This presentation is about commonly used outcome measures of ankle foot complex. It also has information about delorme boot which a tool for progressive resisted exercise training

1. Presented by: Antu Anna Roy
BPT Intern
Medical Trust Institute of Medical Sciences, Kochi

2. JOINTS OF ANKLE FOOT COMPLEX
The joints of the foot is
divided into three
sections: hind foot, mid
foot and fore foot

3. Hindfoot (Rearfoot)
 1. Talocrural (Ankle) Joint.
 2. Subtalar (Talocalcanean).
Midfoot
 1. Talocalcaneonavicular joint.
 2. Cuneocuboid Joint.
 3. Cuneonavicular Joints
 4. Cuboideonavicular joint
 5. Calcaneocuboid Joint.
Fore foot
 1. Tarsormetatarsal Joints.
 2. Metatarsophalangeal Joints.
 3. Interphalangeal joints.

4. IMPORTANT JOINTS
 Ankle Joint (Talocrural): The talocrural joint is a uniaxia
(modified hinge, synovial joint) located between the talus, the
medial malleolus of the tibia, and the lateral malleolus of the
fibula. The movements possible at this joint are dorsiflexion
and plantar flexion.
 Subtalar (Talocalcaneal) Joint: A gliding multiaxial synovial
joint which consists of the talus on top and calcaneus on the
bottom. The subtalar joint allows movements about an
oblique axis, allowing the foot to side to side motion
(inversion and eversion).

5.  Transverse tarsal joint: It is formed of 2 joints that lie
side by-side. These are the talo-navicular joint
(between the head of talus and navicular), and
calcaneo-cuboid joint (between the caleaneus and
cuboid). It is little to no motion and assists in eversion
and inversion.

6. LIGAMENTS OF ANKLE JOINT
The joint is supported by:
i. Fibrous capsule
ii. Deltoid or medial ligament
o Anterior or tibionavicular fibers
o Middle or tibiocalcaneal fibers
o Posterior or tibiotalar fibers
iii. Lateral ligament
o Anterior talofibular ligament
o Posterior talofibular ligament
o Calcaneofibular ligament

7. MEDIAL LIGAMENT
 Deltoid ligaments: supports
the medial side of ankle.
 It is triangular shapedwith
apex at tip of medial
malleolus and base at talus,
navicular, calcaneus
 It has two major components

8.  Superficial deltoid ligament which resist talar
abduction and primarily resists eversion of hindfoot.
Tibionavicular portion prevents inward displacement
of head of talus, while tibiocalcaneal portion prevents
valgus displacement.
 Deep deltoid ligament prevents lateral displacement
of talus & prevents external rotation of the talus and
latter effect is pronounced in plantar flexion, when
deep deltoid tends to pull talus into internal rotation.

9. LATERAL LIGAMENTS
 Talofibular ligaments: from the lateral
malleolus of the fibula to connects the talus
and support the lateral side of the joint .
 Anterior Talofibular Ligament: It prevents
anterior subluxation of talus when ankle is in
plantar flexion.
 Posterior Talofibular Ligament: it prevents
posterior and rotatory subluxation of the talus.
 Calcaneofibular: connecting lateral malleolus
to calcaneus .It acts primarily to stabilize sub-
talar joint & limit inversion. it is lax in normal,
standing position due to relative valgus
orientation of calcaneus

10. LIGAMENTS OF FOOT
 Spring ligament: attaches
from calcaneus to navicular. It
supports longitudinal arch
and the head of talus
especially in standing.
 Plantar aponeurosis: runs
from calcaneus to proximal
phalanges, ties posterior and
anterior sections together
and windlass action in ankle,
where full dorsflexion is
limited by plantar
aponeurosis.

11. MOVEMENTS OF ANKLE JOINT
Active movements of ankle
joint are dorsiflexion and
plantar flexion.
In dorsiflexion, the forefoot
is raised, and the ankle
between the front of the
leg and the dorsum of the
foot is dimininshed.
In plantar flexion, the
forefoot is depressed, and
the ankle between the leg
and the foot is increased.

