Physical therapy treatment of ankle and foot pain

1. Foot & Ankle
Touro College
April 19th, 2012
Adrian Miranda, PT, DPT, OCS

2. Objectives
 Understand the patho-biomechanics and
how it relates to foot/ankle injuries
 Understand the clinical concepts of the foot
and ankle rehabilitation
 Review the literature on foot and ankle
dysfunctions and treatment
 How to utilize the evidence and make it
relevant.
 Gain a better understanding of the concept
of Regional Interdependence

3. Foot & Ankle Pain
 Anterior Impingement
 Achilles Tendonitis
 Posterior Tibialis
Tendonitis/Dysfunction
 Ankle Sprains
 Peroneal Tendonitis
Question: But WHY?

4. Anatomy
 Know your foot & ankle anatomy

5. Anatomy
 But also know your GENERAL ANATOMY
– Think about the hip, knee, ankle
– Ankle muscles, ankle joints, ankle ligs.

6. Regional
Interdependence
 “Seemingly unrelated impairments in a
remote anatomical region may
contribute to, or be associated with,
the patient’s primary complaint.”
Wainner RS, Whitman JM, Cleland JA, Flynn TW.
Regional interdependence: a musculoskeletal examination model whose time has
come. J Orthop Sports Phys Ther. 2007 Nov;37(11):658-60.

7. Anterior Impingement

8. Anterior Impingement
 Can be bone/capsular or soft tissue
approximation
 Talus can have an anterior
displacement
 Scar tissue or thickened tendon due to
overuse
 Several possibilities

9. Anterior Impingement
 Typically reduced dorsiflexion
 Painful
 Treatment Options:
– Soft tissue to structures anterior to
talocrural joint
– Posterior Glides of Talus

10. Evidence: AP

11. Evidence: AP

12. Evidence: AP

13. Achilles Tendon Injury

14. Achilles Injuries
 Achilles is expending too much energy
– “physics”
– Gets too hot: leads to “–itis”
 Achilles meant to be powerful in the
sagittal plane
 Check frontal plane regions
– i.e. (class?)

15. Evidence: AT

16. Evidence: AT
 “The dancers with a history of achilles
tendinopathy displayed greater peak
hip adduction during the braking
phase and more knee internal
rotation during the push off phase
than a control group.”

17. Posterior Tibialis
Tendon Injury

18. Posterior Tibialis
Tendon Injury
 “Flat Foot”
– Typically referred to as overstretched
 Anatomy and location of PTT
 Orthotics?
 Again check frontal plane

19. Evidence: PTT

20. Evidence: PTT
 Significant differences between PTTD group
vs. Control
– Hip Abduction Strength
– Hip Extension strength
– Plantar Flexion strength
 “These findings suggest that pathology in
the foot/ankle is accompanied by
diminished performance of the hip
musculature .”

21. Peroneal Tendon
Injuries

22. Peroneal Tendon
Injuries
 Consider path of peroneal tendon
– i.e. peroneus longus
– Where does it course?
 Overused
 Irritated due to a mobility dysfunction

23. Evidence: PT

24. Evidence: PT
 50 year old female
 8 visits
 Pain
– Baseline = 6
– Discharge = 0
 Lower Extremity Functional Scale
– Baseline = 51
– Discharge = 61

25. Ankle Sprains

26. Ankle Sprains
 Multi-factorial
 Theory
– ATFL is strong, pulls the fibula
 Cuboid involvement
 Frontal plane weakness
– i.e. Hip

27. Evidence: AI
 “Strength of the hip abductors was
significantly weaker on the involved
side than on the uninvolved side.”

28. Evidence: AI

29. Evidence: AI
 7 Patients
 Cuboid Thrust Manipulation
 All returned to pre injury level within 1
or 2 visits, with long term resolution

30. Evidence: AI

31. Evidence: AI
 “These results lend support to the
hypothesis that a positional fault
occurs at the inferior tibiofibular joint in
ankle sprain patients.”
 May have implications for treatment for
a proportion of our patients.

32. Videos

33. Conclusion
 Importance of “Regional
Interdependence”
 Look at the bigger picture
 Search for the ‘cause of the cause’
 Use your knowledge of anatomy
– Check for impairments, dysfunctions,
imbalances, etc.
 Examine > Treat > Re-Examine

34. References
 Wainner RS, Whitman JM, Cleland JA, Flynn TW.
 Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop
Sports Phys Ther. 2007; 37:658-60.
 Hensley CP, Kavchak AJ. Novel use of a manual therapy technique and management of a patient with
peroneal tendinopathy: a case report. Man Ther. 2012 ;17:84-88.
 Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains: a case
series. J Orthop Sports Phys Ther. 2005; 35:409-15.
 Kulig K, Loudon JK, Popovich JM Jr, et al. Dancers with achilles tendinopathy demonstrate altered
lower extremity takeoff kinematics. J Orthop Sports Phys Ther. 2011; 4: 606-13.
 Kulig K, Popovich JM, Noceti-Dewit LM, et al. Women with posterior tibial tendon dysfunction have
diminished ankle and hip muscle performance. J Orthop Sports Phys Ther. 2011; 40: 687-94.
 Friel K, McLean N, Myers C, et al. Ipsilateral hip abductor weakness after inversion ankle sprain. J Athl
Train. 2006; 41:74-8.
 Hubbard TJ, Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Man
Ther. 2008; 13: 63-7.
 Kavanagh J. Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic
ankle sprains compared to normals? Man Ther. 1999; 4: 19-24.
 Wikstrom EA, Hubbard TJ. Talar positional fault in persons with chronic ankle instability. Arch Phys Med
Rehabil. 2010; 91: 1267-71.
 Landrum EL, Kelln CB, Parente WR, et al. Immediate Effects of Anterior-to-Posterior Talocrural Joint
Mobilization after Prolonged Ankle Immobilization: A Preliminary Study. J Man Manip Ther. 2008; 16:
100-5.
 Cleland JA, Abbott JH, Kidd MO, et al. Manual physical therapy and exercise versus electrophysical
agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial. J
Orthop Sports Phys Ther. 2009;39: 573-85.

35. Thank You!
 Discussion
 Questions?