Important muscles and ligaments of the foot. Treatment of flat feet.

Sprained ligaments - symptoms and treatment

There is no single algorithm for diagnosing sprains. The most commonly used are radiography, ultrasound, computed tomography and magnetic resonance imaging.

Doctors often perceive a sprain as a minor injury, so when making a diagnosis they do not always indicate which ligament is damaged. Most often, only radiography is performed to exclude concomitant bone damage.

Radiography

Radiography is the main method of primary diagnosis for injuries of bones and joints. The examination is inexpensive and can be done in almost any clinic. But soft tissues are poorly visible on x-rays, so in case of sprained ligaments, this method only allows one to exclude concomitant bone injuries [12].

Nowadays, film radiography is increasingly being replaced by digital methods. The main advantage of digital radiography is the ability to quickly obtain images. Images can be printed on a special printer, saved and recorded on digital media.

Ultrasonography

Ultrasound, ultrasonography and sonography are different names for the same method. Like radiography, ultrasound is performed in the initial diagnosis of musculoskeletal injuries.

Ultrasound examination is based on the creation of acoustic waves, or ultrasound, by a device. These waves travel unevenly through the body's tissues. Having reached the boundary of two different environments, for example, adipose tissue and muscle, the waves partially pass through the tissue and are partially scattered. The image of tissues is created based on reflected waves.

The accuracy of ultrasound is quite low. It depends both on the device and on the diagnostician: many parameters must be configured manually. In addition, the method has physical limitations associated with the depth of penetration of sound waves into tissue: at greater depths, the quality of visualization decreases. Also, when performing an ultrasound, the contact area of ​​the sensor with the surface of the body is limited, which is why the picture of the damage is incomplete.

The advantages of ultrasound are the ability to assess the condition of tissues during movement, the absence of radiation exposure, the accessibility and low cost of the examination [1].

CT scan

During a computed tomography (CT) scan, x-rays pass through different types of tissue at different intensities. Bone tissue is very dense, so it absorbs these rays well and its structure is clearly visible in the photographs. Soft tissues are less well visualized on CT images, so if they are suspected of being damaged, orthopedic traumatologists rarely use this method.

The advantages of CT include the speed of diagnosis, which is especially important when examining children - they do not have to lie still for a long time, as during an MRI. In addition, CT allows one to evaluate the results of surgery, including after injuries to ligaments and tendons.

Magnetic resonance imaging

MRI plays an important role in imaging sports injuries and other musculoskeletal injuries. Unlike CT, MRI does not use X-rays, i.e. there is no radiation exposure.

Magnetic resonance imaging provides the highest contrast images of soft tissue, so it can be used to assess damage to muscles, tendons, ligaments, cartilage and bone marrow. Images can be taken in any plane, which allows the method to be adapted to each specific pathology.

The disadvantages of MRI are the relative high cost, the risk of developing an attack of claustrophobia and the need to remain in a stationary position for a long time (30 minutes or more).

It is usually recommended to start with the most accessible methods: radiography and ultrasound.

Muscles and tendons of the leg

Calf muscle

This powerful calf muscle consists of two heads, medial and lateral, which originate on the posterior surface of the distal end of the thigh and are attached by the Achilles tendon to the calcaneus.

The gastrocnemius muscle is involved in running, jumping, and all types of activities that involve high-intensity stress on the lower extremities.

Together with the soleus muscle, it forms the calf muscle, called the triceps surae muscle. The function of the gastrocnemius muscle is to flex the foot and ankle downward (plantar flexion).

Forceful dorsiflexion of the foot can cause damage to this muscle.

Soleus muscle

This muscle starts from the tibia below the level of the knee joint and is located under the gastrocnemius muscle. Distally, its tendon unites with the gastrocnemius tendon to form the Achilles tendon. Like the gastrocnemius muscle, the main function of this muscle is plantar flexion of the foot.

The calf muscle is involved in walking, dancing, and maintaining an upright body position when we stand. Also, one of its important functions is to ensure blood flow through the veins from the lower limb to the heart.

Plantaris muscle

It is a small muscle that originates along the lateral head of the gastrocnemius muscle. The tendon of this muscle is the longest tendon in the human body. It is a weak but still plantar flexor of the foot. Damage to this muscle can occur when playing sports.

Achilles tendon

The Achilles tendon is formed at the mid-calf level by the gastrocnemius and soleus muscles and is attached to the heel bone. This is the most powerful and durable tendon in the human body.

It is subjected to the most significant loads compared to all other tendons. When running and jumping, the tendon is subjected to loads that are 8 times greater than body weight, and when walking - 4 times.

Through the Achilles tendon, the gastrocnemius and soleus muscles perform plantar flexion of the foot and ankle joint.

