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The Med Cell:

The Foot

Dr Stefan Eriksson

The following information is for educational purposes only.

“bare feet are for bathing in, boots are for kicking in”

The foot is the first region of the body to be covered in the Med Cell series. It is one of the most important areas available to the combat practitioner for two opposing reasons. First, due to its structural properties, the foot is an extremely effective weapon, and is employed frequently in martial combat. Conversely, the injured foot can have devastating consequences to the victim. As a structure subjected to essentially constant weight bearing, the foot reacts very differently to even small degrees of  bone or joint mal-alignment that are easily tolerated, for example, in the hand or other non-weight-bearing or low-stress joints. In fact, of all traumatic orthopedic injuries encountered in the emergency department, foot and ankle injuries appear to result in higher functional loss than any other orthopedic injury does (including all 4 extremities and the pelvis). Put the foot out of action and the whole lower limb on that side becomes useless. It follows that adequate footwear  is important (especially in military settings), as is proper care and maintenance of  the foot.

Foot injuries are common among athletes, especially those engaging in martial arts or combat. According to a survey conducted in Victoria, Australia, between 1995 and 2000 there were 600 presentations to Emergency Departments as a result of injury sustained during martial arts practice. 91 (15.2%) of these presentations involved the foot (including toes).

This article will follow the format below:

Anatomy of the Foot

The foot is a very complex structure

Bones
It is simpler to think of the foot as being divided into 3 regions.

bones of the right foot
XRAY 1 Bones of the right foot and their divisions. Oblique view

Bones of the left foot
XRAY 2 Bones of the left foot and their divisions. Lateral view

Essential Joints
As mentioned, there are 31 articulations in the foot. However, the joints essential for proper foot function are subtalar, talonavicular, and lesser metatarsophalangeal (MTP) joints. The remaining joints can be malfunctioning yet have little effect on foot function.

foot joints
XRAY 3 Important joints of the foot

Normal Gait
The normal human gait can be broadly divided into two phases, stance and swing phase. Stance phase commences with the heel striking the ground and ends when the toes push off and the foot loses contact with the ground. During the swing phase the leg swings forward and does not come into contact with the ground. The stance phase is then repeated.

Proper functioning of the foot is required for normal gait. It is the intention of combat strikes to the foot to disrupt this mechanism, so impairing the ability to walk.

A more comprehensive description of gait can be found here: http://www.oandp.org/jpo/library/1997_01_010.asp

Weight Distribution

The weight of the body is supported by the foot, and is transmitted and distributed over 6 areas; the calcaneus in the heel, the sesamoids of the first metatarsal head, and the 2nd, 3rd, 4th and 5th metatarsal heads.
During normal gait the foot supports loads of up to 7 times bodyweight, and during barefoot gait, the forefoot actually encounters three times as much load distribution as the hindfoot.


contact points of the sole of the foot
Diagram 1 Contact points of the sole of the foot during normal weight bearing.

Consequently, these areas absorb a large amount of energy during walking and running. It follows that these contact points are crucial to striking during close combat. The foot stamp and axe kick when performed correctly transmit force to the opponent through the contact points illustrated above - usually the calcaneus, being one of the most dense bones in the body. This emphasises the importance of hard soled boots in combat.

Despite this strong component, when trauma victims fall onto their feet from a height, the result is usually (bilateral) calcaneus fractures. It is known as the “Don Juan syndrome”, though only Don Juan in the movies can jump from a balcony, land on his feet and walk painlessly away. In the gulf war, a large number of foot and ankle injuries were the result of parachute jumps by servicemen wearing full combat loads of gear. In more serious falls, the fractures extend upwards to the knees, hips, pelvis, lumbar and thoracic vertebrae, and in some instances, the cervical vertebrae can  punch through the base of the skull into the brain.

Lets now examine each foot region in turn beginning with the Hindfoot

Hindfoot Injuries

Talar Fractures

Talar neck and anterior body fractures are the most common

Talar head fractures less common

Chip fractures

Lateral process fractures

Subtalar Injury

subtalar dislocation
XRAY 4  Subtalar dislocation. Note the talus (T) has shifted posterior away from the navicular (N) and calcaneus C. This was the result  of twisting the foot inwards (inversion injury).
 
Calcaneal Fractures

Calcaneal fracture
XRAY 5  Calcaneal fracture sustained from a fall. Blue arrow indicates direction of force on impact.

