Monograph 27

Ankle, Foot, and Toe Trauma

By R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1997

Copied by Chiro.Org with permission from   ACAPress

Background Ankle Instability Quick Screening of Ankle Function Gait Clues Draw Sign Talar Slide Test Lateral-Medial (Eversion-Inversion) Stability   Tests Postural Distortions of the Ankle and Foot Effects of Chronic Ankle Pronation Roentgenography: Severe Ankle and Foot Injuries Heel Fractures Talus and Cuboid Fractures Classification of Ankle Fractures Fatigue Fractures of the Foot Stress Cysts of the Foot Arthrokinematics Joint Actions of the Ankle and Foot Kinesiology of the Ankle and Foot Dorsiflexion Plantar Flexion Clinical Management Electives for Ankle or Foot Strain/Sprain Commentary Ankle Trauma Contusions Peroneoextensor Spasm Disorders of the Deep Peroneal Nerve Achilles Tendon Injuries Ankle Strains Special Concerns with Runners Trigger Point Syndromes of the Ankle Area Ankle Sprains Subtalar Arthritis

Kohler's Disease Talar Osteochondritis Dissecans Tarsal Tunnel Syndrome Posttraumatic Spurs and Related Disorders Bowler's Spurs Football/Soccer Ankle Postural Distortions In-Toeing Out-Toeing Miscellaneous Circulatory Disturbances Circulatory Insufficiency Screening Tests Edema Volkmann's Ischemic Contracture of the Foot Erythromelalgia Black Heel Tennis Toe Articular Therapy Clinical Features Management Foot Trauma Heel Injuries Bursitis Foot Bruises and Wounds Plantar Strains Foot Sprains Toe Sprains Exostoses Heel Spur Metatarsalgia Plantar Neuroma Selected Disorders of Toes Flat Foot (Pes Planus) Ankle Fixations Ankle Subluxations Foot Fixations Foot Subluxations Toe Fixations and Subluxations References and Bibliography

---

The lower leg, ankle, and foot work as a functional unit. Total body weight above is transmitted to the leg, ankle hinge, and foot in the upright position, and this force is greatly multiplied during locomotion. Thus, the ankle and foot are uniquely affected by trauma and static deformities infrequently seen in other areas of the body.


BACKGROUND

Ankle and foot injuries are common in sports, much less so in the workplace except from those caused by a fall or a dropped object. Excepting a few sports such as rowing, kite flying, and auto racing, the base of an athlete's activity is provided by the soft tissues and osseous complex of the ankle and foot. Ankle injuries in sports are close in incidence to that of knee injuries. One study shows 50% of ankle injuries during all athletics at one major college occurred in basketball. Soccer also presents a high incidence.

The most common ankle injuries are bruises, muscle strains, tendon lesions, postural stress, compression syndromes, and lower tibia and fibula fractures. Bruises of the lower leg are less frequent than those of the thigh or knee, but the incidence of intrinsic strain, sprain, and stress fractures is much greater.

Ankle Instability

Jogging by the average citizen often strengthens the antigravity muscles at the expense of the gravity muscles --producing a dynamic imbalance unless both gravity and antigravity muscles are developed simultaneously. An anatomical or physiologic short leg as little as 1/8 inch can affect a stride and produce an overstrain in long-distance running activities. Ankle instability typically results when inversion or eversion overstress stretches or ruptures supporting ligaments.

Quick Screening of Ankle Function

Bilateral screening tests for active ranges of motion can be made by toe walking to test plantar flexion and toe motion, heel walking to test dorsiflexion, lateral-sole walking to test inversion, and walking on the medial borders of the feet to test eversion.

To test passive subtalar inversion and eversion, stabilize the distal end of the tibia with one hand and firmly grip the heel with the active hand. Alternately invert and evert the heel. Pain during this maneuver suggests subtalar arthritis that is possibly a posttraumatic effect of an old fracture.

Gait Clues

Note heel strike, foot flat, midstance, and toe push-off of each extremity. When the foot slaps sharply after heel strike, weak dorsiflexors are suspect. On the other hand, fused ankles will prevent a midstance flat foot. Failure to hyperextend the foot during push-off is a sign of arthrosis. A flat-footed calcaneal gait during push-off is symptomatic of weak gastrocnemius, soleus, and flexor hallucis longus muscles.

Pain in a foot during midstance may be caused by corns, calluses from a fallen transverse arch, rigid pes planus, or subtalar arthritis. Pushing off with the lateral side of the front of the foot is usually seen in disorders involving the great toe. Sharp pain on push-off is often caused by corns between the toes or by metatarsal callosities. Inability of a foot to heel strike suggests a heel spur and associated bursitis.

During the swing phase, observe acceleration, midswing, and deceleration of each extremity. If the hip is flexed excessively to bend the knee and thus prevent the toe from scrapping the floor as in a steppage gait, weak ankle dorsiflexors are the usual cause. The foot will have trouble clearing the floor if the ankle dorsiflexors are weak or the knee is unable to flex properly.

Draw Sign

Tears of the anterior talofibular ligament produce joint instability, allowing the talus to slide forward (subluxate) on the tibia. To test for instability and subluxation of the tibia-talus articulation, place one hand on the anterior aspect of the sitting patient's lower tibia and grip the heel with your other palm. When the calcaneus and talus are pulled anteriorly and the tibia is simultaneously pushed posteriorly, the anterior talofibular ligament should not allow forward movement of the talus on the tibia. The test is positive if the talus slides anteriorly from under the cover of the ankle mortise. Sometimes the abnormal bone slide can be heard as well as felt during the manipulation.

Talar Slide Test

Excessive lateral or medial motion with pain indicates ligament instability and diastasis of the distal tibiofibular articulation. The talar slide test evaluates horizontal ankle translation joint play. With the patient in either the prone or the supine position, stand to the side and face the ankle to be tested. Your cephalad hand grasps the patient's lower leg just above the malleoli and your caudad hand grasps the heel just below the malleoli. A pull is made with your upper hand on the lower leg while your lower hand pushes the patient's heel horizontally. Then a push is made with your upper hand while your lower hand pulls the patient's heel horizontally. Pain induced by these testing maneuvers suggests subtalar arthritis (eg, related to an old fracture).

Lateral-Medial (Eversion-Inversion) Stability Tests

Gross lateral instability results when both the anterior talofibular and calcaneofibular ligaments are torn. To test lateral stability, stabilize the patient's leg and invert the heel back and forth, noting if the talus rocks loosely in the ankle mortise. Medial instability is the result of a tear or stretch of the deltoid ligament. To test medial stability, stabilize the patient's leg and evert the heel back and forth, noting any gap at the ankle mortise.


Postural Distortions of the Ankle and Foot

Postural foot alterations can produce and maintain far-reaching effects both in spinal and pelvic distortions as well as distant somatic or visceral disturbances. When these changes are overlooked, symptoms referred to other parts of the body continue because their cause, being in the feet, has failed to be properly diagnosed and removed.

The foot does not necessarily have to be painful to be the cause of postural imbalance and resulting nerve and muscular tensions in other parts of the body. It is well to keep in mind that a painful foot results in a protective posture and gait in which the entire neuromusculoskeletal system participates.

A progressive distortion may begin in the foot and move upward or be reflected into the foot from above. Weight-bearing distortions in time may produce such symptoms as generalized fatigue, dull leg and knee aches, and back pain at any vertebral level but usually at a hypermobile joint near an area of fixation. To perceive the relationship between foot and pelvic mechanics, palpate the greater trochanters while rolling the feet medially and laterally. Femur rotation can be felt with minimal foot rotation.

Effects of Chronic Ankle Pronation

In-roll of the talocalcaneal articulation is a common disorder. When this is noted, remember that a weak foot is usually hypermobile. An associated chronic or recurring shin-splint syndrome often arises in the flexor group that may be isolated within the posterior tibial muscle. The most common cause of excessive pronation is foot weakness and fatigue. The focal source may be remote in the kinematic chain.

Local and Remote Effects. Abnormal ankle pronation features the superior aspect of the calcaneus tilting and rolling toward the midline, carrying the talus with it. This releases the navicular from its articulation with the talus and allows it to roll toward the midline. As the navicular is the keystone of the medial longitudinal arch, its downward subluxation results in collapse of the arch and the beginning of a progressive distortion that may extend as far as the occiput. Symptoms may occur only at the hindfoot, but a flattened arch is usually associated.

Achilles Distortion. When viewed from the rear, observe the exposed Achilles tendon. Note its deviation with the inward tilting of the calcaneus. An associated tendon inflammation may be related to abduction strain, characterized by motion restriction, pain, tenderness behind the medial malleolus, and infrequently crepitus.

Ankle-Lumbopelvic Biomechanical Linkage. When the arch rolls inwardly (pronates), the tibia twists, the knee strains, the femur rotates, the pelvis tilts forward, and the curves of the spine are affected.

-- As the inward tilting of the foot includes the talus, which supports the tibia, unusual and downward tilting of the articulating surface of the talus produces an inward rotation of the tibia that extends onto the femur. This brings the greater trochanter forward and outward, chronically stretching the piriformis muscle.

-- The piriformis inserts into the apex of the trochanter and is placed on a windlass-type stretch. As this muscle's origin is at the anterolateral aspect of the sacrum, the sacrum may be pulled into a classic subluxated anteroinferior position. In compensation, the gluteus maximus muscle contracts to resist the downward and forward pelvic tilt. Because the gluteus maximus has its origin on the outer lip of the posterior third of the iliac crest, the ilium rotates posteriorly, producing a typical pelvic distortion.

-- With the sacrum thus drawn into an anteroinferior position, the vertebral body of L5 gravitates and rotates toward the low side according to Lovett's law to likely establish the beginning of a scoliosis. Thus, the biomechanical effects of pronation can be witnessed as high as the occiput.

Aberrant Reflexes. The basic problem starts essentially as an inward roll of one foot or both resulting in lengthening of the foot involved with an automatic stretching of the plantar muscles. This stretching of plantar muscles is thought to produce many reflex patterns that can express themselves as sciatic pain, numbness, tingling and various other paresthesias --all of reflex origin.

Abnormal Torques and Mechanoreceptor Effects. As the foot pronates and rolls inward, it produces an inward roll of the talus. This inward roll continues to have an inward torque on the tibia. Ordinarily, the fibula follows suit with the torque continuing through the knee joint, producing a sustained torque to the femur that then allows the lesser trochanter to displace backwards and laterally. This produces microavulsion at the trochanteric attachment of the iliopsoas muscle. Thus, if the psoas tests weak, a foot pronation problem should be an early suspicion. The thigh abductors and neck flexors will usually be weak on the side of a weak iliopsoas, and a lower inner longitudinal arch will usually be found on the side of the weak iliopsoas.

Loading Reactions. Bone design of the foot typically conforms to the habitual mechanical stress that exists at its every weight-bearing point. In each case, nature seeks to provide maximum strength with minimal material to support the weight above and assist the body to maintain equilibrium to the body's center line of gravity. Each articulation is designed to allow its component parts the best possible range of motion to normal balance against gravitational force. This principle is true throughout the skeleton. When changes are overlooked, symptoms referred to other parts of the body continue because their cause, here being in the ankle-foot complex, has failed to be properly diagnosed and corrected.

Other Biomechanical Effects. Associated foot and ankle signs include a lateroinferior cuboid, medioinferior navicular, posterocalcaneal torque, internally rotated tibia, inferior tarsals, inferior 2nd--4th metatarsals, superior 1st and 5th metatarsals, lateral deviation of the Achilles tendon during weight bearing, and flattening of the longitudinal arch. A corn at the 2nd metatarsal head, a tailor's bunion on the lateral 5th metatarsal head, Haglund's deformity, and/or bunion are typical findings.

Evaluation and Mensuration. Remove the patient's shoes and inspect (from the front, side, and back) the patient's foot posture during standing and the degree of inward pronation or outward supination. Insert an index finger under the inner longitudinal arch to a point midway under the foot, and palpate the plantar fascia for tension. Rotate the foot to its outer border and the knee laterally, then repeat plantar palpation. Tenderness on pressure and "fiddle string" fascia that disappears when the foot is rotated to its outer border will indicate a degree of pronation in an apparently normal foot.

Do not miss checking the inside of the patient's shoes. You may find that the source of pain is a small nail or thorn that has penetrated the sole of the shoe. Also keep in mind that the shoes worn to your office may not be those commonly worn.

Drop a plumb line from the center of each patella. Normally, the bob will be in the approximate midline of the ankle. In pronation, the bob will be near the medial malleolus. To record the effects of foot pronation, measure the amount of knee rotation by placing a mark with a skin pencil in the middle of each patella and measuring the distance between the marks. Then roll the feet to their outer borders and measure the distance between the patella marks: pronation causes inward rotation of the knees.



ROENTGENOGRAPHY: SEVERE ANKLE AND FOOT INJURIES

Lateral, A-P, and oblique x-ray views are standard for evaluating possible ankle fracture, and sometimes tomography or stress views during inversion and eversion are required.

Ankle fractures are frequently associated with severe ligament injury. One report states that rupture of one or more syndesmotic ligaments occurs in more than 90% of malleolar fractures. Ligament injury is always present in displaced malleolar fractures. One of the more common fracture sites occurs when the talus is displaced in the ankle mortise, shifting the talus and fibula laterally. When this happens, a slight widening of the distal interosseous space between the tibia and fibula (indicating interosseous membrane rupture) will be found.

