MAIN IDEAS
Identify important aspects of the structure and function of the ankle and foot.
How many parts are there?
what motions does the ankle produce?
What motions does the ankle and foot produce?
how many metatarsals and phalanges?
Leg: tibia and fibula (mortise of the joint)
Hindfoot: talus and calcaneus
Midfoot: navicular, cuboid, 3 cuneiforms
Forefoot: 5 metatarsals, 14 phalanges
Motions of the ankle
Sagittal plane: dorsiflexion and plantar flexion
Frontal plane: inversion/eversion
Transverse plane: adduction/abduction
Motions of the foot and ankle
Pronation: dorsiflexion, eversion, abduction
Supination: plantarflexion, inversion, adduction
Symptoms described as:
swelling, restricted, painful motion
Weight bearing activities are affected
Ex: rising from chair, climbing up and down stairs
Acute symptoms
Direction of motion
Talocrural joint
Supination with inversion: posterior articulation slides ______
Pronation with eversion: posterior articulation slides ______
Talonavicular joint
Supination: navicular on the head of talus slides ______ and medial
Pronation: navicular on the head of talus slides ______ and lateral
1. Lateral, Medial
2. Plantar, Dorsal
Symptoms described as:
restricted motion, decreased joint play, firm capsular end feel
Joint restriction, weakness, and affected ambulation (decreased distance and affected gait pattern)
Chronic symptoms
What are the major nerves of the foot and ankle?
Where does each originate?
Which can be irritated or compressed with overpronation?
What is tarsal tunnel syndrome?
Major nerves
Common peroneal (fibular)
Originates from sciatic nerve
Passes between the biceps femoris tendon and lateral head of the gastroc
Trauma may cause a neuropathy
Posterior tibial nerve
Behind the medial malleolus along with posterior tibialis tendon
Entrapment is known as “tarsal tunnel syndrome”
Plantar and calcaneal nerves
Branches of the posterior tibial nerve
May be irritated or compressed with overpronation
May mimic an acute foot strain
What is Hallux valgus?
Hallux valgus, also known as a bunion, is a common foot deformity that occurs when the big toe bends towards the other toes.
Describe the role of the foot and ankle during the gait cycle.
How does the ankle move?
What happens at midstance?
Which muscles fire and why?
During normal gait:
Ankle goes through a range of 32-35 degrees (7* dorsiflexion occurs at the end of midstance and 25 degrees of plantar flexion at the end of stance phase)
Anterior tibialis: decelerator at heel strike, accelerator from foot flat to midstance
Ankle plantar flexors: control rate of forward movement of tibia in early stance (eccentrically), initiate push-off in midstance
Post and ant tibialis: control pronation
What are claw/hammer toes?
A foot deformity that causes the toes to bend up at the joint where they meet the foot, and down at the middle and tip joints. This makes the toes curl downward toward the floor.
Ankle stabilization procedures
3 kinds what are they?
Which is the most common?
Which uses tenodesis?
Which one uses radiofrequency to shrink loose ligaments?
Direct repair (brostrom-gould)
Open procedure and is most common
Repair of ATF and Df ends by reinserting them to bone
Lateral retinaculum is tightened over involved structures by securing it to the fibula
Provides stability without having to harvest a graft and has a greater outcome in patient having full ROM and returning to activity
Reconstruction with augmentation (Evans, Watson-Jones)
Use tenodesis - usually an autograft of fibularis brevis
These procedures did NOT work well due to compromising the everters
Gracilis is now used or a bone patellar tendon allograft
Thermal assisted capsular shift
Shrinks the loose ligaments through radiofrequency
Longer immobilization and NWB is longer due to vulnerable ligame
What are some pathologies related to heel pain?
Plantar fasciitis
Achilles tendonitis
Achilles repair surgical procedures.
What happens in primary repair and when is it done?
What happens in delayed repair/reconstruction?
A cast will place a pt. in about 15-20 degrees of what?
What to watch out for?