Midfoot fractures

Lisfranc Injuries (Tarsometatarsal injuries)

  1. Sudden torque on the foot (a runner falling into a hole)
  2. Axial loading (e.g. rugby player with forefoot fixed on ground, dorsiflexed, and another player landing on the heel),
  3. Direct Trauma (dropping heavy object onto foot), usually open fractures.


Lisfranc injury
XRAY 6 Lisfranc injury sustained from sudden twisting motion on uneven ground. Arrows point to dislocations of the tarsophalangeal joints.

Navicular Fractures

Two types of fractures

  1. Acute fractures
    • rarely isolated to just the navicular
    • equally divided between avulsion fractures which occur when the foot is plantar flexed AND inverted or everted, and body fractures when a high energy axial force is applied
  2. Stress fractures of the navicular (more common)
    • occur frequently in running and jumping athletes
      (See section on stress fractures)

Navicular fracture
XRAY 7 Navicular fracture after being stomped on. Undisplaced fracture. This highlights the susceptibility of the dorsum of the foot to being injured if inappropriate footwear is used in combat.

Other midfoot bones
The cuboid and cuneiform bones are rarely fractured in isolation, but can be disrupted as part of a larger injury such as that resulting from an explosion or car accident.

Forefoot Injuries

This section is detailed as these injuries are encountered frequently in combat.

Metatarsal injuries

Metatarsal fractures are among the most common traumatic injuries to the musculoskeletal system.
They account for:

Mechanism of injury

Overall, fractures are usually the result of direct trauma. However, exceptions are fractures to the fifth metatarsal and stress fractures.

Single traumatic fractures are usually non-displaced due to the restraining forces of the surrounding ligaments.

Because there is little in the way of tissue on the dorsum (top) of the foot to protect the metatarsal bones, they are particularly prone to crushing injuries. This is important to the combatant as they make an easy target , especially if the opponent is wearing flimsy shoes or is barefoot. Martial artists frequently injure the dorsum of their foot when kicking with this region which is why this style of kick is not employed in military combat.

First Metatarsal

Comminuted fracture
XRAY 8 Comminuted fracture first (and second) metatarsals after dropping a weight onto the forefoot. A leg stamp would have a similar effect if performed in heavy soled boots.

Second, Third and Fourth Metatarsals

Fifth Metatarsal

1. Avulsion Fracture

Diagram 2 below: C = Calcaneus, T = Talus, Cu = Cuboid, 5th Met = 5th Metatarsal, Ligament = Peroneus Ligament. The drawing depicts an inversion injury i.e. rolling the foot over. The peroneus ligament stretches, and avulses or tears off the base (shaded red) of the fifth metacarpal. It is demonstrated in the x-ray below the drawing.

fracture to fifth metatarsal
XRAY 9 Fracture to base of fifth metatarsal - avulsion fracture as demonstrated in picture above i.e. inversion injury.

2. Jones Fracture

3. Stress Fracture (see section on stress fractures)

4. Shaft (diaphyseal) fractures

Due to the high incidence of these injuries in sports/combat, a brief diagnostic technique follows:

Treatment

Metatarsophalangeal (MTP) joint injury

turf toe
XRAY 10 “turf toe” from kicking barefoot with toe and forefoot dorsiflexed

Injury to the proximal phalanx and first ITP joint

Injury to the lesser phalanges and ITP joints

Injury to the distal phalanx and nail bed

Fracture to distal phalanx
XRAY 11 Fracture to distal (and proximal) phalanx after being hit with an axe.

Nail Avulsions

Stress Fractures

Since all stress fractures follow the same basic cause, diagnosis and treatment, they will be discussed as a group, though the information here applies to any particular bone with a stress fracture.

Stress fractures result from the cumulative effect of repetitive micro trauma that is insufficient to cause an acute fracture, but eventually leads to stress failure of the involved bone.

Order of frequency, from most common to least common:
Tibia, 2nd metatarsal, 3rd metatarsal, 5th metatarsal, desmoids, navicular, femur, fibula and pelvis

Left untreated, stress fractures can progress to displacement with malunion, and subsequent foot deformity or poor weight bearing capacity.

Compartment Syndrome

Important limb threatening and life threatening condition that occurs as a result of swelling within a confined anatomical space (or compartment).

