1	INTRODUCTION The foot is an intricate web of bones, muscles, ligaments and nerves. Along with the ankle, the foot provides shock absorption to the leg, a stable base for support to propel the body forward, and does well at adapting to the levels and unevenness of the ground below it.
2	INTRODUCTION (cont’d) Foot bones are specialized in their articulations with each other, allowing a wide range of flexibility that is able to withstand the incredible amounts of stress on them. Each stride of an adult person places 900 pounds per square inch on the bottom of each foot.
3	"We will discuss different aspects..." We will discuss different aspects of the foot including: The osteology and articulations Musculoskeletal, ligaments and nerve pathways Longitudinal and metatarsal arches Pathologies; specifically Hammertoe and Clawtoe Prevention, treatment and other modalities
4	OSTEOLOGY OF THE FOOT
5
6
7	TARSAL BONES Seven irregular shaped bones categorized into: Proximal row (closer to body) Talus, Calcaneus & Navicular Distal row (closer to toes) Cuboid, & all three Cuneiforms
8	TALUS The talus affects the movement of the other tarsal bones and distributes weight in three different directions: Posteriorly to the heel and towards the medial aspect-through the subtalar joint Anteriorly and medially through the talonavicular joint toward the medial arch Anteroirly and laterally through the subtalar joint toward the lateral arch
9	CALCANEUS Largest tarsal bone that forms the inferior/lateral portion of the ankle Posteriorly is the heel of the foot, bears most of the immediate weight during gait Superior surface is smooth and slopes anteriorly and superiorly Inferior surface is rough and slopes inferiorly and anteriorly
10	CALCANEUS (cont’d) Attachment site for calcaneal tendon Lateral aspect is almost flat, the medial aspect is the site of the sustentaculum tali (projects medially) The point of contact with the ground in standing position is called the Tuber Calcanei
11	CUBOID Outer portion of ankle that articulates with proximal portion of metatarsals four and five, lateral cuneiform, medially/posteriorly with the calcaneus Named for its rough cubic shape
12	NAVICULAR Also called scaphoid Distally articulates with all three cuneiforms and proximally with the talus The midtarsal joint is formed by the talonavicular and cuboidocalcaneal joints Named for boat-like shape
13	CUNEIFORM All three are located in the distal row of tarsals Medial-largest, articulates posteriorly with the navicular, anteriorly with first metatarsal and posteriolateraly with intermediate cuneifrom
14	CUNEIFORM (cont’d) Intermediate-smallest, articulates posteriorly with navicular, anteriorly with second metatarsal, posteriomedially with medial cuneiform and posteriolaterally with lateral cuneiform Lateral-articulates with cuboid posteriolaterally and with proximal portion of 2^nd 3^rd and 4^th metatarsals
15	METATARSALS All five are long bones and form the longer, broad structure of the foot, between the tarsals and the phalanges First metatarsal is numbered starting at the Hallux (great toe) moving laterally 2^nd, 3^rd, 4^th, to the smallest which is the 5^th metatarsal
16	METATARSALS (cont’d) The distal portion of each has a bulbous projection for ligament and muscle attachment. The lateral aspect of the fifth has a prominent tuberosity also for muscle attachment First is most medial, largest and thickest, two to five are wider at the base on the dorsal (top) than on the plantar (bottom) aspects
17	PHALANGES Each phalanx also has a bulbous projection for ligament attachment Proximal portion articulates with metatarsals, intermediate (between distal and proximal), distal portion are the end projections of the toes. Each toe has three with the exception of the hallux which only has two They are referred to by position in extention
18	JOINTS The intertarsal joints are gliding, diarthrotic and synovial The metatarsal phalangeal joints (MTP) where the metatarsal heads articulate with the proximal phalanges There are five joints allowing; flexion, extension, hyperextension, adduction and abduction
19	JOINTS (cont’d) The hallux MTP joint is very flexible and allows approximately 45 degrees of flexion/extension, 90 degrees of hyperextension Second to fifth MTPs allow approximately 40 degrees flexion/extension and only 45 degrees hyperextension The foot requires less dexterity than the hands, therefore, the Proximal Interphalangeal joints (PIP) and Distal Interphalangeal joints (DIP) are less significant individually
20	JOINTS (cont’d) The Great toe has only one Interphalangeal joint (IP) The Subtalar / Talocalcaneal joint consists of the inferior talus articulating with the superior calcaneus which produces mostly a gliding motion The Transverse Tarsal joint consists of the posterior navicular and cuboid articulating with the anterior talus and calcaneus producing very little motion
21	JOINT VIDEO
