Chapter 19

Chapter 19Chapter 19

The Leg, Foot and AnkleThe Leg, Foot and Ankle

OverviewOverview

The ankle and foot is a complex structure The ankle and foot is a complex structure comprised of 28 bones (including 2 comprised of 28 bones (including 2 sesamoid bones) and 55 articulations sesamoid bones) and 55 articulations (including 30 synovial joints), (including 30 synovial joints), interconnected by ligaments and musclesinterconnected by ligaments and muscles

In addition to sustaining substantial In addition to sustaining substantial forces, the foot and ankle serve to convert forces, the foot and ankle serve to convert the rotational movements that occur with the rotational movements that occur with weight bearing activities into sagittal, weight bearing activities into sagittal, frontal, and transverse movements frontal, and transverse movements

AnatomyAnatomy

Anatomically and biomechanically, the Anatomically and biomechanically, the foot is often subdivided into:foot is often subdivided into:

The rearfoot or hindfoot (the talus and The rearfoot or hindfoot (the talus and calcaneus)calcaneus)

The midfoot (the navicular, cuboid and The midfoot (the navicular, cuboid and the 3 cuneiforms)the 3 cuneiforms)

The forefoot (the 14 bones of the toes, The forefoot (the 14 bones of the toes, the 5 metatarsals, and the medial and the 5 metatarsals, and the medial and lateral sesamoids) lateral sesamoids)

AnatomyAnatomy

Distal Tibiofibular JointDistal Tibiofibular Joint– Classified as a syndesmosisClassified as a syndesmosis– Consists of a concave tibial surface Consists of a concave tibial surface

and a convex or plane surface on and a convex or plane surface on the medial distal end of the fibula the medial distal end of the fibula

AnatomyAnatomy

The talocrural (ankle) jointThe talocrural (ankle) joint Formed between the saddle-Formed between the saddle-

shaped talus and the distal tibiashaped talus and the distal tibia Classified as a synovial hinge or a Classified as a synovial hinge or a

modified sellar jointmodified sellar joint

AnatomyAnatomy

Subtalar (talocalcaneal) jointSubtalar (talocalcaneal) joint– The subtalar joint is a synovial, bicondylar The subtalar joint is a synovial, bicondylar

compound joint consisting of two separate, compound joint consisting of two separate, modified ovoid surfaces with their own joint modified ovoid surfaces with their own joint cavities (one male and one female)cavities (one male and one female)

– This relationship ensures that the anterior This relationship ensures that the anterior and posterior aspects can move in opposite and posterior aspects can move in opposite directions to each other during functional directions to each other during functional movements (while the anterior aspect is movements (while the anterior aspect is moving medially, the posterior aspect is moving medially, the posterior aspect is moving laterally) moving laterally)

AnatomyAnatomy

Talocalcaneal joint ligamentsTalocalcaneal joint ligaments– A number of ligaments provide support A number of ligaments provide support

to this joint, although some confusion to this joint, although some confusion exist in the descriptions and exist in the descriptions and nomenclature of these ligamentsnomenclature of these ligaments The two superficial ligaments are the lateral The two superficial ligaments are the lateral

and posterior talocalcaneal ligamentsand posterior talocalcaneal ligaments The deep ligaments include the The deep ligaments include the

interosseous, cervical, and axial ligaments, interosseous, cervical, and axial ligaments, often referred together as the interosseous often referred together as the interosseous ligaments ligaments

AnatomyAnatomy

The midtarsal joint complex The midtarsal joint complex – Consists of the talonavicular and Consists of the talonavicular and

calcaneocuboid articulationscalcaneocuboid articulations The talonavicular joint is classified as a The talonavicular joint is classified as a

synovial, compound, modified ovoid jointsynovial, compound, modified ovoid joint– Formed by components of the talus, Formed by components of the talus,

navicular, calcaneus and plantar navicular, calcaneus and plantar calcaneonavicular (spring) ligamentcalcaneonavicular (spring) ligament

The calcaneocuboid joint is classified as a The calcaneocuboid joint is classified as a simple, synovial modified sellar joint simple, synovial modified sellar joint

