identify key anatomical muscles and structures of the leg, ankle and foot. identify common tissue...

PTA 130 – Fundamentals of Treatment

Leg, Foot, and Ankle

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

Bones of the Ankle and Foot

Distal tibia Distal fibula 7 tarsals 5 metatarsals 14 phalanges

Structure of the Foot The foot is divided into three segments:

Hindfoot- Talus and calcaneus Midfoot- Navicular, cuboid, three

cuneiformsForefoot- Metatarsals and phalanges

Leg, Ankle, and Foot Joints Tibiofibular Joints Ankle (Talocrural) Joint Subtalar (Talocalcaneal) Joint Talonavicular Joint Metatarsophalangeal and

Interphalangeal Joints of the Toes

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

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

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

Talonavicular Joint

Formed between the talus and navicular

Functions with the subtalar joint, resulting in pronation and supination

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?

Motions of the Foot and Ankle

Primary Plane MotionsSagittal plane motionFrontal plane motionTransverse plane motion

Motions of the Foot and Ankle

Triplanar MotionsPronation-

A combination of dorsiflexion, eversion, and ABDuction

Supination- A combination of plantarflexion, inversion

and ADDuction

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

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

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?


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


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

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

Tarsal Tunnel

Management of Foot and Ankle Disorders and Surgeries

Joint Hypomobility: Nonoperative Management

Common joint pathologies and etiology of symptomsRheumatoid ArthritisDJDPost-immobilization stiffnessGout

Symptoms commonly affect the great toe


Common impairments and functional limitations and disabilitiesRestricted motionCommon deformities

Hallux valgusHallux rigidusDislocation of proximal phalange on

metatarsal headClaw toe and hammer toe

Hallux Valgus Hallux Rigidus

Claw Toe Deformity Hammer Toe Deformity

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


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

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


Plantar Fasciitis – Inflammation of the thick tissue on the

plantar aspect of the footPossible causes:

Abnormalities of the archObesity or sudden weight gainLong-distance running, especially running

downhill or on uneven surfacesShortened Achilles tendonShoes with poor arch support


Shin SplintsThe 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 splintsPosterior shin splints


Anterior Shin SplintsMost common is the overuse of what

muscle?Pain increases with active _____?

Posterior Shin SplintsTight gastroc-soleus complexPain when foot is passively dorsiflexedMuscle fatigue with vigorous exercise

Shin Splints


Maximum protection phaseDecrease inflammation-> Rest, modalitiesCross-friction massageGentle muscle settingActive ROM within pain-free rangePatient education- avoid activities that

provoke the painTaping


Controlled motion and return to function phasesCorrect flexibility and strength

imbalancesOrthotics HEPPatient education- warm-up activities;

proper foot support, allow time for recovery after high-intensity workouts

Achilles Tendon

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.

Common Impairments Achilles Tendonitis-

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.

Common Impairments Turf toe-

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

Joint Surgery & Postoperative Management

Total Ankle Arthroplasty (TAA) Indications

Severe, persistent painLigament integrity for ankle stabilitySatisfactory flexibilityLow physical demands by patient (elderly)Bilateral ankle involvement

ContraindicationsChronic infection, severe osteoporosis, impaired

vascular supply, and/or long term use of corticosteroids

Total Ankle Arthroplasty (TAA)

Post-operative managementCan be immobilized up to 6 weeksWeight bearing status - per the surgeon

Ranges from NWB to PWB

Maximum Protection PhaseGait trainingBegin Isometric strengtheningRegain AROM when permissible to remove

immobilizer

Total Ankle Arthroplasty (TAA)

Moderate and Minimum Protection PhaseRemove immobilizer for exerciseRestore ROMRestore strengthMuscular enduranceBalance Improve aerobic capacityFunctional activitiesPatient education

Joint Surgery & Postoperative Management

Arthrodesis of the ankle and footIndications-

Late stage arthritis of the ankle, the foot, and the toes

Debilitating painMarked instability of one or more jointsDeformity of the toes, foot or ankleHigh functional demandSalvage procedure after failed TAA

Arthrodesis of the Ankle & Foot

Post-operative ManagementImmobilization per surgeonWeight bearing restrictionsROM exercise to un-operated joints

proximal or distal to the operated jointOnce the bony fusion has occurred and

the use of the immobilizer has been removed, the same techniques for hypomobility can be used

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


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

Ligament Sprain Grade I –

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)

Functional Limitations & Disabilities

Pain Instability or excessive motion of the joint Proprioceptive deficits Decreased ROM in recurrent lateral ankle

sprainDue to subluxation and impaired tracking of

the talus Restricted ambulation during acute and

subacute phases


Maximum protection phasePatient Education-

RICE, Partial weight-bearing, gentle joint mobs, isometrics, active toe curls

Controlled motion phaseSplint while weight bearingCross-fiber massage to ligaments as toleratedAROM, towel scrunch, progress to

strengthening, endurance and stabilization exercise


Return to function phaseAdd elastic resistanceProgress stabilization, proprioception

and balance trainingAdd coordination and reflex response

Rocker, wobble or BAPS board

Progress to sports activity- May need to brace, splint, or tape

Repair of Complete Lateral Ligament Tears

Indicated with chronic mechanical and functional instability – unresolved after conservative management

Post-operative ManagementEarly weight bearing while immobilizedProtected ROMExercise progression similar to non-

operative management

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

Torn Achilles Tendon

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

Achilles Tendon Repair Minimum Protection Phase-

Begins at 12-16 weeksStretching exercise to reach full ROMEccentric resistance exercisesEventual plyometric exercisesProprioception activitiesJogging, running, and agility drillsPotential to resume sport @ 5-6 months

Fractures Ankle Fractures Distal tibia compression fracture (Pilon

fracture) Calcaneal fracture Talus fracture

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

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

Review Ankle Girth Measurement

Exercise Interventions for the Ankle and Foot

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

Gastrocnemius Stretch in Standing

Soleus Stretch in Standing

Subtalar Neutral Positioning

Flexibility exercises for limited mobility of the toes

Passive MTP Flexion Passive IR Extension Active MTP Flexion Great Toe Extension

Stretching the plantar fascia of the foot

Self deep tissue massage Ball or small roller (Frozen water bottle)

Self Massage to Plantar Aspect of the Foot

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

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

BAPS Board

NWB or PWB Strengthening Exercise

Theraband exercises Towel slides (weighted or unweighted) Marble pick-up Seated BAPS board

T-Band Exercises

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

Orthopedic Special Tests

Tests for Ligamentous Instability

Anterior Drawer TestPrimarily to test the anterior talofibular

ligamentA positive test when there is anterior

translation

Tests for Ligamentous Instability

Talar TiltDetermine whether the calcaneofibular

ligament is torn

Thompson’s Test AKA Simmonds’ Test Checks for Achilles Tendon Rupture Positive sign is when there is an

absence of plantarflexion

QUESTIONS?

identify key anatomical muscles and structures of the leg, ankle and foot. identify common tissue...

Documents

supination slide

fibula slide

adduction slide

stable forefoot slide

foot ankle inverters

loosepacked position

ground ankle dorsiflexors

ankle dorsiflexors function