Recognition & Treatment of Foot Injuries

The average person walks about 1,000 miles each year, with each step putting 1.5 times their body weight on their feet. Because of improper footwear, lack of stretching, traumatic events and overuse, 43.¹ million Americans have foot problems.¹ Fifteen percent of all sports-related injuries affect the feet alone.² This article discusses some common foot injuries seen by prehospital providers.

Anatomy
     Understanding the underlying structures of the foot is key to assessing and treating injuries.

     Topographic anatomy is the language of orthopedics, using the following terms to locate a body structure relative to another structure: proximal-closer to the body's core; distal-further from the core; medial-toward the center of the body; lateral-toward the side or edge; superior-top of the foot; inferior-toward the bottom; anterior and posterior-front and back. Understanding these terms can help us locate anatomical structures and communicate the location of injuries.

     The foot has four ranges of motion. It moves upward during dorsiflexion and downward during plantar flexion. Inward movement is known as inversion; outward movement is eversion.³

     The foot has 26 major bones, which are split into three regions: the forefoot, midfoot and hindfoot. The forefoot consists of the phalanges, or toe bones, and five metatarsal bones, numbered 1 through 5 medial to lateral. Comprising the midfoot are the cuneiform, navicular and cuboid bones. The bones of the midfoot are also known as tarsal bones. The calcaneus (heel bone), which is the foot's largest bone, and the talus make up the hindfoot.

     Tendons control foot movement by connecting the muscles in the lower leg to bones in the foot. The Achilles tendon, the largest tendon in the foot, controls plantar flexion, or the ability to stand on our toes. It runs from the calf muscle to the base of the calcaneus.

     Three tendons run through the tarsal tunnel across the superior surface of the foot. The flexor hallicus longus, which flexes the great toe, is the most posterolateral tendon and inserts at the great toe. Immediately next to it is the flexor digitorum longus, which inserts into and flexes the other four digits of the foot. The final tendon in the tarsal tunnel is the tibialis posterior tendon, which inserts into the navicular and cuneiform bones, as well as the middle metatarsals. It is responsible for foot inversion and adduction.

     Peroneus longus and peroneus brevis tendons run behind and around the lateral malleolus. The peroneus longus plantar flexes the first metatarsal and ankle and abducts the foot. The peroneus brevis flexes the ankle and everts the foot.²

     The plantar fascia is a large band of connective tissue that links the base of the calcaneus to the base of the phalanges. This extremely thick band provides a majority of support for the arch and allows the foot to stretch. Each time we take a step or stand on our toes while shifting weight, the plantar fascia supports the entire body's mass.

     There are 109 ligaments in the foot and ankle connecting bone to bone. Ligaments give integrity to the foot structure.

     There are two arteries in the ankle that prehospital personnel must be able to locate to accurately assess circulation in the foot after an injury. The dorsalis pedis artery extends from the anterior tibial artery across the top of the ankle onto the dorsum of the foot. The deep peroneal nerve lies on the lateral side of the artery. The other artery is the posterior tibial artery, which runs down the posterior tibia and around the medial malleolus, and is best felt on the inferior aspect of the medial malleolus.

     Inside the foot, the neurovascular bundles continue to follow the inferior aspect of the most medial and lateral metatarsals as they travel toward the toes.

     Nerves run adjacent to the blood vessels. The neurovascular bundles are vulnerable to compressive forces and swelling between the metatarsals.²

MOI and Injury Patterns
     Many mechanisms can lead to foot injuries. Patients who fall, are in motor vehicle crashes or twist their ankles can have foot fractures. Tendons and ligaments often are injured during falls and from overuse. Foot dislocations, while uncommon, are caused by things like tripping in a hole, foot entrapment in a saddle stirrup, or when the foot is stepped on during movement.² Objects falling on the foot are a crushing mechanism that can cause multiple problems within the foot from fractures to compartment syndrome.

     Some foot injuries require emergency department care, and some do not. Recognizing the difference can save both the patient and emergency department time and resources.

Scenario 1: Track Meet
     You are working in the first aid tent at a track meet, where your job is to assess and treat injured athletes and determine which of them need emergency room treatment.

     A 17-year-old male, who is limping slightly, approaches the tent. He tells you he has been training heavily for the mile run for several weeks and denies any traumatic incident. He has no significant medical history or prior foot injuries, but says the base of his right heel has been getting progressively more painful for several days. This morning, there was significantly increased pain with each step.

