This document summarizes a presentation on foot and ankle pathologies and rehabilitation. The objectives are to understand biomechanics related to injuries, clinical concepts in rehabilitation, literature on dysfunctions and treatments, and how to apply evidence. Common conditions discussed include anterior impingement, Achilles tendinitis, posterior tibialis dysfunction, ankle sprains, and peroneal tendinitis. The importance of examining regional interdependence and impairments in distant areas that may contribute to problems is emphasized. Evidence is presented for various treatments related to specific conditions.

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?