ANKLE AND FOOT

The leg is structurally adapted to transmit ground reaction forces from the foot upward to the
knee joint and femur during upright activities
Provide foundation of either stability or motion to the distal extremity that assists the leg in
managing forces and demands
The foot is divided into three segments:
o Hindfoot. The talus and calcaneus make up the posterior foot segment
o Midfoot. The navicular, cuboid, and three cuneiforms make up the middle foot segment
o Forefoot. Five metatarsals and 14 phalanges make up the anterior foot segment. Each
toe has 3 phalanges except for the large toe, which has 2 phalanges
The leg is structurally adapted to transmit ground forces from the foot upward to the knee joint
and femur during upright activities
Provide a foundation of either stability or motion to the distal extremity that assists the leg in
managing forces and demands

COMMON ANKLE AND FOOT CONDITIONS

Weak foot produces moderate pronation. Severe pronation with flattening of the foot is
associated with congenital or ligamentous laxity and is deemed to be occurring in the foot is
pronating beyond 25% of the stance phase
Hypermobile foot- this type of foot give symptoms with running
o Hypermobile at the foot and ankle can lead to increased stress on the bone and so
tissues, especially the ligaments, and an overreliance on the muscular support
Flat foot/pes planus is manifested by little or no longitudinal arch with full weight bearing,
which is present beyond the age of 6 y/o
o the abnormal positioning associated with at flat foot deformity include the following:
▪ plantar flexion of the talus
▪ lateral drift of the calcaneus
▪ lateral drift of cuboid as it follows the calcaneus
▪ dorsi flexion of the metatarsals
▪ abduction foot
 Stiff foot or pes cavus (high arch) is an abnormally supinated and stiff foot. Common causes are
neuromuscular problems in childhood and in the elderly

THREE CLASSIFICATIONS OF ABNORMAL SUPINATION:

Pes cavus- classic type is characterized by a fixed plantar flexed forefoot, or an equinus forefoot,
which places the hindfoot in neutral during weight bearing
Pes cavocarus- this type is characterized by a fixed plantar flexed medial column or first ray,
places the calcaneus in varus or inversion during weight bearing so that the foot lands on its
lateral border
Pes equinovarus- this type demonstrate a fixed plantar flexed forefoot and hindfoot, with no
compensation occurring with weight bearing

SPECIFIC JOINT DEFORMITIES AND DEVIATIONS

Talipes equinovarus- talocrural joint

Lack of a minimum of 10 degrees of dorsiflexion at the talocrural joint is termed as
talipes equinus
A common cause or a lack of dorsiflexion at the ankle is adaptive shortening of the
gastrocnemius and soleus muscle groups. Other cause include trauma, spasticity,
structural bone deformities, and inflammatory diseases
Hindfoot varus
Most common structural foot deformity and is the most common abnormality of the
subtalar joint
 Practical significance of a hindfoot varus is that at heel strike,
the calcaneus is inverted more than normal, and the medial
condyle of the calcaneus is farther from the ground, resulting in
an increase in lateral heel contact

METATARSAL DEFORMITIES

Metatarsus adductus- is a transverse plane deformity with adduction of all the five
metatatarsals, which occurs at the tarsometatarsal joint
Metatarsus varus- deformity is characterized by a medial subluxation of the tarsometatarsal
joints with an adduction and inversion deformity of the metatarsals
Metatarsus addctovarus- is a combined transverse and frontal plane deformity of forefoot
adduction and inversion that occurs at the transverse tarsal joint

Hallux limitus/rigidus- is typically a progressive degenerative disorder

characterized by decreased dorsiflexion of the first MTP joint, and pain
and swelling in the posterior (dorsal) aspect of the joint
Hallux valgus, sometimes referred to as HAV- described a deformity of
the first MTP joint, in which the proximal phalanx is deviated laterally
with respect to the first metatarsal. Specifically, there is an abduction of the first MTP joint and
adduction of the first metatarsal

Turt toe- is used to describe a hyperextension sprain of the first MTP joint
with an axial load to the heel while in ankle plantarflexion
more common in football, baseball, and soccer players
ankle syndesmosis sprain- injury to the distal tibiofibular joint or
syndesmosis often referred to as a “high ankle” sprain, typically involves
injuries to the interosseous tibiofibular ligament, anterior inferior tibiofibular, and posterior
inferior tibiofibular ligaments. The most common MOI is excessive external rotation or forced
dorsiflexion
lateral ankle inversion sprain- is a study recently showed that ankle instability, and thus sprains,
could only occur during systemic loading and unloading, but not while the ankle is fully loaded,
due to the articular restraints
the most common mechanism of an ankle sprain is one of inversion and plantarflexion
with eversion and external rotation, the deltoid and/or ligaments of the distal
tibiofibular joint can be injured, producing the so-called medial and central sprains