     As you examine his feet, you notice the base of his right foot is swollen, and there is pain upon palpation along the inferior aspect of the calcaneus.

     The patient's problem is plantar fasciitis, the most common cause of heel pain.⁴

     Plantar fasciitis is inflammation of the plantar fascia. It is common in both overweight adults and anyone with a history of repetitive strenuous activity. Patients with plantar fasciitis experience pain mostly in the morning, just after getting up. Pain is typically described as a sudden searing sensation along the undersurface of the heel.⁴

     There is generally no need for a patient with isolated plantar fasciitis to be seen in the emergency department. Treatment includes additional arch support with either a cushion for the heel or an ACE wrap, and stretching the foot two to three times per day. Nonsteroidal anti-inflammatory drugs, like ibuprofen, may help relieve swelling and pain.⁵

Scenario 2: Track Meet
     During the afternoon of the track meet, a 34-year-old male enters your first aid tent complaining of a burning pain in his right foot that is worse when walking.

     The foot had bothered him the last week of training, but the pain increased significantly during his 3,200-meter race. He denies any fall, twist or trauma to his foot and ankle.

     The patient's injured foot feels warm and is swollen. Palpating the foot reveals point tenderness along the third metatarsal. Based on physical findings and lack of traumatic history, the patient probably has a stress fracture.

     Stress fractures are extremely common, representing nearly 10% of all sports injuries.² They can be caused by either sudden or repetitive overuse without proper conditioning. Either mechanism results in cracking the outer shell of a bone.

     Stress fractures most commonly occur in the second and third metatarsals, but can also occur in the tarsal bones.⁴ They are characterized by point tenderness, mild swelling, increased temperature at the injury site and increased pain with movement. The patient usually denies a single traumatic event, such as a fall or kick to the foot.

Scenario 3: Fall from Ladder
     A 32-year-old female has fallen from a ladder. She is lying on the ground complaining of bilateral heel pain after falling eight feet and landing on her feet.

     After stabilizing her spine and performing an initial assessment, you assess her feet. Both heels look wider than normal, and you notice crepitus upon palpation. There is also pain when she attempts dorsiflexion. This patient has bilateral calcaneus fractures, or two broken heels.

     Ten percent of all fractures occur in the foot³ and are often complicated by nerve and tendon injuries.⁷ Fractures range from the obviously deformed and open fractures to subtle fractures that can be seen only on x-ray. Anytime a physical exam reveals point tenderness along a bone, suspect a fracture. Calcaneus fractures are most common in feet- first falls and motor vehicle accidents. Tarsal and metatarsal fractures typically result from a direct blow.⁷

Scenario 4: Crush Injury
     A 43-year-old male was splitting wood when several logs fell onto his foot. He is still wearing boots, his pain is 10 of 10, and he cannot bear any weight on his left foot.

     You carefully expose his crushed foot by cutting away his sock and shoe. You are unable to find a dorsalis pedis pulse, there are multiple abrasions, and crepitus is present throughout the foot. This patient has suffered a major crush injury.

     Crush injuries can cause an incredible amount of damage to the foot. They are common in major trauma incidents like industrial, agricultural and motor vehicle accidents, as well as when heavy objects fall on top of the foot.

     In addition to shattered bones, all of the foot's soft tissues-ligaments, tendons, vessels and fatty padding-can be damaged as well.

     These injuries may or may not break the skin. If the skin has been broken, there is an excellent chance of infection.

     Whenever a patient presents with a crush-injury pattern, maintain a high index of suspicion for compartment syndrome, which occurs when swelling of one of the fascia increases the intracompartment so much that it squeezes arteries closed and cuts off distal circulation.

     Compartment syndrome is characterized by incredible pain, dusky skin color, tingling in the toes, pain when attempting to move the foot, and major swelling that causes the skin to become so taut that it develops a shiny appearance.⁷

     It is possible for compartment syndrome to develop within minutes of injury; however, onset may be slower, as swelling develops over 24 hours.

     Early recognition of compartment syndrome is critical, since it requires immediate surgical intervention to lower the pressure within the affected fascia.

Scenario 5: Impaled Object
     You are helping your neighbor build a tree house when she lets out a piercing scream. She has stepped on a nail that extended from a large board. The 4-inch-long nail, which can't be seen between the board and Julie's shoe, has pierced the center of her foot. You call 9-1-1 and stabilize her foot and the board.