22	MOTIONS Motion is dictated by the three compartments of the foot Hindfoot- talus/calcaneus, first to make contact with ground in gait therefore is paramount to the function and movement of the other two compartments Midfoot- navicular/cuboid, provides stability, mobility and transfers weight and movement from the hindfoot to the forefoot Forefoot- three cuneiform/all metatarsals and phalanges, last point of contact in gait and essential for adapting to surface levels
23	MOTIONS (cont’d) Adduction- foot moves toward midline Abduction- foot moves away from midline The above occurs in the transverse plane at the forefoot Supination- a combination of plantarflexion/inversion/adduction Pronation- a combination of dorsiflexion/eversion/abduction The above occur at the subtalar/transverse joint and are triplanar. Functionally these joints can not be separated therefore are combined motions
24	TALOCRURAL MOTION Plantarflexion- toes pointing down, 30 to 50 degrees maximum range of motion Dorsiflexion- toes pointing up, 20 degrees maximum range of motion The above occur in the sagittal plane at the talocrural joint
25	SUBTALAR MOTION Inversion- raise the medial border of the foot inward, is a result of the rotation of the tarsal joints (navicular/cuboid move medially) Eversion- raise the lateral border of the foot outward, also results from rotation of tarsal joints (cuboid moves lateral, navicular follows) The above occur in the coronal plane at the subtalar joint
26
27	MEDIAL LIGAMENTS Deltoid ligament (a.k.a Medial collateral ligament) – consists of four fanned shaped ligaments: Posterior Tibiotalar ligament – is the posterior portion that runs from the tibia to the talus Anterior Tibiotalar ligament – is part of the anterior portion that runs from the tibia to the talus Tibionavicular ligament – is another part of the anterior portion that runs from the tibia to the navicular Tibiocalcaneal ligament – is the middle portion that runs from the tibia to calcaneus Together these ligaments resist eversion
28	MEDIAL VEIW
29	LATERAL LIGAMENTS Lateral collateral Ligaments consists of three ligaments: Anterior Talofibular ligament – runs from anterior fibula to lateral neck of the talus. Resists posterior movement of the fibula from talus Calcaneofibular ligament – runs from the lateral malleolus down and back to upper lateral calcaneus. Resists dorsiflexion Posterior Talofibular ligament – runs from the malleolar fossa to the posterior aspect of talus. Resists anterior displacement of the tibia and fibula on talus and inversion
30	LATERAL VEIW
31	SUBTALAR LIGAMENTS Interosseous Talocalcaneal ligament – starts on the underside of the talus runs downward and lateral to dorsum of the calcaneus. Resists eversion Cervical Talocalcaneal ligament – runs from inferiorlateral talar neck down to the lateral dorsum of the calcaneus. Resists inversion Talocalcaneal ligament – runs from talus to the calcaneus. Resists inversion
32	MIDTARSAL LIGAMENTS Spring ligament – sustentaculum tali runs forward to the inferomedial navicular helps maintain normal arched configuration of the foot Plantar Calcaneocuboid ligament (a.k.a Short Plantar ligament) – runs from the anterior tubercle of plantar aspect of calcaneus to underside of cuboid
33	MIDTARSAL LIGAMENTS (cont’d) Long Plantar ligament – runs from the posterior tubercles of the calcaneus to base of 5^th, 4^th, 3^rd and sometimes 2^nd metatarsals The Short and Long Plantar ligament together support normal arched configuration of the foot by helping to maintain a twisted relationship between hindfoot and forefoot Metatarsophalangeal ligament – stabilizes the longitudinal arch by tensing the plantar aponeurosis during toe flexion
34	INTERPHALANGEAL LIGAMENTS Plantar ligament – attaches onto the lateral part of the fibrous capsule. It is a thickening of the joint capsule of the PIP’s and DIP’s Collateral ligament – runs on the lateral aspect of the base of phalanx to the distal head of next phalanx. Stabilizes the lesser MTP joints and it also has a role in claw toe
35	LATERAL ARCH Lateral Longitudinal Arch – a.k.a the weight-bearing arch Involves calcaneus, cuboid, 4^th & 5^th metatarsls and toes The keystone is the cuboid Spring ligament, Peroneus Longus, Plantar Aponeurosis, Long and Short Plantar ligaments support this arch
36	MEDIAL ARCH Medial Longitudinal arch involves calcaneus, talus, navicular, cuneiforms and 1^st to 3^rd metatarsals The keystone is the talus This arch keeps the foot in balance and is the major shock absorber
37	ELEVATED ARCH Elevated arch is called Pes Cavus. It is sometimes associated with claw toe People with condition can have corns and hard skin under 5^th & 1^st toes, may experience tenderness and stiffness along the arch Pain can be relieved through massage to calf muscles, but can not be corrected
38	DROPPED ARCH A dropped arch is called Pes Planus (flat foot). It is caused by tight posterior leg muscles. Being overweight, standing all day, hard uneven floor, sports and bad foot wear increase your chances of this condition. Massage relieves pain temporarily. We can’t correct this condition, but we can suggest proper foot wear, shoe inserts and corn treatments.