Heel Fractures

Fractures of the calcaneus are frequent. They usually result from falls where the victim lands stiff legged on the heels. Fracture of the calcaneus may be obvious with a widely separated fracture line and grossly disturbed positioning of fragments or it may be quite discrete with little obvious change visible. Examination should include the posterior halves of both heels. In later views, the fracture line is seldom seen.

Compression heel injuries are frequently accompanied by compression fractures in the lumbar or lower thoracic regions from force traveling up the legs to the spine. Thus, it is always a good rule to x-ray the thoracolumbar region when a crushing fracture of a heel is found.

Boehler's Angle. For the purpose of accurate diagnosis, the use of Boehler's angle is recommended during roentgenographic analysis. For the normal calcaneus, Boehler's angle results from a line drawn first from the posterosuperior margin of the talocalcaneal joint through the posterosuperior margin of the calcaneus, producing an angle of 35° --40° with a second line drawn from the posterosuperior margin of the talocalcaneal joint to the superior articular margin of the calcaneocuboid joint. Less than 28° is considered definitely abnormal and poor position from a functional standpoint.

Talus and Cuboid Fractures

Fracture of the talus and cuboid are next in frequency to those of the calcaneus. Bilateral films are helpful to rule out a trigonum, the posterior extension of the talus occasionally occurring as a separate bone. Another anatomical variation that sometimes leads to interpretative error is a separate ossification center at the base of the fifth metatarsal (usually bilateral).

Fractures also commonly occur in the posterior or midportion of the talus. These areas may be the sites of avascular necrosis, viewed as a lucent crescent under the articular margin of the talus. In advanced cases, the superior portion of the talus may show collapse of its articular margins. This is best seen on an A-P view because overlapping malleoli cloud the picture in lateral films.

An examiner should not confuse a sharp or rough-edged fracture fragment at the posterior talus with a rounded-edged accessory ossicle (os trigonum). Fractures secondary to impact of the talus are oblique and frequently comminuted, while those secondary to ligamentous avulsion are typically horizontal. The obliquity of the fracture line is determined by the direction of force. As little as 1 mm of lateral displacement reduces the area of tibial-talar contact by 42%.


Classification of Ankle Fractures

The patterns of ankle injuries can be classified according to direction of primary and secondary forces such as external rotation, abduction, adduction, and vertical compression.

External Rotation Injuries. The common mechanism involved in ankle injury is traumatic external rotation plus abduction. The classic fracture here is an oblique fibular line directed from the anterior-inferior to the posterior-superior aspect that is frequently comminuted along the posterior cortex. Excessive foot pronation is the usual mechanism, associated with a deltoid tear. The interosseous ligaments are usually spared if the foot is in supination rather than pronation. An oblique transverse fracture of the medial malleolus at or beneath the tibial articular surface may occur, with fragments displaced inferiorly by the pull of the deltoid ligament and tearing of the anterior tibiofibular ligament. A small posterior malleolar fracture may result from the rotating fibula.

Abduction Injuries. An abduction fibula fracture is typically oblique and short. Comminution of the lateral cortex is usually related. As with external rotation injuries, abduction injuries produce transverse malleolar fractures or deltoid tears. This fibula fracture usually occurs below or within the syndesmosis but may occur above the syndesmosis if it ruptures. When external rotation is a secondary force added to abduction, the fracture is usually higher on the fibula and/or more oblique. In abduction injuries, the lateral fibular cortex may be comminuted, small dorsal tibial and fibular avulsions may be noted, and diastasis is more common because the syndesmosis is ruptured. A horizontal fracture of the medial malleolus, a torn deltoid, a high fibula fracture, and a complete rupture of the syndesmosis (called a Dupuytren fracture-dislocation) are unstable injuries resulting from forceful abduction and lateral rotation.

Adduction Injuries. Adduction ankle injuries usually result in distal fibular horizontal fractures at or below the articular surface. Frequently associated is a vertical fracture of the medial malleolus projecting above the articular surface that is often related to a fracture of the lateral aspect of the talar dome. Diastasis is not typically associated with adduction injuries, but posttraumatic arthritis may result from comminution of the articular surface. Fractures to the posterior margin are not common.

Vertical Compression Injuries. Vertical compression injuries are subdivided by Dalinka into posterior marginal fractures, anterior marginal fractures, and supramalleolar fractures.

-- Anterior marginal fractures. This type of fracture, frequently isolated, may be comminuted. It usually occurs in the dorsiflexed foot.

-- Posterior marginal fractures. These types of fractures may occur (1) with significant vertical compression of the articular margin or (2) without vertical compression. External rotation injuries, with or without an abduction factor, may produce small posterior marginal fractures. Vertical compression with external rotation force is more likely to produce large fragments. When the posterior articular fragment is large, the incidence of posttraumatic arthritis and chronic instability is high. Posterior marginal fractures seldom occur as isolated injuries; thus the proximal fibula must also receive careful evaluation. Rips of the anterior tibiofibular ligament are frequently associated.

-- Supramalleolar fractures. This type of fracture, invariably associated with fracture of the fibula, is of the distal 4 cm of the tibia above the ankle line (Malgaine fracture). It is commonly open, severely comminuted, and related to high-impact forces in the direction of axial compression.

Fatigue Fractures of the Foot

March fractures are characterized by point tenderness and sometimes, if old, a palpable callus. The onset of symptoms may be rapid or gradual. Diagnosis is made early by exclusion and late by roentgenographic findings. The condition is not common to athletes but is occasionally found in unconditioned joggers who run on hard surfaces. The second metatarsal is the site of the most common fatigue fractures found in the foot. Various congenital or acquired factors such as Morton's toe, warts, and bunion may be the underlying factor in symptomatic runners. Management is similar to that for metatarsalgia: rest and support.

Stress Cysts of the Foot

Bowerman points out that chronic stress of the talus may produce marginal degenerative cysts, similar to those seen in other weight-bearing joints (eg, knee, hip). Usually, but not always, the joint space near the cyst will be narrowed.


ARTHROKINEMATICS

Where the ankle, essentially a hinge joint, leaves off and the foot begins is a matter of differing opinions. Most authorities consider the ankle to be formed by the tibia, fibula, and talus. The foot includes all structures distal to the talus. Subtalar joint motion occurs about an axis that is oblique to the three axes around which usual ankle flexion-extension, abduction-adduction, and rotation occur.

Joint Actions of the Ankle and Foot

Normal ankle and foot movements use a combination of (1) ankle dorsiflexion (20° ) and plantar flexion (50° ), (2) subtalar inversion (5° ) and eversion (5° ), (3) midtarsal forefoot adduction (20° ) and abduction (10° ), and (4) toe flexion (45° ) and extension (80° ). When the ankle is stabilized, the major joint motions of the foot are pronation, supination, toe dorsiflexion, and toe plantar flexion. Muscles controlling the ankle, foot, and toes are shown in Table 1.

Table 1. Muscles of the Ankle, Foot, and Toes

Muscle	Major Functions	Spinal Segment
THE ANKLE AND FOOT
Extensor digiti longus	Dorsiflexion	L4-S1
Extensor hallucis longus	Dorsiflexion	L5-S1
Flexor digiti longus	Plantar flexion, foot inversion	L5-S1
Flexor hallucis longus	Plantar flexion	L5-S2
Gastrocnemius	Plantar flexion	S1-S2
Peroneus brevis, longus	Plantar flexion, foot eversion	L5-S1
Peroneus tertius	Dorsiflexion, foot eversion	L4-S1
Plantaris	Plantar flexion	L5-S1
Soleus	Plantar flexion	S1-S2
Tibialis anterior	Dorsiflexion, weak foot inverter	L4-L5
Tibialis posterior	Plantar flexion, foot inversion	L5-S1
THE TOES
Abductor digiti quinti	Small toe abduction	S1-S2
Adductor hallucis	Hallux adduction-flexion of great toe	L5-S2
Dorsal interossei	Abduction-flexion of toes 2-4	S1-S2
Extensor digiti brevis	Toe extension	L5-S1
Extensor digiti longus	Toe extension of lateral four toes	L4-S1
Extensor hallucis longus	Hallux extension	L5-S1
Flexor digiti	Flexion of lateral toes	L5-S2
Flexor hallucis brevis	1st metatarsophalangeal flexion	L5-S1
Flexor hallucis longus	Hallux flexion	L5-S2
Interossei	1st metatarsophalangeal flexion	S1-S2
Lumbricales	Flexion of toes	L5-S2
Plantar interossei	Abduction-flexion of lateral three toes	S1-S2
Quadratus plantae	Assist flexion of lateral four toes	S1-S2

Note: Spinal innervation varies somewhat in different people. The spinal nerves listed here are averages and may differ in a particular patient; thus, an allowance of a segment above and below those shown should be considered.

---

Descriptors of foot motion have yet to be standardized. Most authorities, however, use the following terminology: Plantar flexion and dorsiflexion are motions about a horizontal axis (through the ankle) that lies in the frontal plane. Eversion occurs about an axis running in the A-P direction of the foot. Adduction occurs around a vertical axis. Pronation refers to combined dorsiflexion, eversion, and abduction of the foot; and supination is the result of combined plantar flexion, inversion, and adduction of the foot.

Dorsiflexion and Plantar Flexion. To passively test ankle dorsiflexion and plantar flexion, firmly stabilize the heel and hindfoot with one hand and grip the forefoot with the other hand. Then push the foot into dorsiflexion and plantar flexion with the active hand. Ligament shortening, pain, or swelling commonly restricts passive manipulation of the ankle.

Subtalar Inversion and Eversion. In testing passive subtalar inversion and eversion, stabilize the distal end of the tibia with one hand and firmly grip the heel with the active hand. Alternately invert and evert the heel. Again, pain during this maneuver suggests subtalar arthritis.

Forefoot Pronation and Supination. To passively test forefoot inversion and eversion, stabilize the heel and ankle with one hand and grip the forefoot firmly in the active hand. Manipulate the forefoot medially and laterally to test passive range of motion of forefoot adduction (supination) and abduction (pronation).

Flexion and Extension of the Toes. When evaluating toe flexion and extension, first gently test the great toe. To test motion of the 1st metatarsophalangeal joint, stabilize the foot with one hand while the active hand flexes and extends a particular joint. Fixation in this joint frequently produces a protective gait restricting push-off. Flexion is the only motion of the great toe's proximal interphalangeal joint. In the lesser toes, flexion and extension occur at the proximal and distal interphalangeal joints and the metatarsophalangeal joints.

Restricted extension of the proximal and distal interphalangeal joints and restricted flexion of the metatarsophalangeal joints are features of claw toes. Restricted flexion of the distal interphalangeal joint and metatarsophalangeal joint with restricted extension of the proximal interphalangeal joint are features of a hammer toe.

KINESIOLOGY OF THE ANKLE AND FOOT

Slight intermittent muscle action is involved to control normal body sway. This minimal action is necessary because body weight does not fall through the center of the joint but slightly anterior to the center.

Dorsiflexion

Dorsiflexion is provided by the tibialis anterior (L4--L5), extensor hallucis longus (L5--S1), peroneus tertius (L4--S1), and extensor digitorum longus (L4--S1). All are supplied by the deep peroneal nerve. Test tibialis anterior strength by applying increasing resistance when the patient attempts to dorsiflex and invert his foot. It is helpful to palpate the tibialis anterior muscle with the stabilizing hand. Test strength of the extensor hallucis longus by resisting active dorsiflexion of the great toe with increasing pressure on the nail.

Ankle Dorsiflexion Test for Contractures. Limitation of the gastrocnemius or soleus muscle restricting ankle dorsiflexion can be differentiated by the ankle dorsiflexion test. Have the patient sit on the examining table with his knees flexed and relaxed. Grasp the foot and flex the knee to slacken the gastrocnemius, then dorsiflex the ankle. If this can be achieved, the gastrocnemius is the cause of the restriction. If the soleus is at fault, it will not be affected by knee flexion; ie, it will be the same in either knee flexion or extension.

Plantar Flexion

Plantar flexion is provided by the peroneus longus and brevis (L5--S1), gastrocnemius (S1--S2), soleus (S1--S2), flexor hallucis longus (L5--S2), flexor digitorum longus (L5--S2), plantaris (L5--S1), and tibialis posterior (L5--S1). The peroneus longus and brevis are innervated by the superficial peroneal nerve, all the rest by the tibial nerve. To test the peronei, oppose plantar flexion and eversion of the foot. Palpate with the stabilizing hand the first two tendons posterior to the lateral malleolus.

Toe Flexion and Extension. Flexion of the toes is controlled by the dorsal interossei, flexor digiti, interossei, plantar interossei, lumbricals, quadratus plantae, adductor hallucis, and flexor hallucis brevis and longus. Extension of the toes is governed by the extensor digiti brevis and longus, and the extensor hallucis longus.

Strength of the Great Toe. Test the strength of the flexor hallucis longus by opposing flexion of the great toe; that of the flexor digitorum longus by offering resistance to curling toes in flexion. Resistance to plantar flexion and inversion tests the strength of the tibialis posterior muscle.



CLINICAL MANAGEMENT ELECTIVES FOR ANKLE OR FOOT STRAIN/SPRAIN

1. Stage of Acute Inflammation and Active Congestion

The major goals are to control pain and reduce swelling by vasoconstriction, compression, and elevation; to prevent further irritation, inflammation, and secondary infection by disinfection, protection, and rest; and to enhance healing mechanisms. Common electives include:

Disinfection of open skin (eg, scratches, abrasions, etc)
Cryotherapy
Cold packs
Cold immersions
Ice massage
Vapocoolant spray
Compression
Pressure bandage
Aircast
Protection (padding)
Elevation
Indirect therapy (reflex therapy)
Iontophoresis/phonophoresis
Auriculotherapy
Meridian therapy
Microcurrents
Spondylotherapy
Mild pulsed ultrasound
Pulsed alternating current
Rest
Bedrest
Cane
Crutches
Foam/padded appliance
Shoe orthotic
Shoelift
Immobilization
Rigid appliance
Plaster cast
Indicated diet modification and nutritional supplementation.