12. MUSCLES PRODUCING MOVEMENT
 Dorsi flexion
Principal muscle: Tibialis
Anterior
Accessory muscles: Extensor
Digitorum Longus, Extensor
Hallucis Longus, Peroneus
Tertius
 Plantar flexion
Principal muscle: Soleus,
Gastrocnemius
Accessory muscles: Plantaris,
Tibialis Posterior, Flexor
Hallucis Longus, Flexor
Digitorum Longus

13. MOVEMENTS OF FOOT
The active movements taking place in the
subtalar and talocalcaneonavicular joint
is inversion and eversion.
Inversion is a movement in which the
medial border of the foot is elevated,
so that sole faces medially.
Eversion is a movement in which the
lateral border of foot is elevated, so
that the sole faces laterally.
In inversion and eversion, the entire part
of the foot below the talus moves
together. The calcaneum and navicular
bones move medially or laterally round
the talus carrying the forefoot with
them.

14.  Pronation is composed of
three cardinal
plane components: subtalar
eversion, ankle dorsiflexion,
and forefoot abduction.
 Supination is composed of
inversion, ankle plantar
flexion and adduction.

15. COMMON PATHOLOGIES OF ANKLE FOOT
COMPLEX
Injury to ligament
Paralysis or spasticity
Soft tissue injuries
Fractures
Neurological conditions

16. INJURIES OF LIGAMENTS
ANKLE SPRAIN
Injuries of the lateral ligament
Ankle sprains usually occur on the
lateral side because the joint
capsule and ligaments are stronger
on the medial side of the ankle.
Mechanism of injury of ankle
sprain is inversion of the
supinated, plantarflexed foot . It
usually occurs when the foot rolls
over on the outside of the ankle.
When the ligament is completely
torn or detached from the fibula,
the talus is free to tilt in the
mortice of the tibia and fibula.

17. Injuries of Medial Ligament
The medial ligament is immensely strong and if stressed in
ankle joint injuries generally avulses the medial malleolus
rather than itself tearing. Nevertheless tears do occur,
and are seen particularly in conjunction with lateral
malleolar fractures. A mechanism is combination of
external rotation at ankle, abduction of hindfoot,&
eversion of forefoot while the upper body externally
rotates over the fixed foot.

18. PARALYSIS OR SPASTICITY
Tibialis Posterior:
 Paralysis of tibialis posterior alone causes a planovalgus
deformity. Spasticity of Tibialis Posterior cause dynamic
varus deformities of foot.
Tibialis Anterior:
 Paralysis (polio) results in development of equinovalgus
deformity. This is seen initially during swing phase of gait.
Failure to raise the foot sufficiently during the early swing
phase causes Toe drag.

19. Gastrocnemius-soleus paralyzed:
 The patient cannot rise on tiptoes, and the gait is severely
affected because of inability to increase walking speeds
beyond the normal pacing. However, despite uneven step
lengths, patient will have uniform forward progression.
Patient will have excessive dorsiflexion of the ankle and
diminished plantar flexion on the involved side .
 The act of climbing stairs is awkward and slow, and
activities such as running and jumping are all but
impossible.

20. SOFT TISSUE INJURIES
Footballer’s ankle:Repeated incidents of forced plantar flexion of the
foot which result in tearing of the anterior capsule of the ankle
joint. These may lead to mechanical restriction of dorsiflexion.
Peroneal tendon disruption (peroneus brevis tear):
 Mechanism of this injury is forced dorsiflexion with slight inversion
and concomitant eccentric contraction of the peroneal muscles
may produce a subluxation or dislocation of the peroneal tendons.
Anterior (Talotibial) Impingement Syndrome:
 The mechanism of injury is repetitive forced dorsiflexion as
demiplie position in ballet can lead to impingement of anterior lip
of tibia on talar neck.

21. Posterior (Talotibial,) Impigement Syndrome:
 The mechanism of injury is repetitive, forced
plantarflexion such as may occur with practicing karate
kicks or dancing .
Shortening of the Achilles tendon
 Mechanisms for tendinitis have been proposed by
repeated tension or repeated loading .Shortening results
in plantar flexion of the foot and clumsiness of gait as the
heel fails to reach the ground (Insufficient push off).

22. Plantar Fasciltis:
 Mechanism of Injury are overuse
or repetitive stretching of the
plantar fascia associated with
training errors or associated with
incomplete rehabilitation
(strengthening) following a
previous ankle injury because
weak peroneal muscles may
inadequately support the arch.
Thus placing additional stress on
the plantar fascia. All of which
reduce the foot’s shock absorbing
capability.