39	METATARSAL ARCH Also known as the false arch Runs transverse across the metatarsal bones Metatarsalgia may develop when this arch drops Common in arthritics and diabetics Caused by bad footwear
40	ARCH TREATMENT Pain can be reduced by massaging the tight calf and hamstring muscles Stretching tight musculature, changing shoes or orthotics may help with this condition Deep moist heat/paraffin wax may help symptoms or ice if inflammation is present
41	MUSCLES OF CLAW TOE
42	EXTENSOR DIGITORUM BREVIS Origin: Dorsal aspect of calcaneus Insertion: 2-4 phalanges via extensor digitorum longus tendon Action: extends 2-4 phalanges at MTP and IP joints Nerve: Peroneal
43	EXTENSOR DIGITORUM LONGUS Origin: Lateral condyle of tibia, proximal fibula and interosseous membrane Insertion: Middle and distal phalanges 2-5 Action: extends phalanges 2-5 dorsiflexes and everts foot Nerve: Peroneal
44
45	FLEXOR DIGITORUM LONGUS Origin: Middle ½ of posterior tibia Insertion: Distal phalanges 2-5 Action: Flexes phalanges 2-5, plantarflexes and inverts foot Nerve: Tibial
46
47	FLEXOR DIGITORUM BREVIS Origin: Plantar aspect of calcaneus Insertion: Middle phalanges 2-4 Action: Flexes PIPs of phalanges 2-4 Nerve: Plantar
48
49	QUADRATUS PLANTAE Origin: Medial head: Medial surface of calcaneus Lateral head: lateral border of calcaneus Insertion: Both heads join into a band inserting onto the tendon of flexor digitorum longus Action: assists flexor digitorum Nerve: Lateral Plantar
50
51	MUSCLES OF HAMMER TOE
52	PLANTAR INTEROSSEOUS Origin: 3 muscles that originate on the bases and medial sides of metatarsals 3-5 Insertion: Medial sides of the bases of the proximal phalanges 3-5 Action: Adduct phalanges 3-5, flex proximal phalanges and extend distal phalanges Nerve: Lateral Plantar
53	DORSAL INTEROSSEOUS Origin: 4 bipennate which arise from 2 heads from adjacent sides of the metatarsal bones Insertion: 1^st inserts onto medial aspect of proximal phalanx of 2^nd toe, 2^nd – 4^th onto lateral sides of those toes Action: Flex proximal, extend distal and abduct phalanges Nerve: Medial and Lateral Plantar
54
55	LUMBRICALS Origin: tendons of flexor digitorum longus- 1^st arises from medial side of tendon to 2^nd toe, etc. Insertion: onto the extensor digitorum longus tendons on the dorsal surface of the proximal phalanges Action: flex proximal at MTP and extend distal phalanges 2-4 Nerve: medial and lateral plantar
56
57	NERVE INNERVATION These muscles are all innervated by the Sciatic nerve running from the sacral plexus which comes off the ventral rami of spinal nerves L4-S4 This nerve runs along the posterior wall of the pelvis, through, under or above the piriformis muscle, down to each muscle.
58	NERVE INNERVATION (cont’d) It is made up of the tibial and peroneal nerves combined in a sheath which innervate the buttocks and posterior thigh and divides into medial and lateral plantar (tibial) and superficial and deep (peroneal) just above the popliteal space.
