1. PTA 130 – Fundamentals of Treatment Leg, Foot, and Ankle

2. Lesson Objectives
Identify key anatomical muscles and structures of the leg, ankle and foot.
Identify common tissue injuries, conditions and surgical interventions.
Analyze restorative interventions for common injuries, conditions, and surgical procedures.
Identify soft tissue specific mobilizations
Identify flexibility, strengthening, functional, and stabilization exercises

3. Bones of the Ankle and Foot
Distal tibia
Distal fibula
7 tarsals
5 metatarsals
14 phalanges

5. Structure of the Foot The foot is divided into three segments:
Hindfoot- Talus and calcaneus
Midfoot- Navicular, cuboid, three cuneiforms
Forefoot- Metatarsals and phalanges

6. Leg, Ankle, and Foot Joints
Tibiofibular Joints
Ankle (Talocrural) Joint
Subtalar (Talocalcaneal) Joint
Talonavicular Joint
Metatarsophalangeal and Interphalangeal Joints of the Toes

7. Tibiofibular Joints
Superior and inferior tibiofibular joints are separate from the ankle but provide accessory motions that allow greater movement at the ankle
With dorsiflexion and plantarflexion of the ankle, there are slight accessory movements of the fibula

8. Ankle (Talocrural) Joint
Formed by the mortise (distal end of the tibia and tibial and fibular malleoli) and the trochlea (dome) of the talus
Dorsiflexion is the close-packed, stable position of the talocrural joint
Plantarflexion is the loose-packed position

9. Subtalar (Talocalcaneal) Joint
Formed by three articulations between the talus and calcaneous
Located in the rearfoot
The ROM that occurs at the subtalar joint is the same during OCK and CKC activities – they differ only in whether the forefoot moves on a stable talus, or the talus moves on the stable forefoot

10. Talonavicular Joint Formed between the talus and navicular
Functions with the subtalar joint, resulting in pronation and supination

11. MTP and IP Joints Same as the MTP and IP joints of the hand
Extension ROM is more important than flexion ROM in the toes
Why?

12. Motions of the Foot and Ankle
Primary Plane Motions
Sagittal plane motion
Frontal plane motion
Transverse plane motion
Ankle-mortise & trochlea of talus
MTP= Metatarsophalangeal

13. Motions of the Foot and Ankle
Triplanar Motions
Pronation-
A combination of dorsiflexion, eversion, and ABDuction
Supination-
A combination of plantarflexion, inversion and ADDuction

14. Muscle Function in the Ankle & Foot
Gastrocnemius and Soleus
Tibialis posterior
Flexor hallucis longus and Flexor digitorum longus
Peroneus longus and brevis
Tibialis Anterior
Intrinsics

15. K&C pg 761 fig 22.2

16. The Ankle/Foot Complex and Gait
During heel strike to foot flat (loading response) the heel strikes the ground in neutral or slight supination
As weight is transferred over the foot, it begins to pronate and the entire LE rotates inward
Once the foot is fixed on the ground, DF begins as the tibia moves over the foot
Mistance -> Terminal stance – the tibia begins to externally rotate and the hindfoot begins to supinate

17. Muscle Control during Gait
Ankle dorsiflexors function during initial contact and loading response
Controls lowering of foot to the ground
Ankle dorsiflexors also function during the swing phase of gait
Why?

18. Muscle Control during Gait
Ankle plantarflexors function early in stance phase to control the rate of forward movement of the tibia
During midstance they work to initiate plantarflexion to prepare for push off

19. Muscle Control during Gait
Ankle evertors contract during the stance phase of gait to transfer weight from the lateral side to the medial side of the foot
Ankle inverters help to control the pronation force of the hindfoot during the load response
Intrinsic muscles support the transverse and longitudinal arches during gait

20. Referred Pain & Nerve Injury
L4, L5, S1 and S2 nerve roots
Common peroneal nerve-
Courses around the fibular head – referral pattern will be into the anterior and lateral aspects of the lower leg
Plantar and calcaneal nerves-
May become entrapped under the medial aspect of the foot with overpronation
Posterior tibial nerve-
May become entrapped in the Tarsal Tunnel