23. FRACTURES
Pott’s Fracture
It is the fracture of both
malleoli.
It is caused by forced abduction
or adduction force.

24. Fracture of Talus
Injuries of talus are rare and
result from fall from height
or forced dorsiflexion injury
to the ankle.

25. Fracture of Calcaneum
Fracture of calcaneum
results from a fall from
height.
The calcaneum is pushed
up against talus and gets
crushed.

26. Fracture of Metatarsals
Fracture of metatarsals occurs
due to fall of a heavy object
on the foot or in road side
accidents.
The base of fifth metatarsal
may be fractured by sudden
pull of peroneus brevis
muscle, due to forced
inversion and plantar flexion
of foot.

27. NEUROLOGICAL CONDITIONS
Foot Drop
It is a gait abnormality in which the
dropping of the forefoot happens
due to weakness, irritation or
damage to the common fibular
nerve including the sciatic nerve, or
paralysis of the muscles in the
anterior portion of the lower leg. It
is usually a symptom of a greater
problem, not a disease in itself. It is
characterized by inability or
impaired ability to do dorsiflexion.
Person shows high stepping gait.

28. Diabetic Foot
A diabetic foot is a foot that exhibits
any pathology that results directly
from diabetes mellitus or any long-
term (or "chronic") complication of
diabetes mellitus. Due to
the peripheral nerve
dysfunction associated with diabetes
(diabetic neuropathy), patients have
a reduced ability to feel pain. In
diabetes, peripheral nerve
dysfunction can be combined
with peripheral artery disease(PAD)
causing poor blood circulation to the
extremities (diabetic angiopathy).

30. WHAT IS AN OUTCOME MEASURE?
 An outcome measure is the result of a test that is used to
objectively determine the baseline function of a patient
at the beginning of treatment.
 Once treatment has commenced, the same instrument
can be used to determine progress and treatment
efficacy. With the move towards Evidence Based Practice
(EBP) in the health sciences, objective measures of
outcome are important to provide credible and reliable
justification for treatment.
 The instrument should also be convenient to apply for the
therapist and comfortable for the patient.

31. OUTCOME MEASURES OF ANKLE FOOT COMPLEX
 Foot and Ankle Disability Index(FADI)
 Foot and Ankle Ability Measure(FAAM)
 American Orthopedic Foot and Ankle Society
Score(AOFAS)
 Foot Function Index(FFI)
 Foot and Ankle Outcome Score(FAOS)
 Manchester Foot Pain and Disability Index
 Olerud and Molander Ankle Score
 Lower Extremity Functional Scale(LEFS)

32. FOOT AND ANKLE DISABILITY INDEX(FADI)
 FADI is a region specific self report of function.
 It is a 34 item questionnaire divided into 2 subscales: FADI &
FADI sports
 The FADI has 26 items in which 4 are pain related and 22
activity related.
 FADI sport has 8 items
 FADI has a total point value of 104 points
 Each of the 26 items is scored on a 5 point Likert scale from :
4 – no difficulty at all
3 – slight difficulty
2 – moderate difficulty
1 – extreme difficulty
0 – unable to do

34. FOOT AND ANKLE ABILITY MEASURE(FAAM)
 FAAM is a self reported outcome instrument
developed to assess physical function for individuals
with foot and ankle related impairment.
 It is a 29 item questionnaire divided into 2 subscales:
FAAM, 21 item activities of daily life & FAAM, 8 items
sports subscale.
 FAAM is identical to FADI except for an additional 5
items found on the FADI.
 Each item is scored on a 5 point Likert scale.
 Items score total ranges from 0-84 in ADL subscale
and 0-32 for sports subscale, and transformed to
percentage scores..