2. Stage of Passive Congestion

The major goals are to control residual pain and swelling, provide rest and protection, prevent stasis, disperse coagulates and gels, enhance circulation and drainage, maintain muscle tone, and discourage adhesion formation. Common electives include:

Alternating superficial heat and cold
Pressure bandage
Protect lesion (padding)
Indirect therapy (reflex therapy)
Light nonpercussion vibrotherapy
Passive exercise of adjacent joints
Mild surging alternating current
Mild pulsed ultrasound
Phonophoresis
Cryokinetics (passive exercise)
Meridian therapy
Spondylotherapy
Rest
Bedrest
Cane
Crutches
Shoe orthotic
Shoelift
Immobilization
Shoe orthotic
Plaster cast
Indicated diet modification and nutritional supplementation.


3. Stage of Consolidation and/or Formation of Fibrinous Coagulant

The major goals are the same as in Stage 2 plus enhancing muscle tone and involved tissue integrity and stimulating healing processes. Common electives include:

Mild articular adjustment technics
Moist superficial heat
Thermowraps
Spray-and-stretch
Cryokinetics (active exercise)
Moderate active range-of-motion exercises
Meridian therapy
Alternating traction
Sinusoidal current
Ultrasound, continuous
Microwave
Vibromassage
High-volt therapy
Interferential current
Spondylotherapy
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Rest
Bedrest
Cane
Crutches
Shoe orthotic
Shoelift
Immobilization
Shoe orthotic
Semirigid appliance
Indicated diet modification and nutritional supplementation.


4. Stage of Fibroblastic Activity and Potential Fibrosis

At this stage, causes for pain should be corrected but some local tenderness likely exists. The major goals are to defeat any tendency for the formation of adhesions, taut scar tissue, and area fibrosis and to prevent atrophy. Common electives are:

Deep heat
Articular adjustment technics
Spondylotherapy
Local vigorous vibromassage
Transverse friction massage
Spray-and-stretch
Active range-of-motion exercises without weight bearing
Negative galvanism
Ultrasound, continuous
Sinusoidal and pulsed muscle stimulation
Microwave
High-volt therapy
Interferential current
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Rest
Bedrest
Cane
Crutches
Shoe orthotic
Shoelift
Shoe orthotic
Indicated diet modification and nutritional supplementation.


5. Stage of Reconditioning

Direct articular therapy for chronic fixations
Progressive remedial exercise
Passive stretching
Isometric static resistance
Isotonics with static resistance
Isotonics with varied resistance
Plyometrics
Aerobics
Indicated diet modification and nutritional supplementation.



COMMENTARY

As disruption of the mechanics of the kinematic chain can lead to pathologic function, the foot and ankle must ideally combine a complex series of controlling forces and integrate to meet the demands of static and dynamic situations. In addition, being the final links in the human axial kinematic chain and those approximating the supporting surface, the segments of the foot and ankle must be flexible enough (free of fixation) to accommodate to different surfaces yet be stiff enough to provide the required torque for locomotion.

Ankle Trauma

Note: The area of greatest weakness in children during ankle trauma is at the growth plate. Epiphyseal separations are more common than fractures as the ligaments attach to the epiphysis.

In many sports, fast running with sudden stops, quick changes of position, and jumping account for chronic ankle and foot stress. Soccer players especially present with chronic ankle strains/sprains, spurs, and degenerative changes as a result of kicking the ball with the dorsum of the foot. About a third of the time in professional basketball players, roentgenography shows bony spurs of the anterior or dorsal talus. Trauma is but one of the causes; focal infections, metabolic disturbances, and contracted plantar fascia may be involved.

Often overlooked are fatigue fractures of the 2nd metatarsal and fibula. Other sites of related fatigue fractures include the calcaneus, tarsal navicular, tibia, and femur.

Ankle Contusions

Ankle bruises are usually bone bruises that readily respond to cold, elevation, a dressing, and an elastic ankle bandage or strap for 1--3 days. Resumed activity should be safeguarded with a protective pad for 2--3 weeks. The incidence of ankle contusions without sprain is highest in hockey from stick and puck blows.

Peroneoextensor Spasm

Peroneoextensor spasm produces a spastic flat foot that is painful at the lower lateral leg and ankle. It is especially common after cross-country runs. There is little or no area tenderness, but dorsiflexion and inversion are restricted. Spasm in eversion may become marked and indicate an eversion subluxation. Management consists of standard muscle techniques, passive peroneal stretching, interferential therapy, ultrasound, and progressive mobilization and strengthening.

Management. Treatment is similar to that for any acute strain, with cold, rest, elevation, compression, and strapping for 8--12 days, and carefully monitored graduated active exercises. Severe peronei tendovaginitis is difficult to manage and sometimes requires referral for tendovaginotomy.

Disorders of the Deep Peroneal Nerve

Induced Deep Peroneal Nerve Compression. The deep peroneal nerve can become compressed at the anterior ankle by shoes that are too tight or tightly laced. Tenderness will be found on the anterior aspect of the ankle where the deep peroneal nerve becomes superficial. Decreased sensation manifests between the 1st and 2nd toes, and the extensors of the great toe may be weak. These signs of nerve compression should not be confused with an anterior compartment syndrome of the lower leg. Simple avoidance of tightly fitted or laced shoes will correct the disorder if that is the cause.

Duchenne's Test for Peroneal Paralysis. Place the patient supine with the lower limbs extended in a relaxed position. Place your thumb on the plantar aspect of the head of the 1st metatarsal on the involved side, and instruct the patient to plantar flex the foot. If during this action the head of the 1st metatarsal offers little or no pressure against your thumb, the medial border of the foot dorsiflexes while the lateral border plantar flexes, and the arch disappears, the test is positive for peroneus longus paralysis (L4--S1).


Achilles Tendon Injuries

A painful Achilles tendon is frequently associated with plantar fascitis, leg or ankle tendinitis, peritendinitis, tendon rupture, or local inflammation.

Clinical Tests. There are three common tests to evaluate the integrity of the Achilles tendon: Simmond's test, Thompson's test, and the Achilles tap test. All involve the plantar flexion reflex.

-- Simmond's test. The patient is placed prone and the knee is flexed to a right angle. Grasp the center of the leg with both hands and apply strong pressure so that the calf muscles are squeezed against the tibia and fibula. Normally, the foot will plantarflex slightly; if not, a ruptured Achilles tendon is suggested. This test is a common variant of Thompson's test.

-- Thompson's test. To detect a rupture of the Achilles tendon, have the patient kneel on a chair with the feet extended over the edge. Then firmly squeeze the middle third of the calf. If the Achilles tendon is ruptured, especially the soleus portion, this squeeze will not cause the normal plantar flexion response.

-- Achilles tap test. With the patient prone, the patient's knee is flexed to a right angle. The Achilles tendon is tapped with a reflex hammer about an inch above its insertion at the heel. If pain is induced or the normal plantar flexion reflex of the foot is absent, a rupture of the Achilles tendon should be suspected.

Achilles Strains. The prominent Achilles tendon inserts firmly into the calcaneus and is formed by the common tendon of the gastrocnemius and soleus muscles. Signs of tenderness, swelling, tenosynovitis, and crepitation should be sought. Rupture or tear results in lack of push-off during gait.

Achilles Rupture. Because of the great tensile strength of the healthy Achilles tendon, femoral or calcaneus fractures invariably occur before the tendon ruptures. This may not be true, however, when excessive force is applied to a previously injured or diseased tendon. The common cause of Achilles overstress can usually be traced to overuse, direct violence during stretch, or a poorly placed injection.

-- Complete rupture. Achilles rupture may occur even if the patient can extend the foot against resistance. A tender gap in the tendon is reliable evidence, but the sulcus may be hidden by a blood clot. The site of tear is invariably about 2 inches above the attachment of the tendon at the heel. The patient will be unable to stand on the ball of the foot. Complete separation is characterized by sharp pain, often accompanied by perception of an abrupt "thud" at the site. The sharp pain soon subsides, but ankle weakness produces a flat-footed gait. Plantar flexion is usually, but not always, impossible. Passive dorsiflexion is restricted. The onset of a complete rupture is always sudden, a tendon deficit is usually palpable, and Thompson's test is usually positive. The calf muscles retract to a higher position than normal.

-- Partial tear. Less common than complete rupture, a partial tear features acute pain during activity that persists until stress can be avoided. When activity is resumed, severe pain returns. A tender swelling is noted when the site is palpated, and the onset of symptoms is usually sudden. The soleus and gastrocnemius test weak during weight bearing. Thompson's test may be positive or negative, and the tenderness is often more severe than that found with complete rupture.

Achilles Tendinitis. The onset of achillodynia in Achilles tendinitis is insidious and almost always the result of chronic overstress of calf muscles. There are burning pain, tenderness, restricted ankle motion, severe swelling, dry crepitus, and disability. Thompson's test is negative, and passive ankle dorsiflexion aggravates the pain. The cause of Achilles tendinitis can sometimes be traced to tape or a support applied too tightly over the tendon.

Proper taping can be described in three steps: (1) Two anchors of 3-inch-wide tape are applied; one encircles the instep at the center of the longitudinal arch, the other encircles the leg above the malleoli. (2) Three or four strips are applied from the arch anchor, over the heel, and to the calf anchor. (3) This taping is anchored by a continuous figure-8 and heel lock, also of 3-inch-wide tape.

Management of Achilles tendinitis is extremely long and frequently disappointing, thus surgical decompression is considered the treatment of choice if considerable relief from conservative measures does not occur within a week. Some relief may be obtained by standard physiotherapy, rest, and heel lifts. A short leg walking cast may be helpful during healing.

Pronation Syndrome. It is good policy to check for ankle distortion in any case of Achilles tendinitis. The inflammatory reaction may be the result of an ankle pronation syndrome. The valgus torque placed on the insertion of the tendon during pronation leads to overstress pain and inflammation. A tight or shortened Achilles tendon restricting dorsiflexion of the foot is likely in the history but unknown to the patient. The foot compensates for this lack of motion through abnormal supination of the forefoot and subtalar or hindfoot pronation.

Dry Sheath. This disorder of unknown cause is the result of diminished lubricating fluid within the sheath of the tendon. Adhesions form that bind the tendon proper to its covering. Features include a burning pain during and after strenuous activity, the inability to raise the heel from the ground during weight bearing, tenderness, mild swelling, and restricted ankle motion. Crepitus is often present. Contrast or whirlpool baths (108° --110° F) at least twice daily, analgesic packs, interferential therapy, and vitamin-mineral supplementation may be helpful. Immobilization may be necessary during the acute stage. Bilateral heel pads should be provided to reduce the strain on the tendons.

Taping begins in slight extension with a vertical strip run from the heel up the calf to just below the knee. The second strap is applied on the medial heel, crosses the tendon, and is attached to the lateral calf just below the knee. The third strip is secured on the lateral heel, crosses the Achilles tendon, and is attached to the medial calf just below the knee. These strips are secured by semicircular horizontal strips of overlapping 2-inch tape from the ankle to the upper calf. Bilateral heel lifts should be provided to accommodate for the fixed partial extension.

Focal Stress Degeneration. The common site of central-tendon degeneration is at the midpoint between the musculotendinous junction and insertion of the Achilles tendon: the site of poorest blood supply in the tendon. Ischemia appears to be the triggering mechanism. Low-heeled shoes, heel-strike running events, running on hard surfaces, and severe training schedules are causative factors in sports. Spontaneous rupture can result if excessive force is applied against a degenerated tendon.

During the early stages, pain is felt only during initial warm-up --disappearing with exercise. Later, the pain becomes persistent and increases in severity. The onset is gradual, swelling is characteristic, tenderness is severe, and Thompson's test is negative. Somewhere in the range of motion, a painful point in the arc is manifested. Of the conservative measures, rest, ultrasound, interferential therapy, and heel padding offer temporary relief, but continued vigorous activity causes relapse. Surgical procedures appear to be the alternative after a thorough trial of conservative measures.

Achilles Tenosynovitis. Achilles tenosynovitis often produces local pain increased by use. It is sometimes associated with palpable crepitus. Other features include pain on motion, tenderness, and a distinct limp. Treat as any inflammatory tendon reaction with emphasis on hydrotherapy and ultrasound.

Achilles Peritendinitis. In acute peritendinitis, the onset is rapid and there is swelling. Little tenderness is associated. Crepitus may or may not be present. In chronic peritendinitis, the onset is gradual, swelling may or may not be present, and a thickened nontender paratendon is palpable. Thompson's test is negative in both acute and chronic cases. Conservative management is usually successful unless there are associated fibrosis and strictures of the paratendon.

Ankle Strains

Many ankle strains involve the peroneus or posterior tibial muscles. Symptoms usually arise a day or two after injury. Strains must be differentiated from ankle or foot sprain, referred trigger point pain, and fatigue fractures. For differentiation, the common causes of ankle pain are shown in Table .2.

