Ankle & Foot -

ANKLE AND FOOT OVERVIEW

General Information

  • Overview of the anatomy and function of the ankle and foot systems.

  • Importance of understanding anatomy for rehabilitation and surgical interventions.

ANATOMY

Lateral and Medial View

  • Key components visible in both views:

    • Tibia

    • Fibula

    • Talus

    • Navicular

    • Cuneiform

    • Cuboid

    • Calcaneus

Foot Structure

  • Divided into three areas:

    • Hindfoot: Posterior segment (Talus and Calcaneus)

    • Midfoot: Middle segment (Navicular, Cuboid, and three Cuneiforms)

    • Forefoot: Anterior segment (5 metatarsals and 14 phalanges)

MOTIONS OF THE FOOT AND ANKLE

Primary Planes of Motion

  • Sagittal Plane: Dorsiflexion (DF) and Plantarflexion (PF)

  • Frontal Plane: Inversion and Eversion

  • Transverse Plane: Abduction and Adduction

Triplanar Motions

  • Pronation:

    • Dorsiflexion

    • Eversion

    • Abduction

  • Supination:

    • Plantarflexion

    • Inversion

    • Adduction

JOINT HYPO-MOBILITY: NONOPERATIVE MANAGEMENT

Common Conditions

  • Rheumatoid Arthritis (RA), Juvenile RA (JRA), Degenerative Joint Disease (DJD), Trauma, Dislocation or Fracture

  • Impairments often include:

    • Restricted motion

    • Muscle weakness

    • Impaired balance leading to increased fall frequency

    • Pain during weight-bearing (WB)

    • Gait deviations decreasing ambulation ability

Management Strategies

Maximum Protection Phase

  • Patient education and pain management (PRICE)

  • Utilize distraction or oscillation techniques

  • Gradual progression from Passive Range of Motion (PROM) to Active Therapist Assisted Range of Motion (AAROM) to Active Range of Motion (AROM) pain-free

  • Include muscle setting and isometric exercises pain-free to maintain muscle strength

  • Home exercise programs and proper footwear considerations

  • Consider aquatic therapy for low-impact exercise

Control Motion and Return to Function Phase

  • Increase intensity and use Grades III and IV mobilizations

  • Soft tissue and muscle stretching

  • Focus on improving balance and proprioception

  • Gradually increase WB activities

  • Develop muscle strength through Open Kinetic Chain (OKC) and Closed Kinetic Chain (CKC) exercises

  • Initiate light plyometrics and cardiovascular training

TOTAL ANKLE ARTHROPLASTY (TAA)

Indications for Surgery

  • Low to moderate physical demands and sufficient ligament integrity

  • Manage end-stage arthritis and avascular necrosis

Contraindications

Absolute

  • Active infection, severe osteoporosis, poor bone stock, peripheral neuropathy, long-term use of steroids

Relative

  • History of infection, marked instability, obesity, high-demand activities

POST-OPERATIVE MANAGEMENT

Total Ankle Arthroplasty

  • Immobilization:

    • Neutral position for 10-21 days

    • Transition to short-leg walking cast or CAM-Boot from weeks 2 to 6

  • Weight Bearing:

    • Protocols vary (NWB, PWB, WBAT) based on fixation and procedure

    • Generally, FWB indicated by week 6 without CAM-Boot

Maximum Protection Phase

  • Protect ankle while regaining functionality during first 6 weeks

  • Implement gait training with assistive devices (AD)

  • Pain-free AROM of toes and gentle ranges for DF and PF

  • Avoid inversion/eversion until week 6

Moderate to Minimum Protection Phase

  • Aim to achieve 100% ankle range of motion (ROM)

  • Gradual progression of exercises and activities

  • Patient education and modifications for activities

  • Increase strength and balance gradually

ANKLE FRACTURES

Classification

  • Lauge-Hansen: based on foot position and force direction

    • Supination-Adduction, Supination-External Rotation, Pronation-Abduction, Pronation-External Rotation

Treatment Approaches

  • Simple malleolar fractures: immobilization

  • Complex fractures: Operative fixation (ORIF)

  • Gradual return to movement and strength training post-cast removal

LIGAMENTOUS INJURIES

Ankle Sprains

  • Most commonly from inversion injury affecting the ATFL and CFL

  • Rarely includes the PTF in isolation

Indications for Surgery

  • Chronic instability or confirmed complete tears of ligaments

Post-Operative Management

  • Maximum protection phase includes NWB with AD, elevated positioning for edema

  • Balance and strength exercises as recovery progresses

RUPTURED ACHILLES TENDON

Overview

  • Common in ages 40-60; especially males

  • Often due to forceful contraction during sudden movement

  • Presenting signs include pain, swelling, and inability to plantar flex

Postoperative Management

Early Phase

  • Proper immobilization and gradual weight-bearing as tolerated

Progressive Phase

  • Increasing range of motion and strength training

COMPARTMENT SYNDROMES

Definitions

  • Condition arises from elevated tissue pressure within a closed space

Symptoms

  • Acute: Pain, swelling, and tense skin

  • Chronic: Aching pain during exercise with potential paresthesias

MORTON'S NEUROMA

Definition and Symptoms

  • Affects plantar interdigital regions, most commonly between the 3rd and 4th toes

  • Symptoms include burning, cramping, and pain radiating to toes

Treatment

  • Conservative care through metatarsal pads and footwear changes

  • Surgical excision when conservative methods fail

FOOT DEFORMITIES

Hallux Valgus

  • Deviation of the great toe leading to soft tissue and bony deformity

  • Management includes conservative methods and surgery (Bunionectomy)

Lesser Toe Deformities

  • Hammer, Mallet, Claw toes exacerbated by improper footwear

Medial Tibial Stress Syndrome (MTSS)

  • Overuse injury of the posterior medial tibia characterized by tenderness and inflammation

  • Classified from Grade I (post-exercise pain) to Grade IV (full stress fracture)

Treatment

  • Address symptoms through rest and rehabilitation exercises

PLANTAR FASCIITIS

Overview

  • Inflammation of the plantar fascia, often with associated heel spurs

  • Characterized by morning pain and difficulty with the first steps

Treatment Strategies

  • Include rest, stretching, manual therapy, and orthotic devices

ARCH DEFORMITIES

Pes Planus

  • Flatfoot condition with reduced medial arch height, may result from various factors

Pes Cavus

  • High arch condition often associated with pain and discomfort; requires shock attenuation treatments.