Tarsi syndrome- sinus tarsi is located between the inferior neck of the talus and the superior
aspect of the calcaneus. It is inferior and slightly anterior to the ATFL
Sinus tarsi syndrome is a sprain of the subtalar joint, with an injury to the talocalcaneal
interosseous ligament
 Mechanism of injury involves an inversion sprain in a plantar flexed position that injures
both the talocrural subtalar joint

INFLAMMATION OR INFECTION OF THE NAILS AND SKIN

Subungual hematoma- is also called “black toenails” or “runner’s toe” and results from
bleeding under the toenails due to chronic friction or bumping of the toe against ill fitting shoes,
or from over trauma to the posterior (dorsal) aspect of the toe
Subungual exostosis is a hypertrophic bone, usually affecting the medial border of the hallux, as
the result of excessive pressure that produces pain on ambulation

Onychocryptosis- is more commonly referred to as ingrown toenails. It is commonly associated

with a secondary pyogenic infection or paronychia

Onychia- is an infection of one or both sides of the nail and nail plate, which can result from a
number of factors including chronic pressure on the nail plate, allergies, nail polish, improperly
cutting the nails, or certain soaps
 Onychauxis- is an overgrowth of the nail that can be the result of microtrauma or macrotrauma,
peripheral neuritis, old age, nutritional disrubances, or decreased circulation, producing fufute
nail growth distortion
Onychomycosis is a chronic fungal condition of the nails, which is often responsible or causing
onychaxis

Tinea pedis- is more commonly known as athlete’s foot. It usually presents with redness or
itchiness but can also appear as dry and flaky skin
Blisters- occur secondary to friction and shearing and can give the clinician valuable information
as to where the stresses of the foot are occurring

TENDINOPATHY

Fibularis peroneus longus tendinopathy- patient usually presents with pain behind and distal to
the lateral malleolus. There may be associated swelling in the acute phase. There will also be a
pain with resisted foot eversion
Tibialis anterior tendinopathy- is most commonly seen in runners, especially in those who
participate in up or down hill training. Examination will show point tenderness over the tendon
Achilles tendinopathy- tenderness located 2-6 cm proximal to the insertion is indicative of
noninsertional tendinopathy, whereas pain at the bone-tendon junction is more indicative of
insertional tendinopathy
Sever’s disease or calcaneal apophysitis- is a traction apophysitis at the insertion of the achilles
tendon and is a common cause of heel pain in the athletically active child, with 61% of cases
occurring bilaterally
 Plantar heel pain- which is the term used to describe pain arising from the insertion of the
plantar fascia, with or without heel spur, has been experienced by 10% of the population.
Plantar heel pain is usually unilateral
Plantar fascitis- on palpation there is “rice crispies” on the plantar aspect of the foot

BURSISTIS

Retrocalcaneal bursitis- is a distinct entity denoted by pain that is anterior to the achilles
tendon, just superior to its insertion on the os calcis

Haglund’s deformity- refers to an abnormal prominence of the posterior superior lateral border
of the calcaneus. Because of its association with various shoe types, it is often referred to as a
“pump pump” “high heel” and “winter heel”
Metatarsalgia- is defined as pain in the plantar aspects of the lesser metatarsal heads adjacent
to the MTP joints due to repetitive high pressure loading under the metatarsal head that causes
pain

Interdigital neuroma, which is also referred to as a morton’s neuroma, is a mechanical

entrapment neuropathy of one of the interdigital nerves in the forefoot
o Name of the condition is a misnomer, as a true neuroma does not exist,. Rather, there is
a thickening of the tissues around the nerve due to peineural fibrosis, fibrinoid
degeneration, demyelination, and endoneural fibrosis

Anterior shin splints. Overuse of the anterior tibialis muscle is the most common type of shin
splint. Impairments associated with shin splints include hypomobile gastrocnemius-soleus
complex, weak anterior tibialis muscle, and excessive pronation with walking or running. Pain
increases with active dorsiflexion and when the muscle is stretched into plantarflexion
 Posterior shin splints. A tight gastrocnemius-soleus complex and a weak or inflamed posterior
tibialis muscle, along with increased foot pronation are associated with posteromedial sin
splints. Pain is experienced when the foot is passively pronated to end range with overpressure
and/or actively supinated against resistance

TOTAL ANKLE ARTHROPLASTY

Indications for surgery

Patient with end stage ankle arthritis who has failed conservative management and has
persistent pain that compromises functional mobility