Table 2. Common Causes of Ankle Pain

Acute Pain	Chronic Pain
Arthritis/synovitis	Acquired Flatfoot
Bone bruise	Congenital fault (eg, calcaneovalgus)
Contusion	Degenerative joint disease
Dislocation	Fixation
Fracture	Peripheral vascular disease
Osteomyelitis	Postural foot disorder
Strain/sprain	Rheumatoid arthritis
Subluxation	Spur
Talar osteochondritis	Subluxation
Tarsal tunnel syndrome	Tuberculosis
Tendinitis	Tumor (rare)

Peronei Strain. The peronei tendons pass behind the lateral malleolus and are best palpated during active eversion and plantar flexion. The peronei are the primary foot everters and help in plantar flexion. An aseptic tendon inflammation is often involved after overstress. If stenosis of the tunnel in which the tendons run occurs, the peroneal tubercle will be tender and thick. Tenderness here also suggests bursitis or fracture of the styloid process in severe sprain. When an associated peroneal tenosynovitis or tendovaginitis is associated with strain, it is characterized by acute tenderness, pain, motion restriction, swelling of the sheath, a probable squeaking crepitus on joint movement, and possibly ecchymosis.

Posterior Tibia Tendon Strain. While peronei tendons pass behind the lateral malleolus, the tendon of the posterior tibial muscle courses behind the medial malleolus. The clinical picture of posterior tibial overstress is similar to that of peronei strain and inflammation: tenderness, sheath swelling, crepitus, and possible ecchymosis.


SPECIAL CONCERNS WITH RUNNERS

Running has become an essential element in many personal fitness programs. It provides relatively inexpensive aerobic activity and requires no special talent or facilities. However, logical preparation is necessary because some precise kinematic interrelationships are involved. K. M. Naughton points out, "Novice runners are frequently ill prepared to begin a sound training program and often overestimate their capabilities. Consequently, they experience recurring injuries and frustration. While appropriate chiropractic intervention can obviate symptomatology, improper training habits left uncorrected will render the runner susceptible to further injury. Ultimately, this cycle of failed expectations and injury may prove overwhelming and compel the runner to abandon running or exercise altogether. The chiropractic physician can serve a pivotal role in breaking this cycle by addressing both relief and prevention. A thorough investigation of the patient's biomechanics, injury history, running style, and training habits is necessary to adequately evaluate any runner. However, it is especially important to focus upon these aspects in the novice runner where relatively minor changes and recommendations may deter further injury and disappointment."

Pronation and supination are essential during gait when properly performed in correct sequence. Ankle pronation/supination occur primarily at the subtalar joint. As described previously, pronation includes dorsiflexion, eversion, and abduction to provide flexibility. Supination incorporates plantar flexion, inversion, and adduction, and contributes to stability through joint compression.

Naughton strongly recommends that evaluation of a runner should include assessing weight-bearing ankle pronation and supination. She describes that degrees of pronation and supination can be easily determined because the longitudinal arch of a truly overpronated foot is absent on weight bearing and a medial bulge is prominent. Less pronounced overpronation is determined by drawing lines bisecting the Achilles tendon and calcaneus. When weight bearing or the subtalar joint is in the neutral position, these lines are normally in close alignment. "The pronated foot will demonstrate a valgus heel-to-tendon alignment, while the supinated heel will demonstrate a varus position.

Navicular drop can also be measured to assess pronation. The approximate midpoint of the navicular is marked with the foot in neutral. This position is marked in relation to the floor. It is remeasured with weight bearing. A drop greater than 15 mm indicates hyperpronation."

Common Overpronation Effects. Runners with pronated ankles frequently present with shin splints, heel pain from plantar fascitis, fatigue fractures, bunions, medial or lateral knee pain and some forms of ankle sprain. In addition, for proper congruency with the ground at midstance, the foot excessively pronates and hyperpronation symptoms are encouraged.

Common Oversupination Effects. Although oversupination distortion is far less common than overpronation, the predisposed trauma from oversupination may be harsh because the supinated foot is rigid and does not transmit force well. Thus ground reactive forces, especially those related to running, are inadequately dispersed. Fatigue fractures can result. Runners with oversupination or who have tibial varum land on the extreme lateral borders of their feet (varus position) at heel strike. Overinversion is particularly prevalent when running on irregular surfaces. It should also be noted that the heel pain associated with plantar fascitis may also be found in the supinated foot because plantar fascia in the high-arched foot acts as a windlass to produce traction irritation at fascial insertions.

Trigger Point Syndromes of the Ankle Area

A trigger point in the upper anterolateral aspect of the leg within the tibialis anticus muscle is frequently the cause of pain referred chiefly to the front of the ankle and big toe. Firm sustained pressure on this trigger point sets off an aggravating ache. At other times, a trigger area just lateral to this site, located in the extensor digitorum longus muscle, refers pain more laterally in the ankle and/or to the dorsum of the foot in the area of the 4th metatarsal bone.

Management. Treat as a moderately severe strain/sprain. If the area of pain is sprayed with a vapocoolant, the pain will be relieved only momentarily, but spraying over the focal trigger area may abolish the pain, free restricted motion, and relieve deep tenderness in the reference zone for many hours if not permanently.

Ankle Sprains: General Considerations

Ankle sprains are frequently seen. As in knee sprains, they involve a wide variety of damage depending on which ligaments are stretched and the degree of tear. Isolated tears are rare, and fibula fractures are often associated with severe ruptures. The stability of the complex series of joints comprising the ankle and foot is primarily maintained by an expansive network of ligaments. In comparison to the knee, little is known about the integrated biomechanical actions within the ankle and foot.

Most ankle strain/sprains are diffuse to some degree. Lateral sprain, the most common ankle sprain, often produces an indirect tenderness in the deltoid ligament area from impaction. After eversion sprain, this area exhibits primary tenderness with secondary tenderness from impaction on the lateral aspect. Hyperextension sprain exhibits lateral, medial, and sometimes posterior tenderness and swelling.

Inversion Sprains

The most common form of tarsotibial sprain occurs by twisting the leg in varus; ie, ankle inversion with internal rotation. This is especially true when the foot is plantar flexed with the heel raised from the ground, which especially injures the talofibular bundle of the lateral ligament. The ligament tears are usually at their attachments, with or without avulsion, rather than at the middle of the ligament. Isolated tenderness may be most acute over the anterior talofibular ligament. It is less often found over the calcaneofibular ligament if stress occurs when the ankle is at a right angle. During inversion stress, the mechanism of injury is a first-class lever joint amplifying the external force (five or six times) above the resistance limit supplied by the bones and ligaments.

Dias showed complete rupture of the anterior fibulotalar ligament is the first lesion to occur in lateral ankle sprains. However, if a supination force is applied to the neutral-positioned ankle, an incomplete rupture of the fibulocalcaneal ligament may precede the total rupture of the anterior fibulotalar ligament. A partial tear of the deep anterior fibers of the deltoid ligament occurs in extreme degrees of internal rotation or plantar flexion.

Clinical Features. The local manifestations of inversion ankle sprain are mild--severe pain and swelling beneath the affected tendons and ligaments, tenderness, possible ecchymosis, hypermobile inversion, and spastic functional impairment. The lateral malleolus, talus, and cuboid will feel prominent on palpation. The talus is usually subluxated from the ankle mortise. In mild cases, only the lateral sulcus is filled with effusion.

To support the diagnosis, check for the draw sign, judge lateral and medial instability, and use Thompson's or an alternative test. Acute traumatic arthritis of the ankle following severe sprain can be produced by rupture or stretching of the ligaments of the joint by direct or indirect violence unless appropriate rehabilitation measures are taken.

Eversion Sprains

In this less common form of ankle sprain, low fibula bone damage is more the rule than isolated medial ligament tears because of the inherent strength of the deltoid ligament. If the inferior tibiofibular ligament tears, the fibula and tibia separate at the ankle mortise (diastasis). This joint widening produces instability readily leading to degenerative changes. Local manifestations include pain, tenderness, swelling, possible ecchymosis, eversion hypermobility, and restricted inversion mobility.

Management. Inadequately treated initial injuries invariably lead to chronic disorders. Structural alignment, cold immersions, elevation, and pressure strapping should be applied as soon as possible after injury to control swelling. Casting should be avoided unless there are severe fractures associated. During the acute stage, positive galvanism, mild ultrasound, periodic rest, and possibly elevation are also indicated. An application of hyaluronidase may be helpful in reducing tissue swelling and edema if used with iontophoresis. Passive or active stretching is helpful but, obviously, avoid inversion in inversion sprains and eversion in eversion sprains. Swelling should subside in 36 hours. Ideal healing requires time and patience.

After 48 hours, passive congestion may be managed by contrast baths, light massage, interferential therapy, gentle passive manipulation, sinusoidal stimulation, heel lifts, and/or light ultrasound. During the stage of consolidation, local moderate heat, moderate active exercise, bracing, moderate range of motion manipulation, or ultrasonics are beneficial. In the stage of fibroblastic activity, deep heat, deep massage or vibrotherapy, active exercise (eg, toe walking, inversion and eversion walking), negative galvanism, ultrasound, and active joint manipulation speed recovery and inhibit posttrauma effects. Add peroneal muscle exercises against resistance according to patient tolerance. Active taxing exercises should not begin until the walking gait is normal and pain free.

Ankle Taping

Strapping should be applied during slight eversion in lateral sprain or inversion in medial sprain. After strapping over a protective underwrap, mild periodic walking is encouraged after several days of rest because functional use facilitates recovery. Keep in mind that the greater the support, the greater the atrophy. Pain relief is enhanced by placing a 2- x 2-inch gauze pad (about 1/4-inch thick) within the longitudinal arch before taping. Double pads are necessary for especially heavy patients.

Preventive Strapping. In preventive strapping for athletic activity, the anterior talofibular ligament, which runs from the distal fibula to the talus, is the most important ligament to protect for lateral stability. Especially protect the anterior portion of the deltoid ligament after medial sprain. During rehabilitation, a lateral heel wedge is helpful in lateral instability; a medial heel wedge in medial instability. Vitamin C and manganese glycerophosphate appear to be helpful during rehabilitation.

Simplified Postinjury Taping Procedure. When swelling has subsided or disappeared, and the ankle shows no ligamentous tear, tape can be applied in a basketweave ankle lock. Weight-bearing can then be resumed. During application, the strips begin from the inside and run under the foot to the outside to hold the heel slightly everted when lateral instability exists. Competitive activity must be avoided for 2--3 weeks for Grade III sprains. Taping during stressful activity should continue for several more weeks.

The Gibney Taping Method. This is one of the more time-consuming, but stable, methods of ankle strapping. It also allows for swelling without constriction. The foot and leg are shaved and the foot is held at a right angle to the leg while the dressing is being applied. A strip of 1-1/2- or 2-inch-wide adhesive tape is placed against the outer aspect of the leg, passed downward over the outer malleolus, under the heel, and making firm upward pressure against the arch by traction as the remainder of the strip is applied to the inner aspect of the leg. A second strip is placed at a right angle to the first, beginning on the outer aspect of the foot over the cuboid bone and passing on the medial side of the foot over the internal cuneiform bone. Successive strips are placed alternately about the leg and foot until the ankle is encased. Semicircular strips of tape are used about the anterior foot and leg to retain the dressing. Whatever taping method is used, avoid wrinkling the tape during application.

Subtalar Arthritis

Subtalar arthritis is a posttraumatic joint inflammation that often follows calcaneal fracture. The foot usually has a "rocker bottom" shape, in which there is a valgus deformity and the long arch is flattened. Other clinical features include heel pain aggravated during weight bearing, tenderness over the sinus tarsi, crepitation on motion, and possibly peroneal spasm to splint the joint. Underwater ultrasound, relieving ankle and foot fixations, and antivalgus exercise are helpful.

Kohler's Disease

The cause of avascular necrosis of the tarsal navicular is unknown, but interference with the circulation to the bone, leading to ischemia, is generally thought to be involved. The typical onset is near the age of 5 and features variable degrees of local pain, tenderness, swelling of the navicular bone, and a painful limp. Diagnosis is confirmed by roentgenography. Check for something that might inhibit local circulation such as a subluxation-fixation syndrome, postural weakness, restricted motion due to a scar or contracture, etc. During initial treatment, a short walking cast is often applied for about 2 months. Reossification should be completed in 2--3 years if the area is protected from injury. Spontaneous recovery often occurs.

Talar Osteochondritis Dissecans

A small area of necrotic bone on the articular surface of the talus (usually the medial aspect) develops in this disorder, which is often the consequence of trauma. It is easily confused with an ankle sprain that stubbornly refuses to heal, but the initial trauma may not be remembered. The onset is gradual and usually occurs during adolescence or early adulthood and features point tenderness over the talus when the foot is plantar flexed, ankle motion restriction, chronic ankle swelling following activity, and a painful limp.

Weight-bearing irritation must be avoided during the healing process, and this can be aided by a short walking cast or, better, a firm brace. If symptoms and signs do not improve within a logical course of conservative therapy, surgical referral should be considered to possibly remove necrotic bone.

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome (TTS) is a nerve compression syndrome of the neurovascular bundle (especially the posterior tibial nerve) that lies under the medial malleolus. The cause may be a subluxation syndrome, a space-occupying lesion, a posttraumatic scar or adhesion, arthritic changes, or something leading to a deformed heel or foot.

Just as an upper thoracic lesion may produce carpal tunnel symptoms, misdiagnosis can occur as the result of vasospasm produced by a lumbosacral subluxation syndrome. Parasympathetic fibers have not been found in the extremities but sympathetic fibers are widespread and especially innervate the arterioles.

