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Chapter 22 The Ankle and Foot. Talocrural Joint Distal fibula Tibia Talus. Midfoot Navicular Cuboid 3 cuneiform bones Forefoot 5 metatarsals Phalanges. Osteology. Osteology of Foot and Ankle. Ligaments of Talocrural (TCJ), Subtalar (STJ) and Midtarsal Joints (MTJ). Anterior

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Presentation Transcript
Talocrural Joint

Distal fibula






3 cuneiform bones


5 metatarsals


muscles of the foot and ankle

Anterior tibialis

Extensor hallucis longus

Extensor digitorum longus

Peroneus tertius

Open Chain Action


Extension of phalanges – 1st ray

Extension of phalanges – toes

Everts foot

Muscles of the Foot and Ankle
muscles of the foot and ankle cont
Lateral Compartment

Peroneus longus

Peroneus brevis


Open Chain Action


Muscles of the Foot and Ankle (cont.)
muscles of the foot and ankle1





Posterior tibialis

Flexor hallucis longus

Flexor digitorum longus

Open Chain Action

Plantar flexion

Plantar flexion

Plantar flexion

Plantar flexion and inversion

First ray flexion

Flexion – Phalanges of toes

Muscles of the Foot and Ankle
talocrural subtalar midtarsal joints
Talocrural/Subtalar/Midtarsal Joints


  • Shock absorption
  • Absorb lower extremity rotatory forces
  • Provide lever for effective propulsion
pronation supination


Movement in the direction of eversion, abduction and dorsiflexion.


Movement toward inversion, adduction, and plantar flexion.

Talocrural – Pronates (dorsiflexion most dominant with eversion and abduction)

–Supinates (dominated most by plantar flexion with inversion and adduction)

Subtalar – Closed chain pronation (calcaneus everts, talus adducts and flexes)

– Closed chain supination (calcaneus inverts, talus adducts and dorsiflexes)

midtarsal joint mtj
Midtarsal Joint (MTJ)

Subtalar pronation – Promotes mobility in MTJ

and forefoot.

Subtalar supination – Promotes stability in MTJ and forefoot.

Depends on subtalar joint biomechanics

  • Must be assessed from subtalar neutral position (neither pronated nor supinated).
  • Subtalar joint assessed in both prone and weight-bearing positions.
  • Forefoot and rearfoot alignment are evaluated separately.
alignment of tibia foot ankle
Alignment of Tibia, Foot, Ankle

Sagittal Plane

  • Plumbline alignment is slightly anterior to midline through knee and lateral malleolus.
  • Navicular tubercle, line from medial malleolus to where MTP joint of great toe rests on floor.

Frontal Plane

  • Distal one third of tibia is in sagittal plane.
  • Great toe is not deviated toward midline of foot.
  • Toes are not hyperextended.
anatomic impairments
Anatomic Impairments

First ray hypermobility – Dorsal translation with soft endpoint.

Subtalar varus – Inverted twist within body of calcaneus.

Forefoot varus – Inversion deviation of forefoot relative to bisection of posterior calcaneus.

Forefoot valgus – Eversion deviation of forefoot relative to bisection of posterior calcaneus.

examination and evaluation
Examination and Evaluation
  • Patient/client history
  • Balance
  • Joint integrity and mobility
  • Muscle performance
  • Pain
  • Posture
rom and muscle length
ROM and Muscle Length

Examination of knee, hip, ankle, and spine is essential!

  • Hip and knee ROM and muscle length
  • Calcaneal inversion and eversion ROM
  • Midtarsal joint supination and pronation ROM
  • First ray position and mobility
  • Hallux dorsiflexion ROM
  • 1st–5th ray mobility
  • Ankle dorsiflexion and plantar flexion ROM with knee flexed and extended
therapeutic exercise intervention for common physiologic impairments
Therapeutic Exercise Intervention for Common Physiologic Impairments

Balance Impairment

  • Restoration requires positional sense (proprioception).
  • Balance machine, balance board, external perturbation.

Home Exercises

  • Balancing on one leg with eyes open, progress to eyes closed in door frame.
  • Standing on one leg on a pillow or couch cushion with eyes open, progress to eyes closed.
muscle performance
Muscle Performance

Intrinsic Muscles

  • Patient flexes at proximal MTP joint before distal MTP joint.
  • Draw towel under foot, pick up marbles.
  • Using resistant bands to resist proximal MTP joint flexion.

