Download The Ankle and Foot

Chapter 22
The Ankle and Foot
Copyright 2005 Lippincott Williams & Wilkins
Osteology
Talocrural Joint
Distal fibula
Tibia
Talus
Midfoot
Navicular
Cuboid
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
Anterior tibialis
Extensor hallucis
longus
Extensor digitorum
longus
Peroneus tertius
Open Chain Action
Dorsiflexion/inversion
Extension of
phalanges – 1st ray
Extension of
phalanges – toes
Everts foot
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Muscles of the Foot and Ankle (cont.)
Lateral Compartment
Peroneus longus
Peroneus brevis
Posterior
Open Chain Action
Eversion
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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
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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
Activity
Contraction
Type
Initial
TCJ
O° DF
Plantar
flexion
Dorsiflexors
Isometric
STJ
Supination
Everters
Isometrics
TCJ
Plantar flexes
from 0–15°
PF
Plantar
flexion
Dorsiflexors
Eccentric
Moving to
valgus
Inverters
Eccentric
Plantarflexors
Inverters
Eccentric
Eccentric –
Concentric
PlantarEccentric –
flexors
concentric
Evertors
Isometric
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Loading
response
STJ
Starts
pronating
Midstance
Terminal
Stance
TCJ
10° DF
STJ
Begins
supination
Moving to
DF
ValgusVarus
TCJ
15° DF
Dorsiflexion
STJ
Supinating
Varus
Kinetics and Kinematics of Gait Cycle (cont.)
Phase
Joint
ROM
Moment
Muscle
Activity
Contraction
Type
Pre-swing
TCJ
20° PF
Dorsiflex
STJ
Remains
supinated
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
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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.
2.
Tibial nerve
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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