21. Tarsal Tunnel

22. Management of Foot and Ankle Disorders and Surgeries

23. Joint Hypomobility: Nonoperative Management
Common joint pathologies and etiology of symptoms
Rheumatoid Arthritis
DJD
Post-immobilization stiffness
Gout
Symptoms commonly affect the great toe

24. Joint Hypomobility: Nonoperative Management
Common impairments and functional limitations and disabilities
Restricted motion
Common deformities
Hallux valgus
Hallux rigidus
Dislocation of proximal phalange on metatarsal head
Claw toe and hammer toe

25. Hallux Valgus Hallux Rigidus

26. Claw Toe Deformity
Hammer Toe Deformity

27. Common Impairments Muscle weakness
Impaired balance and postural control
Increased frequency of falling
Painful weight bearing
Gait deviations
Decreased ambulation

28. Joint Hypomobility: Nonoperative Management
Maximum protection phase
Patient education, joint protection
Decrease pain
Maintain Joint and Soft Tissue Mobility
Controlled motion and Return to function phases
Increase joint play and accessory motions
Improve joint tracking
Increase mobility of soft tissues and Muscles
Regain muscle strength
Improve balance and proprioception
Develop cardiopulmonary fitness

29. Overuse (Repetitive Trauma) Syndromes: Nonoperative Management
Tendonitis –
May be caused by trauma or inflammatory arthritis
Tenosynovitis-
Inflammation of the lining of the sheath that surrounds a tendon; may be caused by:
Infection
Injury
Overuse
- LR

30. Overuse (Repetitive Trauma) Syndromes: Nonoperative Management
Plantar Fasciitis –
Inflammation of the thick tissue on the plantar aspect of the foot
Possible causes:
Abnormalities of the arch
Obesity or sudden weight gain
Long-distance running, especially running downhill or on uneven surfaces
Shortened Achilles tendon
Shoes with poor arch support
A.D.A.M. Medical Encyclopedia – Pub Med - LR

31. Recent evidence states PF does NOT lead to heel spurs - LR

32. Overuse (Repetitive Trauma) Syndromes: Nonoperative Management
Shin Splints
The most common cause is inflammation of the periosteum of the tibia (sheath surrounding the bone).
Traction forces on the periosteum from the muscles of the lower leg cause shin pain and inflammation.
Two Common Types:
Anterior shin splints
Posterior shin splints

33. Overuse (Repetitive Trauma) Syndromes: Nonoperative Management
Anterior Shin Splints
Most common is the overuse of what muscle?
Pain increases with active _____?
Posterior Shin Splints
Tight gastroc-soleus complex
Pain when foot is passively dorsiflexed
Muscle fatigue with vigorous exercise

34. Shin Splints

35. Overuse (Repetitive Trauma) Syndromes: Nonoperative Management
Maximum protection phase
Decrease inflammation-> Rest, modalities
Cross-friction massage
Gentle muscle setting
Active ROM within pain-free range
Patient education- avoid activities that provoke the pain
Taping

36. Overuse (Repetitive Trauma) Syndromes: Nonoperative Management
Controlled motion and return to function phases
Correct flexibility and strength imbalances
Orthotics
HEP
Patient education- warm-up activities; proper foot support, allow time for recovery after high-intensity workouts

37. Achilles Tendon

38. Achilles Tendon
The Achilles tendon is the largest and most vulnerable tendon in the body. The gastrocnemius (calf) and the soleus muscles insert to the calcaneus via the Achilles Tendon.
The gastrocnemius muscle crosses the knee, the ankle, and the subtalar joints and can create stress and tension in the Achilles tendon.

39. Common Impairments Achilles Tendonitis- Plantar fasciitis-
Chronic injury that occurs primarily from overuse.
Tends to come on gradually over time until pain is constant.
Plantar fasciitis-
Common cause of pain on the bottom of the heel and usually defined by pain during the first steps of the morning.
Chronic injury rather than an acute injury.