AnatomyAnatomy

Ligaments of the mid-tarsal jointsLigaments of the mid-tarsal joints– A number of ligaments help provide A number of ligaments help provide

support to this region:support to this region: The spring ligament (plantar The spring ligament (plantar

calcaneonavicular) connects the calcaneonavicular) connects the navicular bone to the sustentaculum tali navicular bone to the sustentaculum tali on the calcaneuson the calcaneus

The ligaments of the calcaneocuboid The ligaments of the calcaneocuboid joint include the long plantar ligament joint include the long plantar ligament and a portion of the bifurcate ligament and a portion of the bifurcate ligament dorsally dorsally

AnatomyAnatomy

The cuneonavicular jointThe cuneonavicular joint– Classified as a compound, synovial, Classified as a compound, synovial,

modified ovoid joint modified ovoid joint

AnatomyAnatomy

Intercuneiform and Cuneocuboid Intercuneiform and Cuneocuboid JointsJoints– These joints are classified as These joints are classified as

compound, synovial, modified ovoid compound, synovial, modified ovoid joints joints

AnatomyAnatomy

Cubometatarsal joint Cubometatarsal joint – When considered alone, this joint is When considered alone, this joint is

classified as a compound modified classified as a compound modified ovoid, synovial joint ovoid, synovial joint

AnatomyAnatomy

The cubonavicular jointThe cubonavicular joint– Classified as a syndesmosis, or a Classified as a syndesmosis, or a

plane surfaced joint plane surfaced joint

AnatomyAnatomy

Intermetatarsal jointsIntermetatarsal joints– The first intermetatarsal joint is The first intermetatarsal joint is

classified as a simple, synovial, classified as a simple, synovial, modified ovoid joint, while the 2nd, modified ovoid joint, while the 2nd, 3rd and 4th are classified as 3rd and 4th are classified as compound joints compound joints

AnatomyAnatomy

The metatarsophalangeal (MTP) The metatarsophalangeal (MTP) jointsjoints– Classified as simple, synovial, Classified as simple, synovial,

modified ovoid jointsmodified ovoid joints

AnatomyAnatomy

The interphalangeal (IP) jointsThe interphalangeal (IP) joints– Classified as simple, synovial Classified as simple, synovial

modified sellar joints modified sellar joints

AnatomyAnatomy

Plantar fascia/aponeurosisPlantar fascia/aponeurosis– The plantar fascia is the investing fascial The plantar fascia is the investing fascial

layer of the plantar aspect of the foot that layer of the plantar aspect of the foot that originates from the os calcis and inserts originates from the os calcis and inserts through a complex network to the plantar through a complex network to the plantar forefootforefoot

– A tough, fibrous layer, composed A tough, fibrous layer, composed histologically of both collagen and elastic histologically of both collagen and elastic fibers fibers

– Three portionsThree portions

AnatomyAnatomy

Plantar fascia/aponeurosisPlantar fascia/aponeurosis– With standing and weightbearing, With standing and weightbearing,

the plantar fascia plays a major role the plantar fascia plays a major role in the support of the weight of the in the support of the weight of the body by virtue of its attachments body by virtue of its attachments across the longitudinal arch. across the longitudinal arch.

AnatomyAnatomy

RetinaculaRetinacula– There are four important ankle There are four important ankle

retinacula, which function to tether retinacula, which function to tether the leg tendons as they cross the the leg tendons as they cross the ankle to enter the foot ankle to enter the foot

AnatomyAnatomy

The extrinsic muscles of the footThe extrinsic muscles of the foot– Can be divided into anterior, Can be divided into anterior,

posterior superficial, posterior deep, posterior superficial, posterior deep, and lateral compartments and lateral compartments

AnatomyAnatomy

The extrinsic muscles of the footThe extrinsic muscles of the foot– Anterior compartmentAnterior compartment

This compartment contains the dorsiflexors This compartment contains the dorsiflexors (extensors) of the foot. These include the (extensors) of the foot. These include the tibialis anterior, extensor digitorum longus, tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertiusextensor hallucis longus, and peroneus tertius

– Posterior superficial compartmentPosterior superficial compartment This compartment, located posterior to the This compartment, located posterior to the

interosseous membrane, contains the calf interosseous membrane, contains the calf muscles which plantarflex (flex) the foot. These muscles which plantarflex (flex) the foot. These include the gastrocnemius, soleus, and the include the gastrocnemius, soleus, and the plantaris muscle plantaris muscle