The tendon consists of three parts:

• Musculotendinous part (proximal part of the tendon, at the level of which muscle fibers turn into tendon fibers)
• Non-insertional part (body) of the Achilles tendon
• Insertion part of the Achilles tendon

The blood supply to the Achilles tendon is quite poor compared to other anatomical structures. The tendon in its upper section receives blood supply from the muscles that form the tendon, and below - from the heel bone to which it is attached. The middle part of the tendon is supplied with blood by the branches of the peroneal artery and this blood supply is the poorest, so it is not surprising that this part of the tendon is most susceptible to damage. The Achilles tendon is surrounded by a soft tissue sheath called the paratenon. The middle part of the tendon receives its blood supply precisely through this sheath. The paratenon allows the Achilles tendon to glide relative to surrounding tissues for up to 1.5 cm.

Anterior to the Achilles tendon is the Kager fat pad, which performs an important function of protecting the Achilles tendon.

MR anatomy of the Achilles tendon

1. Musculotendinous part
2. Kager fat body
3. Non-insertional part of the Achilles tendon
4. Insertion part of the Achilles tendon

Diagnostics

Disease history

• The patient may experience pain in the big toe when walking or making any movements. This may indicate degeneration of intra-articular cartilage.
• The pain may be aching in the metatarsal area due to wearing shoes. Possible increase in deformation. .
• It is necessary to find out what physical activities increase the pain and what relieves the pain (maybe just taking off your shoes).
• History of injury or arthritis.
• It is quite rare to experience sharp pain or tingling in the dorsal region of the bursa of the thumb, which may indicate traumatic neuritis of the middle dorsal cutaneous nerve.
• The patient may also describe symptoms caused by the deformity, such as a painful second toe, interdigital keratosis, or ulcer formation.

Visual inspection

• It is necessary to observe the patient's gait. This will help determine the degree of pain and possible gait disturbances associated with problems in the legs.
• The position of the big toe in relation to the other toes. Distortion of the joint can be in different projections.
• Prominent joint position. Erythema or swelling indicates shoe pressure and irritation.
• Range of motion of the big toe at the metatarsal joint. Normal posterior flexion is 65-75° with plantar flexion less than 15°. Moreover, it is necessary to pay attention to whether pain and crepitus are present. Pain without crepitus suggests the presence of synovitis.
• The presence of any keratosis, which suggests pathological chafing from abnormal gait..
• Associated deformities may include hammertoes and flexible or rigid flat feet. These deformities can cause hallux valgus to progress more rapidly as the lateral support of the foot is reduced.

Changes in movement of the thumb joint:

• Increased abduction of the big toe in the transverse and frontal planes.
• Increased average toe prominence.
• Change in backward flexion of the joint.

In addition, it is necessary to pay attention to the condition of the skin and peripheral pulse. Good blood circulation is especially important if surgical treatment is planned and normal healing of the postoperative wound is necessary.

Treatment

Conservative treatment

Treatment of hallux valgus almost always begins with the selection of comfortable shoes that do not cause friction or stress. In the early stages of Hallus valgus, wearing shoes with a wide front can stop the progression of the deformity. Since the pain that results from bunions occurs due to pressure from shoes, treatment focuses on relieving the pressure that shoes place on the deformity. Wider shoes reduce pressure on bunions. Bunion pads can reduce pressure and friction from shoes. There are also numerous devices, such as spacer orthotics, that can splint the toe and change the load distribution on the foot.

Drug treatment and physiotherapy

Nonsteroidal anti-inflammatory drugs and physical therapy may be prescribed to reduce inflammation and relieve pain. In addition, corticosteroid injections are possible. Long-term physical therapy has not proven to be therapeutically effective.

Orthopedic products

It is possible to use various orthopedic products (instep supports, toe correctors, interdigital rollers). The use of orthopedic devices helps to stop further deformation in the early stages. With severe deformation, the use of orthopedic products can only slightly reduce pain. Custom insoles help correct damaged arches.

If the deformity is caused by a metabolic disorder or a systemic disease, then it is necessary to carry out treatment aimed at correcting the underlying disease with the involvement of a rheumatologist or endocinologist.

Foot pain

General information

foot is the lowest part of the lower limb . The part of the foot that is in direct contact with the ground is called the foot or sole. The foot has three bony support , two of which are located in the forefoot and one in the hindfoot.
The hindfoot is the heel ; the forefoot is the toe of the foot, which includes five toes. The toes include the phalanges of the foot skeleton. The bones of the foot extend from the tips of the toes to the heel, uniting in the body of the foot.

The metatarsals and phalanges are similar to the metacarpus and phalanges of the hand, but are less developed due to their less mobility. When walking, the heel comes into contact with the surface first, then the lateral edge of the foot, the balls of the sole and the big toe.

