1. Copyright 2005 Lippincott Williams & Wilkins Chapter 22 The Ankle and Foot

2. Copyright 2005 Lippincott Williams & Wilkins Osteology Talocrural Joint  Distal fibula  Tibia  Talus Midfoot  Navicular  Cuboid  3 cuneiform bones Forefoot  5 metatarsals  Phalanges

3. Copyright 2005 Lippincott Williams & Wilkins Osteology of Foot and Ankle

4. Copyright 2005 Lippincott Williams & Wilkins Ligaments of Talocrural (TCJ), Subtalar (STJ) and Midtarsal Joints (MTJ)

5. Copyright 2005 Lippincott Williams & Wilkins Muscles of the Foot and Ankle Anterior  Anterior tibialis  Extensor hallucis longus  Extensor digitorum longus  Peroneus tertius Open Chain Action  Dorsiflexion/inversion  Extension of phalanges – 1 st ray  Extension of phalanges – toes  Everts foot

6. Copyright 2005 Lippincott Williams & Wilkins Muscles of the Foot and Ankle (cont.) Lateral Compartment  Peroneus longus  Peroneus brevis  Posterior Open Chain Action  Eversion

7. Copyright 2005 Lippincott Williams & Wilkins Muscles of the Foot and Ankle Posterior  Gastrocnemius  Soleus  Plantaris Deep  Posterior tibialis  Flexor hallucis longus  Flexor digitorum longus Open Chain Action  Plantar flexion  Plantar flexion and inversion  First ray flexion  Flexion – Phalanges of toes

8. Copyright 2005 Lippincott Williams & Wilkins Innervation (Superficial)

9. Copyright 2005 Lippincott Williams & Wilkins Talocrural/Subtalar/Midtarsal Joints Function:  Shock absorption  Absorb lower extremity rotatory forces  Provide lever for effective propulsion

10. Copyright 2005 Lippincott Williams & Wilkins Pronation/Supination Pronation Movement in the direction of eversion, abduction and dorsiflexion. Supination Movement toward inversion, adduction, and plantar flexion.

11. Copyright 2005 Lippincott Williams & Wilkins Pronation/Supination

12. Copyright 2005 Lippincott Williams & Wilkins Talocrural – Pronates (dorsiflexion most dominant with eversion and abduction) – Supinates (dominated most by plantar flexion with inversion and adduction) Subtalar – Closed chain pronation (calcaneus everts, talus adducts and flexes) – Closed chain supination (calcaneus inverts, talus adducts and dorsiflexes)

13. Copyright 2005 Lippincott Williams & Wilkins Midtarsal Joint (MTJ) Subtalar pronation – Promotes mobility in MTJ and forefoot. Subtalar supination – Promotes stability in MTJ and forefoot.

14. Copyright 2005 Lippincott Williams & Wilkins Locking and Unlocking of Midtarsal Joint

15. Copyright 2005 Lippincott Williams & Wilkins Kinetics and Kinematics of Gait Cycle PhaseJointROMMomentMuscle Activity Contraction Type InitialTCJ STJ O° DF Supination Plantar flexion Dorsiflexors Everters Isometric Isometrics Loading response TCJ STJ Plantar flexes from 0–15° PF Starts pronating Plantar flexion Moving to valgus Dorsiflexors Inverters Eccentric MidstanceTCJ STJ 10° DF Begins supination Moving to DF Valgus- Varus Plantar- flexors Inverters Eccentric Eccentric – Concentric Terminal Stance TCJ STJ 15° DF Supinating Dorsiflexion Varus Plantar- flexors Evertors Eccentric – concentric Isometric

16. Copyright 2005 Lippincott Williams & Wilkins Kinetics and Kinematics of Gait Cycle (cont.) PhaseJointROMMomentMuscle Activity Contraction Type Pre-swingTCJ STJ 20° PF Remains supinated Dorsiflex Varus Initial swing TCJDorsiflexes to 10° PF Dorsiflexors MidswingTCJDorsiflexes to 0° Dorsiflexors Terminal swing TCJStays at 0°Dorsiflexors

17. Copyright 2005 Lippincott Williams & Wilkins Alignment  Must be assessed from subtalar neutral position (neither pronated nor supinated).  Subtalar joint assessed in both prone and weight-bearing positions.  Forefoot and rearfoot alignment are evaluated separately.