AnatomyAnatomy

The extrinsic muscles of the footThe extrinsic muscles of the foot– Posterior deep compartmentPosterior deep compartment

This compartment contains the flexors This compartment contains the flexors of the foot. These muscles include the of the foot. These muscles include the posterior tibialis, flexor digitorum posterior tibialis, flexor digitorum longus, and flexor hallucis longus longus, and flexor hallucis longus

– Lateral compartmentLateral compartment This compartment contains the This compartment contains the

peroneus longus and brevisperoneus longus and brevis

AnatomyAnatomy

The intrinsic muscles of the footThe intrinsic muscles of the foot– Subdivided into 4 layersSubdivided into 4 layers

1st layer:1st layer:– Abductor hallucisAbductor hallucis– Abductor digiti minimis Abductor digiti minimis – Flexor digitorum brevis Flexor digitorum brevis

22ndnd layer layer– Flexor digitorum accessorius (quadratus Flexor digitorum accessorius (quadratus

plantae)plantae)– LumbricalesLumbricales

AnatomyAnatomy

The intrinsic muscles of the footThe intrinsic muscles of the foot– 33rdrd layer layer

Flexor hallucis brevis Flexor hallucis brevis Flexor digiti minimis Flexor digiti minimis Adductor hallucis Adductor hallucis

– 44thth layer layer Dorsal interossei Dorsal interossei Plantar interossei Plantar interossei

AnatomyAnatomy

The dorsal intrinsic muscles of the The dorsal intrinsic muscles of the footfoot– Consist of the extensor hallucis Consist of the extensor hallucis

brevis (EHB) and extensor digitorum brevis (EHB) and extensor digitorum brevis (EDB) musclesbrevis (EDB) muscles

AnatomyAnatomy

Arches of the footArches of the foot– There are 3 main arches: There are 3 main arches:

The medial longitudinalThe medial longitudinal The lateral longitudinalThe lateral longitudinal The transverseThe transverse

AnatomyAnatomy

NeurologyNeurology– The saphenous nerve, the largest cutaneous The saphenous nerve, the largest cutaneous

branch of the femoral nerve, provides branch of the femoral nerve, provides cutaneous distribution to the medial aspect of cutaneous distribution to the medial aspect of the footthe foot

– The sciatic nerve provides the sensory and The sciatic nerve provides the sensory and motor innervation for the foot and legmotor innervation for the foot and leg

It divides into the common peroneal and tibial It divides into the common peroneal and tibial nerves. The common peroneal nerve in turn divides nerves. The common peroneal nerve in turn divides into the superficial peroneal, deep peroneal nerves. into the superficial peroneal, deep peroneal nerves. The tibial nerve divides into the sural, medial The tibial nerve divides into the sural, medial calcaneal, medial plantar, and lateral plantar nerves calcaneal, medial plantar, and lateral plantar nerves

AnatomyAnatomy

Vascular supplyVascular supply– Two branches of the popliteal artery, Two branches of the popliteal artery,

the anterior tibial artery and the the anterior tibial artery and the posterior tibial artery, form the main posterior tibial artery, form the main blood supply to the footblood supply to the foot

BiomechanicsBiomechanics

TerminologyTerminology– Motions of the leg foot and ankle consist of Motions of the leg foot and ankle consist of

single plane and multi-plane movements. single plane and multi-plane movements. The single plane motions include:The single plane motions include:

The frontal plane motions of inversion and The frontal plane motions of inversion and eversioneversion

The sagittal plane motions of dorsiflexion and The sagittal plane motions of dorsiflexion and plantarflexion plantarflexion

The horizontal plane motions of adduction and The horizontal plane motions of adduction and abduction abduction


A triplane motion describes a A triplane motion describes a movement about an obliquely movement about an obliquely oriented axis through all three body oriented axis through all three body planes.planes.

Triplanar motions occur at the Triplanar motions occur at the talocrural, subtalar, and midtarsal, talocrural, subtalar, and midtarsal, joints, and at the first and fifth rays.joints, and at the first and fifth rays.