Primary repair
Minimally invasive open technique
Done with the first few days and sutures the two torn ends together
Ankle is slightly PF and in a subtalar neutral position
Delayed repair/reconstruction
Open approach
Requires reconstruction using auto or allografts
Such as flexor hallucis longus, plantaris, peroneus brevis
Cast places patient in about 15-20 degrees PF
Watch out for DVTs and infections
What is Achilles tendonitis?
where is the pain?
what movement decreases?
what movement increases?
Achilles tendonitis
Pain usually at mid portion of tendon or at calcaneal insertion
Decreased DF is present
Patient has increased pronation
Pain and stiffness following period of inactivity and initially decrease with return to activity, but then increase with additional activity
Achilles rupture post Op management
0-4 weeks?
4-6 weeks?
6-8 weeks?
12 weeks?
Achilles Post Op Management
0-4 weeks
Patient wears a below knee cast held in 15 to 30 degrees PF
At 2-3 weeks boot is usually adjusted with less PF
NWB and ambulates with crutches
4-6 weeks
Walking cast of CAM brace is used to limit DF to 0
NWB to TDWB while in immobilizer, WB progressed as tolerated in boot
6-8 weeks
AROM exercise initiated while in brace
FWB wearing functional brace, transition to show with heel lift
12 weeks
Functional brace discontinued, FWB without heel lift if ankle is PF and 10 degrees of DF is attained
What is plantar fasciitis?
Where is the pain?
when does one usually feel the pain?
What should treatment focus on?
Plantar fasciitis
Pain on insertion at medial calcaneus
Pain first thing in the morning (foot is usually in plantar position during sleeping); pes cavus (high arch stretches out ligaments); pes planus
Increase with weight bearing
Focus treatment on stretching gastroc/soleus
Achilles rupture Maximum Protection Phase (0-6 weeks)
What should we maintain?
Do muscle setting of all except what?
What movement should you not do until 2 weeks post op?
What should we prevent?
Maximum Protection Phase (0-6 weeks)
Maintain ROM in non-immobilized joints
Prevent reflex inhibition of immobilized muscle groups
Do muscle setting of all except PF
Don’t do PF until 2 weeks post op
Prevent joint stiffness and soft tissue adhesions
Begin early ROM program if allowed by MD
Begin to restore balance reactions in standing
If partial WB is permitted, start weight shifting in brace
Maintain cardio
UBE (upper body ergometer - arm bike)
Tendon pathology of ankle and leg
What muscles can hey occur in?
What muscle is the most common to develop tendinitis in the ankle/foot?
Can occur in any muscle in the lower leg from repetitive activity
Posterior tib tendonitis is most common after achilles tendonitis
Achilles rupture Moderate Protection Phase (6-12 weeks)
Is WBAT okay?
How should we incr. ROM?
How should we improve STR and endurance?
What should we do about their gait?
Moderate Protection Phase (6-12 weeks)
WB as tolerated usually after 6 weeks
Increase ROM with joint mobs and stretching
Grade III mobs
Self stretching with towel to increase DF
AROM to ankle, seated ROM on wobble board
Postpone unilateral stretching until 12 weeks
Improve strength and endurance
Open/closed chain low load, high rep program
Heel raise while seated
Standing heel raise on shuttle or total gym
Partial lunges
Improve balance reaction
Firm to soft surface, DL to SL progression
Re-establish symmetrical gait pattern
What are shin splints?
What are the different types?
What causes them?
Shin splints
General term for several conditions
Musculotendonitis, stress fracture of tibia, periosteitis, compartment syndrome, irritation to interosseous membrane
Anterior shin splints (anterior tib overuse)
Pain increases with active DF and passive PF
Tight gastroc and weak anterior tib contribute to problem
Posterior shin splints (posterior tib overuse)
Tight gastroc and weak/inflamed posterior tibialis, along with pronated foot contribute to posterior shin splints
Increased pain with passive DF with EV and with active inversion with PF
Achilles rupture Minimum Protection Phase (12-16 weeks)
Directed towards returning patient to what level of function?
Emphasizing what kind of loading during training?
Plyometrics can be initiated in what kind of environment?