35. Foot and Ankle Ability Measure (FAAM)
Activities of Daily Living Subscale
Please Answer every question with one response that most closely describes your
condition within the past week.
If the activity in question is limited by something other than your foot or ankle mark “Not
Applicable” (N/A).
No Slight Moderate Extreme Unable N/A
Difficulty Difficulty Difficulty Difficulty to do
Standing 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Walking on even Ground 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Walking on even ground 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
without shoes
Walking up hills 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Walking down hills 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Going up stairs 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Going down stairs 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Walking on uneven ground 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Stepping up and down curbs 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Squatting 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Coming up on your toes 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Walking initially 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Walking 5 minutes or less 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
Walking approximately 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
10 minutes
Walking 15 minutes or 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀
greater

36. AMERICAN ORTHOPEDIC FOOT AND ANKLE SOCIETY
SCORE (AOFAS)
 It is one of the most commonly used clinician reporting
tools for foot and ankle conditions.
 It measures outcomes on four different anatomical areas
of the foot:- the ankle- hindfoot, midfoot,
metatarsophalangeal(MTP)- interphalangeal(IP) for the
hallux and MTP-IP for the lesser toes.
 The four anatomic regions of the foot are all represented
by a different version of the survey with each tool designed
to be used independently.
 The questionnaire consists of nine items that are
distributed over three categories: Pain (40 points), function
(50 points) and alignment (10 points). These are all scored
together for a total of 100 points.

40. FOOT FUNCTION INDEX(FFI)
 A Foot Function Index (FFI) was developed to measure
the impact of foot pathology on function in terms of pain,
disability and activity restriction.
 It has been shown to be a reasonable tool for use with
low functioning individuals with foot disorders and
patients with rheumatoid arthritis and non-traumatic foot
or ankle problems.
 It may not be appropriate for individuals who function at
or above the level of independent activities of daily
living.

41.  The FFI (questionnaire) consists of 23 self-reported items divided
into 3 subcategories, namely: pain, disability and activity
limitation.
 The patient has to score each question on a scale from 0 (no
pain or difficulty) to 10 (worst pain imaginable or so difficult it
requires help), that best describes their foot over the past week.
 The pain subcategory consists of 9 items and measures foot pain
in different situations, such as walking barefoot versus walking
with shoes.
 The disability subcategory consists of 9 items and measures
difficulty performing various functional activities because of foot
problems, such as difficulty climbing stairs.
 The activity limitation subcategory consists of 5 items and
measures limitations in activities because of foot problems, such
as staying in bed all day.
 Recorded on a visual analogue scale (VAS), scores range from 0
to 100, with higher scores indicating worse pain.

42. Foot Function Index
No Pain 1 2 3 4 5 6 7 8 9 10 Worst Pain Imaginable
Pain Subscale: How severe is your foot pain: Foot pain
at its worst?
Pain standing with shoes?
Foot pain in morning?
Pain walking with orthotics?
Pain walking barefoot?
Pain standing with orthotics?
Pain standing barefoot?
Foot pain at end of day?
Pain walking with shoes?

43. Disability Subscale: How much difficulty did you have:
Difficulty walking in house?
Difficulty standing tip toe?
Difficulty walking outside?
Difficulty getting up from chair?
Difficulty walking 4 blocks?
Difficulty climbing curbs?
Difficulty climbing stairs?
Difficulty walking fast?
Difficulty descending stairs?

44. Activity Limitation Subscale: How much of the time do
you:
Stay inside all day because of feet?
Use assistive device indoors?
Stay in bed because of feet?
Use assistive device outdoors?
Limit activities because of feet?
Score: ____/230 points (MDC: 7 points; No Disability “0”)

45. FOOT AND ANKLE OUTCOME SCORE(FAOS)
 FAOS was developed to assess the patients opinion about a
variety of foot and ankle related problems.
 FAOS has this far been used in patients with lateral ankle
instability, Achilles tendinitis, and plantar fasciitis.
 FAOS is a 42 item questionnaire consists of 5 subscales; Pain,
other Symptoms, Function in daily living (ADL), Function in
sport and recreation (Sport(Rec), and foot and ankle-related
Quality of Life (QOL). The last week is taken into
consideration when answering the questionnaire.
 Standardized answer options are given (% Likert boxes) and
each question gets a score from 0 to 4. A normalized score
(100 indicating no symptoms and 0 indicating extreme
symptoms) is calculated for each subscale.