The base of the foot is made up of 26 bones, the most important function of which is springing. The special structure of the foot (the presence of a longitudinal and transverse arch) ensures a softening of the load on the lower limbs, pelvis and spine. When the longitudinal arch is flattened as a result of weakness of the ligamentous-muscular system, deformation of the foot occurs, the disease flatfoot.

Depending on the nature of the damage to the arch, longitudinal and transverse flat feet are distinguished. It is possible to combine these forms with each other and with other foot deformities.

Pain in the foot due to illness

Foot pain is a very common cause of patient complaints. They can be general, diffuse, involving the entire foot, or limited to certain and small areas of the feet. Diffuse foot pain is sometimes associated with load or tension, but can also appear at rest, without any tension on the foot. Pain associated with exercise without any additional clinical manifestations may be early signs of foot insufficiency associated with calcium depletion (osteopathy) with:

• rickets;
• osteomalacia;
• senile osteoporosis.

What is striking is the pain of all the bones when pressing on them with the tip of a finger. Long-term bed rest for various diseases also causes diffuse pain in the feet, which is associated not with bones, but with insufficiency of the musculo-ligamentous apparatus . The same pain from insufficiency occurs with a rapid increase in total body weight or prolonged increased stress. Especially severe pain in the feet at rest and the almost complete loss of their ability to support with inflammatory-trophic changes accompany osteoporosis , which occurs after damage and diseases of the bones, joints and soft tissues of the ankle joint and foot. Severe diffuse foot pain , prolonged or paroxysmal, occurs with functional and organic vascular lesions. Local pain limited to certain areas of the foot can be due to a number of reasons. Methodical palpation by pressing with a fingertip in typical places makes it possible to make a topical diagnosis, and with it to find out the nature of the disease. The most common cause of foot pain is plantar fasciitis .

Plantar fasciitis

The plantar fascia is a wide band of connective tissue that runs along the plantar surface of the foot from the heel bone to the metatarsal heads in the forefoot. Plantar fasciitis is caused by stretching of the fascia, which is caused by excessive pronation of the foot.

Inflammation caused by stretching of the fascia in the heel area leads to pain both in the heel itself and in the arch of the foot. Pain in the feet is especially noticeable in the morning, when a person gets out of bed after a long rest.

a heel spur develops where it attaches to the heel bone . Therefore, it is important to begin treating functional changes before complications develop.

Other causes of foot pain

Foot pain can also be caused by the following reasons:

• arthritis;
• impaired blood supply;
• compression of the nerves between the fingers;
• deformation of the metatarsal bones.

Most often, this pain is caused by nerve damage or age-related changes in the foot, called metatarsalgia.

Foot pain due to age-related changes. With age, the protective function of the shock-absorbing fat layer in the area of ​​the metatarsal heads gradually decreases. This condition can lead to compression of the bursae in the area of ​​the metatarsal heads, which leads to their inflammation - bursitis.

Joint inflammation or rheumatoid arthritis can also cause pain.

Foot pain can be caused by a benign growth of nerve tissue called a neuroma, which surrounds the nerve. The neuroma usually occurs in the base of the third or fourth toe (Morton's neuroma), although it can also occur in other toes.

Neuromas usually occur on one foot and are more common in women. Typically, in the early stages, neuroma manifests itself as moderate pain in the area of ​​the third or fourth toes, and is sometimes accompanied by a burning or tingling sensation. Negative symptoms are aggravated by wearing certain uncomfortable shoes, especially those with narrow toes. As the process progresses, the tingling becomes constant, regardless of what kind of shoes the person wears.

Traumatic foot injuries

Dislocation in the Lisfranc joint is also rare and can be complete or incomplete. With complete dislocation , all metatarsal bones are displaced; with incomplete dislocation, individual metatarsal bones are displaced from their normal position. The patient has pain in the foot. The shape of the foot changes.

The foot appears shortened and widens in the forefoot. If one of the metatarsal bones on the surface of the foot is dislocated, a protrusion in the form of a step is determined. The diagnosis is confirmed by X-ray examination.

Dislocation of the tarsal bones or dislocation of the Chopart joint is extremely rare. Dislocation occurs when the foot turns sharply. The patient is bothered by pain in the foot, which usually increases sharply with movement. Subsequently, swelling occurs, which quickly increases. In the foot below the site of dislocation, the blood supply is disrupted. The victim must be given pain relief and quickly taken to the hospital for urgent reduction of the dislocation.

Subtalar foot dislocation is rare. This dislocation occurs in the talocalcaneal and talonavicular joints. The mechanism of dislocation is a sharp twisting of the foot in any direction.

The talus bone is displaced from its place, and on the side opposite to the displacement a ligament rupture occurs. The patient complains of pain in the foot. The shape of the foot has been changed. To exclude fractures of the foot bones, X-rays are taken.

