Chapter 22

The Ankle and Foot

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 Osteology

Talocrural Joint Midfoot

 Distal fibula  Navicular
 Tibia  Cuboid
 Talus  3 cuneiform bones

Forefoot
 5 metatarsals
 Phalanges

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Osteology of Foot and Ankle

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

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 Muscles of the Foot and Ankle

Anterior Open Chain Action

 Anterior tibialis  Dorsiflexion/inversion

 Extensor hallucis  Extension of
longus phalanges – 1st ray
 Extensor digitorum  Extension of
longus phalanges – toes
 Peroneus tertius  Everts foot

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 Muscles of the Foot and Ankle (cont.)

Lateral Compartment Open Chain Action

 Peroneus longus  Eversion

 Peroneus brevis
 Posterior

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 Muscles of the Foot and Ankle

Posterior Open Chain Action

 Gastrocnemius  Plantar flexion
 Soleus  Plantar flexion
 Plantaris  Plantar flexion
Deep
 Posterior tibialis  Plantar flexion and
 Flexor hallucis longus inversion
 Flexor digitorum longus  First ray flexion
 Flexion – Phalanges of
toes
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Innervation (Superficial)

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Talocrural/Subtalar/Midtarsal Joints

Function:

 Shock absorption
 Absorb lower extremity rotatory
forces
 Provide lever for effective
propulsion

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 Pronation/Supination

Pronation
Movement in the direction of eversion, abduction
and dorsiflexion.

Supination
Movement toward inversion, adduction, and
plantar flexion.

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Pronation/Supination

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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)

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 Midtarsal Joint (MTJ)

Subtalar pronation – Promotes mobility in MTJ

and forefoot.

Subtalar supination – Promotes stability in MTJ

and forefoot.

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Locking and Unlocking of
Midtarsal Joint

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 Kinetics and Kinematics of Gait Cycle
Phase Joint ROM Moment Muscle Contraction
Activity Type
Initial TCJ O° DF Plantar Dorsiflexors Isometric
flexion
STJ Supination Everters Isometrics
Loading TCJ Plantar flexes Plantar Dorsiflexors Eccentric
response from 0–15° flexion
PF
STJ Moving to Inverters Eccentric
Starts valgus
pronating
Midstance TCJ 10° DF Moving to Plantar- Eccentric
DF flexors Eccentric –
STJ Begins Valgus- Inverters Concentric
supination Varus
Terminal TCJ 15° DF Dorsiflexion Plantar- Eccentric –
Stance flexors concentric
STJ Supinating Varus Evertors Isometric
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 Kinetics and Kinematics of Gait Cycle (cont.)
Phase Joint ROM Moment Muscle Contraction
Activity Type

Pre-swing TCJ 20° PF Dorsiflex

STJ Remains Varus

supinated
Initial TCJ Dorsiflexes to Dorsiflexors Dorsiflexors
swing 10° PF

Midswing TCJ Dorsiflexes to Dorsiflexors Dorsiflexors

0°

Terminal TCJ Stays at 0° Dorsiflexors Dorsiflexors

swing

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 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.

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Ideal Rearfoot Alignment

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 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.

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 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.

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Forefoot Varus

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Forefoot Valgus

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Examination and Evaluation

 Patient/client history
 Balance
 Joint integrity and mobility
 Muscle performance
 Pain
 Posture

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 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

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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.

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 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.).

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Intrinsic Muscles/Extrinsic Muscles

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

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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.).

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 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.

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 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.

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 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.

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Subtalar Pronation/Supination

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 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.

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 Plantar Faciitis – Treatment (cont.)

If pronated

 Mobilize TCJ
 Stretch gastrocnemius and soleus
 Strengthen tibialis anterior and extensor digitorum
 Initiate functional and proprioceptive activities

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 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.

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 Achilles Tendinosis
 Overuse pathology of Achilles tendon.

Treatment
 Restore TCJ mobility
 Stretching is essential after TCJ mobility is
restored.
 Strengthening exercises following
inflammation recovery.

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 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

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 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

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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.

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 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

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 Adjunctive Interventions
 Adhesive strapping
 Wedges and pads
 Biomechanical foot
orthotics
 Heel and full sole lifts

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 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.

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 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.
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