47. MANCHESTER FOOT PAIN AND DISABILITY INDEX
 The Manchester Foot Pain and Disability Index (MFPDI) is a
Patient Reported Outcome (PRO) measure developed and
validated to measure pain specifically related to a foot
disability.
 The MFPDI is a suitable instrument for assessing the impact
of painful foot conditions in community and clinical
populations.
 The MFPDI is a self-administered, paper based PRO
consisting of 19-items assessing foot pain and disability. The
PRO contains three constructs (four subscales) which reflect
disabilities associated with foot pain and two additional
items relating to work and leisure

48. The three constructs identified within the MFPDI are:
 Functional limitation (10 items)
 Pain intensity (7 items)
 Personal appearance (2 items)
Responses are recorded on a three point scale:
 None of the time
 On some days
 On most /every day(s)

49. MANCHESTER FOOT PAIN AND DISABILITY INDEX – ENGLISH VERSION
Below are some statements about problems people have because of
pain in their feet. For each statement indicate if this has applied to
you during the past month. If so, was this only on some days or on
most or every day in the past month?
None of On some On most/
the time days every day/s
Because of pain in my feet:
I feel self-conscious about my feet
I get self-conscious about the shoes I have to wear
I have constant pain in my feet
My feet are worse in the morning
My feet are more painful in the evening
I get shooting pains in my feet
I still do everything but with more discomfort

50. None of On some On most/
the time days every day/s
Because of pain in my feet:
I avoid walking outside at all
I avoid walking long distances
I don’t walk in a normal way
I walk slowly
I have to stop and rest my feet
I avoid hard or rough surfaces when possible
I avoid standing for a long time
I catch the bus or use the car more often
I need help with housework / shopping
I get irritable when my feet hurt

51. None of On some On most/ Not
the time days day/s applicable
Because of pain in my feet:
I am unable to carry out my previous
work
I no longer do all my previous activities
(sport, dancing, hill-walking, etc)

52. OLERUD-MOLANDER ANKLE SCORE(OMAS)
 Olerud-Molander Ankle Score (OMAS), is an ordinal
rating scale from 0 points (totally impaired function)
to 100 points (completely unimpaired function)
 It is related to 9 different items given different points:
pain, stiffness, swelling, stair climbing, running,
jumping, squatting, supports and work/activity level.
 Commonly used to assess patients with ankle
fractures

54. LOWER EXTREMITY FUNCTIONAL SCALE(LEFS)
 The LEFS is a self-report questionnaire.
 Patients answer the question "Today, do you or would you have
any difficulty at all with:" in regards to twenty different everyday
activities.
 Patients select an answer from the following scale for each
activity listed:
Extreme Difficulty or Unable to Perform Activity
Quite a Bit of Difficulty
Moderate Difficulty
A Little Bit of Difficulty
No Difficulty
 The patient's score is tallied at the bottom of the page. The
maximum possible score is 80 points, indicating very high
function. The minimum possible score is 0 points, indicating very
low function.

57. PROGRESSIVE RESISTANCE EXERCISE
 A system of dynamic resistance training in which a
constant external load is applied to the contracting
muscle by some mechanical means.
 The concept of PRE was introduced over 60 years ago by
Delorme .
 Delorme studied and proposed the use of 3 sets of a
percentage of 10-RM with progressive load during each
set.
 Other investigators developed a regimen, the oxford
technique, with regressive loading in each set.

58. DELORME BOOT
 Delorme boot is a weighted device used for progressive
resisted exercise training.
 It is made of aluminium casting with rods for holding
weights.
 The boot is used for quadriceps strengthening and
strengthening of ankle dorsiflexors through progressive
resistance exercise.

59. PARTS OF BOOT
 It has an aluminium cast
base for ankle support.
 The boot consist of a
collor and a rod to hold
weight to give
progressive graded
exercise.
 The boot has two straps
to secure the foot firmly
in place.

60. METHOD OF APPLICATION
 Patient position: sitting position with knee 90* flexed
 Ask the patient to pull his foot up (dorsiflex) and bring
down (plantar flex) simultaneously.
 The weights are added according to the repetition
maximum of the patient.
 Repetition maximum indicates the heaviest weight a
person can lift with maximum effort in a single repetition.

61.  Training using delorme boot induces contraction of
dorsiflexors.
 It also increases the size and volume of muscle fiber.
 When the ankle goes into plantarflexion, the weight of
the boot along with the pull of gravity causes lengthening
of dorsiflexors giving an effect of stretching.
For strengtehing of quadrieps, ask the patient to lift his leg
up and down with knee in full extension.

62. USES OF BOOT
 For giving progressive graded resistance exercise
 Strengthening of dorsi flexors
 Lengthening of plantar flexors
 Strengthening of quadriceps
 To reduce tightness of antagonistic muscle
 Hypertrophy(increase in size) of muscle caused by
increase in myofibrillar volume.