Dislocation of the foot in the ankle joint is not common and is accompanied by rupture of the ankle ligaments and joint capsule and ankle fractures, less often other articular fractures. Types of foot dislocations: external, internal, forward, backward and upward. An outward dislocation of the foot occurs when the foot is twisted sideways and outward.

In this case, a fracture of the outer ankle occurs. When the foot turns inwards, a fracture of the inner malleolus occurs and the foot dislocates inwards. A posterior dislocation of the foot can occur with a strong blow to the shin or with a sharp and strong plantar flexion of the foot, and an anterior dislocation occurs when the foot is bent towards the rear or the shin is struck from behind.

Rarely, upward dislocation of the foot occurs when falling from a height. The patient is worried about pain in the foot , the inability to stand on the foot and walk. The shape of the foot has been changed. The diagnosis is confirmed by X-ray examination. As first aid, it is necessary to give the victim an anesthetic and take him to the hospital. A heel spur is a small bony growth on the plantar surface of the heel bone. The cause of such growths is excessive traction of the tendon at the point of attachment to the heel bone. Heel spurs are a common phenomenon, but they do not always manifest themselves as pain in the foot.

Pain in the foot, namely in the heel, occurs when inflammation develops in the soft tissues surrounding the spur. The first manifestations of a heel spur are usually noted when a person has just gotten up in the morning and stepped on his heel, or after the first steps, when he has been sitting for a long time.

Flat feet

The foot with flat feet touches the surface with the entire area of ​​the sole and ceases to perform a spring function, pain and fatigue of the feet and legs occur when walking, standing, and running.

Acquired flat feet (congenital is extremely rare) most often develops as a result of various overloads of the feet, especially during the period of growth of the body. In adulthood, flat feet often develop when standing for a long time (for example, sellers, hairdressers). Flat feet can also be caused by:

• carrying heavy objects for a long time;
• excess body weight.

Traumatic flatfoot develops after a fracture of the ankles or foot bones. With fractures of the bones of the lower limb, flat feet also often develop, moreover, on the side opposite to the fracture.

Erythromelalgia

This disease affects the legs, usually the feet. It occurs most often among middle-aged men. Characterized by the following characteristic symptoms :

• burning pain;
• redness of the foot.

The disease is usually preceded by heating of the limb or its forced position. The pain is relieved by applying cold or elevating the affected limb.

This disease accompanies other diseases, such as:

• hypertension;
• reaction to a drug;
• polycythemia;
• thrombocytosis.

May occur in myeloproliferative diseases such as leukemia. But it can also happen without connection with other diseases. The cause of this disease is unknown.

A burning sensation in a limb often occurs as a response to heat. Pain in the foot can also cause forced positioning of the limb. The affected area turns red. Foot pain also occurs due to ingrown toenails, bunions, calluses and plantar warts. The overwhelming cause of these diseases is wearing ill-fitting shoes.

Prevention and treatment

For prevention , doctors recommend:

• swimming, jogging, cycling, skiing, walking more;
• do a warm-up before putting any weight on your foot;
• play sports in sports shoes, change them every six months;
• rest if you feel pain and fatigue in your legs;
• walk barefoot on the grass;
• buy shoes in the afternoon, when the foot swells a little;
• make sure that the shoes are comfortable and do not rub;
• wear heeled shoes less often.

Each specific case will require its own system for treating foot pain . First you need to find out the cause of the pain. If you have flat feet, the solution may be to systematically wear special orthopedic insoles. For heel spurs, special ointments in combination with bed rest can help.

Surgical methods of treatment

Globally, all operations to remove hallux valgus are divided into minimally invasive and open. Minimally invasive ones are performed through small incisions in the skin. In most cases, there is no need for stitches. Recovery is quick and easy.

There are three categories of open surgical interventions:

Manipulation of soft tissues.

An example is the McBride operation. The muscles and ligaments of the foot are cut. Bones are not affected. The intervention is effective for minor deformities and can be performed in case of contraindications from the osteoarticular system.

Osteotomy.

An artificial fracture of the metatarsal bone is performed. The doctor selects the location of the fracture. Due to this, the position of the metatarsus is corrected

Arthrodesis.

The operation is used in advanced stages of hallux valgus deformity, when it is necessary to return the physiological shape of the joint.

The doctor, from all the methods of surgical intervention available to him, selects the one that best solves the problems of a particular patient.

The operation requires preliminary preparation. We need to get some test results. These include clinical and biochemical blood and urine tests, a blood test with a detailed coagulogram, and tests for blood-borne infections. Electrocardiography is prescribed, and x-rays of the foot are performed (necessarily in two projections).

If no contraindications to surgery to remove hallux valgus are identified, the method of anesthesia is agreed upon. Most often, local anesthesia is sufficient.