TTS is characterized by burning pain and paresthesia (eg, tingling) in the toes and plantar surface that may radiate up the back of the leg. The pain is typically referred along the posterior tibial nerve, infrequently radiating as high as the buttocks, and invariably increased by activity and usually worse in the evening. Deep palpation posterior to the medial malleolus finds tenderness or aggravates pain in the sensory distribution of the nerve. A sensory loss is usually found on the inferior aspect of the heel and/or the sole of the foot, depending on which branch of the nerve is most involved. When the neurovascular bundle is percussed, a positive Tinel's sign is typically elicited with radiating pain. In the chronic stage, intrinsic foot weakness and claw toes develop that restrict extension.

Tinel's Foot Test. With the patient prone and the knee flexed to a right angle, percuss the posterior tibial nerve as it passes behind the lateral malleolus. If this induces paresthesias in the foot, tarsal tunnel syndrome is suggested.

Ankle Tourniquet Test. A sphygmomanometer cuff is wrapped around the suspected ankle, inflated slightly above the patient's systolic blood pressure, and maintained for 1--2 minutes. An increase in foot pain signifies tarsal tunnel syndrome or a similar circulatory deficit.

Management. An early priority is to find the cause of the compression. This may be traced to effects of chronic subluxation with ankle pronation, scar or adhesion formation, tenosynovitis, venous engorgement, valgus deformity of the foot, etc. Recurrent trauma is usually involved. Cold packs, cool immersions, or vapocoolant sprays are helpful during the acute stage. A temporary medial heel wedge or heel seat is often beneficial in relieving traction from the nerve by slightly inverting the heel. If symptoms fail to respond some to conservative care in 7 days, referral for exploratory surgery should be considered.

POSTTRAUMATIC SPURS AND RELATED DISORDERS

Two common posttraumatic abnormalities are talonavicular spurs and narrowing of the subtalar joint. These commonly occur from chronic stress to the talonavicular ligament in sports requiring constant speed, jumping, and rapid changes in direction such as seen in basketball, tennis, soccer, and field hockey. They sometimes arise in nurses and orderlies who must quickly travel long hard hallways repetitively during their shift. They also have a significant incidence in professional bowlers (bowler's spurs).

Bowler's Spurs

Degenerative changes or fracture may result in spur formation of the posterior talus that may irritate the posterior margin of the tibia's inferior articular surface. Once formed, the spur becomes constantly irritated by forced ankle flexion. Conservative care is often frustrating when activity is continued. Deep heat and graduated exercises bring good results, but referral for surgery to remove spurs or loose bodies may be required. Progression into osteoarthrosis is a common complication.

Football/Soccer Ankle

This disorder consists of traumatic osteitis that is sometimes confused with chronic sprain. There are general ankle pain, minimal swelling, and soreness aggravated by kicking the ball. Roentgenography shows new bone formation on the margins of the inferior articular surface of the tibia, but the joint surfaces are not involved as in osteoarthrosis. Conservative care incorporating rest and graduated active exercises will usually suffice. If not, the spurs must be removed surgically.



POSTURAL DISTORTIONS

In-Toeing

Internal Tibial Torsion. Excessive toe-in, especially in children, is often the product of excessive internal rotation of the tibia. This is often caused by a fixed point at either end of the tibia. In infants, habitually sleeping with the feet turned inward may be the cause. Common points of fixation are at the malleoli in the ankle or the tibial tubercle below the knee joint. The ankle mortise normally faces 15° externally; but in internal tibial torsion, it faces anteriorly or internally. This abnormal position is called the toe-in sign.

To confirm a suspicion of internal tibial torsion, have the patient sit on a table with the relaxed knees flexed at 90° . The tibial tubercle will palpate as if it is directed straight anterior. Grasp the malleoli with your thumb and index finger, and determine the position of the ankle joint. In normal adults, about 20° --30° of external tibial torsion is present, and the lateral malleolus will be posterior to the medial malleolus. If internal tibial torsion exists, the lateral malleolus will be anterior to its medial mate.

Metatarsus Varus Sign. The patient sits on a table with the knees flexed at 90° . Note the posture of the relaxed bare foot. The lateral border of the foot will appear convex and the medial border concave if there is metatarsus.

Internal Femoral Torsion. Internal femoral torsion is found if the patellae are marked with a skin pencil and these points are observed during gait. There will be toe-in, the patellae will face medially, an internal contracture of the hip will usually be found, and there will be excessive anteversion of the femur in metatarsus varus. If there is toe-in and the patellae face forward (as is normal), the focal deformity will be distal to the knee. Mercier states that an internal rotation deformity exists at the hip when internal rotation exceeds external rotation by more than 30° .

Out-Toeing

There are three common causes of external lower extremity rotation and out-toeing:

-- External tibial torsion, characterized by a markedly posterior position of the lateral malleolus relative to the medial malleolus. An everted heel and flat arch are commonly associated.

-- Soft-tissue shortening or adhesions at the hip or retroversion of the femur (external torsion). If this is the cause, external rotation of the femur will be much greater than internal rotation.

-- Flat feet, calcaneovalgus, or genu valgum. In infants, habitually sleeping supine with the feet turned outward or the constant use of excessively wide diapers may be the cause.

Dr. John Palo reports in personal correspondence that both in-toeing and out-toeing are seen in young, squatting television viewers. "Children who watch much TV, squatted with feet in the toed-in position, will be found walking with toed-in supinated feet. Children who watch much TV, squatted with feet in a toed-out position will be found walking with toed-out pronated feet. A temporary reversal of their habitual foot position while watching television helps to reverse the distorting process."


MISCELLANEOUS CIRCULATORY DISTURBANCES

Circulatory Insufficiency Screening Tests

Skin color normally darkens in the weight-bearing position. An elevated pink foot that markedly deepens in color in the standing position suggests arterial insufficiency or vascular disease. Note the venous filling time on the dorsum of the foot at this time. Collapsed veins should fill within 12 seconds on standing. If the pulse is absent in a limb, check the most distal palpable pulse and auscultate for an audible bruit suggesting the site of obstruction. Apply finger pressure to the medial dorsal area of the foot and note time for the white spot to disappear; then rotate weight to outer border and repeat test. Blanching time is delayed in cases of pronation and arch weakness due to circulatory interference.

To evaluate the capillary filling time of the toes, compress a selected toe until it blanches white, then release pressure quickly. Normal color should return within 6-10 seconds. Tenderness along the transverse arch is common in aseptic necrosis from a circulatory disturbance.

Edema

Lymphatic obstruction, venous disease, or acute arterial occlusion may result in lower extremity edema. Edema is usually greatest in the front of the leg, top of the foot, and back of the thigh. Tenderness frequently accompanies edema from any cause. Venous disease is the most common cause of pitting on pressure. Trauma or local disease is the usual cause for unilateral swelling. Unilateral edema may be due to thrombosis of a vein, pressure of tumors in the pelvis, or an inflammatory lesion.

Nontraumatic bilateral edema is due to uncompensated heart lesions (primary or secondary from lung disease), lymphatic disorders, nephritis, cirrhotic liver, anemia, cancer complications, neuritis, varicose veins, obesity, flatfoot, and other less common causes of deficient local circulation. In some cases, an absolute cause cannot be found (angioneurotic, essential, hereditary types). It may also be due to neuritis, trichinosis, or another source of local inflammation. Diagnosis depends on the history and the examination of the remainder of the body.

Volkmann's Ischemic Contracture of the Foot

This condition (postischemic fibrosis) may appear in either the lower or upper extremity. The long flexors of the toes primarily exhibit the effects of inadequate nutrition. The contracture is the result of impairment of or injury to a major artery or innervating nerve. The tissues below the blockage are cool, cyanotic, painful, and swollen. Tibial fracture leading to embolism or thrombosis may be involved when this type of contracture is seen in the leg and foot.

Muscle swelling or prolonged spasm within a fascia-encased compartment and ischemia-enhanced edema may cause or contribute to the disorder. The resulting necrosis leads to fibrosis and contracture. Prolonged cast pressure or tourniquet applications may be involved. The anterior compartment of the leg is tightly bound and has difficulty in expanding to compensate for increased internal pressure.

Management. Once the cause has been determined and corrected, conservative rehabilitative procedures should be directed to enhancing circulation and softening of fibrotic tissues (eg, mobilization, deep heat, galvanism, ultrasound, vibromassage).

Erythromelalgia

Red neuritis of the extremities is common in the feet. The toes (or fingers) are red, hot, tender, and painful. In Raynaud's disease, the digits are cold and painless or numb. The attacks are aggravated by heat and not by cold as with Raynaud's disease. Such attacks are probably akin to the condition of "hot feet" often seen in the arteriosclerosis of elderly people. The patient kicks off the bed clothes from his feet at night because of warm burning sensations. Other evidences of insufficient arterial blood supply (eg, clubbing, intermittent claudication, cramps, gangrene) may coexist.

Black Heel

Pigmented areas on the back of the heel secondary to petechial hemorrhage are sometimes seen. Heel pain following activity is the common complaint, but the disorder is frequently asymptomatic. In sports, it is most often associated with tennis, badminton, basketball, and soccer.

Tennis Toe

A chronic complaint of pain in one or more of the longer toes is frequently associated with hemorrhage, usually horizontal, under the toenails (tennis toe). The cause is thought to be from sudden stops, quick changes of direction, and the severe forward motion of the body that propels the long toes against the front of the inside shoe. If the hemorrhage is longitudinal in a nonathlete, the disorder is easily confused with the splinter hemorrhages consequential to subacute bacterial endocarditis after a recent illness.



FLAT FOOT (PES PLANUS)

The human foot is normally held in an arched position only by the power of the muscles acting coordinately the instant weight is borne. This is anticipating that there is nothing to hinder the bones of the arch from taking their normal position and that the Achilles tendon is not pathologically short. In addition, the feet of the same patient may vary in size and design to an amazing degree. One foot may have a strong arch and be in a straight-line position while the other foot is flattened and toed-out. A patient with an apparently short leg often has a greater pronation or inward roll on that leg, and the arch may be lessened. But contrary to popular belief, a rigid high arch will cause more problems (eg, plantar strains) than a rigid fallen arch.

The "arches" of the feet serve more like springs than they do rigid mechanical arches. Generally, a "flat foot" results from a breaking down or weakening of the normal medial longitudinal arch of the foot. The cause may be traumatic, atrophic, congenital, or the effect of obesity or ill-fitting shoes. A postural flattened arch must be differentiated from that associated with benign hypotonia, spastic flat foot, congenital tarsal abnormalities, spina bifida occulta, or cerebral palsy.

Clinical Features

There may or may not be changes in the sole print (a useful record). Valgus or eversion of the heel and abduction of the forefoot are usually associated. When the arch flattens, the head of the talus drops downward and medially from under the navicular and stretches the tibialis posterior and spring ligament, obliterating the longitudinal arch and forming a callus under the talar head. There is usually a pronated gait, joint stiffness, loss of spring in the step, disability during gait, excessive eversion during weight bearing, and peroneal muscle spasm.

Related pain may be local in the arch or extend to the medial malleolus, knee, hip, or lumbar area. There may be pain and tenderness near the attachment of the ligaments and often higher up on the leg, but many cases are symptomless.

A convex medial border of the foot (when viewed from above) is a sign of an extremely flattened arch. Check for foot pronation that may be associated with a fallen arch but is a separate deviation. Note the existence of hammer toes or marked deviation of the large toe toward the midline of the foot (hallux valgus).

Flexible Flatfoot. A flexible flatfoot appears normal when examined in a nonweight-bearing position; but during weight bearing, the medial longitudinal arch disappears, the forefoot pronates and abducts, and a mild genu valgum (knock-knee) or internal tibial torsion may be present. When distress is produced by a flexible flatfoot, the typical symptoms are foot pain, burning sensations, and fatigability. A hypermobile foot that flattens on weight-bearing is usually a hereditary state that may or may not produce symptoms. When associated with a shortened Achilles tendon, heel eversion results and a pronation syndrome follows. If the Achilles tendon is tight, passive dorsiflexion is limited when the heel is inverted.

Rigid Flatfoot. A rigid flatfoot is frequently caused by protective peroneal spasm leading to contractures. This is usually secondary to a motion-restricting hindfoot arthritis or a tarsal disorder. It cannot be passively or actively reduced in a nonweight-bearing position. Common complaints associated with a rigid flatfoot are stiffness, pain and tenderness over the peroneal tendons or in the hindfoot, and pain aggravated by forefoot adduction and inversion. When symptoms appear, they usually do so gradually during adolescence. Physical signs include a painful limp, heel eversion, restricted and painful midtarsal and subtalar motion, forefoot abduction, and possibly mild swelling.

Compensatory Flatfoot. A lowered longitudinal arch might be thought to be a common cause of a physiologic short leg, but Gillet has not found this to be the case. His studies showed that while most deficiencies in femur height are of several millimeters, the influence of a flattened arch on femoral height does not usually exceed a millimeter. On the contrary, he found most flattened arches on the side of the long leg. When a heel lift was added to the short side, the fallen arch would correct itself in a few days. The supposition is that such a fallen arch is a product of the hip of the long leg rotating outward (producing foot eversion) to cause the line of force to fall more medially over the arch and/or is an innate biomechanical attempt to reduce the discrepancy in functional limb length. If either of these theories is true, an arch support or a heel wedge on the side of the long leg would be contraindicated.

Management

Free any subluxation-fixations in the spine, pelvis, and lower extremities. Note fit, quality, and wear of the patient's shoes. A longitudinal arch that is dropped in both the standing and nonweight-bearing position is rigid and may be aggravated by arch supports. On the other hand, a longitudinal arch that is absent in the weight-bearing position but present in the nonweight-bearing position may be aided by longitudinal arch supports. In general, strengthening exercises and orthoses for chronic flexible flatfoot syndromes offer only palliative comfort and little curative value.