63. INDICATIONS OF BOOT
COMMON PERONEAL
NERVE INJURY
 The nerve supplies the anterior
and lateral aspect of leg and
dorsum of foot.
 Injury to common peroneal
nerve causes weakness of
dorsiflexors resulting in foot
drop.
 Delorme boot can be used to
give strengthening exercise to
the dorsiflexors thus recovering
normal gait pattern

64. LEPROSY
 Leprosy, also called Hansen's disease, is a chronic
infectious disease that primarily affects the skin, the
peripheral nerves, the mucosa of the upper respiratory
tract, and the eyes. Leprosy can lead to progressive
permanent damage of these structures, and the resulting
devastating disfigurement and disability .
 When the disease affects the lateral popliteal nerve,the
person will have weakness of dorsiflexors.
 Delorme boot can be used in strengthening of
dorsiflexors.

65.  Transfering of tibialis posterior tendon to the
dorsum of the foot can restore dorsi flexion and
prevent chances of ulcers.
 The insertion of tibialis posterior tendon into
naviculum is detatched and is attached to tibialis
anterior tendon.
 Delorme boot can be used to strengten tibialis
anterior and lengethen the tibialis posterior
muscles.
 It can be also used in training new action.

66. POST POLIO SYNDROME
 Post-polio syndrome (PPS) is a condition that affects polio
survivors years after recovery from an initial acute attack of
the poliomyelitis virus.
 Post-polio syndrome is mainly characterized by new
weakening in muscles that were previously affected by the
polio infection and in muscles that seemingly were unaffected.
 Ankle dorsiflexors are commonly affected in post polio
syndrome.
 High intensity resistance training has proved to be effective in
restoring muscle strength.
 Delorme boot can be used to give strengthening exercise to
ankle muscles.

67. ACUTE ANKLE SPRAIN OR CHRONIC
INSTABILITY
 Ankle sprain and ankle instability are common conditions of
ankle complex.
 First line of rehabilitation focuses on cryotherapy and
resting of ankle.
 Strength training is given in the later stages of
rehabilitation.
 Strength training via delorme boot improves strength and
stability of ankle.
 Increased stability also results improvements in gait and
joint position sense.

68. TIBIAL STRESS SYNDROME(SHIN SPLINT)
 Shin splints is a common term for
pain or inflammation in the front or
inside section of the tibia.
 The patient will complain of tightness
or tenderness and sometimes
throbbing pain along the border of
the tibia.
 Anterior tibial stress is often
experienced by new runners or
walkers when pain occurs in the
anterior muscles of the shin during
exercise.
 Posterior shin splints (medial tibial
pain) is a more chronic condition
occurring along the inside edge of the
tibia. It generally occurs with overuse
during sports.

69.  Initial treatment includes ice therapy and resting of the
muscles.
 Later phase of rehabilitation includes stretching of the
tight muscles and strengthening.
 Delorme boot can be used for stretching the plantar
flexors in medial tibial syndrome.
 In lateral tibial syndrome, delorme boot can be used for
strengthening the dorsi flexors.
 Inclusion of delorme boot as a strengthening measure in
the fitness regimen of athelets can reduce the risk of
developing shin splints.

70. PRONATION DISTORSION SYNDROME
 Pronation distortion syndrome is characterized by
excessive foot pronation (flat feet) with concomitant knee
internal rotation and adduction (“knock-kneed”).
 Functionally tightened muscles that have been associated
with pronation distortion syndrome include the
peroneals, gastrocnemius, soleus, IT-band, hamstring,
adductor complex, and tensor fascia latae (TFL).
 Functionally weakened or inhibited areas include the
posterior tibialis, anterior tibialis, gluteus medius and
gluteus maximus.

71.  First, inhibit the muscles that may be tight/overactive via self-
myofascial release.
 The next step is to lengthen the tight muscles via static
stretching. Key muscles to stretch include the
gastrocnemius/soleus, TFL, bicep femoris and adductor
complex.
 Once the overactive muscles have been addressed, activate
the underactive muscles. Key areas to target with isolated
strengthening are the anterior tibialis via resisted dorsiflexion,
posterior tibialis via a single-leg calf raise, gluteus medius via
wall slides and gluteus maximus via floor bridges.
 Delorme boot can be used in lengthening of tibialis posterior
and strengthening of tibialis anterior.

