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The Foot and ankle complex: understanding the science behind both movement and dysfunction By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS

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Introduction The foot is where movement begins, from the initiating of simple functional movements such as sit to stand or walking, to climbing stairs, to more complex dynamic sport movements such as playing soccer, football, rugby, and tennis. The ankle and foot complex require proper mobility in order for the body to initiate movement or change direction. In this article, we will review the anatomy of the ankle, common injuries to the ankle, functional assessments and training strategies to work with clients with previous injuries.
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     The Foot and ankle complex: understanding the science behind both movement and dysfunction By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS Introduction  The foot is where movement begins, from the initiating of simple functional movements such as sit to stand or walking, to climbing stairs, to more complex dynamic sport movements such as playing soccer, football, rugby, and tennis. The ankle and foot complex require proper mobility in order for the body to initiate movement or change direction. In this article, we will review the anatomy of the ankle, common injuries to the ankle, functional assessments and training strategies to work with clients with previous injuries. Figure 1. Walking requires adequate ankle mobility   Basic anatomy Let’s look at the basic anatomy of the foot. There are three functional areas within the ankle; the forefoot(front), midfoot(form the arch) and the rear foot(back), which can be seen in figure 2.  The forefoot  is composed of the five toes (called phalanges) and their connecting long bones (metatarsals). The midfoot  has five irregularly shaped tarsal bones that forms the foot's arch, serving as a shock absorber. The rear foot  is comprised of top of the talus is connected to the two long bones of the lower leg (tibia and fibula), forming a hinge that allows the foot to move up and down. The heel bone (calcaneus) is the largest bone in the foot. It joins the talus to form the subtalar joint . Metatarsals/phalanges(forefoot) Midfoot Rear foot Figure 2. Functional areas of the ankle     #  When we look at the support and stability within the ankle, the primary support comes from the ligaments within the ankle. There are several important ligaments that stabilize, and a few, particularly that are often injured more than others. Primary ligament restraints of the talocrural joint:  There are three primary ligaments that support the ankle, the anterior talofibular ligament, the calcaneofibular ligament and the deltoid ligament. These ligaments can be seen in figure 3.   a. Anterior talofibular(ATFL) ligament srcinates on front aspect of the fibula, 1 cm from the tip of the lateral malleolus and inserts along the outside aspect of the talar neck. b. Calcaneofibular ligament(CFL) srcinates on the tip of the fibula, and inserts on the outside of the calcaneous(heel bone). It is the most often lig ment injured due to being the we kness of   lig ment  and because most ankle sprains involve inversion of the foot. (toe going inward). This is seen in figure 4.   c. Deltoid ligament srcinates from front & below aspects of medial malleolus and inserts on medial and posteromedial aspect of the talus. It resists eversion motion of the foot. Figure 3. Ligaments of the foot Common injuries and causes  There are different types of injuries the ankle can sustain. The most common are the ankle sprain, plantar fasciitis and achilles tendonitis. In this next section, we will review each condition providing a deeper understanding of each. a. Ankle Sprains Mechanism of injury/pathophysiology: occurs as a result of direct trauma where  85-90% of all ankle sprains are lateral (inversion)   ankle sprains, as seen in figure 4.    With lateral sprains, the foot is plantar flexed and inverted at the time of injury injuring the anterior talofibular ligament (ATFL) initially, with the calcaneofibular ligament (CFL).   $ Figure 4. Inversion of the ankle Figure 5. Ankle sprain Sprains are graded from one to three based on the severity of the sprain and are as follows:  Grade 1:  There is some loss of function with minimal tearing of the anterior talofibular ligament and mild swelling visibly present.  Grade 2:  There is moderate loss of function, particularly with walking and negotiating uneven surfaces. Anatomically, there is partial tearing of the anterior talofibular ligament(ATFL) and calcaneofibular(CFL) ligaments, presenting moderate amount of swelling throughout the ankle.  