FOOT TRAUMA

It is not uncommon that the foot is caught between forces from both above and below. Even minor traumatic disturbances can greatly inhibit optimal performance. When running on a level surface, the force on the supporting foot is about three times body weight. This increases to four times body weight during downhill runs. Added to this stress is the effect of unyielding surfaces. One study showed that while 99% of all feet are normal at birth, 8% develop troubles by the first year of age, 41% at age 5, and 80% by age 20.

A tabulation of the common causes of foot pain is shown in Table 3.

Table 3. Common Causes of Foot Pain

Rearfoot Pain	Midfoot Pain	Forefoot Pain	Toe Pain
Achilles strain	Fixation	Cellulitis	Blister
Achilles tendinitis	Flat-foot syndrome	Corn	Corn
Apophysitis	Fracture	Degenerative arthritis	Dislocation
Bursitis	Kohler's disease	Fixation	Fixation
Fracture	Plantaris rupture	Freiberg's disease	Fracture
Plantar fascitis	Sprain/strain	Gout	Hallux rigidus
Spur	Subluxation	Metatarsalgia	Hallux valgus
	Subtalar arthritis	Morton's neuroma	Hallus varus
	Tarsal coalition	Peripheral neuropathy	Hammer toe
		Phlebitis	Osteochondritis
		Plantar neuroma	Peripheral vascular disease
		Plantar wart	Strain/sprain
		Subluxation	Subluxation
		Synovitis

Heel Injuries

Palpate the dome of the calcaneus from above plantarward. Examine the area of the medial tubercle lying on the medial plantar surface of the calcaneus, and check for spurs in adults or signs of epiphysitis in children. Heel bruises are seen affecting the plantar surface of the os calcis. This is especially common in track where the shoes are often heelless, flexible, and ultrathin (eg, long-distance runners, jumpers, hurdlers). Prolonged stress from heavy heel landings displaces the fat pad and ruptures the fibrous septa under the calcaneus. The area will be tender and often feel thick and boggy.

Heel cups are helpful in prevention and during healing. Chronic cases, often leading to spurs, may require surgical excision of new bone, necrotic fibers, and granulation tissue.

Runner Fascitis. A common cause of heel pain in runners is plantar fascitis. This is an inflammatory reaction caused by prolonged dynamic traction of the plantar aponeurosis, especially at fiber insertions into the calcaneus. This usually long-term stretch of the fascia can result in pain and chronic inflammatory reactions leading to heel spurs. A pronated ankle is often involved.

Bursitis

Palpate the area of the retrocalcaneal bursa located between the anterior surface of the Achilles tendon and the top of the heel. Lift the skin away from the tendon with one hand while palpating anterior to the tendon. Then check the calcaneal bursa situated between the insertion of Achilles tendon and the skin. Both of these bursae are subject to inflammation from pressure or friction from poorly fitting shoes (especially football shoes with their heavy counters). Special care must be taken not to confuse heel bursitis with avulsion of the Achilles insertion.

Management. Treat as any bursitis. During nonactivity, heelless sandals or slippers are recommended. During activity, low-cut shoes and heel padding throughout the counter area are recommended to avoid recurrent swelling.

Foot Bruises and Wounds

Initial treatment must be quick to minimize bleeding and swelling through cold, compression, elevation, and rest. Padding, often specially designed, should be worn as long as tenderness persists. During recovery, mobilization, local heat, ultrasound, and deep vibromassage may be applied to relieve related soreness.

Contusions and Abrasions. Most foot contusions can be traced to a dropped object, foot stubs, or cleat wounds. A blow to the lateral ankle occasionally dislocates the peronei tendons anteriorly from their normal position behind the malleolus.

Bone Bruises. A bone bruise affecting the 2nd or 3rd metatarsal head, and sometimes the transverse arch, is called a "stone bruise" in athletics. It is common in track and the result of running with full weight onto some small, hard object without adequate protection.

Puncture Wounds. A puncture wound of the sole of the foot presents a special problem. In spite of proper care, some may develop cellulitis, osteomyelitis, tetanus, or acute arthritis of the foot. With early suspicions, referral should be made for debridement and/or antibiotics.

Plantar Strains

The strong bands of plantar fascia have their origin at the medial tubercle of the calcaneus, spray across the sole, and insert near the metatarsal heads. Tight plantar fascia raises the longitudinal arch. During palpation, the plantar aponeurosis should feel smooth and without areas of tenderness.

True plantar fascitis is rare, but when it occurs, it is often confused with sprain of the spring ligaments in the arch. It is usually the result of chronic pronation, fascial tears from dorsiflexion overstress, or associated with calcaneal fatigue fractures.

Clinical Features. The typical clinical picture of plantar strain primarily exhibits pain during running due to plantar-fascial stretch. Tenderness is found just distal to the calcaneal tubercles. Palpable stiff cords or nodules within the fascia suggest consequences of chronic plantar fascia spasm, Dupuytren's contractures tender under deep pressure, or plantar warts tender to pinching. Some degree of swelling may be felt. Callosities, like contractures, are tender to pressure but not to pinching. In acute cases, a slight degree of ecchymosis and severe tenderness may be at attachments, especially on the heel. Early roentgenographs are negative, but calcification may appear on later films.

Management. Check thoroughly for possible cuboid or navicular subluxation. Adjunctive care consists of cold packs during elevation and compression, which are later followed by vibromassage, trigger point therapy, contrast baths, and ultrasound. A temporary longitudinal arch support (or taping) and crutches are helpful during initial healing. Chronic low arches do not seem to be a precipitating factor.

Foot Sprains

Calcaneocuboid Sprain. Calcaneocuboid sprain is usually produced by forceful internal rotation of the foot on the talonavicular joint when the foot is inverted. There is immediate severe pain, swelling over the calcaneocuboid area, and great disability. This can be a chronic strain that can set up a subtle pathobiomechanical complex, extending for many years, with distal neurologic effects.

Rearfoot Sprain. Rearfoot sprains are usually chronic in nature, featuring progressive pain with minimal swelling in the rear half of the foot during and following activity. Talar subluxations and restrictions are often related. The cause in some cases can be traced to a low-grade tarsal synovitis from poor foot support on hard ground during strenuous activity.

Spring Ligament Sprain. Overstress of the plantar calcaneonavicular ligament is often associated with navicular subluxation. Symptoms of medial aching pain and tenderness deep within the plantar arch commonly arise after prolonged running when soft shoes are worn. Differentiation must be made from plantar fascitis, which is found farther posterior and usually more acute.

Forefoot Sprain. An ache and tenderness under the 2nd and 3rd metatarsal heads are often the result of postural stress. As a consequence of severe eversion or inversion strain, avulsion of the insertion of the tibialis posterior features acute styloid tenderness.

Management. Correct any fixation-subluxations isolated and apply general sprain management with emphasis on rest, contrast baths, and ultrasound in water. During rehabilitation, arch strapping, passive mobilization of the entire foot, intrinsic exercises, and orthotics improving foot support are helpful.

Toe Sprains

The most common toe sprain is that of the great toe, especially at the metatarsophalangeal joint as the result of forced plantar flexion or dorsiflexion. Sideward sprains rarely occur. Pain and swelling may be severe, but bone tenderness or crepitus is absent. Disability is severe because weight-bearing is predominantly on the hallus. Sprains of the other toes are managed similar to finger sprains.

Exostoses

Bony overgrowths infrequently form at the head of a metatarsal, especially the 1st metatarsal. Treatment is usually by surgery (exostectomy). However, what may appear to be a bony overgrowth during palpation (a knuckle-like prominence) is actually a metatarsocuneiform subluxation that can be demonstrated by roentgenography.

Heel Spur

A heel spur typically forms at the inferomedial aspect of the calcaneus. The cause is attributed to chronic traction of the plantar fascia on calcaneal periosteum. The clinical picture includes a distinct limp, constant pain only during weight bearing, tenderness increased in dorsiflexion, and mild swelling along the medial aspect of the os calcis or plantar fascia attachments at the calcaneal tuberosity.

Management. Minor conditions can be aided by heel pads and any taping procedure that supports the arches of the foot. Surgery is reported to be the treatment of choice, but trauma from the surgery may set the stage for further periosteal reactions and other surgical complications.

Metatarsalgia

Morton's syndrome (metatarsalgia) produces pain near the proximal end of one or more of the three outer toes. It is especially debilitating in track and almost always associated with compression of the foot by tight shoes pinching the external plantar nerves between the metatarsal bones.

Signs and Symptoms. An osseous triad consists of (1) a 1st metatarsal bone that is shorter than the 2nd, (2) hypermobility at the naviculocuneiform and medial-and inter-cuneiform articulations, and (3) posteriorly displaced sesamoids. In addition, there are toe pain, foot fatigue, and pronation complaints that are often associated with plantar callous patterns, bunion, corns, and intermetatarsal neuroma. There also is hypertrophy of the 2nd metatarsal joint, the foot is pronated and the arch flattened, and there is abnormal weight balance and distribution. Differentiation must be made from postural strains, neuroma, march fractures, subluxations, exostoses, and tendon avulsions.

Morton's Test. In metatarsalgia, transverse pressure across the heads of the metatarsals induces sharp pain, especially between the 2nd and 3rd metatarsals.

Strunsky's Test. This test is designed essentially for the recognition of lesions of the metatarsal arch. Under normal conditions when the toes are grasped and quickly flexed, the procedure is painless. Pain results if there is an inflammatory lesion in the metatarsal arch.

Management. Use a shin splint taping procedure in acute cases. After mobilizing all fixated joints from the foot to the hip, adjunctive care includes ultrasound in water, deep vibromassage (many trigger points will be found), padding beneath the tongue of the shoe, and transverse arch support. A metatarsal crescent can be applied to the sole of the shoe or a felt pad placed just behind the plantar metatarsal heads involved. In either case, the object is to slightly lift the stressed joints during weight bearing. The patient should be advised to lace the foreshoe loosely. Graduated tiptoe walking and walking on the lateral edge of the foot are helpful during rehabilitation. Poorly responding cases may require referral for specialized attention.

Plantar Neuroma

A rare cause of metatarsalgia is Morton's neuroma --painful round "beads" found between the heads of the 1st through 4th metatarsals, especially between the 3rd and 4th. They are thought to be the effect of excessive foot rolling where the plantar nerve is chronically impinged on taut fascia or bone. Hypertrophy of the nerve sheath develops, and there is an accompanying digital artery disorder. Shooting distal pains and sometimes periods of numbness are severe but quickly relieved when the shoeless foot is rested. Roentgenographs are negative. The disorder is rare in athletics but must be differentiated from postural strains and tendon avulsions producing forefoot pain and plantar tenderness.


Selected Disorders of Toes

Bunion. A bunion is a progressive effect of prolonged hallux valgus where the great toe displaces laterally with rotation about the long axis so that the nail faces medially. The sesamoid enlarges, and the soft tissues on the lateral aspect of the great toe enlarge. An adventitious bursa forms that often becomes tender and inflamed.

Whenever a bunion is found, check the ankle for hyperpronation. Bunions are especially common in hyperpronated runners and women who habitually wear sharp-pointed shoes. Increased pronation causes a lax peroneus longus tendon, which attaches to the first metatarsal and typically exerts a lateral pull. This laxity from hyperpronation allows the metatarsal to adduct. Shoe irritation and concomitant bursal inflammation produce the painful bunion.

Claw Toes. Claw toes, usually associated with pes cavus, feature flexed proximal and distal interphalangeal joints and hyperextended metatarsophalangeal joints. An early sign is the formation of callosities over the dorsal surface of the toes, on the tips of the toes, and on the plantar surface under the metatarsal heads.

Check for short shoes. Shoe salesmen often measure foot length in nonweight-bearing, which is ridiculous.

Hammer Toe. A hammer toe presents fixed flexion of the proximal interphalangeal joint with hyperextension of the metatarsophalangeal and distal interphalangeal joints. It is usually singular and associated with a callosity on top of the proximal interphalangeal joint. Predisposing factors include forceful plantar flexion of the metatarsal joint, pes cavus, a short metatarsal, forefoot valgus, trauma, or pronation imbalance.

Mallet Toe. A mallet toe is a distal interphalangeal joint flexion contracture that usually occurs in the smaller toes. It is less common than a hammer toe.

Sesamoiditis. Deep palpation within the flexor hallucis brevis tendon may locate the two sesamoids where signs of sesamoiditis develop. Sesamoid necrosis under the head of the 1st metatarsal in the flexor hallucis longus tendon may show roentgenographic signs. Passive mobilization of fixated joints, adjustment of subluxations, strapping, rest, ultrasound in water, sole padding, and improved footwear are beneficial. Progressive exercises may be started immediately after the acute stage has subsided.



ARTICULAR THERAPY

According to an arbitrary anatomical classification, the forefoot is composed of the five metatarsals and phalanges; the midfoot consists of the cuneiform, navicular, and cuboid bones; and the hindfoot (rearfoot) includes the talus and calcaneus.

William Locke, MD, of Ontario, developed a world-wide reputation in the 1930s treating a broad range of human ailments by doing nothing more than adjusting the cuboid.

Ankle Fixations

Two major areas of likely joint restriction exist in the ankle area: above and below the talus. The key structure within the ankle is the talus, which superiorly supports the weight of the tibia, laterally articulates with the nonweight-bearing fibula, and inferiorly rests primarily on the anterior two-thirds of the calcaneus. Similar to a hinge joint, the ankle mortise is designed essentially to allow plantar flexion and dorsiflexion. Only a slight amount of rotation is normally allowed.