72. EXTENSOR HALLUCIS LONGUS
 Weakness of extensor hallucis longus occurs in peroneal nerve
injury or palsy.
 During normal locomotion, an individual contacts the ground
with the heel of the foot first. The ground reaction force
applies a plantarflexion moment to the whole foot, which is
resisted by all of the dorsiflexors.
 Weakness of the EHL diminishes an individual’s ability to
control the descent of the medial portion of the foot,
particularly the great toe.
 Patients with weakness of the extensor hallucis longus also
report that the toe tends to fold under the foot when they are
pulling on socks or shoes and can cause tripping.
 Delorme boot improves strength of EHL

73.  Tightness of the EHL pulls the metatarsophalangeal joint
of the great toe into extension, which, as in the fingers
and thumb, tends to produce flexion at the
interphalangeal joint as the flexor hallucis longus is
stretched, and a claw toe deformity emerges.
 Hyperextension of the great toe pulls the plantar plate
distally, exposing the metatarsal head to excessive loads
and producing pain.
 Delorme boot can be used in lengthening and stretching
of EHL.

74. SPRINT RUNNERS
 In sprint runners, the muscle group to be aware of in the
lower extremity is tibialis anterior.
 Tibialis anterior is a dorsiflexor of the ankle meaning it
pulls your toes towards your knees (along with the
extensor group).
 Increased speed and force of dorsiflexion will shorten the
lever arm of the recovering leg during sprinting.
 This means that the quicker the ankle can go into
dorsiflexion, the quicker the leg can get through into the
next stride. This will obviously increase stride frequency.
 Delorme boot can be an effective in fitness training to
strengthen the dorsi flexors.

75. FRACTURE
 Fractures around ankle joint results in immobilization of
the ankle joint.
 inhibition of movement due to pain and decreased use of
extremities can lead to weakness of muscles.
 Initial rehabilitation phase includes isometrics of ankle
muscles.
 In later phase of rehabilitation, progressive resisted
exercise can be given using delorme boot.

76. STROKE
 The gait pattern of stroke patients is characterized by a
slow gait cycle and velocity, a difference in stride lengths
between the affected and unaffected sides, and short
stance and relatively long swing phases on the affected
side.
 In particular, when the stiffening of the flexor on the
bottom of the ankle joint is severe, it hinders the advance
of the lower limbs during gait, resulting in problems such
as asymmetric postures and balance disorders

77.  Improvement in the ability of the ankle joint had a major
effect on gait velocity and stride length.
 Undesirable gait exhibited by stroke patients is the result
of weakening of the ankle muscles and the lack of their
activation
 Exercises that can increase the ROM of the ankle joint
and strengthen the flexor in the back of the ankle joint
are necessary which can be given using delorme boot.

79. Analysis of the psychometric properties of the American
Orthopaedic Foot and Ankle Society Score (AOFAS) in
Rheumatoid Arthritis patients: application of the Rasch
model
Cristiano Sena et.al
ABSTRACT
Objective: To tested the reliability and validity of Aofas in a
sample of rheumatoid arthritis patients.
Methods: The scale was applicable to rheumatoid arthritis
patients, twice by the interviewer 1 and once by the
interviewer 2. The Aofas was subjected to test–retest
reliability analysis (with 20 Rheumatoid arthritis subjects).
The psychometric properties were investigated using
Rasch analysis on 33 Rheumatoid arthritis patients.

80. Results: Intra-Class Correlation Coefficient (ICC) were (0.90 < ICC <
0.95; p < 0.001) for intraobserver reliability and (0.75 < ICC < 0.91;
p < 0.001) for inter-observer reliability. Subjects separation rates
were 1.9 and 4.75 for the items, showing that patients fell into
three ability levels, and the items were divided into six difficulties
levels. The Rasch analysis showed that eight items was
satisfactory. One erroneous item have been identified, showing
percentages above the 5% allowed by the statistical model.
Further Rasch modeling suggested revising the original item 8.
Conclusions: The results suggest that the Brazilian versions of Aofas
exhibit adequate reliability, construct validity, response stability.
These findings indicate that Aofas Ankle-Hindfoot scale presents a
significant potential for clinical applicability in individuals with
rheumatoid arthritis. Other studies in populations with other
characteristics are now underway.