Foot has 9 anatomic compartments

Gunshot wounds to the foot

Before looking at gunshot wounds to the foot, it is important to understand some basic concepts which can then be applied to other parts of the body.

Ballistics Primer
“Science of motion of projectiles”

 

As a bullet moves through the body, it crushes and shreds surrounding tissue. It also forces tissue outwards, creating a temporary cavity larger than the diameter of the bullet.

This cavity lasts a very short time, but depending on the site, a significant amount of injury can occur.

As the bullet passes through the body, it will yaw. In other words, it starts out in the point forward position, rotates through to 90 degrees where most tissue damage occurs, and then continues to rotate through to a complete 180 degrees with the base forward and thereafter continues to travel base forward (centre of gravity at the base). This is assuming it does not fragment beforehand in which case greater tissue destruction occurs. (Di Maio)


Diagram 3: In (1), the bullet enters the body, point forward. As it travels through the body, it begins to yaw (2), until it reaches its maximum width at 90 degrees (3). Here tissue destruction is greatest, as is cavity size. Finally in (4), the bullet faces base forward and continues like this until exiting or coming to a stop inside the body.

Finally, as mentioned, fragmentation can occur. This comes about either through inherent bullet characteristics (e.g. soft-point or hollow-point from a centre-fire rifle), or through striking bone. The fragments fly off in different directions acting as secondary missiles and so contacting more tissue to increase the size of the wound. A hollow-point bullet that mushrooms can increase its diameter 2.5 times on impact and will increase the area of tissue crush 6.25 times compared with a nondeformed bullet.

Gunshot wounds can be divided into four categories based on the distance between muzzle and target

Gunshot wounds to the foot are usually the result of  low velocity firearms discharging while being cleaned or loaded.

Trench Foot

3 phases (note, hyper-  = excess, -emic means blood)

  1. Pre-hyperemic phase: “cold and numb”, foot is white/yellow and cold to touch
  2. Hyperemic phase: hot, painful and swollen, can last up to 10 weeks. Muscles, nerves and arteries damaged
  3. Post-hyperemic phase: alternating pain and numbness, nerve and muscle wasting leads to loss of motor control which affects gait that can last a lifetime.

Acute treatment is drying and slight elevation of the foot.
Long term prognosis is poor.
Prevention is the key

A future article will look at cold injuries, specifically frostbite

Summary

The foot, although a potent weapon if utilized correctly, is prone to serious injuries, many of which are permanently debilitating. The following mechanisms of injury when applied by the combat practitioner can result in injuries as outlined above:

1. Foot stamp to top of foot when foot flat on ground

2. Kick to side of foot from either direction when foot fixed

3. Inversion injury e.g. applying force to the lateral aspect of the foot or ankle when it is fixed to the ground

4. Eversion injury e.g. applying force to the medial aspect of the foot or ankle when it is fixed to the ground

5. Strike to heel when foot plantarflexed on ground I.e imagine soldier lying prone in shooting position, with toes on ground, then striking his from above

6. As above, but a direct strike to the heel pad (unlikely if other soldier wearing heavy soled boots)

Re-reading through the article should enable readers to anticipate other injuries based on the direction of force applied when the foot is in various positions.

Lastly, a reminder why bare feet are not used for combat. This photo appeared in the last article but is worth showing again. The deep laceration resulted from stepping on broken glass and required surgical repair of the tendons.

Deep laceration of the foot

In the next issue we will examine ankle injuries in combat.

References:

Auerbach: Wilderness medicine, 4th ed, Mosby 2001

Browner: Skeletal Trauma; Basic Science, Management and reconstruction, 3rd ed
Saunders Press 2003

Di Maio, VJM: Gunshot wounds: practical aspects of firearms, ballistics, and forensic techniques, 2nd Ed, CRC Press 1999

Emergency War Surgery, 3rd United States edition 2004, Borden Institute Military Sudies

Grants Atlas of Anatomy, Agur, Ed, 10th ed, Lippincott, Williams, and Wilkins Pub 1999

Injuries associated with the martial arts, from the Victorian Emergency  Minimum Dataset 2001

Mason, JK and Purdue, BN The Pathology of trauma, 3rd Ed, Arnold Publishers 2000

Milgrom et al J. Bone Joint Surg.Br. 1985; 67:732-5

 

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