Grade 3:  There is severe loss of function, affecting a person’s ability to bear weight and walk due to severe pain and the complete tearing of the anterior talofibular ligament, calcaneofibular ligament and posterior talofibular ligaments. Clinically, there is a significant amount of swelling throughout the ankle.  Healing time of ligaments:  Typically a grade one sprain, requires 0-4 weeks to completely heal, a grade 2, requires 4-8 weeks to heal and a grade three can take up to12 weeks to heal and may require surgical intervention.  b. Plantar fascitis Mechanism of injury/pathophysiology: Plantar fascitis is caused by repetitive mechanical loading of the plantar fascia, due to excessive pronation of the foot, resulting in an irritation and inflammation of the plantar fascia. Risk Factors:  Excessive pronation, decreased arch, unsupported shoes, muscle imbalance between the evertors and invertors. Sign and symptoms: Pain occurs along the plantar fascia(typically along the medial aspect), with symptoms of gradual, insidious onset, with pain being worst in weight bearing, and localized heel pain as well. Medical treatment: In the acute phase, physical therapy utilizes modalities to decrease inflammation and assist with tissue healing. In addition, taping, stretching, manual therapy and stabilization/strengthening exercises are utilized. c. Achiles tendonitis Mechanism of injury:  The achilles tendon is among the most prone to overuse injury, with tendon problems accounting for up to 18% of injuries in runners (Magnussen et al 2009).     %  Achilles tendonitis is defined as the acute inflammation of the tendon while an achilles tendinopathy, is defined as chronic pain in the achilles tendon. Injury to the Achilles tendon can be a result of overuse, commonly seen in sports that involve running and jumping. Excessive loading of the tendon during vigorous training activities is regarded as the main pathological stimulus or cause.  Achilles ruptures, typically affect younger individuals, in which running, jumping, and agility activities involving explosive, eccentric loading to the Achilles tendon. Natural aging allows predisposing chronic degeneration of the tendon. Blood flow decreases and stiffness increases with aging to decrease the ability to withstand stress( Hess, G 2010).  Pathophysiology:  An overuse tendon injury, is caused by repetitive strain of the affected tendon such that the tendon can no longer endure tensile stress. As a result, tendon fibers begin to disrupt microscopically, leading to inflammation and pain(Paavola, M et al 2002).  Contributing factors:  Training errors, running a distance that is to long, running too intense, increasing distance too greatly, excessive motion of the hind foot in the frontal plane, especially a lateral heel strike with excessive compensatory pronation, are all thought to cause or influence an achilles injury. Sign and symptoms: Localized pain,   the tendon is diffusely swollen and, on palpation, tenderness is usually greatest in its middle third. Chronic achilles injuries, will present with a tender, nodular swelling and pain again with dorsiflexion of the foot. Medical treatment: Patients may be given initially NSAIDS for pain relief, are advised to rest, use ice and decrease the load to the foot complex. The role of corticosteroid injections in the treatment is controversial. Gentle stretching of gastrocnemius and conservative management is used for achilles tendonopathies. Diagnostically, ultrasound and MRI may be used to rule out tears. Common assessments  The ankle is where all movement begins, therefore, possessing proper mobility is vital. Limitations in dorsiflexion can impair functional as well as sport movements. Several studies published have shown that limited dorsiflexion impacts the squat, step down(stairs), and landing from a jump. Therefore, lacking ankle mobility, particularly in the elderly predisposes them biomechanically to a fall. One simple test to assess ankle mobility . It is the standing wall test,  as seen in the figure below. In this test, have your client should be barefoot and begin in the standing position as if they were going to stretch their calf muscles. The lead foot should be 6” from the wall, this is important in standardizing the test. Measure and mark accordingly. From this position, have the client lean in, keeping their heel on the ground. From this position, you can measure the distance of the knee cap from the wall or measure the client’s great toe to the  wall, watching for the heel to come off the floor.

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