Pronation and supination are Pronation and supination are considered triplanar motions considered triplanar motions


PronationPronation– The three body plane motions in The three body plane motions in

pronation are abduction in the pronation are abduction in the transverse plane, dorsiflexion in the transverse plane, dorsiflexion in the sagittal plane, and eversion in the sagittal plane, and eversion in the frontal plane frontal plane


SupinationSupination– The three body plane motions in The three body plane motions in

supination are a combined supination are a combined movement of adduction, movement of adduction, plantarflexion, and inversionplantarflexion, and inversion


Proximal tibiofibular jointProximal tibiofibular joint– Because of the interaction between Because of the interaction between

the proximal and distal tibiofibular the proximal and distal tibiofibular joints with the knee and the ankle joints with the knee and the ankle function, the clinician should always function, the clinician should always evaluate the functional mobility of evaluate the functional mobility of both these complexes when treating both these complexes when treating one or the otherone or the other


Talocrural JointTalocrural Joint– The primary motions at this joint are The primary motions at this joint are

dorsiflexion and plantar flexion, with a total dorsiflexion and plantar flexion, with a total range of 70-80°range of 70-80°

– Theoretically, the capsular pattern of the Theoretically, the capsular pattern of the ankle joint is more restriction of plantarflexion ankle joint is more restriction of plantarflexion than dorsiflexion, although clinically this than dorsiflexion, although clinically this appears to be reversedappears to be reversed

– The close-packed position is weight-bearing The close-packed position is weight-bearing dorsiflexion, while the open-packed position is dorsiflexion, while the open-packed position is midway between supination and pronation.midway between supination and pronation.


The subtalar jointThe subtalar joint– Subtalar joint supination and Subtalar joint supination and

pronation are measured clinically by pronation are measured clinically by the amount of calcaneal or hindfoot the amount of calcaneal or hindfoot inversion and eversioninversion and eversion

– In normal individuals, there is an In normal individuals, there is an inversion to eversion ratio of 2:3 to inversion to eversion ratio of 2:3 to 1:3, which amounts to 1:3, which amounts to approximately 20° of inversion and approximately 20° of inversion and 10° of eversion10° of eversion


Subtalar jointSubtalar joint– The capsular pattern of this joint The capsular pattern of this joint

varies. In chronic arthritic conditions, varies. In chronic arthritic conditions, there is an increasing limitation of there is an increasing limitation of inversion, but with traumatic arthritis, inversion, but with traumatic arthritis, eversion appears most limited eversion appears most limited clinicallyclinically

– The close-packed position for this joint The close-packed position for this joint is full inversion, while the open-packed is full inversion, while the open-packed position is inversion/plantarflexionposition is inversion/plantarflexion


The midtarsal joint complex The midtarsal joint complex – Provides the foot with an additional mechanism for Provides the foot with an additional mechanism for

raising and lowering the arch, and to absorb some raising and lowering the arch, and to absorb some of the horizontal plane tibial motion that is of the horizontal plane tibial motion that is transmitted to the foot during stancetransmitted to the foot during stance

– The talonavicular joint two degrees of freedom: The talonavicular joint two degrees of freedom: plantar flexion/dorsiflexion and inversion/eversion, plantar flexion/dorsiflexion and inversion/eversion, with motion occurring around a longitudinal and with motion occurring around a longitudinal and oblique axis, both of which are independent of oblique axis, both of which are independent of each othereach other

The capsular pattern is a limitation of dorsiflexion, The capsular pattern is a limitation of dorsiflexion, plantar flexion, adduction and internal rotationplantar flexion, adduction and internal rotation

The close packed position is pronationis pronation The open packed position is midway between The open packed position is midway between

extremes of range of motion extremes of range of motion


The midtarsal joint complex The midtarsal joint complex – The capsular pattern for the The capsular pattern for the

calcaneocuboid joint is a limitation calcaneocuboid joint is a limitation of dorsiflexion, plantar flexion, of dorsiflexion, plantar flexion, adduction and internal rotationadduction and internal rotation


The cuneonavicular jointThe cuneonavicular joint– Has one to two degrees of freedom: Has one to two degrees of freedom:

plantar/dorsiflexion, inversion/eversionplantar/dorsiflexion, inversion/eversion– The capsular pattern is a limitation of The capsular pattern is a limitation of

dorsiflexion, plantar flexion, adduction and dorsiflexion, plantar flexion, adduction and internal rotationinternal rotation