     The paramedics assess the injury and, to your surprise, gently but firmly pull the nail out of her foot. After removing the nail, they dress the exposed wound and immobilize her foot.

     There are several special considerations when treating an impaled object in the foot.

     The depth of penetration determines the extent of injury. Deep punctures can damage vessels and nerves. Impaled objects break the skin, the body's protective barrier, which immediately puts the patient at high risk for infection. Proper field treatment is essential for infection prevention. Finally, you must decide whether to remove the impaled object.

Scenario 6: Fall from Horse
     A 15-year-old girl has fallen off her horse during a jumping competition. You are advised that although she was thrown from the horse, her foot was caught in the stirrup and she was dragged about 50 feet. She is lying supine on the ground.

     First responders are maintaining manual c-spine stabilization. She is conscious, alert and oriented, complaining of severe pain in the center of her right foot, and has no other injuries. Her right boot appears bent in the middle.

     After cutting off the boot and sock, you see her foot is obviously deformed; her toes and forefoot are all displaced inferiorly. You are unable to locate the dorsalis pedis pulse, her toes are grey and dusky, and the patient says they are tingling.

     As you palpate the foot, you can feel bone displacement along the proximal end of the metatarsals, which indicates a tarsometatarsal dislocation.

     Tarsometatarsal dislocation is a dislocation of the tarsal-metatarsal joint. Another name for this is the Lisfranc dislocation, named after Napoleon's physician, who recognized the injury pattern in hundreds of soldiers who had fallen off horses.

     In addition to the horse stirrup mechanism, twists, uneven steps and falls where the foot is caught in a hole can cause these dislocations.⁷

     Lisfranc dislocations may also be seen in snowboarding, windsurfing, football and rugby accidents.² These dislocations require surgery for reduction.⁷ Signs that suggest a Lisfranc fracture include:

• Mid-foot pain
• Inability to bear weight
• Edema and ecchymosis
• Deformity
• Absence of dorsalis pedis pulse
• Shortening of the foot
• Pain upon palpation of the base of the metatarsals.²

Foot Exam
     Foot injury is rarely life-threatening; however, gross deformity and exposed bone ends can distract a rescuer's attention from other injuries. Be sure to identify and treat life threats before attending to an injured foot.

     A good exam includes obtaining a patient history to understand the mechanism of injury and whether there have been previous foot injuries. If the patient fell, find out how, when and where the fall occurred. Develop a detailed mental picture of the mechanism.

     Ask your patient to point to where the foot hurts most. Determine if the injury is from overuse. Try to identify any underlying medical condition, such as syncope or seizure, that might have caused the fall. Ask for permission to examine the foot, then explain your actions and share your findings with the patient.

     Begin the physical examination by removing the patient's shoes and socks and pulling up or cutting the pant leg. Expose the lower leg from knee to toes, and also expose the uninjured foot for symmetry comparison.

     Look for gross deformity, which suggests a fracture or dislocation, and look for breaks in the skin from displaced bones.

     Assess swelling. Rapid-onset swelling indicates a more serious injury; however, swelling will continue to develop for 6-24 hours after injury.

     Ask the patient to rate and describe the pain using the OPQRST mnemonic.

     Check skin color and condition at the site of most pain and deformity and distal to the injured area. Pale or cyanotic skin suggests possible vascular compromise. Is the injured foot warmer or cooler than the uninjured foot?

     Determine the presence of pulses in the injured foot. Assess for a pulse at the dorsalis pedis and posterior tibial arteries. Mark the location of both pulses with an "X" for easier reassessment. If a pulse is absent, document the time of this important finding.

     Capillary refill is not a good assessment of circulatory quality; however, a capillary refill time that continues to worsen can be a sign of decreasing circulation.

     To assess neurological function-movement and sensation-ask the patient to wiggle his toes. Next, determine if he can distinguish between a sharp and soft object to assess sensation.

     Have the patient extend and flex his foot against the pressure of your hand to test for motion and weight- bearing ability. Compare the mobility of both feet and note any decreased range of motion or increase in pain in the injured foot.

     Palpate the bones to examine for any subtle deformities, crepitus or instability. (Crepitus is the sensation of broken bone ends grinding together.) Pay special attention for pain upon palpation of a specific bone or bone end.