40. Common Impairments Turf toe- Heel Spurs-
Named because this injury is especially common among athletes who play on artificial turf.
Joint at the base of the big toe is injured.
The injury often occurs when an athlete forcefully jams his/her toe into the ground or pushing off repeatedly
Heel Spurs-
A bony growth formed on normal bone.
Can cause wear and tear or pain if it presses or rubs on other bones or soft tissues such as ligaments, tendons, or nerves in the body

41. Joint Surgery & Postoperative Management
Total Ankle Arthroplasty (TAA)
Indications
Severe, persistent pain
Ligament integrity for ankle stability
Satisfactory flexibility
Low physical demands by patient (elderly)
Bilateral ankle involvement
Contraindications
Chronic infection, severe osteoporosis, impaired vascular supply, and/or long term use of corticosteroids

42. Total Ankle Arthroplasty (TAA)
Post-operative management
Can be immobilized up to 6 weeks
Weight bearing status - per the surgeon
Ranges from NWB to PWB
Maximum Protection Phase
Gait training
Begin Isometric strengthening
Regain AROM when permissible to remove immobilizer

43. Total Ankle Arthroplasty (TAA)
Moderate and Minimum Protection Phase
Remove immobilizer for exercise
Restore ROM
Restore strength
Muscular endurance
Balance
Improve aerobic capacity
Functional activities
Patient education

44. Joint Surgery & Postoperative Management
Arthrodesis of the ankle and foot
Indications-
Late stage arthritis of the ankle, the foot, and the toes
Debilitating pain
Marked instability of one or more joints
Deformity of the toes, foot or ankle
High functional demand
Salvage procedure after failed TAA

45. Arthrodesis of the Ankle & Foot
Post-operative Management
Immobilization per surgeon
Weight bearing restrictions
ROM exercise to un-operated joints proximal or distal to the operated joint
Once the bony fusion has occurred and the use of the immobilizer has been removed, the same techniques for hypomobility can be used

46. Ligamentous Injuries: Nonoperative Management
Following a trauma to the ankle, the ligaments may be stressed or torn
First- and second-degree sprains are usually treated conservatively
A third-degree sprain may be treated conservatively or through surgery

47. Ligamentous Injuries: Nonoperative Management
Inversion Sprain (most common)
Can result in a partial or complete tear of the ATFL and often CFL
Eversion Stress (less common)
Greater likelihood of an avulsion from, or fracture of, the medial malleolus vs a sprain of the deltoid ligament
Depending on the severity of the sprain, the joint capsule and articular cartilage lesions may also occur

48. Ligament Sprain Grade I – Grade II – Grade III –
Stretch and/or minor tear of the ligament without laxity (loosening)
Grade II –
Tear of ligament plus some laxity
Grade III –
Complete tear of the affected ligament (very loose)

49. Functional Limitations & Disabilities
Pain
Instability or excessive motion of the joint
Proprioceptive deficits
Decreased ROM in recurrent lateral ankle sprain
Due to subluxation and impaired tracking of the talus
Restricted ambulation during acute and subacute phases

50. Ligamentous Injuries: Nonoperative Management
Maximum protection phase
Patient Education-
RICE, Partial weight-bearing, gentle joint mobs, isometrics, active toe curls
Controlled motion phase
Splint while weight bearing
Cross-fiber massage to ligaments as tolerated
AROM, towel scrunch, progress to strengthening, endurance and stabilization exercise

51. Ligamentous Injuries: Nonoperative Management
Return to function phase
Add elastic resistance
Progress stabilization, proprioception and balance training
Add coordination and reflex response
Rocker, wobble or BAPS board
Progress to sports activity-
May need to brace, splint, or tape

52. Repair of Complete Lateral Ligament Tears
Indicated with chronic mechanical and functional instability – unresolved after conservative management
Post-operative Management
Early weight bearing while immobilized
Protected ROM
Exercise progression similar to non- operative management

53. Repair of Ruptured Achilles Tendon
Typically associated with a forceful concentric or eccentric contraction of the gastrocs
Indications
Acute, complete rupture
Chronic, previously undiagnosed rupture
Recommended for the patient who would like to return to high demand functional activities
Post-operative management
Conventional vs Early Mobilization
6 weeks immobilization- conventional