– The close-packed position is supinationThe close-packed position is supination– The open-packed position is considered to The open-packed position is considered to

be midway between the extremes of range be midway between the extremes of range of motionof motion


Intercuneiform and Cuneocuboid JointsIntercuneiform and Cuneocuboid Joints– Due to their very plane curvature, these Due to their very plane curvature, these

joints have only one degree of freedom: joints have only one degree of freedom: inversion/eversioninversion/eversion

– The close packed position for these joints The close packed position for these joints is supinationis supination

– The open packed position is considered to The open packed position is considered to be midway between extremes of range of be midway between extremes of range of motion motion


Cubometatarsal JointCubometatarsal Joint– The capsular pattern of this joint is a The capsular pattern of this joint is a

limitation of dorsiflexion, plantar limitation of dorsiflexion, plantar flexion, adduction and internal rotationflexion, adduction and internal rotation

– The close-packed position is pronation.The close-packed position is pronation.– The open-packed position is considered The open-packed position is considered

to be midway between extremes of to be midway between extremes of range of motion range of motion


Cubonavicular JointCubonavicular Joint– The close-packed position for this The close-packed position for this

joint is supinationjoint is supination– The open-packed position is midway The open-packed position is midway

between extremes of range of between extremes of range of motion motion


Intermetatarsal JointsIntermetatarsal Joints– The close-packed position for these The close-packed position for these

joints is supinationjoints is supination– The open-packed position is midway The open-packed position is midway

between extremes of range of between extremes of range of motionmotion


Metatarsophalangeal JointsMetatarsophalangeal Joints– The MTP joints have two degrees of freedom: The MTP joints have two degrees of freedom:

flexion/extension and abduction/adduction.flexion/extension and abduction/adduction.– Range of motion of these joint is variable, Range of motion of these joint is variable,

ranging from 40° to 100° dorsiflexion (with a ranging from 40° to 100° dorsiflexion (with a mean of 84°), 3° to 43° (mean, 23°) plantar mean of 84°), 3° to 43° (mean, 23°) plantar flexion, and 5° to 20° varus and valgusflexion, and 5° to 20° varus and valgus

– The closed-packed position for the MTP joints The closed-packed position for the MTP joints is full extensionis full extension

– The capsular pattern for these joints is The capsular pattern for these joints is variable, with more limitation of extension variable, with more limitation of extension than flexionthan flexion

– The open-packed position is 10º of extension. The open-packed position is 10º of extension.


1st Metatarsophalangeal Joint1st Metatarsophalangeal Joint– The function of the great toe is to provide The function of the great toe is to provide

stability to the medial aspect of the foot, stability to the medial aspect of the foot, and to provide for normal propulsion during and to provide for normal propulsion during gait. Normal alignment of the 1st MTP joint gait. Normal alignment of the 1st MTP joint varies between 5° varus and 15° valgusvaries between 5° varus and 15° valgus

– The great toe is characterized by having a The great toe is characterized by having a remarkable discrepancy between active remarkable discrepancy between active and passive motion. Approximately 30° of and passive motion. Approximately 30° of active plantar flexion is present, and at active plantar flexion is present, and at least 50° of active extension, which can be least 50° of active extension, which can be frequently increased passively to between frequently increased passively to between 70-90°.70-90°.


Interphalangeal (IP) JointsInterphalangeal (IP) Joints– Each of the IP joints has one degree of Each of the IP joints has one degree of

freedom: flexion/extensionfreedom: flexion/extension– The capsular pattern is more limitation The capsular pattern is more limitation

of flexion than of extensionof flexion than of extension– The close-packed position is full The close-packed position is full

extensionextension– The open-packed position is slight The open-packed position is slight

flexionflexion

ExaminationExamination

The examination is used to identify The examination is used to identify static and dynamic, structural or static and dynamic, structural or mechanical foot abnormalitiesmechanical foot abnormalities

The clinical diagnosis is based on an The clinical diagnosis is based on an assessment of the changes in joint assessment of the changes in joint mobility and tissue changes at the foot mobility and tissue changes at the foot and ankle, and the effect these have and ankle, and the effect these have on the function of the remainder of the on the function of the remainder of the lower kinetic chainlower kinetic chain


HistoryHistory– The primary purposes of the history are to:The primary purposes of the history are to:

Determine the severity of the conditionDetermine the severity of the condition Determine the area, nature and behavior of the Determine the area, nature and behavior of the

symptomssymptoms Help determine the specific structure at faultHelp determine the specific structure at fault Detect systemic conditions (collagen disease, Detect systemic conditions (collagen disease,

neuropathy, radiculopathy, and vascular neuropathy, radiculopathy, and vascular problems), or the presence of serious pathology problems), or the presence of serious pathology


Systems ReviewSystems Review– As symptoms can be referred distally to the leg, As symptoms can be referred distally to the leg,

foot and ankle from a host of other joints and foot and ankle from a host of other joints and conditions, the clinician must be able to conditions, the clinician must be able to differentially diagnose from the presenting signs differentially diagnose from the presenting signs and symptomsand symptoms

– The cause of the referred symptoms may be The cause of the referred symptoms may be neurological or systemic in origin. If a disorder neurological or systemic in origin. If a disorder involving a specific nerve root (L 4, L 5, S1, or S 2) involving a specific nerve root (L 4, L 5, S1, or S 2) is suspected, the necessary sensory, motor and is suspected, the necessary sensory, motor and reflex testing should be performedreflex testing should be performed

– Peripheral nerve entrapments, although not Peripheral nerve entrapments, although not common, may also occur in this region and often common, may also occur in this region and often go unrecognized go unrecognized


Systems ReviewSystems Review– Systemic problems that may involve Systemic problems that may involve

the leg, foot and ankle include the leg, foot and ankle include diabetes mellitus (peripheral diabetes mellitus (peripheral neuropathy), osteomyelitis, gout and neuropathy), osteomyelitis, gout and pseudogout, sickle cell disease, pseudogout, sickle cell disease, complex regional pain syndrome, complex regional pain syndrome, peripheral vascular disease, and peripheral vascular disease, and rheumatoid arthritis rheumatoid arthritis


ObservationObservation– Observation of the lower extremity is Observation of the lower extremity is

extensive. It is extremely important to extensive. It is extremely important to observe the entire kinetic chain when observe the entire kinetic chain when assessing the leg, foot, and ankle. Weight assessing the leg, foot, and ankle. Weight bearing and non-weight bearing postures of bearing and non-weight bearing postures of the foot are compared.the foot are compared.

– Observing the patient while they move from sit Observing the patient while they move from sit to stand, and walk to the treatment area, gives to stand, and walk to the treatment area, gives the clinician a sense of the patient’s functional the clinician a sense of the patient’s functional ability in weight bearing, and provides the first ability in weight bearing, and provides the first opportunity for gait analysis. opportunity for gait analysis.


PalpationPalpation– Careful palpation should be Careful palpation should be

performed around the leg, foot, and performed around the leg, foot, and ankle to differentiate tenderness of ankle to differentiate tenderness of specific ligaments and other specific ligaments and other structuresstructures

– Areas of localized swelling and Areas of localized swelling and ecchymosis over the ligaments on ecchymosis over the ligaments on the medial or lateral aspects of the the medial or lateral aspects of the foot and ankle should be notedfoot and ankle should be noted


Active and Passive Range of MotionActive and Passive Range of Motion– AROM tests are used to assess the AROM tests are used to assess the

patient’s willingness to move and the patient’s willingness to move and the presence of movement restriction patterns presence of movement restriction patterns such as a capsular on non-capsular pattern such as a capsular on non-capsular pattern

– General active range of motion of the foot General active range of motion of the foot and ankle in the non-weight bearing and ankle in the non-weight bearing position is assessed first, with painful position is assessed first, with painful movements being performed lastmovements being performed last

– In addition to the foot and ankle tests, the In addition to the foot and ankle tests, the clinician should also assess hip and knee clinician should also assess hip and knee range of motionrange of motion


Strength testingStrength testing– Isometric tests are carried out in the Isometric tests are carried out in the

extreme range, and if positive, in the extreme range, and if positive, in the neutral rangeneutral range

– The straight plane motions of ankle The straight plane motions of ankle dorsiflexion, plantar flexion, inversion and dorsiflexion, plantar flexion, inversion and eversion are tested initially. Pain with any eversion are tested initially. Pain with any of these tests requires a more thorough of these tests requires a more thorough examination of the individual muscles examination of the individual muscles