If strength is equal compared bilaterally most people can resume athletics by how long?
Directed toward returning patient to pre-injury level of function
Emphasize eccentric loading
Plyometrics can be initiated in a pool
After 16 weeks
Jogging, plyos, running, agility drills, cutting pivoting, sport specific training
If strength is equal compared bilaterally most people can resume athletics by 6 months
Ankle sprains.
Mechanism of injury - 80% of ______ injuries are sprains; 20% _______
80% of ______ sprains have fractures associated with them; 20% are merely sprains
Inversion, Fractures, Eversion
Achilles Precautions
Achilles tendon repair precautions
General precautions?
Postpone all of what type of exercise until FWB W/O pain?
Stretching to increase what movement?
Limit DF to no more than 10 degrees beyond neutral until how long after post op?
Begin strengthening exercises in what kind of position before progressing to an exercise against body weight?
Where should advanced training begin?
What kinds of activities should be postponed until 16 weeks post op?
General precautions
Progress all exercises very cautiously that place resistance or stretch on gastroc/soleus
Postpone all unilateral weight-bearing exercise on the operated side until FWB without pain is possible
Stretching to increase ankle DF
Begin with NWB stretches such as towel stretch
Limit DF to no more than 10 degrees beyond neutral until 8-12 weeks post op
Initiate WB stretches in sitting with feet on floor or rocker board
Begin standing stretches in bilateral stance only if pain free
Postpone unilateral/bilateral standing stretches with heels over edge of a step until advanced activities are permitted (12-14 weeks post op)
Resistance exercise
Begin strengthening exercises in a NWB position against low loads before progressing to a CKC exercise against body weight
Advanced training
Begin plyometric training in a pool (chest deep progressing to waist deep)
Postpone land based plyos, high impact activities, and change of direction activities until 16 weeks post op
Impairments and function limitations of an ankle sprain
Impairments:
Pain
Instability
Proprioception deficit
Reflex muscle inhibition
Function limitations
When acute, inability to bear weight, need help with ambulation
Recurrence of injuries leading to falling and safety issues
Achilles Rupture
Who does it most frequently happen to?
Its associated with a change in direction from _____ to _____.
What are some factors that contribute to an Achilles rupture?
What test do you use to test for an Achilles rupture?
Achilles Rupture
More frequently in men 30-50 years who intermittently exercise
Associated with a change of direction from concentric to eccentric
Factors that contribute to achilles rupture
Decreased flexibility
Excessive body weight
Pre-existing tendonitis
Steroid injections to the tendon
Decreased vascularity
Thompson Test
Patient prone
Squeeze the calf group
Failure to plantar flexion means disruption of the tendon
How to treat an ankle sprain in the acute phase
Acute Stage
Ice, compression, and elevation = ICE
Grade I joint mob to decrease pain
Immobilized in neutral or in slight dorsiflexion with eversion
WB with crutches if there are problems with ambulation
Muscle setting
Active and passive ROM
Patient education on self management
How to treat an ankle sprain in the subacute stage
Subacute
Support
Cross fiber friction massage as tolerated
Grade II mobilization techniques
Active ROM
Mild passive stretching of the healing ligament within the pain-free range
Stretch the gastroc/soleus
Stabilization exercises
How to treat an ankle sprain in the chronic stage
Chronic
Resistance to all motions, Theraband, ankle weights, MRE
Training to improve proprioception in full WB
Forward/backward walk, crossover stepping, Bosu, cutting, change of direction drills
Wrap or tape upon return to activity
Balance/proprio training in KEY in ankle rehab
Research has shown it to be a very important factor in decreasing continued injury to the ankle
When to get surgery for an ankle sprain?
usually a complete tear of what?
Rarely a complete tear of what?
Surgical interventions.
3rd degree sprain
Complete tear of the ATF, often the CF ligaments, rarely PTF
Gross instability of the ankle
Mechanism: inversion with PF
Sometimes can lead to jones fracture, fracture of lateral malleolus
Positive anterior drawer and increased talar tilt
Surgery is done after conservative measures fail