54. Torn Achilles Tendon

55. Achilles Tendon Repair
Maximum Protection Phase
ROM of nonimmobilized joints
Patient Education
Control edema
Gait training
Moderate Protection Phase
Progress to weight-bearing as tolerated
ROM and joint mobilization techniques
Gentle strengthening
Balance training
Muscular and cardio endurance

56. Achilles Tendon Repair
Minimum Protection Phase-
Begins at weeks
Stretching exercise to reach full ROM
Eccentric resistance exercises
Eventual plyometric exercises
Proprioception activities
Jogging, running, and agility drills
Potential to resume 5-6 months
Begins at weeks

57. Fractures Ankle Fractures
Distal tibia compression fracture (Pilon fracture)
Calcaneal fracture
Talus fracture

58. Stress Fracture Usually caused by overtraining or overuse.
May also be caused by repeated pounding or impact on a hard surface, such as running on concrete.
Increasing the time, type or intensity of exercise too rapidly may cause stress fractures to the feet.
Treatment:
ROM/Stretch, Modalities, Isometrics

59. Review Ankle Girth Measurement
Small tape measure
Choose starting point
Bring tape around plantar surface then up and around superiorly at the malleoli
Using a “Figure 8” pattern
Record the measurement

60. Review Ankle Girth Measurement

61. Exercise Interventions for the Ankle and Foot

62. Exercise Techniques to Increase Flexibility and Range of Motion
Flexibility exercises for the ankle region
Flexibility exercises for limited mobility of the toes
Stretching the plantar fascia of the foot

64. Gastrocnemius Stretch in Standing

65. Soleus Stretch in Standing

66. Subtalar Neutral Positioning

67. Flexibility exercises for limited mobility of the toes
Passive MTP Flexion
Passive IR Extension
Active MTP Flexion
Great Toe Extension

68. Stretching the plantar fascia of the foot
Self deep tissue massage
Ball or small roller (Frozen water bottle)

69. Self Massage to Plantar Aspect of the Foot

70. Exercises to Develop and Improve Muscle Performance and Functional Control
Activities to develop dynamic neuromuscular control
Open-chain strengthening exercises
Weight-bearing exercises for strength, balance, and function

71. Activities to Develop Dynamic Neuromuscular Control
Draw Alphabet
Pick up marbles
Towel scrunch
Raise medial longitudinal arch
Rocker or balance board
Walking with emphasis on weight shift

72. BAPS Board

74. NWB or PWB Strengthening Exercise
Theraband exercises
Towel slides (weighted or unweighted)
Marble pick-up
Seated BAPS board

75. T-Band Exercises

76. T-Band Exercises

78. WB Exercise for Strength, Balance & Function
Bilateral toe/heel raise, progress to unilateral
Perturbations in standing bilateral then unilateral
Resisted walking
Squatting, lunging, push/pull, climbing stairs
Plyometric drills
Agility drills

80. Orthopedic Special Tests

81. Tests for Ligamentous Instability
Anterior Drawer Test
Primarily to test the anterior talofibular ligament
A positive test when there is anterior translation
Patient lies supine with foot relaxed. The examiner stabilizes the tibia and fibula, holds the patient's foo tin 20° of plantar flexion, and draws the talus forward in the ankle mortise.
If the foot is also placed in inversion it will increase the stress on the ligament and on the calcaneofibular ligament, if both ligaments are torn greater translation occurs.

82. Tests for Ligamentous Instability
Talar Tilt
Determine whether the calcaneofibular ligament is torn
The patient lies in supine or side lying with the foot relaxed. The patient's gastroc muscle ay be relaxed by flexion of the knee. The foot is held in anatomic position. The talus is then tilted firn side to side into adduction and abduction. Abduction stresses the deltoid ligament. Must be compared to the normal side.

83. Thompson’s Test AKA Simmonds’ Test Checks for Achilles Tendon Rupture
Positive sign is when there is an absence of plantarflexion
The patient lies prone or kneel on a chair with the feet over the edge of the table or chair. While the patient is relaxed, the examiner squeezes the calf muscles.

84. QUESTIONS?