Chapter 22 The Ankle and Foot

1. Chapter 22The Ankle and Foot

2. Talocrural Joint Distal fibula Tibia Talus Midfoot Navicular Cuboid 3 cuneiform bones Forefoot 5 metatarsals Phalanges Osteology

3. Osteology of Foot and Ankle

4. Ligaments of Talocrural (TCJ), Subtalar (STJ) and Midtarsal Joints (MTJ)

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

6. Lateral Compartment Peroneus longus Peroneus brevis Posterior Open Chain Action Eversion Muscles of the Foot and Ankle (cont.)

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

8. Innervation (Superficial)

9. Talocrural/Subtalar/Midtarsal Joints Function: • Shock absorption • Absorb lower extremity rotatory forces • Provide lever for effective propulsion

10. Pronation/Supination Pronation Movement in the direction of eversion, abduction and dorsiflexion. Supination Movement toward inversion, adduction, and plantar flexion.

11. Pronation/Supination

12. 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. Midtarsal Joint (MTJ) Subtalar pronation – Promotes mobility in MTJ and forefoot. Subtalar supination – Promotes stability in MTJ and forefoot. Depends on subtalar joint biomechanics

14. Locking and Unlocking of Midtarsal Joint

15. Kinetics and Kinematics of Gait Cycle

16. Kinetics and Kinematics of Gait Cycle (cont.)

17. 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. Ideal Rearfoot Alignment

19. 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. 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. Forefoot Varus

22. Forefoot Valgus

23. Examination and Evaluation • Patient/client history • Balance • Joint integrity and mobility • Muscle performance • Pain • Posture

24. 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 • 1st–5th ray mobility • Ankle dorsiflexion and plantar flexion ROM with knee flexed and extended

25. 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. 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. Intrinsic Muscles/Extrinsic Muscles

28. Pain • Exercise initiated in pain-free range • Soft tissue mobilization • Cryotherapy • NMES/TENS • Exercise for neighboring regions

29. 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. 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. 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. 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. Subtalar Pronation/Supination

34. 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. Plantar Faciitis – Treatment (cont.) If pronated • Mobilize TCJ • Stretch gastrocnemius and soleus • Strengthen tibialis anterior and extensor digitorum • Initiate functional and proprioceptive activities

36. 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. 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. 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: • Tibial nerve • Peroneal nerve

39. 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. Ligament Sprains – Treatment • Grade I–II, 1st 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. 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. Adjunctive Interventions • Adhesive strapping • Wedges and pads • Biomechanical foot orthotics • Heel and full sole lifts

43. 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. 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.