18. Copyright 2005 Lippincott Williams & Wilkins Ideal Rearfoot Alignment

19. Copyright 2005 Lippincott Williams & Wilkins Alignment of Tibia, Foot, Ankle Sagittal Plane  Plumbline alignment is slightly anterior to midline through knee and lateral malleolus.  Navicular tubercle, line from medial malleolus to where MTP joint of great toe rests on floor. Frontal Plane  Distal one third of tibia is in sagittal plane.  Great toe is not deviated toward midline of foot.  Toes are not hyperextended.

20. Copyright 2005 Lippincott Williams & Wilkins Anatomic Impairments First ray hypermobility – Dorsal translation with soft endpoint. Subtalar varus – Inverted twist within body of calcaneus. Forefoot varus – Inversion deviation of forefoot relative to bisection of posterior calcaneus. Forefoot valgus – Eversion deviation of forefoot relative to bisection of posterior calcaneus.

21. Copyright 2005 Lippincott Williams & Wilkins Forefoot Varus

22. Copyright 2005 Lippincott Williams & Wilkins Forefoot Valgus

23. Copyright 2005 Lippincott Williams & Wilkins Examination and Evaluation  Patient/client history  Balance  Joint integrity and mobility  Muscle performance  Pain  Posture

24. Copyright 2005 Lippincott Williams & Wilkins ROM and Muscle Length Examination of knee, hip, ankle, and spine is essential!  Hip and knee ROM and muscle length  Calcaneal inversion and eversion ROM  Midtarsal joint supination and pronation ROM  First ray position and mobility  Hallux dorsiflexion ROM  1 st– 5 th ray mobility  Ankle dorsiflexion and plantar flexion ROM with knee flexed and extended

25. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention for Common Physiologic Impairments Balance Impairment  Restoration requires positional sense (proprioception).  Balance machine, balance board, external perturbation. Home Exercises  Balancing on one leg with eyes open, progress to eyes closed in door frame.  Standing on one leg on a pillow or couch cushion with eyes open, progress to eyes closed.

26. Copyright 2005 Lippincott Williams & Wilkins Muscle Performance Intrinsic Muscles  Patient flexes at proximal MTP joint before distal MTP joint.  Draw towel under foot, pick up marbles.  Using resistant bands to resist proximal MTP joint flexion. Extrinsic Muscles  Resisted talocrural plantar flexion with slow eccentric return to talocrural dorsiflexed position.  Closed chain exercises (double leg heel rises, etc.).

27. Copyright 2005 Lippincott Williams & Wilkins Intrinsic Muscles/Extrinsic Muscles

28. Copyright 2005 Lippincott Williams & Wilkins Pain  Exercise initiated in pain-free range  Soft tissue mobilization  Cryotherapy  NMES/TENS  Exercise for neighboring regions

29. Copyright 2005 Lippincott Williams & Wilkins Posture and Movement Impairment  Excessive pronation and supination most common.  Exercises developed from components of gait.  Goal is to control motions in/out of static positions at varying speeds.  Static weight shifting on bathroom scale.  Forward/backward stepping.  Circular weight-shifting drill.  Functional drills (retrowalking, sidestepping, etc.).

30. Copyright 2005 Lippincott Williams & Wilkins ROM, Muscle Length, Joint Integrity, Mobility Acute Phase  Hypermobile segment should be protected (taping, bracing, casting, etc.).  Adjacent hypomobile segments should be mobilized with manual therapy or mobility exercise.  Dynamic stabilization exercise should be initiated at the hypermobile segment.

31. Copyright 2005 Lippincott Williams & Wilkins ROM, Muscle Length, Joint Integrity, Mobility – Talocrural Joint Talocrural Dorsiflexion  Gastrocnemius and soleus stretching (prevent subtalar pronation).  TCJ dorsiflexion ROM (soleus stretch with talar joint in neutral or slightly supinated position.  Step-down training to facilitate eccentric control of dorsiflexion.