Injury Risk Factors
     Athletics
     Running and jumping overstress ligaments, and jumpers also risk landing on the sides of their feet. Those who participate in kicking and contact sports, such as football, soccer and basketball, face additional forces and risk direct trauma to the foot.¹ Many 'weekend warriors' become injured by overexerting their untrained bodies. Unconditioned ligaments and tendons are prone to overstretching and tearing.⁴

     Obesity
     Extremely obese people subject the tendons, ligaments and foot bones to much greater forces than they were designed to withstand. Occurrences of both tendonitis and plantar fasciitis increase proportionally to patient weight.

     Age
     Youth and teenagers have stronger tendons and ligaments than adults, and, as a result, are more likely to have a fracture in the foot than a torn ligament.³ As age increases, however, tendons and ligaments become more brittle and tear more easily.

     Repetitive Activity
     Anyone subjecting their feet to repetitive strenuous activity, regardless of physical shape, risks additional injuries. Repetitive motion wears down ligaments and tendons, and constantly stresses foot bones. A stress fracture is one of the most common repetitive-activity injuries.

Treatment
     There are five treatment goals for the injured foot: stabilization, positioning, complete immobilization, pain management and transport to an appropriate facility.

     Remember, not all foot injuries require emergency room care.

     Early in your assessment, direct your partner, first responder or bystander to provide hand stabilization to the injured foot. This may be done before you examine the foot.

     Stabilize the foot in the position found by placing your hands above the ankle and below the site of injury to minimize movement, reduce pain and prevent further injury.

     If there is an impaled object, you must decide whether to immobilize it in place or remove it. If you decide on immobilization, make sure it will not move and that it is protected from causing further injury during transport. After stabilizing the foot, stabilize the impaled object with bulky dressings.

     The patient will often remove an impaled object prior to EMS's arrival. If the object has been removed, treat it as a high-risk puncture wound. Removal of impaled objects is especially appropriate in delayed or prolonged transport contexts.

     Use the following guideline to determine if you should remove an impaled object:
     Can the impaled object be safely immobilized in place?

     This means the object won't move at all during transport. For example, a nail sticking three inches out of the foot can be immobilized in place safely; however, if a board is attached to the nail, immobilization becomes much more difficult.

     Is it safe to remove the object?

     A pulsing object clearly going through an artery should not be removed, but something like a wood splinter in the pad of the big toe is safe to remove.

     Is the object easy to remove?

     Objects that are safe and easy to remove and cannot be immobilized in place should be removed in the field. Unsecured impaled objects left in place may cause additional tissue, vessel and nerve damage if they move during transport.

     Clean any open foot wound, whether an abrasion or puncture, before dressing. Wound cleaning is especially important for services with long transport times. After controlling bleeding, wash around the wound with water to remove any debris. Irrigate deep wounds and puncture wounds with sterile water. Flushing the wound with a syringe increases the mechanical effectiveness of water irrigation. Also rinse the wound with a 1% povidone iodine solution to reduce risk of infection. After cleaning, cover the wound with a sterile dressing, using a bandage to hold the dressing in place.

     Punctures and foreign objects are high-risk wounds because they can introduce bacteria deep into the body. Thus, there is potential for an infection from bacterium introduced directly into the bloodstream, leading to a systemic infection. Sepsis, or a systemic infection, can develop rapidly. If you are treating a patient who has signs and symptoms of sepsis from a foot injury sustained several days earlier, initiate IV access and EKG monitoring.

     Nearly all trauma-related foot injuries require immobilization. Ideally, immobilize the foot in the anatomical position of comfort, or in mid-range. Mid-range positioning improves circulation, reduces tendon tension and is generally most comfortable for the patient. Try to position the foot in-line with the ankle. However, remember that foot injuries often have associated ankle injuries, so do not force foot movement if you meet resistance. If you meet resistance, immobilize the foot in the position found.

     Although an open fracture may be particularly grotesque and painful, it is not a life-threatening injury.

     Treat an open fracture as you would any other fracture. If there is bleeding, apply well-aimed direct pressure to the source. Assess distal circulation, sensation and motion, and, if necessary, reposition the foot to restore distal circulation.

     Do not force exposed bones back into the skin. Bone ends may slide back in as you realign or reposition; otherwise, what is out stays out. If any bones have fallen completely out of the ankle, treat them as you would an amputation.

     Cover the opening with a sterile dressing and immobilize the foot. Proper immobilization is essential to foot injury treatment, as it keeps the ankle joint in anatomical position and prohibits foot movement.

