Chapter 22 The Ankle and Foot

Copyright 2005 Lippincott Williams & Wilkins

Chapter 22The Ankle and Foot


Osteology

Talocrural JointDistal fibulaTibiaTalus

MidfootNavicularCuboid3 cuneiform bones

Forefoot5 metatarsalsPhalanges


Osteology of Foot and Ankle


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


Muscles of the Foot and Ankle

Anterior

Anterior tibialisExtensor hallucis

longusExtensor digitorum

longusPeroneus tertius

Open Chain Action

Dorsiflexion/inversionExtension of

phalanges – 1st rayExtension of

phalanges – toesEverts foot


Muscles of the Foot and Ankle (cont.)

Lateral Compartment

Peroneus longusPeroneus brevisPosterior

Open Chain Action

Eversion


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 Plantar flexion

Plantar flexion and inversion

First ray flexion Flexion – Phalanges of

toes


Innervation (Superficial)


Talocrural/Subtalar/Midtarsal Joints

Function:

Shock absorptionAbsorb lower extremity rotatory

forcesProvide lever for effective

propulsion


Pronation/Supination

Pronation

Movement in the direction of eversion, abduction and dorsiflexion.

Supination

Movement toward inversion, adduction, and plantar flexion.


Pronation/Supination


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)


Midtarsal Joint (MTJ)

Subtalar pronation – Promotes mobility in MTJ

and forefoot.

Subtalar supination – Promotes stability in MTJ and forefoot.


Locking and Unlocking of Midtarsal Joint


Kinetics and Kinematics of Gait CyclePhase Joint ROM Moment Muscle

Activity

Contraction Type

Initial TCJ

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

Eccentric

Midstance TCJ

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


Kinetics and Kinematics of Gait Cycle (cont.)Phase Joint ROM Moment Muscle

Activity

Contraction Type

Pre-swing TCJ

STJ

20° PF

Remains supinated

Dorsiflex

Varus

Initial swing

TCJ Dorsiflexes to 10° PF

Dorsiflexors Dorsiflexors

Midswing TCJ Dorsiflexes to 0°

Dorsiflexors Dorsiflexors

Terminal swing

TCJ Stays at 0° Dorsiflexors Dorsiflexors


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.


Ideal Rearfoot Alignment


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.


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.


Forefoot Varus


Forefoot Valgus


Examination and Evaluation

Patient/client historyBalanceJoint integrity and mobilityMuscle performancePainPosture


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


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.


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.).


Intrinsic Muscles/Extrinsic Muscles


Pain

Exercise initiated in pain-free range

Soft tissue mobilizationCryotherapyNMES/TENSExercise for neighboring regions


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.).


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.


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.


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.


Subtalar Pronation/Supination


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.


Plantar Faciitis – Treatment (cont.)

If pronated

Mobilize TCJStretch gastrocnemius and soleusStrengthen tibialis anterior and extensor digitorumInitiate functional and proprioceptive activities


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.


Achilles Tendinosis

Overuse pathology of Achilles tendon.

Treatment Restore TCJ mobility Stretching is essential after TCJ mobility is

restored. Strengthening exercises following

inflammation recovery.


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


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


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.


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


Adjunctive Interventions

Adhesive strapping Wedges and pads Biomechanical foot

orthotics Heel and full sole lifts


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.


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.

Chapter 22 The Ankle and Foot

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