59	TIBIAL NERVE Comes off of dorsal rami of L4-S3 Supplies gastrocnemius, soleus, plantaris, popliteus, tibialis posterior, flexor digitorum longus, flexor hallicus longus
60	PLANTAR NERVES Medial plantar: Abductor hallicus, flexor digitorum brevis, flexor hallicus brevis Lateral Plantar: Abductor digiti minimi, quadratus plantae, lumbricals, adductor hallicus, flexor digiti minimi brevis, plantar interossei, dorsal interossei
61
62	PERONEAL NERVES Superficial: peroneus longus and brevis Deep: tibialis anterior, extensor hallicus longus, extensor digitorum longus and brevis, peroneus tertius
63
64
65
66
67
68	TREATMENT Treatments include using forefoot products designed to relieve hammer toes, such as hammer toe crests and hammer toe splints Gel toe shields and gel toe caps are also recommended to eliminate friction between the shoe and the toe, while providing comfort and lubrication Surgical correction in case of fixed deformity.
69
70	CLAW TOE
71	WHAT IS CLAW TOE? A claw toe is a toe that is bent at both the middle and end joints in the toe, known anatomically as the DIP and the PIP joints, and a dorsiflexion deformity at the metatarsal phalangeal joint. This condition can lead to severe pressure and pain.
72	CAUSE OF CLAW TOE Ligaments and tendons that have tightened will cause the toe’s joints to curl downwards. Claw toes may occur in any toe, except the big toe. There is often discomfort at the top part of the toe that is rubbing against the shoe and at the end of the toe that is pressed against the bottom of the shoe.
73	CLASSIFICATION OF CLAW TOE - FLEXIBLE Claw toes are classified based on the mobility of the toe joints There are two types of claw toes: Flexible - the joint has the ability to move, can be straightened manually
74	CLASSIFICATION OF CLAW TOE - RIGID Rigid - the joint does not have ability to move, the flexed position of the PIP and DIP joints remains constant, the collateral ligaments fibrose along the sides of the PIP & DIP joints and the position of their joints becomes fixed. Movement is very limited and can be extremely painful.This sometimes causes foot movement to become restricted leading to extra stress at the ball-of-the- foot, and possibly causing pain and the development of corns and calluses
75	ETIOLOGY Claw toes result from imbalance between the intrinsic and extrinsic musculature of the toes which causes the collateral ligaments lose their resilience and tendons become unnaturally tight. This results in the joints curling downwards. Claw toe can also result from wearing high-heeled shoes and shoes that squeeze your toes. Arthritis can lead to many different forefoot deformities, including claw toes.
76	PATHOPHYSIOLOGY When the MTP joint is in neutral, the lumbricals, intrinsic muscles and the extensor digitorum are very strong extensors of the DIP and PIP joints. Because of hyperextension of MTP joint, the extension of the DIP & PIP is reduced due to mechanical disadvantage. Flexor digitorum will tighten and keep the DIP & PIP in a flexed position due to lack of the strength of antagonist.
77	TREATMENT AND PREVENTION Massage the affected muscles extrinsically Passive movements of MTP, DIP,PIP joints. Toe exercise to strengthen and stretch muscles. Towel scrunches work great, just place a towel on the ground and crumple it under your feet. Manually extend DIP and PIP joints Changing the type of footwear worn is a very important step in the treatment of claw toes When choosing a shoe, make sure the toe area is high and broad, and can accommodate the claw toes
78	"A shoe with a high" A shoe with a high, broad toe box will provide enough room in the forefoot area so that there is less friction against the toes Other conservative treatments include using forefoot products designed to relieve claw toes, such as toe crests and hammer toe splints. These devices will help hold down the claw toe and provide relief to the forefoot Gel toe shields and gel toecaps are also recommended to eliminate friction between the shoe and the toe, while providing comfort and lubrication
79	BIBLIOGRAPHY
80	BIBLIOGRAPHY
81	BIBLIOGRAPHY
82	BIBLIOGRAPHY http://www.healthatoz.com/healthatoz/Atoz/ency/hammertoe.html http://www.dynomed.com/encyclopedia/encyclopedia/foot and ankle/claw Toe.html http://www.podiatrychannel.com/hammertoes/index.shtml http://www.aofas.org/clawtoes.asp