Management: wear correctly fitting shoes, wear appropriate orthotic, place a felt/sponge rubber doughnut pad over 1st/5th metatarsal, wear a tape splint, engage in daily foot exercises (ultimately may need surgical procedure)

9) seasmoiditis
• Etiology: caused by repetitive hypersextension of the great toe resulting in inflammation (most common in dancing and basketball)
• Symptoms and Signs: pain under the great toe, especially during push-off, palable tenderness under the 1st metatarsal head
• Management: variety of orthotic devices (metatarsal pads, arch supports and metatarsal bar) decrease activity to allow inflammation to subside

10) metatarsalgia
• Etiology: pain under the 2nd and sometimes the 3rd metatarsal head, a heavy callus often forms in the pain area; causes are fallen metatarsal arch or restricted extensibility of the gastrocnemius-soleus complex
• Symptoms and Signs: pain, a cavus deformity can also cause metatarsalgia
• Management: applying a pad to elevate the depressed metatarsal heads, perform static stretching, A Thomas heel could be helpful

11) metatarsal Arch strain
• Etiology: due to fallen metatarsal arch or pes cavus (1st '2/6 of the body weight' & 5th ' 1/6 of the body weight' metatarsals bear more weight)
• Symptoms and Signs: pain or cramping in the metatarsal region, point tenderness and weakness (Morton's test may produce pain in the metatarsals)
• Management: applying a pad to elevate the depressed metatarsal heads (placed - center and just behind the ball of the foot)

12) Morton's Neuroma
• Etiology: located between the 3rd and 4th metatarsal heads
• Symptoms and Signs: burning and server intermittent pain in the forefoot, pain is often relieved with non-weight-bearing activity
• Management: teardrop pad placed between the heads of the 3rd and 4th metatarsal (help reduce pain), select a shoe that is wide in the toe-box, rare occasions surgical excision may be required.
1) sprained toes
• Etiology: caused by kicking some nonyielding objects, force that causes the joint to extend beyond its normal ROM (jamming it)
• Symptoms and Signs: pain is immediate & intense but short lived1-2 days swelling and discolloration; stiffness and pain may last several weeks
• Management: RICE immediately; casting or splinting to hard for small toes so "buddy tape"

2) great toe hyperextension (Turf Toe)
• Etiology: results in a sprain of the metatarsophalangeal joint (single trauma or repetitive overuse) usually due to turf and more flexible shoes designed for turf
• Symptoms and Signs: pain and swelling, hurts worse when pushing off the foot or when running/jumping
• Management: adding an orthoplast to be placed under the shoe insole, taping the toe, modalities include ice and ultrasound, rest!

3) fractures and dislocations of the phalanges
• Etiology: occurs by kicking an object, stubbing a toes or being stepped on. Dislocations are LESS common than fractures.
• Symptoms and Signs: immediate and intense pain and increased when toes are moved; with dislocation deformity will be obvious; swelling of the joint and discoloration of the area
• Management: "buddy tapping" unless its the big toes, dislocations should be reduced by a physician

4) hallux Rigidus
• Etiology: painful condition caused by bony spurs on the dorsal aspect of the foot
• Symptoms and Signs: great toe is unable to dorsiflex, forced dorsiflexion causes pain walking is hard due to weight bearing on lateral side of the foot
• Management: stiffer shoe with larger to shoe box; an orthosis; anti-inflammatory med; or osteotomy

5) hammertoe, mallet toe, and claw toe
• Etiology: smaller toe deformities are either fixed or flexible; hammertoe=flexible deformity that becomes fixed; usually caused by wearing shoes that are to small for a long period of time
• Symptoms and Signs: 3 conditions (MP, PIP, and DIP) joints become fixed; blistering, swelling, pain, callus formation, and infection
• Management: footwear that allows toes more room; padding and protective taping; shaving the calluses should help with irritation; once the deformities become fixed then surgical procedure needs to be done.

6)overlapping toes
• Etiology: congenital or due to improperly fitting footwear (too narrow)
• Symptoms and Signs: outward projection of the great toe articulation or a drop in the longitudinal or metatarsal arch
• Management: surgery is the only cure; some therapeutic modalities (whirlpool bath) can assist in inflammation; taping may help tension within the sport shoe

7) blood under the toenail (subungual hematoma)
• Etiology: due to being stepped on, dropping an object, kicking another object; repetitive shearing forces on toenails (long-distnace runner)
• Symptoms and Signs: extreme pain and loss of nail; immediate or slow bleeding can occur; blueish-purple color
• Management: ice and elevation; within 12-24 hours drill a small whole into the toe nail to relieve pressure
1) general body conditions - must find a way to continue conditioning without using weight-bearing exercise (running in pool/upper-extremity ergometer)

2) weight bearing - can use weight-bearing crutch if can't walk without limp; using incorrect gait mechanics will affect other joints

3) joint mobilization - useful in maintaining or normalizing joint motions
• Anterior/posterior calcaneocuboid glides
- increases adduction and abduction
• Anterior/posterior cuboidmetatarsal glides
- increases mobility of the 5th metatarsal
• Anterior/posterior tarsometatarsal glides
- decrease hypomobility of the metatarsals
• Anterior/posterior talonavicular glides
- increase adduction and abduction
• Anterior/posterior metatarsophalangeal
- anterior glide increase extension
- posterior glide increase flexion

4) flexibility - restoring full ROM to the phalanges is important after an injury; stretching is important after an injury dealing with the plantar fascists as well as the gastrocnemiusoleus

5) muscular strength - can be done useing a variety of resistance methods (rubber tubing, towel exercises, and manual resistance)
• write the alphabet with pointed toes (3x)
• picks up small objects with the toes and placed them into a container
• ankle circumduction in as extreme a range of possible (10 circles in each direction)
• gripping and spreading the toes (10x)
• towel gathering (weight can be added) 10x
• towel scoop (10x) pg.514 figure 18-42B

6) Neuromuscular control - walking, running, and hopping exercises involving directional changes performed on varying surfaces. Balance board or wobble exercises can be useful to establish a dynamic base of support
• the exercise sandals are excellent for increasing muscle activation in the foot and lower leg

7) foot orthotics and taping - 3 types of orthotics
• pads and flexible felt supports (soft orthotics)
- used for mild overuse syndromes
• semirigid orthotics (thermoplastic, rubber, or leather)
- used for increases symptoms (good for sports with speed or jumping)
• functional, or rigid, orthotics (hard plastic)
- allow control for most overuse symptoms
1) orthotics for correcting excessive pronation and supination
• to correct forefoot varus (excessively pronate)
- rigid type orthotics and a medial wedge under the head of the 1st metatarsal (can also add a small wedge under the medial calcaneus to make the orthotic more comfortable)
• to correct forefoot valgus (excessively supinates)
- semirigid orthotics and have a lateral wedge under the 5th metatarsal (adding a small wedge under the lateral calcaneus will make it more comfortable)
• rearfoot varus deformity pg. 517

8) Functional progressions - used following injury to the foot in order to gradually regain the ability to walk, jog, run, change directions, and hop