1. Foot and Ankle Seminar
Jim Clover, MED, ATC

2. Foot Anatomy Review Bony Anatomy Talus Calcaneus Tarsals Metatarsals
5 bones
Metatarsals
Phalanges
14 bones
Bones of the Foot
Talus
Calcaneus
Tarsals (Navicular, Cuboid, Lateral / Middle / Medial Cuniform)
Metatarsals
Phalanges (Proximal / Middle (except Great Toe) / Distal Phalanges)
Pictures From: Bartelby.com, Anatomy of the Human Body, Henry Gray.

3. Foot Anatomy Muscles of the Foot Figure Two Figure Three Figure One
Dorsal Layer (Figure One)
Extensor Digitorium Brevis
First / Second Layer (Figure Two)
Abductor Hallicus
Abductor Digiti Minimi Pedis
Flexor Digitorium Brevis
Quadratus Plantae
Flexor Digiti Minimi Brevis Pedis
Lumbricalis Pedis
Third / Fourth Layer (Figure 3)
Adductor Hallucis
Flexor Hallucis Brevis
Interosseus Plantaris
Interosseus Dorsalis Pedis
Pictures From: Bartelby.com, Anatomy of the Human Body, Henry Gray.
Figure Two
Figure Three
Figure One

4. Foot Biomechanics Transverse Arch (A) Medial Longitudinal Arch (B)
Lateral Longitudinal Arch (C)
Pictures From: Principles of Athletic Training, Prentice & Arnheim,

5. Lower Leg Anatomy Bony Tibia Fibula
Pictures From: Bartelby.com, Anatomy of the Human Body, Henry Gray.

6. Lower Leg Anatomy Musculature Anterior Medial Lateral Posterior
Tibialis Anterior
Medial
Tibialis Posterior
Extensor Digitorum Longus
Extensor Hallicus Longus
Lateral
Peroneals
Posterior
Gastrocnemius
Soleous
Pictures From: Bartelby.com, Anatomy of the Human Body, Henry Gray.

7. Lower Leg Anatomy Other Structures Joints Ligament Cartilage
Pictures From: Principles of Athletic Training, Prentice & Arnheim,

8. Foot / Ankle Anatomy
Nerve Supply
Blood Supply

9. Foot Biomechanics – Normal Gait
Two phases:
Stance or support phase which starts at initial heel strike and ends at toe-off
Swing or recovery which represents time from toe-off to heel strike
Foot serves as shock absorber at heel strike and adapts to uneven surface during stance
At push-off foot serves as rigid lever to provide propulsive force
Initial heel strike while running involves contact on lateral aspect of foot with subtalar joint in supination

10. Foot Biomechanics – Normal Gait
80% of distance runners follow heel strike pattern
Sprinters tend to be forefoot strikers
With initial contact there is obligatory external rotation of the tibia with subtalar supination
As loading occurs, foot and subtalar joint pronates and tibia internally rotates (transverse plane rotation at the knee)
Pronation allows for unlocking of midfoot and shock absorption
Also provides for even distribution of forces throughout the foot
Subtalar joint will remain in pronation for 55-85% of stance phase
occurring maximally as center of gravity passes over base of support
As foot moves to toe-off, foot supinates, causing midtarsal lock and lever formation in order to produce greater force

14. Foot Biomechanics – Pronation & Supination
Excessive or prolonged pronation or supination can contribute to overuse injuries
Have them walk in water and see what happens

15. Foot Biomechanics – Pronation & Supination

16. Foot Biomechanics – Excessive Pronation
Excessive Prontation
Major cause of stress injuries due to overload of structures during extensive stance phase or into propulsive phase

17. Foot Biomechanics – Excessive Supination
Limits internal rotation and can lead to inversion sprains, tibial stress syndrome, peroneal tendinitis, IT-Band friction syndrome and bursitis

19. Foot Evaluation (History)
Generic history questions
Past history
Mechanism of injury
When does it hurt?
Type of, quality of, duration of pain?
Sounds or feelings?
How long were you disabled?
Swelling?
Previous treatments?
Questions specific to the foot
Location of pain - heel, foot, toes, arches?
Training surfaces or changes in footwear?
Changes in training, volume or type?
Does footwear increase discomfort?

20. Foot Evaluation (Observation)
Observations
Does athlete favor a foot, limp, or is unable to bear weight?
Shoe Wear Patterns
Over pronators tend to wear out shoe under 2nd metatarsal
Athletes often mistakenly perceive wear on the outside edge of the heel as being the result of over-pronation
Wear on the lateral border of the shoe is a sign of excessive supination
Heel counter and forefoot should also be examined

21. Foot Evaluation (Palpation)
Bony Palpation
Medial calcaneus

22. Foot Evaluation (Palpation)
Soft Tissue
Deltoid ligament
Medial longitudinal arch
Plantar fascia
Transverse arch

23. Foot Evaluation (Special Testing)
Manual Muscle Testing
Toe Flexion
Toe Extension

24. Foot Evaluation (Special Testing)
Tinel’s Sign
Tapping over posterior tibial nerve producing tingling distal to area
Numbness & paresthesia may indicate presence of tarsal tunnel syndrome
Morton’s Test
Transverse pressure applied to heads of metatarsals causing pain in forefoot
Positive sign may indicate neuroma or metatarsalgia

