Hi, I'm Chris Fulmer. I'm one of the faculty members for the Stanford O'Connor Sports Medicine Fellowship. In this case, we'll discuss evaluation of injuries to the foot. I'll start using this model to show some critical anatomic structures that may not be as easily identified as I'm using the model today. So the first bony structure I'd like to point out is the navicular bone, which is right here. When I'm evaluating on the patient, the first bony landmark that I'll use is the navicular tuberosity, which is right here, and I'll palpate that. Once I find that structure, I can palpate along the entire length of the navicular by moving from medial to lateral. The other structure that is important to evaluate, especially if the patient is presenting with midfoot pain, is the lisfranc joint and structures. The lisfranc ligament extends from the medial cuneiform to the base of the second metatarsal. It is one of the main stabilizers of the entire midfoot, and if the patient disrupts that ligament or suffers sprain of that ligament, it is critically important to diagnose this injury in as timely a fashion as possible. For injuries to the tarsal navicular or to the lisfranc injury, your very discreet and focused palpation can be important elements to giving you clues to your diagnosis. Additionally, other bony structures that should be palpated would be the entire lengths of the metatarsals, focusing both on the shaft and also on the metatarsal heads. So on a patient where I suspect a midfoot injury, again, as I mentioned, I'm going to find that bony landmark of the navicular. So on our patient here today, I'm going to palpate along this medial edge of the foot and find that navicular tuberosity. Once I've found that spot, I can palpate from medial to lateral over the entire surface of the navicular, looking for any pinpoint bony tenderness. This could suggest either a fracture or a stress fracture of the navicular. A stress fracture of the navicular in particular is one of those injuries you just do not want to miss because there's a high risk for avascular necrosis. If you're more suspicious of a lisfranc injury, you can palpate starting distally and moving proximally along the first metatarsal shaft until you find that articulation with the tarsal metatarsal joint. From here, you can palpate along the entire width of the midfoot, assessing for any pinpoint tenderness. Other things that you can do to detect injury to the lisfranc ligament would be to piano key the first and second metatarsals by just basically blotting them back and forth. You can also stress the lisfranc by placing the patient into a neutral foot position, grasping onto the hindfoot. I usually will cup the entire calcaneus on the plantar surface to stabilize, and then taking across the midfoot and inducing pronation and abduction. Pain with that would be suspicious or suggestive of a lisfranc injury. Lastly, if you're more concerned for bony injury to the distal metatarsal, such as with Friberg's infarction, you want to palpate along the entire length of the metatarsals. Starting proximally, again, the first metatarsal is probably the easiest one to identify, so I'll start there palpating along its entire length, identifying that metatarsophalangeal joint, so I know that's where the metatarsal head is, and then from there I can move over to the second metatarsal. Again, find that metatarsophalangeal joint and palpate along the entire length of metatarsal from distal to proximal. You can then do that along the length of the third, fourth, and fifth metatarsals.

2nd Edition, CASE 12

2nd Edition

Foot and Ankle

foot injuries

Lisfranc ligament

navicular bone

stress fractures

avascular necrosis