The only motions of joint play to be evaluated within the ankle mortise are long-axis extension and A-P glide. Within the subtalar joint, long-axis extension, talar rock on the calcaneus, medial tilt, and lateral tilt are the primary considerations. Suggested techniques are described below.

Restricted Ankle Mortise Long-Axis Extension. This is a subtle motion to perceive but necessary for complete evaluation of joint motion in the ankle. Place the patient in the supine position with the feet at the end of the table, and stand or squat facing the patient. The plantar surface of the patient's uninvolved extremity should be placed above your knee for stability. Encircle the ankle mortise at the level of the malleoli with the thumb and index fingers of each hand so your index fingers are interlaced and firmed against the Achilles tendon posteriorly and your thumbs are centered over the anterior aspect of the tibiotarsal joint. Apply traction and note the degree of joint play perceived by your thumbs. Care must be taken to avoid pressure against the malleoli during this maneuver.

Restricted Ankle Mortise A-P Glide. This motion refers to A-P movement of the talus between the malleoli. Place the patient supine with the hip and knee on the involved side flexed and the foot at a right angle to the leg (resting on the heel). Stand or sit facing perpendicular to the patient's ankle. With your cephalad hand, grasp the patient's lower leg anteriorly just above the malleoli, with your thumb laterally and your fingers on the medial surface of the patient's ankle. With your caudad hand, grasp the anterior surface of the patient's ankle just below the malleoli. In this position, you will be able to elicit ankle mortise A-P glide by alternately pushing downward and pulling upward with your active (cephalad) hand.

An alternative method to evaluate posterior glide of the talus on the tibia uses the same doctor-patient positions described above. With this procedure, your cephalad hand grasps the underside of the patient's distal leg and applies an upward pressure while your caudad hand on the anterior surface of the patient's ankle just below the malleoli exerts a downward force.

Restricted Subtalar Long-Axis Extension. Place the patient in the supine position with the feet at the end of the table, and stand or squat facing the patient. The plantar surface of the patient's uninvolved extremity should be placed above your contralateral knee for stability. Encircle the involved subtalar area with the thumb and index fingers of each hand so that your index fingers are interlaced and firmed against the heel and your thumbs are centered over the anterior aspect of the talonavicular and talocuboid joints. Apply traction and simultaneously note the degree of joint play perceived by your thumbs. This procedure is similar to that described above for evaluating ankle mortise long-axis extension except that the contacts are applied at a lower level.

Restricted Subtalar Medial and Lateral Tilt. With the doctor-patient positions and contacts the same as described above for evaluating subtalar rock, alternately invert and evert the patient's ankle by rotating your hands clockwise and counterclockwise to evaluate subtalar medial and lateral tilt.

Restricted Subtalar Rock. The doctor-patient positions are the same as described above except that your hand contact is reversed so your thumbs are firmed against the apex of the longitudinal arch of the patient's involved limb and your fingers are wrapped around the anterior surface of the ankle so your index fingers are centered over the talonavicular joint anteromedially and the talocuboid joint anterolaterally. In this position, alternately dorsiflex and plantar flex the patient's foot by rotating your hands upward and downward, noting the subtalar motion elicited under your index fingers.

Ankle Subluxations

Anterior Talus Subluxation. Indications of an anterior talus subluxation include pain and tenderness at the anterior aspect of the ankle, a history of inversion sprain that occurred with plantar flexion, roentgenographic signs of exostosis of the dorsal talonavicular articulation, and excessive postural pronation during weight bearing.

To correct the mechanical displacement, place the patient supine, and sit at the foot of the table (facing the patient). Interlock your fingers across the anterior aspect of the involved ankle with your thumbs placed on the plantar surface of the patient's foot and your elbows moderately flexed. Your third fingers should make specific contact over the anterior aspect of the involved talus. To make the articular correction, apply traction to separate the calcaneus and talus while simultaneously snapping your wrists and elbows inferiorly in a scooping fashion to move the talus from the anterior to the posterior.

Lateral Talus Subluxation. The major features associated with a lateral subluxation of the talus are a history of inversion ankle sprain, excessive postural pronation during weight bearing, pain anterior to the lateral malleolus, and tenderness of the anterior talofibular ligament.

To adjust, place the patient supine. Stand at the foot of the table, facing the patient. Place the 3rd and 4th finger of your medial contact hand over the anterolateral aspect of the involved talus with your thumb on the plantar surface of the patient's foot. Your lateral stabilizing hand supports the patient's heel. To make the correction, apply traction with your stabilizing hand to separate the calcaneus from the talus while simultaneously applying a lateral-to-medial torque maneuver by bringing the fingers of your active hand medially while thrusting laterally with the web between your thumb and 1st finger.

There is an alternative procedure. The doctor-patient position is the same as described above. Internally rotate the patient's leg, and take a double-thumb contact on the lateroanterior aspect of the involved talus. Your lateral hand grips the calcaneus, while your medial hand grasps the anterior surface of the tarsals. Apply pressure with your double-thumb contact, slightly invert the foot, apply traction, and simultaneously make a short, sharp pull toward yourself to correct the malposition.

Medial-Inferior Talus Subluxation. Subluxation of the talus medioinferiorly is often found in association with eversion ankle sprain exhibiting tenderness at the deltoid ligament.

The corrective maneuver for this subluxation is essentially the opposite of the adjustment for a lateral talus. The patient is placed supine. Sit at the foot of the table, facing the patient. Place the third finger of your lateral contact hand over the anteromedial aspect of the involved talus with your thumb on the plantar surface of the patient's foot. Your stabilizing hand supports the heel. To make the adjustment, apply traction with your stabilizing hand to separate the calcaneus from the talus while simultaneously making a medial to lateral torque maneuver toward yourself.

Foot Fixations

The bony complex of a foot (about 27 articulations) is a common site of single or multiple fixations. Gillet looked to the feet as the functional base of the spine. He felt that the cause of many frequently recurring fixations in the spine or pelvis can be traced to fixations in the feet. Several authorities agree with this observation. Gillet's studies showed a distinct relationship between phalangeal fixations and upper cervical fixations, metatarsal fixation and C3--C7 fixations, metatarsal-tarsal fixations and thoracic fixations, intermetatarsal fixations and costospinal subluxations, cuneiform-navicular or cuboid-calcaneus and lumbar fixations, and talus fixations and L5 fixations. These empirical findings are awaiting further confirmation.

Fixation of the distal phalangeal joints is not common but those joints more proximal are. The metatarsophalangeal joint of the great toe is a common site, especially where plantar flexion is restricted. The intermetatarsal ligaments are frequently shortened. Partial or complete fixations are also found at the cuneiform-metatarsal, cuboid-metatarsal, cuneiform-navicular, intercuneiform, cuneiform-cuboid, navicular-cuboid, talus-navicular, and talus-cuboid articulations. Keep in mind that a high stiff arch that does not reduce much during weight bearing is just as abnormal as a flattened arch.

The joint plays to always evaluate for possible fixations are of the midfoot (proximal metatarsal) and forefoot (distal metatarsal) A-P glide and rotation. Hindfoot mobility has been evaluated indirectly during the evaluation of ankle mortise and subtalar mobility.

Proximal Metatarsal A-P Glide. With the patient in the supine position, stand or sit facing perpendicular to the patient's foot. Grasp the patient's foot with your stabilizing cephalad hand so that you have firm contact on the cuneiforms and cuboid. With your active hand, grasp the patient's foot so that your thumb and index fingers are around the proximal aspect of the bases of the patient's metatarsals. While holding these contacts, alternately pull upward and push downward with your active hand to elicit proximal metatarsal glide.

Proximal Metatarsal Rotation. With doctor-patient positions the same as described above, evaluate rotary motion of the proximal metatarsals by rolling your contact hand into pronation and supination so that the patient's foot is rotated medially and laterally.

Distal Metatarsal A-P Glide. Place the patient in the supine position with the feet at the end of the table, and stand or squat facing the patient. With your lateral hand, grasp the head of the 5th metatarsal anteriorly with your index finger and posteriorly with your thumb. With your medial hand, clasp the head of the 4th metatarsal in a similar manner. To evaluate A-P glide between the 5th and 4th metatarsals distally, alternately push with one hand while pulling with the other hand, thus alternately producing distal metatarsal flexion and extension. Continue to evaluate A-P glide between each digit by moving your contacts medially over the distal 4th and 3rd metatarsals, 3rd and 2nd metatarsals, and 2nd and 1st metatarsals.

Distal Metatarsal Rotation. With the doctor-patient positions and contacts the same as described above, rotation is evaluated by trying to move one metatarsal hand over and under its neighbor by rotating your contact fingers clockwise and counterclockwise. Gross screening of forefoot rotational mobility can be evaluated by stabilizing the patient's heel with one hand while your contact hand grasps the patient's forefoot and performs a figure-8 maneuver by supinating and pronating your forearm.

Foot Subluxations

Posterior Calcaneus Subluxation. Subluxation of the calcaneus posteriorly is usually associated with tarsal tunnel syndrome, excessive pronation during weight bearing, and pain located inferior and slightly posterior to the medial malleolus.

To adjust, place the patient prone. Stand at the foot of the table, facing the involved limb. With your medial hand, grasp the anterior aspect of the patient's involved ankle with your fingers and place your thumb firmly against the distal plantar calcaneus. With your lateral hand, cup the patient's heel and apply firm pressure against the posterior aspect of the calcaneus. The adjustment is made with a snapping force by the thumb of the contact hand superiorly while the stabilizing hand rotates the calcaneus toward your body. Both hands must act simultaneously, working in unison.

Anterior Calcaneus Subluxation. The most obvious signs of an anterior calcaneus subluxation are excessive supination and pes cavus during weight bearing.

To correct the displacement, place the patient prone with the involved knee flexed. Stand on the side of involvement. Your caudad hand contacts the anterior plantar aspect of the involved calcaneus with a web contact, while your cephalad hand stabilizes the patient's talus, tibia, and fibula by grasping the posterior ankle with a web contact. To correct malposition, apply pressure with your contact hand against the heel and simultaneously make a short sharp thrust directed from the anterior to the posterior.

Inferomedial Navicular Subluxation. An inferomedial subluxation of the navicular is typically associated with medial longitudinal arch pain, excessive pronation during weight bearing, and a history of inversion or eversion ankle sprain.

To reposition, place the patient prone with the involved knee slightly flexed. Stand at the foot of the table on the side of involvement. Grasp the anterior surface of the patient's foot with your caudad hand so your 2nd and 3rd fingers are hooked over the inferomedial aspect of the navicular. With your cephalad hand, take a pisiform contact over your contact fingers. To correct the malposition, apply traction and simultaneously thrust obliquely lateral toward the floor.

Lateral Cuboid Subluxation. Subluxations of the cuboid are one of the most frequent subluxations found in the foot and frequently involved in a wide variety of noxious reflex manifestations. Lateral subluxation of the cuboid (Locke's basic concern) is usually associated with a history of inversion sprain, lateral longitudinal arch pain and tenderness, and excessive pronation during weight bearing.

To adjust, place the patient supine, stand at the foot of the table centered to the involved limb, and face the patient. Grasp the patient's anterior ankle with your medial hand so your thumb is on the lateral aspect of the cuboid. Your stabilizing hand is placed palm up against the lateral ankle so the thumb of the contact hand is between the thenar and hypothenar pads of the stabilizing hand. While maintaining this contact, stand closer to the patient so the patient's foot is held between your thighs, and assume a crouching position. To make the correction, apply traction by thigh pressure, and simultaneously make a thrust directed medially with the stabilizing palm against your contact thumb.

Inferior Cuboid Subluxation. The typical clinical picture of an inferior cuboid subluxation is lateral longitudinal arch pains and excessive pronation or supination during weight bearing.

To reposition the displacement, place the patient prone. Stand at the foot of the table facing laterally oblique to the involved limb. Locate the plantar aspect of the cuboid. A contact is made with the pisiform of your cephalad hand, with your fingers wrapping around the lateral aspect of the foot. The patient's anterior foot rests in the palm of your caudad stabilizing hand. To correct the malposition, apply traction to the patient's forefoot with your stabilizing hand with emphasis on the 5th metatarsal and simultaneously make a short sharp thrust toward the floor.

With an alternative technic, the doctor-patient positions are the same as described above. Locate the plantar aspect of the cuboid. A contact is made with the thumb of your medial hand with the fingers wrapping around the anterior aspect of the foot for support. Make pisiform pressure over your contact thumb with your cephalad hand. To correct the malposition, apply traction, and simultaneously make a thrust toward the floor with a drooping motion aided by bending your knees.

Superior Tarsal or Proximal Metatarsal Subluxation. The major features of either a superior tarsal or proximal metatarsal subluxation are pain on the dorsum of the foot, a history of inversion sprain resulting in a 1st metatarsal displaced superiorly, pronation syndrome with superior 1st and 5th metatarsals, and excessive supination during weight bearing.

In this adjustment, the patient is placed supine. Stand at the foot of the table, and face the patient. Grasp the lateral aspect of the patient's involved foot with your lateral hand so the superiorly subluxated bone is under the proximal or medial phalanx of your third finger and your thumb can stabilize the plantar surface of the patient's foot. Your medial hand is interlaced over the contact hand so the third finger is on top of the contact hand's third finger and the thumb is firmed against the plantar surface. To correct the malposition, remove any foot inversion or eversion present, apply traction with firm contact pressure, and simultaneously apply a sharp pull toward yourself to move the subluxated bone caudally.