32. Copyright 2005 Lippincott Williams & Wilkins Subtalar Joint  Full active/active-assisted supination can be performed.  Pronation mobility active/active-assisted.  Progressions involve functional training of new mobility in appropriate phase of gait cycle.

33. Copyright 2005 Lippincott Williams & Wilkins Subtalar Pronation/Supination

34. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention for Common Ankle and Foot Diagnoses Plantar Faciitis  Overuse caused by excessive pronation. Treatment  Decrease pain and inflammation, reduce tissue stress, restore muscle strength.  NSAIDs, US, iontophoresis, massage – for pain.  Taping, orthoses, modified footwear to reduce tissue stress.

35. Copyright 2005 Lippincott Williams & Wilkins Plantar Faciitis – Treatment (cont.) If pronated  Mobilize TCJ  Stretch gastrocnemius and soleus  Strengthen tibialis anterior and extensor digitorum  Initiate functional and proprioceptive activities

36. Copyright 2005 Lippincott Williams & Wilkins Posterior Tibial Tendon Dysfunction  Usually excessive subtalar joint pronation and results in acquired foot deformity. Treatment  NWB short leg casting may be necessary for 4–6 weeks (patients with partial tears).  Medication and modalities for inflammation.  Arch strapping to control end-range pronation.  Pain-free, low-intensity, high-repetition open kinetic chain plantar flexion.

37. Copyright 2005 Lippincott Williams & Wilkins Achilles Tendinosis  Overuse pathology of Achilles tendon. Treatment  Restore TCJ mobility  Stretching is essential after TCJ mobility is restored.  Strengthening exercises following inflammation recovery.

38. Copyright 2005 Lippincott Williams & Wilkins Functional Nerve Disorders  Assessment should include spine and hip involvement.  Nerve involvement may resolve with shoe changes, orthotics, alteration of impairments in alignment, mobility, and movement pattern exercises.  Affected nerves include: 1.Tibial nerve 2.Peroneal nerve

39. Copyright 2005 Lippincott Williams & Wilkins Ligament Sprains  70–80% involve anterior talofibular ligament (ATFL), calcaneal fibular ligament (CFL), posterior talofibular ligament (PTFL).  Grade III sprains are further classified: First degree – Complete rupture of ATFL Second degree – Complete rupture of ATFL and CFL Third degree – Dislocation in which ATFL, CFL, and PTFL are ruptured

40. Copyright 2005 Lippincott Williams & Wilkins Ligament Sprains – Treatment  Grade I–II, 1 st 4 days – R.I.C.E.  Severe grade I/II may need crutches in early stage.  Open kinetic chain inversion ROM as tolerated.  Progress as pain and swelling are controlled and weight-bearing tolerance increases.  Grade III rehabilitation is similar to that of I and II.

41. Copyright 2005 Lippincott Williams & Wilkins Ankle Fractures  Supination adduction injury  Supination external rotation injury  Pronated abduction injury  Pronated external rotation injury Treatment  Edema massage, scar mobilization, edema reduction  AROM begins mid-range, low intensity/high reps  As function normalizes, ROM exercise is generally more tolerable

42. Copyright 2005 Lippincott Williams & Wilkins Adjunctive Interventions  Adhesive strapping  Wedges and pads  Biomechanical foot orthotics  Heel and full sole lifts

43. Copyright 2005 Lippincott Williams & Wilkins Summary Three main joints of ankle and foot are TCL, ST, MTL and subdivided into calcaneocuboid and talonavicular. Extrinsic muscles consist of anterior, lateral, posterior groups. Anterior-dorsiflexion, lateral – everters, posterior – plantar flexors. Functions of foot during gait are shock absorption, surface adaptation, and propulsion.

44. Copyright 2005 Lippincott Williams & Wilkins Summary (cont.) Foot and ankle exam must be thorough and include relationships of lower joint extremities. Common anatomic impairments include subtalar varus, forefoot varus/valgus. Common physiologic impairments include loss of mobility, force, torque, balance, impaired balance, and posture. Adjunctive agents may be necessary to treat primary or secondary impairments.