     Definitive immobilization in-hospital is a plaster or fiberglass cast. Ideally, field immobilization provides the same support and protection. The goal of splinting is to stabilize the injury, prevent further injury and reduce pain.

     There are numerous types and sizes of splints used in prehospital care. Regardless of the type you use, the principles are the same. A good splint is complete, compact and comfortable. A comfortable splint is well-padded to provide protection from further injury and comfort to the patient. A complete splint has structural support, is appropriately sized and fits snugly to prevent excess movement. On a joint injury, a complete splint immobilizes the long bones above and below the injury. Used for a long-bone injury, it immobilizes the joints above and below the injury.

     A compact splint has appropriate bulk.

     The patient needs to fit into the ambulance, and you need to be able to reassess CSM after application and during transport. Good splints for foot injuries include vacuum splints, formed foam and Velcro splints, and flexible aluminum SAM splints that are secured with gauze or ACE wrap.

     We have found that padded board splints and pillows are inadequate for splinting foot injuries. A padded board splint allows for foot movement, and pillows provide little structural support, allow for movement and inhibit reassessment of CSM.

     After you have selected your splint of choice, measure it to the uninjured leg for proper sizing. As you apply the splint, look for voids between the splint and the foot or leg that may require additional padding. Fill voids with loose gauze, dressings or towels to prevent excess movement and increase comfort. Whether your splint comes with securing straps or you use tape or triangle bandages, the process remains the same. Apply straps distal to the body and move proximally as you secure additional straps. Do not place straps directly over the injury unless absolutely necessary. The splint should fit snugly, but should not impair circulation.

     Once you have secured the splint, reassess CSM. Look for distal pulses, assess sharp and soft sensation, and assess for toe movement. To examine for coloration, compare the injured to the uninjured foot. If CSM is impaired, readjust the splint.

     Control pain and swelling by following the RICE mnemonic:

• Rest by not using and splinting in a position of function.
• Ice decreases pain and swelling.
• Compress by immobilizing with a complete, compact and comfortable splint.
• Elevation reduces blood flow to the ankle and enhances venous return, which also reduces swelling.

     Verbal reassurance from a friend, family member or EMT is also a powerful pain reliever.

     Pain medication administration can and should be done for patients with foot and other musculoskeletal injuries. Pain management is an essential part of patient care. While foot injuries are not life-threatening, they can be extremely painful.

Summary
     Traumatic foot injuries can be isolated; however, they often occur in conjunction with other injuries. Recognizing the mechanism of injury will aid you in predicting foot-injury patterns. Thorough foot examination will help identify the injury. Proper immobilization and treatment are essential to long-term recovery.

References

1. American Academy of Orthopedic Surgeons. The Foot and Ankle. https://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=100&topcategory=Foot.
2. Schanen D, Rupp T, Karageanes S. Athletic Foot Injuries. www.emedicine.com/sports/topic39.htm.
3. Silbergleit R. Foot Fractures. www.emedicine.com/emerg/topic195.htm.
4. Vonhof J. Fixing Your Feet: Prevention and Treatment for Athletes, 3rd Ed. Berkeley, CA:Wilderness Press, 2005.
5. Hurwitz SR. Plantar Fasciitis. www.emedicine.com/orthoped/topic542.htm.
6. Aldridge T. Diagnosing heel pain in adults. Am Fam Phys 70(2):332, 2004.
7. Myerson M. Compartment Syndrome of the Foot. Mercy Medical Center. https://footandankle.mdmercy.com/conditions/trauma/compartment.html.

Suggested Reading
Ganley TJ. Ankle injury in the young athlete: Fracture or sprain? J Musculoskeletal Med 17:311-325, 2000.
Judd D, Kim D. Foot fractures frequently misdiagnosed as ankle sprains. Am Fam Phys, Sept 2002.
Larsen D. Assessment and management of foot and ankle fractures. Continuing Professional Development, Orthopedics 17:37-46, 2002. O'Keefe D, et al. The ankle. Br Med J 308:331-337, 1994.

Kevin Collopy, BA, NREMT-P, WEMT, is a paramedic crew chief for Bell Ambulance in Milwaukee, WI. He currently writes for Mosby and www.rapidce.com through Emergency Preparedness Systems. He is also a lead instructor for Wilderness Medical Associates. Contact him at kcollopy@colgatealumni.org.