81. Evidence of Validity for the Foot and Ankle
Ability Measure (FAAM)
RobRoy L. Martin et.al
ABSTRACT
Background: There is no universally accepted instrument that can
be used to evaluate changes in self reported physical function for
individuals with leg, ankle and foot muscular disorders. The
objective of this study was to develop an instrument to meet this
need: the Foot and Ankle Ability Measure (FAAM). Additionally,
this study was designed to provide validity evidence for
interpretation of FAAM scores.
Methods: Final item reduction was completed using item response
theory with 1027 subjects. Validity evidence was provided by 164
subjects that were expected to change and 79 subjects that were
expected to remain stable. These subjects were given the FAAM
and SF-36 to complete on two occasions 4 weeks apart.

82. Results: The final version of the FAAM consists of the 21-item
activities of daily living (ADL) and 8-item Sports subscales,
which together produced information across the spectrum
ability. Validity evidence was provided for test content,
internal structure, score stability, and responsiveness. Test
retest reliability was 0.89 and 0.87 for the ADL and Sports
subscales, respectively. The minimal detectable change based
on a 95% confidence interval was ±5.7 and ±−12.3 points for
the ADL and Sports subscales, respectively. Two-way repeated
measures ANOVA and ROC analysis found both the ADL and
Sports subscales were responsive to changes in status (p <
0.05). The minimal clinically important differences were 8 and
9 points for the ADL and Sports subscales, respectively. Guyatt
responsive index and ROC analysis found the ADL subscale was
more responsive than general measures of physical function
while the Sports subscale was not.

83. The ADL and Sport subscales demonstrated strong
relationships with the SF-36 physical function subscale (r
= 0.84, 0.78) and physical component summary score (r =
0.78, 0.80) and weak relationships with the SF-36 mental
function subscale (r = 0.18, 0.11) and mental component
summary score (r = 0.05, −0.02).
Conclusions: The FAAM is a reliable, responsive, and valid
measure of physical function for individuals with a broad
range of musculoskeletal disorders of the lower leg, foot,
and ankle.

84. Psychometric Properties of the Foot and Ankle
Outcome Score in a Community-Based Study of
Adults With and Without Osteoarthritis
Yvonne M. Golightly et.al
Objective. Foot and ankle problems are common in adults,
and large observational studies are needed to advance
our understanding of the etiology and impact of these
conditions. Valid and reliable measures of foot and ankle
symptoms and physical function are necessary for this
research. This study examined psychometric properties of
the Foot and Ankle Outcome Score (FAOS) subscales
(pain, other symptoms, activities of daily living [ADL],
sport and recreational function [sport/recreation], and
foot- and ankle-related quality of life [QOL]) in a large,
community-based sample of African American and white
men and women ages >50 years.

85. Methods. Johnston County Osteoarthritis Project participants
(n 1,670) completed the 42-item FAOS (mean age 69 years,
68% women, 31% African American, mean body mass index
[BMI] 31.5 kg/m2). Internal consistency, test–retest reliability,
convergent validity, and structural validity of each subscale
were examined for the sample and for subgroups according
to race, sex, age, BMI, presence of knee or hip osteoarthritis,
and presence of knee, hip, or low back symptoms.
Results. For the sample and each subgroup, Cronbach’s alpha
coefficients ranged from 0.95–0.97 (pain), 0.97–0.98 (ADL),
0.94–0.96 (sport/recreation), 0.89–0.92 (QOL), and 0.72–0.82
(symptoms).

86. Correlation coefficients ranged from 0.24–0.52 for pain and
symptoms subscales with foot and ankle symptoms and
from 0.30–0.55 for ADL and sport/recreation subscales
with the Western Ontario and McMaster Universities
Osteoarthritis Index function subscale. Intraclass
correlation coefficients for test–retest reliability ranged
from 0.63–0.81. Items loaded on a single factor for each
subscale except symptoms (2 factors).
Conclusion. The FAOS exhibited sufficient reliability and
validity in this large cohort study.

87. CONCLUSION
There are many outcome measures available for ankle foot
complex which are either patient reported or clinician
reported.
Using a valid and reliable outcome measure is important to
assess the condition and progress of treatment.