25. Foot Evaluation (Special Testing)
Pictures From: Principles of Athletic Training, Prentice & Arnheim,

26. Foot Common Injuries Tarsal Region Fractures (Calcaneus, Talus, Etc.)
Stress Fractures
Subluxations
See Attached Document

27. Foot Common Injuries Metatarsal Region Strains
Fractures (Jones’) / Stress Fractures
Bunion
Neuroma
See Attached Document

28. Ankle Evaluation (History)
Generic History questions
Past history
Mechanism of injury
When does it hurt?
Type of, quality of, duration of pain?
Sounds or feelings?
How long were you disabled?
Swelling?
Previous treatments?

29. Severity of sprains is graded (1-3)
With inversion sprains the foot is forcefully inverted or occurs when the foot comes into contact w/ uneven surfaces

30. Grade 1 Inversion Ankle Sprain
Etiology (how it happens) Mechanism
Occurs with inversion plantar flexion and adduction
Causes stretching of the anterior talofibular ligament (ATFL)
Signs and Symptoms
Mild pain and disability; weight bearing is minimally impaired; point tenderness over ligaments and no laxity
Management/Treatment/Rehabilitation
PRICE for 1-2 days; limited weight bearing initially and then aggressive rehab
Tape may provide some additional support
Return to activity in days

31. Grade 2 Inversion Ankle Sprain
Etiology (how it happens) Mechanism
Moderate inversion force causing great deal of disability with many days of lost time
Signs and Symptoms
Ligaments have an “end” point
Feel or hear pop or snap; moderate pain w/ difficulty bearing weight; tenderness and edema
Positive talar tilt and anterior drawer tests
Possible tearing of the anterior talofibular and calcaneofibular ligaments
Management/Treatment/Rehabilitation t
PRICE for at least first 72 hours; X-ray exam to rule out fx; crutches 5-10 days, progressing to weight bearing

32. Management (continued)
Will require protective immobilization but begin ROM exercises early to aid in maintenance of motion and proprioception
Taping will provide support during early stages of walking and running
Long term disability will include chronic instability with injury recurrence potentially leading to joint degeneration
Must continue to engage in rehab to prevent against re-injury

33. Grade 3 Inversion Ankle Sprain
Etiology / Mechanism
Relatively uncommon but is extremely disabling
Caused by significant force (inversion) resulting in spontaneous subluxation and reduction
Causes damage to the anterior/posterior talofibular and calcaneofibular ligaments as well as the capsule
Signs and Symptoms
Severe pain, swelling, discoloration
Unable to bear weight
Positive talar tilt and anterior drawer (no “end” point

36. Injury Prevention
Strength training allows the supporting musculature to stabilize where ligaments may no longer be capable of holding the original tension between bones of the joint. This will also help prevent reinjury.

37. Management
PRICE, X-ray (physician may apply dorsiflexion splint for 3-6 weeks)
Crutches are provided after cast removal
Isometrics in cast; ROM, PRE and balance exercise once out
Surgery may be warranted to stabilize ankle due to increased laxity and instability

38. Dislocation

39. Ankle Evaluation (Observation)
Observations
Is there difficulty with walking?
Deformities, asymmetries or swelling?
Color and texture of skin, heat, redness?
Patient in obvious pain?
Is range of motion normal?

40. Ankle Evaluation (Palpation)
Bony Anatomy
Soft Tissue Anatomy
Soft Tissue Anatomy

41. Ankle Evaluation (Special Testing)
Fracture Tests
Tap / Percussion / Bump
Active / Passive Range of Motion (R.O.M.)
Manual Muscle Testing
Check all motions of the Foot and Ankle
Joint Stability Tests
Anterior Drawer
Special Pathology Tests
Thompson Test

42. Ankle Evaluation (Special Tests)
Fracture Test
Compression Test
Percussion Test

43. Ankle Evaluation (Special Tests)
Ankle Stability Tests
Anterior drawer test
Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarily
A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point
Anterior Drawer Test

44. Ankle Evaluation (Special Tests)
Talar tilt test (ATF,CF,PTF)
Performed to determine extent of inversion or eversion injuries
With foot at 90 degrees calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments
If the calcaneus is everted, the deltoid ligament is tested
Talar Tilt Test

45. Ankle Injury “bad”

46. Ankle Evaluation (Special Tests)
Other Special Tests
Thompson’s Test
Squeeze calf muscle, while foot is extended off table to test the integrity of the Achilles tendon
Positive tests results in no movement in the foot

47. Ankle Evaluation (Special Tests)
Homan’s test
Test for deep vein thrombophlebitis
With knee extended and foot off table, ankle is moved into dorsiflexion
Pain in calf is a positive sign and should be referred

48. Foot Rehabilitation Three simple keys Range of Motion Strength
Needed to increase motion and return to function as quickly as prudent and possible
Strength
Needed to deter further problems or protect the area of injury from further injury
Functionality
Needed to return the student-athlete or patient to normal daily activities within reason.