Strength testingStrength testing– The individual isometric muscle tests can The individual isometric muscle tests can

give the clinician information about patterns give the clinician information about patterns of weakness other than from spinal nerve of weakness other than from spinal nerve root or peripheral nerve palsies and can also root or peripheral nerve palsies and can also help to isolate the pain generatorshelp to isolate the pain generators

– A painful weakness is invariably a sign of A painful weakness is invariably a sign of serious pathology, and depending on the serious pathology, and depending on the pattern, could indicate a fracture or a pattern, could indicate a fracture or a tumor. However, if a single motion is tumor. However, if a single motion is painfully weak this could indicate muscle painfully weak this could indicate muscle inhibition due to pain. inhibition due to pain.


Strength testingStrength testing– Weakness on isometric testing needs to be Weakness on isometric testing needs to be

analyzed for the type:analyzed for the type: Increasing weakness with repeated contractions Increasing weakness with repeated contractions

of the same resistance indicating a palsyof the same resistance indicating a palsy Consistent weakness with repeated contractions Consistent weakness with repeated contractions

which could suggest a deconditioned muscle, or which could suggest a deconditioned muscle, or a significant muscle tear), and the pattern of a significant muscle tear), and the pattern of weakness (spinal nerve root, nerve trunk or weakness (spinal nerve root, nerve trunk or peripheral nerve)peripheral nerve)


Passive articular mobilityPassive articular mobility– Passive articular mobility tests assess Passive articular mobility tests assess

the accessory motions available the accessory motions available between the joint surfaces. These between the joint surfaces. These include tests of the joint glides, joint include tests of the joint glides, joint compression and joint distraction tests. compression and joint distraction tests. As with any other joint complex, the As with any other joint complex, the quality and quantity of joint motion must quality and quantity of joint motion must be assessed to determine the level of be assessed to determine the level of joint involvementjoint involvement


Special testsSpecial tests– Special tests are merely confirmatory testsSpecial tests are merely confirmatory tests– Selection for their use is at the discretion of Selection for their use is at the discretion of

the clinician and is based on a complete the clinician and is based on a complete patient historypatient history

– The results from these tests are used in The results from these tests are used in conjunction with the other clinical findings conjunction with the other clinical findings and should not be used alone to form a and should not be used alone to form a diagnosisdiagnosis

– To assure accuracy with these tests, both To assure accuracy with these tests, both sides should be tested for comparison sides should be tested for comparison


Neurological tests– Important neurological structures that

pass through the ankle and terminate in the foot are the saphenous, superficial peroneal, deep peroneal, posterior and anterior tibial nerves, and the sural nerve

– Symptoms can be referred to the foot and ankle from the L 4-S 2 nerve roots (sciatic) and from a host of non-neurological conditions


Neurological testsNeurological tests– Common reflexes tested in this area Common reflexes tested in this area

are the Achilles reflex (S 1-2), and are the Achilles reflex (S 1-2), and the posterior tibial reflex (L 4-5)the posterior tibial reflex (L 4-5)

– The pathological reflexes (Babinski, The pathological reflexes (Babinski, and Oppenheim), tested when an and Oppenheim), tested when an upper motor neuron lesion is upper motor neuron lesion is suspected suspected

InterventionIntervention


Acute phase goals:Acute phase goals:– Decrease pain, inflammation and swellingDecrease pain, inflammation and swelling– Protect the healing area from re-injuryProtect the healing area from re-injury– Re-establish pain-free range of motionRe-establish pain-free range of motion– Prevent muscle atrophyPrevent muscle atrophy– Increase neuromuscular controlIncrease neuromuscular control– Maintain fitness levelsMaintain fitness levels– Patient to be independent with home Patient to be independent with home

exercise programexercise program


Functional phase goals:Functional phase goals:– Restore normal joint kinematics Restore normal joint kinematics – Attain full range of pain free motionAttain full range of pain free motion– Improve neuromuscular control of the Improve neuromuscular control of the

lower extremity in a full weight bearing lower extremity in a full weight bearing posture on both level and uneven surfaces posture on both level and uneven surfaces

– Regain and improve lower extremity Regain and improve lower extremity strength and endurance through strength and endurance through integration of local and kinetic chain integration of local and kinetic chain exercisesexercises


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Chapter 19