Inferior Tarsal or Proximal Metatarsal Subluxation. The features of either an inferior tarsal or proximal metatarsal subluxation are arch pain, a history of ankle sprain, and excessive pronation or supination during weight bearing.

To adjust the prone patient, slightly flex the patient's knee. Stand at the foot of the table. Face the patient, centered at the involved side. Apply a double-thumb contact on the involved inferior tarsal or proximal metatarsal bone, with your fingers extending around to support the anterior aspect of the foot. To correct the malposition, apply steady plantar flexion to the foot and simultaneously make a snapping thrust with your contact thumbs directed toward the floor.

To adjust the supine patient, the involved foot is placed at a right angle to the leg. Stand at the foot of the table. Face the patient, centered at the involved side. Apply a double-thumb contact on the involved inferior tarsal or proximal metatarsal bone with your fingers extending around to stabilize the anterior aspect of the involved foot. To correct the malposition, apply steady plantar flexion of the forefoot by finger pressure toward your body and simultaneously make a quick short adjustment by thrusting your thumb contacts cephalad by snapping your elbows forward. Your fingers, thumbs, wrists, and elbows must work in unison.

Inferior Distal Metatarsal Subluxation. A distal metatarsal bone subluxated inferiorly is commonly associated with excessive callus formation across the metatarsal heads, a history of plantar forefoot pain, and excessive pronation during weight bearing.

To apply a corrective adjustment, place the patient supine. Stand at the foot of the table, and face the patient. Grasp the patient's involved foot with your medial hand so the inferiorly subluxated bone is under your thumb and your fingers extend around the medial aspect. With the thumb and index finger of your lateral stabilizing hand, grasp the phalanges of the involved metatarsal. To correct the malposition, remove any foot inversion or eversion present, apply traction to the phalanges, and simultaneously make a short thumb thrust cephalad to move the subluxated bone superiorly.

Toe Fixations and Subluxations

Restricted Toe Mobility. In evaluating toe flexion and extension, first test the great toe. To test mobility of the 1st metatarsophalangeal joint, stabilize the patient's foot with one hand while your active hand flexes and extends the joint. Restricted movement in this joint frequently produces a protective gait restricting push-off. Flexion is the only motion of the great toe's proximal interphalangeal joint. Be especially gentle in mobilizing this joint. In other toes, flexion and extension occur at the proximal and distal interphalangeal joints and the metatarsophalangeal joints.

Keep in mind that restricted extension of the proximal and distal interphalangeal joints and restricted flexion of the metatarsophalangeal joints are features of claw toes. Restricted flexion of the distal interphalangeal and metatarsophalangeal joints and restricted extension of the proximal interphalangeal joint are features of a hammer toe.

Hallux Valgus. This is a state of lateral deviation of the great toe, usually found in conjunction with a hypermobile pronated foot and the wearing of pointed-toed shoes producing abuse to the medial aspect of the front foot. The 1st metatarsal becomes fixed in abduction and the hallux subluxates laterally. In time, the abductor hallucis becomes deformed in lateral displacement beneath the metatarsal head. The involved muscles become ineffective in maintaining abduction.

In adjusting, place the patient supine. Stand at the foot of the table, facing the patient and centered to the involved limb. With your medial contact hand, grasp the involved great toe with your 3rd and 4th fingers extended along the plantar and medial aspect of the foot and your thumb placed against the anterior aspect of the involved joint. Your lateral stabilizing hand grasps the wrist of your contact hand for support. Apply traction, remove the valgus deviation, and make a short pull toward your body. Evaluate the integrity of the abductor hallucis and the muscles involved in excessive pronation. Once overt structural joint changes have occurred, adjustments have little benefit except to slow progression.

Hallus Rigidus. This disorder is characterized by pain, tenderness, stiffness, and limited motion of the 1st metatarsophalangeal joint. Incidence is higher in females during youth but higher in males during adulthood. Manual foot and toe mobilization, contrast baths, and a rigid insole are helpful. Stubborn cases may require referral for surgery (phalangeal osteotomy).



REFERENCES AND BIBLIOGRAPHY:

Andrews RA, Harrelson GL: Physical Rehabilitation of the Injured Athlete. Philadelphia, W.B. Saunders, 1991, pp 197--266

Ankle Sprains. The Physician and Sports Medicine, 14(2):101-116, February 1986.

Basmajian JV (ed): Manipulation, Traction, and Massage, ed 3. Baltimore, Williams & Wilkins, 1985.

Basmajian JV, Stecko G: The Role of Muscles in Arch Support of the Foot. Journal of Bone & Joint Surgery, 54A:1184-1190, 1963.

Birnbaum JS: The Musculoskeletal Manual, ed 2. Orlando, FL, Grune & Stratton, 1986.

Bowerman JW: Radiology and Injury in Sport. New York, Appleton-Century-Crofts, 1977.

Cailliet R: Foot and Ankle Pain. Philadelphia, F.A. Davis, 1979, pp 30-35, 42-56, 81-93, 99-106, 109-112, 117-124, 129.

Dalinka MK: Ankle Fractures. In Feldman F (ed): Radiology, Pathology, and Immunology of Bones and Joints: A Review of Current Concepts. New York, Appleton-Century-Crofts, 1978, pp 329-334.

Debrunner HU: Orthopaedic Diagnosis, rev. ed 2. Translated by G Stiasny. Chicago, Year Book Medical, 1982.

Dempster WT: The Range of Motion of Cadaver Joints: The Lower Limb. University of Michigan Medical Bulletin, 22:364-379, 1956.

Dias LS: The Lateral Ankle Sprain: An Experimental Study. Journal of Trauma, 19:266-269, 1979.

Dolan JP, Holladay LJ: First-Aid Management, ed 4, Danville, IL, Interstate Printers & Publishers, 1974.

Garrick JG, Webb DR: Sports Injuries: Diagnosis and Management. Philadelphia, W.B. Saunders, 1990, pp 261, 265, 292--296, 301--304, 309--310, 313--317, 320.

Gollnick PD: Electrogoniometric Study of Walking on High Heels. Research Quarterly, American Association of Health and Physical Education, 35:370-378, 1964.

Gonzna ER, Harrington IJ (eds): Biomechanics of Musculoskeletal Injury. Baltimore, Williams & Wilkins, 1982.

Goodheart GJ: The Psoas Muscle and the Foot Pronation Problem. Collected Published Articles and Reprints. Montpellier, OH, Williams County Publishing, 1969, pp 72-74.

Gottlieb A: Flatfoot and Its Relation to the Triceps Surae Muscle. American Journal of Physical Therapy, 8:321-334, 1932.

Greenawalt MH: Feet and the Dynamic Science of Chiropractic. ACA Journal of Chiropractic, May 1983.

Greenawalt MH: Spinal Pelvic Stabilization, ed 2, Dubuque, IA, Foot Levelers, 1978, pp 7-13, 29-31, 34-35, 38-44, 63-72.

Grice AS, Fligg DB: Class Notes: Introductory Concepts to Clinical Analysis of Joint Movement and Muscle Testing. Department of Biomechanics/Kinesiology, BK101. Toronto, Canadian Memorial Chiropractic College, date not shown.

Hadler NM: Medical Management of Regional Musculoskeletal Diseases. New York, Grune & Stratton, 1984.

Harrington IJ: Biomechanics of joint injuries. In Gonzna ER, Harrington IJ (eds): Biomechanics of Musculoskeletal Injury. Baltimore, Williams & Wilkins, 1982.

Haxton HA: Absolute Muscle Force in the Ankle Flexors of Man. Journal of Physiology, 103:267-273, 1944.

Hirata I Jr: The Doctor and the Athlete, ed 2. Philadelphia, J.B. Lippincott, 1974.

Hollingshead WH, Jenkins DB: Functional Anatomy of the Limbs and Back. Philadelphia, W.B. Saunders, 1981.

Hoppenfeld S: Physical Examination of the Spine and Extremities. New York, Appleton-Century-Crofts, 1976.

Iverson LD, Clawson DK: Manual of Acute Orthopaedic Therapeutics. Boston, Little, Brown, 1977.

Jones RJ: The Human foot: An Experimental Study of Its Mechanics and the Role of Its Muscles and Ligaments in the Support of the Arch. American Journal of Anatomy, 68:1-41, 1941.

Kapandji IA: Physiology of the Joints: Lower Limb, ed 2. New York, Churchill Livingstone, 1981, vol II.

Katoh Y, Chao EYS, Laughman RK, et al: Biomechanical Analysis of Foot Function During Gait and Clinical Application. Clinical Orthopaedics, 177:23-33, 1983.

Kelly ED: A Comparative Study of Structure and Function of Normal, Pronated and Painful Feet Among Children. Research Quarterly, American Association of Health and Physical Education, 18:291-312. 1947.

Kessler RM, Hertling D (eds): Management of Common Musculoskeletal Disorders. Philadelphia, Harper & Row, 1983.

Leek JC, Gershwin ME, Fowler WM Jr: Principles of Physical Medicine and Rehabilitation in the Musculoskeletal Diseases. Orlando, FL, Grune & Stratton, 1986,

Lowman CL: Feet and Body Mechanics. Journal of Health and Physical Education, 11:137, 1940.

Mann RA: Acquired Flatfoot in Adults. Clinical Orthopaedics, 181:46-51, 1983.

Marshall J, et al: The Anterior Drawer Sign: What Is It? American Journal of Sports Medicine, 3:152-158, 1975.

Mennell JMcM: Joint Pain. Boston, Little, Brown, 1964.

Mercier LR: Practical Orthopedics. Chicago, Year Book Medical, 1980.

Naughton KM: Running Injuries --Starting off on the Right Foot. MPI's Dynamic Chiropractic, July 31, 1992.

O'Donoghue DH: Treatment of Injuries to Athletes, ed 4. Philadelphia, W.B. Saunders, 1984, pp 601--606, 627, 632, 640--642, 645--651, 654, 668.

Owen JD: Lower Extremity Problems Relating to Back Problems. ACA Journal of Chiropractic, February 1971.

Palo J: personal correspondence. New York, NY, 1988.

Perry J: Anatomy and Biomechanics of the Hindfoot. Clinical Orthopaedics, 177: 9-15, 1983.

Pollock ML, Wilmore JH: Exercise in Health and Disease, ed 2. Philadelphia, W.B. Saunders, 1990.

Procter P, Paul JP: Ankle Joint Biomechanics. Journal of Biomechanics, 15:627- 634, 1982.

Rosse C, Clawson DK (eds): The Musculoskeletal System in Health & Disease. Hagerstown, PA, Harper & Row, 1980.

Salter RB: Injuries of the Ankle in Children. North American Clinical Orthopaedics, 5:147, 1974.

Sammarco GJ, Burstein AH, Frankel VH: Biomechanics of the Ankle: A Kinematic Study. Orthopaedic Clinics of North America, 4:75-96, 1973.

Schafer RC (ed): Basic Chiropractic Procedural Manual, ed 4. Arlington, VA, American Chiropractic Association, 1984.

Schafer RC: Chiropractic Management of Extraspinal Articular Disorders. Arlington, Virginia, American Chiropractic Association, 1989, pp 294--305, 356--378.

Schafer RC: Chiropractic Management of Sports and Recreational Injuries, ed 2. Baltimore, Williams & Wilkins, 1986, pp 510--534.

Schafer RC: Chiropractic Physical and Spinal Diagnosis. Oklahoma City, American Chiropractic Academic Press, 1980, Chapter XIV.

Schafer RC: Clinical Biomechanics: Musculoskeletal Actions and Reactions, ed 2. Baltimore, Williams & Wilkins, 1987, pp 732--734, 738--740, 742--757.

Schneider RC, Kennedy JC, Plant ML (eds): Sports Injuries: Mechanisms, Prevention, and Treatment. Baltimore, Williams & Wilkins, 1985.

Scott WN, Nisonson B, Nicholas JA (eds): Principles of Sports Medicine. Baltimore, Williams & Wilkins, 1984.

Shephard E: Tarsal Movements. Journal of Bone & Joint Surgery, 33B:258-263, 1951.

Shoji H: The Foot and Ankle. In D'Ambrosia RD: Musculoskeletal Disorders: Regional Examination and Differential Diagnosis. Philadelphia, J.B. Lippincott, 1977, pp 487-494, 500-502, 511-513, 519-521.

Smith JW: The Forces Operating at the Human Ankle Joint During Standing. Journal of Anatomy, 91:545-564, 1957.

Smith JW: Muscular Control of the Arches of the Foot in Standing: An Electromyographic Assessment. Journal of Anatomy, 88:152-162, 1954.

Soderberg GL: Kinesiology: Application to Pathological Motion. Baltimore, Williams & Wilkins, 1986.

Stauffer RN, Chao EYS, Brewster RC: Force and Motion Analysis of the Normal, Diseased, and Prosthetic Ankle Joint. Clinical Orthopaedics, 127:189-196, 1977.

Sutherland DH: An Electromyographic Study of the Plantar Flexors of the Ankle in Normal Walking on the Level. Journal of Bone & Joint Surgery, 48A:66-71, January 1966.

Williams JGP, Sperryn PN (eds): Sports Medicine, ed 2. Baltimore, Williams & Wilkins, 1976.

Wynarsky GT, Greenwald AS: Mathematical Model of the Human Ankle Joint. Journal of Biomechanics, 16:241-252, 1983.

Zange LL: Sesamoiditis: A Sesamometatarsal Lesion. ACA Journal of Chiropractic, February 1982

Return to the   Rehabilitation Monograph Series