49. Foot Rehabilitation Flexibility
Must maintain or re-establish normal flexibility of the foot
Full range of motion is critical
Stretching of the plantar fascia and Achilles is very important for a number of conditions

50. Foot Rehabilitation Range of Motion Joints Functionality of foot
Joint Mobilization
BAPS Board / Disc
Functionality of foot
Plantar Fascia
Towel pulls
Cotton ball movement
Gastroc / Soleus Stretching

51. Can help normalize joint motion
Joint Mobilizations
Can help normalize joint motion

52. Foot Rehabilitation Strengthening Towel Pulls Cotton Ball Pick-up
Thera-band Exercises
Dorsiflexion, Plantar Flexion, Inversion, Eversion
Isometric Exercises
PNF Diagonals / D1 and D2 Patterns
Proprioception
Dyna-Disc / Wobble Boards / Couch Cushions / Etc.

53. Foot Rehabilitation
Towel Exercises

54. Foot Rehabilitation
Rehab plans are focusing more on closed kinetic chain activities
Exercises should incorporate walking, running, jumping in multiple planes and on multiple surfaces

55. Neuromuscular Control Training
Can be enhanced by training in controlled activities
Uneven surfaces, BAPS boards, rocker boards, or Dynadiscs can also be utilized to challenge athlete

56. Foot Rehabilitation Weight Bearing
If unable to walk without a limp, crutch or can walking may be introduced
Poor gait mechanics will impact other joints within the kinetic chain
Progressing to full weight bearing as soon as tolerable is suggested

57. Foot Rehabilitation General Body Conditioning
Because a period of non-weight bearing is common, substitute means of conditioning must be introduced
Pool running & upper body ergometer
General strengthening and flexibility as allowed by injury

58. Ankle Rehabilitation General Body Conditioning Weight Bearing
Must be maintained with non-weight bearing activities
Weight Bearing
Non-weight bearing vs. partial weight bearing
Protection and faster healing
Partial weight bearing helps to limit muscle atrophy, proprioceptive loss, circulatory stasis and tendinitis
Protected motion facilitates collagen alignment and stronger healing

59. Ankle Rehabilitation Joint Mobilizations Flexibility
Movement of an injured joint can be improved with manual mobilization techniques
Flexibility
During early stages inversion and eversion should be limited
Plantar flexion and dorsiflexion should be encouraged
With decreased discomfort inversion and eversion exercises should be initiated
BAPS board progression

60. Ankle Rehabilitation Strengthening
Isometrics (4 directions) early during rehab phase
With increased healing, aggressive nature of strengthening should increase (isotonic exercises
Pain should serve as the guideline for progression
Tubing exercises allows for concentric and eccentric exercises

61. Ankle Rehabilitation

62. Ankle Rehabilitation

63. Ankle Rehabilitation Taping and Bracing Functional Progressions
Ideal to have athlete return w/out taping and bracing
Common practice to use tape and brace initially to enhance stabilization
Must be sure it does not interfere with overall motor performance
Functional Progressions
Severe injuries require more detailed plan
Typical progression initiated w/ partial weight bearing until full weight bearing occurs w/out a limp
Running can begin when ambulation is pain free (transition from pool - even surface - changes of speed and direction)

64. Ankle Rehabilitation

65. Tape vs. Brace Why choose one over another
Taping may be more time consuming over brace
Braces may or may not allow more support over tape
Tape allows more functional movement and often feels more stable
Tape will loosen with time
Braces will often loosen with time
It really is based on the quality of the brace vs. the ability of the person to tape. Both have advantages and disadvantages.

66. Ankle Rehabilitation Return to Activity
Must have complete range of motion and at least 80-90% of pre-injury strength before return to sport
If full practice is tolerated w/out insult, athlete can return to competition
Must involve gradual progression of functional activities, slowly increasing stress on injured structure
Specific sports dictate specific drills

67. Injury prevention
Tight Achilles tendons can predispose someone to injuring the ankle. Tendonitis, plantar fasciitis, and other disorders may occur due to a tight Achilles tendon.

68. Injury Prevention
Footwear is something often overlooked but improper footwear can predispose someone with a foot condition such as pes planus (flat feet) to be more prone to having problems with their feet and ankles.

69. The Ankle What are the 4 bone in the Ankle?
What are the 2 muscles in the posterior of the aspect of the Tibia?
What is the one muscle on the anterior of the Tibia?
If you have a patient that has a possible Stress Fracture what is and how would you explain it to your patient?

70. The Ankle What is the difference between a fracture and a broken bone?
What is a Sprain?
What is a Strain?
What is an Isometric Contraction?
What is an Isotonic Contraction?

71. The Ankle
What is the difference between a 1st, 2nd and 3rd degree sprain?
What is P.R. I.C.E.C.?
What are the exercises you would have someone do in “Phase One” of rehab.?
What would you have them do in “Phase Two”?
“Phase Three”