Contraindications

Active or chronic ankle infection

Severe osteoporosis
Avascular necrosis of a significant portion of the body of the talus
Peripheral neuropathy leading to decreased sensation or paralysis
Impaired LE vascular supply
Long term corticosteroid use
Skeletally immature individual

Immobilization and weight bearing considerations

Placed in a compression dressing and immobilized in a neutral position in a well padded short
leg cast or posterior orthosis
This is left in place for 10 to 21 days
Non weight bearing for 3 to 6 weeks, to minimal immediate postoperative weight bearing that
progresses to weight bearing as tolerated within the first 2 weeks
ARTHRODESIS OF THE ANKLE AND FOOT

Most frequently used surgery for late stage arthritis of the ankle and foot and toe joints
Procedure of choice for relatively young, active patients with posttraumatic arthritis and gross
instability of the ankle and hindfoot
Arthrodesis has been the “gold standard” option for younger patients with high functional
demands and pain free compensatory movements

COMMON TYPES OF ARTHRODESIS

Ankle arthrodesis fuses the talus to the tibia in a position that maximizes function: 0
degrees df and 5 degrees to 10degrees external rotation of the foot
Arthrodesis of the hindfoot- indicated when conservative management (including arch
supports, appropriate footwear, ankle and hindfoot bracing, and oral injected anti
inflammatory medication) has failed
Arthrodesis of the first toe- arthrodesis of the first MTP joint for hallux rigidus and
hallux valgus provides pain relief at rest and with ambulation
Arthrodesis of the IP joints of the toes- fusion of the IP joints of the toes in a neutral
position for hammer toes (typically toes 2 to 3) provides relief of pain with ambulation
and improved shoe fit

REPAIR OF COMPLETE LATERAL ANKLE LIGAMENT TEARS

Grade 3 sprain of the lateral ankle, which usually occurs as the result of a severe inversion
injury, causes a complete tear of the ATF ligament, often the CF ligament, and infrequently the
PTF ligament

Types:

Direct repair: the surgery most commonly performed for a primary repair is the modified
Brostrom procedure, also known as the brostrom-gould procedure. this procedure involves an
anatomic repair of the ATF and/or CF ligaments
Reconstruction with augmentation
o Done when direct repair is not an option because of poor ATF and/or CF ligament tissue
quality or when a patient’s weight (more than 200 to 250 lb) will overly stress a direct
repair
o Used as a revision procedure when previous direct repair has failed to prevent a
recurrence of instability
o Ipsilateral fibularis brevis tendon is the most commonly used autologous graft
(chrisman0snook procedure)

POSTOPERATIVE MANAGEMENT
 Immobilization- after some degree of swelling has subsided, usually within 3 to 5 postoperative
days, the compression dressing and protective cast or orthosis is removed and a short leg cast is
reapplied
Weight bearing- although recent reports indicate that immediate weight bearing to tolerance is
safe and beneficial, a period of nonweightbearing in the protective orthosis or cast is still
frequently recommended
o Weight bearing as tolerated 10 to 14 days following surgery

EXERCISE: MAXIMUM PROTECTION PHASE (4 TO 6 WEEKS)

Submaximal muscle setting (isometric) exercises in neutral ankle position

Active ROM in pain free range for ankle plantarflexion and dorsiflexion, inversion and eversion
active ROM of the toes
gait and active resistive exercises of the hip and knee of the operated lower extremity and
resistance exercises f the upper extremities and non operative lower extremity
perform mini squats in bilateral stance with appropriate weight bearing

EXERCISE: MODERATE AND MINIMUM PROTETCION PHASE (8-12 WEEKS)

this phase is characterized by a gradual weaning from the immobilizer or brace accompanied
by restoration of full, pain free ankle joint mobility
progress AROM, achieving full ankle ROM by 8 weeks
active multiplanar movements, such as figure of eight or ankle alphabet active ROM
perform grade II or III joint mobilization techniques to the tibiotalar and tibiofibular joint if the
joint restriction limits dorsi or plantarflexion
self stretching exercises to improve muscle flexibility particularly for the gastrocnemius-soleus
complex. Begin with a towel stretch; progress to standing on a wedge for an extended duration
PREs of all ankle muscles. Begin in a nonweight bearing and progress to weight bearing positions
Unilateral calf raises should initially be peformed with UE support to minimize chance of
reinjury due to balance loss
Dynamic strengthening evertors, against elastic or manual resistance
Bilateral hip and knee strengthening in weightbearing positions
Plyometric training when weight bearing is pain free, ankle is stable with stress testing, and 25
unilateral heel raises can be performed
Land based activities should initially be peformed with external ankle support (bracing or
taping)
Progression of bilateral and unilateral balance activities beginning on stable surface and
introducing progressive surface instability
Activities to improve agility, such as grapevine walking (carioca), lateral shuffles
REPAIR OF A RUPTURED ACHILLES TENDON