Extrinsic Muscles

  • Resisted talocrural plantar flexion with slow eccentric return to talocrural dorsiflexed position.
  • Closed chain exercises (double leg heel rises, etc.).
  • Exercise initiated in pain-free range
  • Soft tissue mobilization
  • Cryotherapy
  • Exercise for neighboring regions
posture and movement impairment
Posture and Movement Impairment
  • Excessive pronation and supination most common.
  • Exercises developed from components of gait.
  • Goal is to control motions in/out of static positions at varying speeds.
  • Static weight shifting on bathroom scale.
  • Forward/backward stepping.
  • Circular weight-shifting drill.
  • Functional drills (retrowalking, sidestepping, etc.).
rom muscle length joint integrity mobility
ROM, Muscle Length, Joint Integrity, Mobility

Acute Phase

  • Hypermobile segment should be protected (taping, bracing, casting, etc.).
  • Adjacent hypomobile segments should be mobilized with manual therapy or mobility exercise.
  • Dynamic stabilization exercise should be initiated at the hypermobile segment.
rom muscle length joint integrity mobility talocrural joint
ROM, Muscle Length, Joint Integrity, Mobility – Talocrural Joint

Talocrural Dorsiflexion

  • Gastrocnemius and soleus stretching (prevent subtalar pronation).
  • TCJ dorsiflexion ROM (soleus stretch with talar joint in neutral or slightly supinated position.
  • Step-down training to facilitate eccentric control of dorsiflexion.
subtalar joint
Subtalar Joint
  • Full active/active-assisted supination can be performed.
  • Pronation mobility active/active-assisted.
  • Progressions involve functional training of new mobility in appropriate phase of gait cycle.
therapeutic exercise intervention for common ankle and foot diagnoses
Therapeutic Exercise Intervention for Common Ankle and Foot Diagnoses

Plantar Faciitis

  • Overuse caused by excessive pronation.


  • Decrease pain and inflammation, reduce tissue stress, restore muscle strength.
  • NSAIDs, US, iontophoresis, massage – for pain.
  • Taping, orthoses, modified footwear to reduce tissue stress.
plantar faciitis treatment cont
Plantar Faciitis – Treatment (cont.)

If pronated

  • Mobilize TCJ
  • Stretch gastrocnemius and soleus
  • Strengthen tibialis anterior and extensor digitorum
  • Initiate functional and proprioceptive activities
posterior tibial tendon dysfunction
Posterior Tibial Tendon Dysfunction
  • Usually excessive subtalar joint pronation and results in acquired foot deformity.


  • NWB short leg casting may be necessary for 4–6 weeks (patients with partial tears).
  • Medication and modalities for inflammation.
  • Arch strapping to control end-range pronation.
  • Pain-free, low-intensity, high-repetition open kinetic chain plantar flexion.
achilles tendinosis
Achilles Tendinosis
  • Overuse pathology of Achilles tendon.


  • Restore TCJ mobility
  • Stretching is essential after TCJ mobility is restored.
  • Strengthening exercises following inflammation recovery.
functional nerve disorders
Functional Nerve Disorders
  • Assessment should include spine and hip involvement.
  • Nerve involvement may resolve with shoe changes, orthotics, alteration of impairments in alignment, mobility, and movement pattern exercises.
  • Affected nerves include:
    • Tibial nerve
    • Peroneal nerve
ligament sprains
Ligament Sprains
  • 70–80% involve anterior talofibular ligament (ATFL), calcaneal fibular ligament (CFL), posterior talofibular ligament (PTFL).
  • Grade III sprains are further classified:

First degree – Complete rupture of ATFL

Second degree – Complete rupture of ATFL and CFL

Third degree – Dislocation in which ATFL, CFL, and PTFL are ruptured

ligament sprains treatment
Ligament Sprains – Treatment
  • Grade I–II, 1st 4 days – R.I.C.E.
  • Severe grade I/II may need crutches in early stage.
  • Open kinetic chain inversion ROM as tolerated.
  • Progress as pain and swelling are controlled and weight-bearing tolerance increases.
  • Grade III rehabilitation is similar to that of I and II.
ankle fractures
Ankle Fractures
  • Supination adduction injury
  • Supination external rotation injury
  • Pronated abduction injury
  • Pronated external rotation injury


  • Edema massage, scar mobilization, edema reduction
  • AROM begins mid-range, low intensity/high reps
  • As function normalizes, ROM exercise is generally more tolerable
adjunctive interventions
Adjunctive Interventions
  • Adhesive strapping
  • Wedges and pads
  • Biomechanical foot orthotics
  • Heel and full sole lifts
  • Three main joints of ankle and foot are TCL, ST, MTL and subdivided into calcaneocuboid and talonavicular.
  • Extrinsic muscles consist of anterior, lateral, posterior groups. Anterior-dorsiflexion, lateral – everters, posterior – plantar flexors.
  • Functions of foot during gait are shock absorption, surface adaptation, and propulsion.
summary cont
Summary (cont.)
  • Foot and ankle exam must be thorough and include relationships of lower joint extremities.
  • Common anatomic impairments include subtalar varus, forefoot varus/valgus.
  • Common physiologic impairments include loss of mobility, force, torque, balance, impaired balance, and posture.
  • Adjunctive agents may be necessary to treat primary or secondary impairments.