Common in 4th to 6th decade of life for individuals who participate in exercise or athletic
activities, with males affected about three times more than females
The rupture usually is associated with a forceful contraction of the gastrocnemius-soleus
muscles during sudden acceleration or abrupt deceleration, such as jumping or landing
The tendon most frequently ruptures 3 to 4 cm proximal to the calcaneal insertion
Abnormal Thompson squeeze test
Palpable defect in the achilles tendon

TYPE OF PROCEDURE

Primary repair of an acute rupture generally is performed within the first few days after the
injury
o A direct, end to end repair in which the ends of the torn tendon are re-opposed and
sutured together
o Donor graft are the flexor hallucis longus, plataris, fibularis brevis, semitendonosis, or a
flap of fascia from the gastrocnemius
Delayed repair- an opened approach typically is used, requiring reconstruction of the neglected
achilles tendon rupture (>1 month post rupture)

IMMOBILIZATION AND WEIGHT BEAIRNG CONSIDERATIONS

The ankle is immobilized inan approx. 20 deg of plantarflexion for approx. 6 weeks
The patient remains nonweight bearing during all or most of this time
Following the period of strict immbilziation, a CAM orthosis is applied, generally allowing
plantarflexion, but limiting dorsiflexion to 0 degree
EXERCISE: MAXIMUM PROTETCION PHASE

Gait and transfer training in protective orthosis with assistive devices, emphasizing wight
bearing restrictions
In a seated, supine or prone position, perform active ROM of the hip, knee, and toes of the
operated side while wearing the immobilizer
Submaximal, pain free muscle setting exercises of the ankle in the immobilizer within the first
few days after surgery
Active inversion and eversion should be performed in a plantarflexed position
Weight shifting activities in bilateral stance while wearing the protective orthosis
Upper extremity ergometer for endurance training if available

EXERCISE: MOEDERATE PROETCTION PHASE (4 TO 6 WEEKS AND EXTENDS TO 12 WEEKS)

Grade III joint mobilization techniques

Gentle self stretching exercises, such as a towel stretch in a sitting positions, to increase ankle
dorsiflexion with the knee slightly flexed. Progress to stretch with knee fully extended
Gentle manual self stretching to regain full inversion/eversion and dorsiflexion/plantarflexion
and toe extension
Active ankle ROM with patient seated and foot in a wobble or rocker board
Self stretching to increase dorsiflexion by standing on a wedge in bilateral stance with knees
slightly flexed
Open chain resistance exercises for the hip, knee and ankle musculature against a light grade of
elastic resistance
Closed chain exercises such as unilateral heel raising and lowering while seated; add light
resistance as tolerated, typically by 8 weeks
Standing bilateral heel raising/lowering with body weight resistance. Postpone unilateral heel
raising/lowering until 10 to 12 weeks after surgery
Partial lunges with involved leg forward, bilateral minisquats, and toe raises
As strength progresses, add external resistance (handheld weights, weight belt, or weighted
backpack) to supplement body weight with standing exercises

EXERCISE: MINIMUM PROTECTION/RETURN TO FUNCTION PHASE (12 TO 16 WEEKS)

Direct toward returning a patient to a preinjury level of function for expected work related
demands
Strength and muscular endurance training continues, emphasizing eccentric loading of
gastrocnemius-soleus
Descending stairs step over step also emphasizes eccentric loading
 CERVICAL SPINE CONDITION
Upper (proximal) crossed syndrome

Caused by poor posture

Adaptive shortening of levator scapulae, upper trapezius, pectoralis major and minor, SCM, and
weakness of deep neck flexors and lower scapula stabilizers
Elevation and protraction of shoulder rot and abd of scapula, scapular winging, forward head,
decrease stability of gh joint, increase muscle activity of levator scapula and trapezius
Stretching of short muscles, strengthening of weak muscles

Forward head posture

Caused by poor habitual/resting neck posture, poor ergonomic posture

Often associated with upper crossed syndrome; - headaches, neck discomfort, muscle tension in
neck and shoulders, discomfort in midback, chest pain, pain like pins and needles, and
numbness in arms and hands
Tension headache/cervical headache

According to the international headache society, the three categories of headaches are primary
(migraine, cluster, or tension), secondary (headaches caused by another disorder) , and cranial
neuralgias

Secondary headaches

include those that result from cervical spine impairments (musculoskeletal) or

temporomandibular dysfunction (TMD)
soft tissue injury or may be caused by faulty or sustained postures, or sustained muscle
contraction (from faulty posture or emotional tension) leading to ischemia
cervical muscle trigger points can all contribute to pain in the craniofacial region

HISTORY AND SYMPTOMS OF CERVICAL HEADACHES

Unilateral headaches or bilateral headaches with one side predominant

Pain in the neck or suboccipital region that spreads into the head
Intensity can fluctuate between mild, moderate, or severe
Precipitated by sustained neck postures or movements
May be precipitated by stress (also common with other types of headache)
May be related to trauma, DJD, or a sedentary lifestyle and postural stresses
More prevalent in females but no familial tendency
Pain or altered sensation in the face or TMJ region

REFER TO SPECIALIST WITH THE FOLLOWING REPORTED HISTORY OF HEADACHE

Positive cardiac history or signs, send to a cardiologist

Bilateral pain or in multiple joints, send to a rheumatologist
Sinusitis, facial pain, nasal congestion or pressure, send to ENT
Vision loss/disturbances or pain with eye movement, send to ophthalmologist
TMD symptoms, send to a pain center or dentist

GENERAL MANAGEMENT GUIDELINES

Modalities, massage, and muscle setting exercises

 Soft tissue mobilization, myofascial release, ad trigger point release
Dry needling
Mobility and flexibility exercises
Scapular stabilization and posture correction
Stress management

CERVICAL DISK PATHOLOGY

Cervical radiculopathy
Caused by cervical disk herniation or other space occupying lesion that often results in
nerve root inflammation, impingement, or both
Irradiating arm pain that corresponds to a dermatomal pattern, neck pain, paresthesia,
muscle weakness in myotomal pattern, reflex impairment, headaches, scapular pain,
sensory and motor dysfunction in UE and neck
Affection of cervical nerve roots, head turned away from the side of injury
Neck stiffness
Decrease AROM in area of pain (extension, rotation, side bending)
Tenderness along cervical paraspinals, along ipsilateral side of affected nerve root
Hypertonicity or muscle spasm in muscles along medial scapular, proximal arm, and
lateral epicondyle
MMT: subtle weakness in myotomal pattern of nerve roots (shoulder abduction, elbow
flexion and wrist extension, elbow extension and wrist flexion, thumb extension and
wrsit ED)
Loss of diminished sensation in dermatomal pattern

Treatment:

▪ Modified rest
▪ Cervical collar
▪ Oral corticosteroids
▪ NSAIDs
▪ Cervical and cervicothoracic stabilization exercises
▪ Posterior gliding of lower cervical spine
▪ Combination with extension of lower cervical spine and flexion of upper cervical
soine surgical intervention
Cervical spondylosis
Chronic degenerative condition that affects the content of spinal canal (nerve roots and
spinal cord) and cervical vertebral bodies and IVDs. most common cause progressive
spinal cord and nerve root compression
Radiographs shows progressive degenerative changes in the cervical region in some 30
y/o and present in more that 90% of people older that 60 y/o
C5-C6 and C6-C7 are most commonly and most severely affected
 Treatment:

▪ Electrotherapeutic modalities (HMPs, ES, UTZ) immobilization of cervical

spine
▪ Soft cervical collars, more rigid orthoses (Philadelphia collarand Minerva
body jacket)
▪ Molded cervical pillows
▪ Manual techniques
▪ ROM exercises
▪ Isometric exercises
▪ Cervical stabilization exercises
Zygapophyseal dysfunction
Entrapment of a small piece of synovial membrane by zygopophyseal joint
Pain radiographs, CT scan and MRI are typically unremarkable
Can be confirmed by diagnostic intra articular zygapophyseal joint injections or a block
of joint’s nerve supply

Treatment:
▪ Cryotherapy
▪ Electrotherapeutic modalities
▪ Joint mobilization techniques
▪ And isometric exercises
▪ Strengthening exercises (progression)
Cervical myelopathy
Is a disease of the spinal cord
it results from degeneration or stenosis of the central spinal cord
patient may experience neurological symptoms in both his hands and feet,
uncoordinated gait, upper motor neuron lesion symptoms, including bowel and bladder
imapairments
therapy interventions are based on the associated impairments and identifying the
cause
acute torticollis (acute wry neck)
 both symptoms and a disease
cause in unclear, but most patients appear to experience symptoms upon awakening or
may be result of an injury to a muscles, joints, or ligaments through sleeping with
unusual neck position
painful neck (visible and palpable), limited ROM and neck

treatment:

▪ gentle traction, modalities