OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY

Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

MRAT 211: • Intractable pain & hypesthesia on distal area of

Ankle & Foot Rehabilitation the involved compartment (early symptoms).
• 3P’s (pain, paresthesia, paralysis).
CHRONIC EXERTIONAL COMPARTMENT • Extreme pain upon long muscle stretching -
SYNDROME (CECS) Most important physical sign.
• Chronically raised intracompartmental pressure.
• Can result to: SIDE NOTES:
- Nerve Impingement • Necrosis - Is the death of body tissue. It occurs
- Tissue Ischemia when too little blood flows to the tissue. This
• May occur concurrently with tibial stress can be from injury, radiation, or chemicals.
fracture. Necrosis cannot be reversed. When large areas
• Pain with exercise & progress as the activity of tissue die due to a lack of blood supply, the
increases in intensity diminish after activity. condition is called gangrene.
• Volkmann Ischemic Contracture - Is a
Neurologic Involvement: deformity of the hand, fingers, and wrist caused
• Anterior - Dorsiflexor weakness & numbness by injury to the muscles of the forearm.
of the first web space (DPN). • Hypesthesia - Partial or total loss sensitivity to
• Lateral - Evertor weakness and numbness of stimulation, particularly to tactile (touch)
the dorsal foot & AL distal shin. stimuli.
• Deep Posterior - Cramping of the foot • Pain - This is expected with a muscle injury,
intrinsics & numbness of the medial arch of the pain described as deep and constant and poorly
foot (TN). localized, that increases when stretching or
manipulating the muscle, and is unrelieved by
pain medications and could be a sign of
compartment syndrome.
• Paresthesia - The patient may experience
a pins-and-needles sensation, tingling, tickling,
prickling or burning.
• Paralysis - This is usually a late finding,
paralysis or numbness in a limb can be a sign of
compartment syndrome. This is most common
when a patient’s leg or arm has been crushed in
an accident.

ACUTE COMPARTMENT SYNDROME

• Acute decrease in perfusion of the muscle &
nerve tissues.
• Intracompartmental tissue pressure acutely
becomes elevated - Increase Venous Pressure =
Obstruction of Venous Outflow.
• Necrosis develops within 4-8 hours.
• MC after traumatic injury/fractures of the long
bone.
• MC Site:
- Volar Aspect of the Forearm.
- Anterior Compartment of the Leg.
• Necrosis - Secondary muscle paralysis, muscle
contractures, sensory impairment (Volkmann
Ischemic Contracture).

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

ANKLE SPRAIN
• Lateral
- MC: 85% of all the AS.
- MOI: INV on a PF foot.
- Hx of "rolling over" the ankle.
• Medial
- MOI: PRON, EV position with IR of the
upper body.

MEDIAL TIBIAL STRESS SYNDROME • Provocative Test:

• AKA Shin splints. - Anterior Drawer Test: ATFL
• Common cause of exercise-induced leg pain. - Talar Tilt Test: CFL & ATFL
• Overuse injury resulting from chronic traction
on the periosteum at the periosteal-fascial
junction.
• Periosteum detached from the bone due to
ballistic overload.
• Fibrofatty filling may occurs at the site.
• MC site:
- Attachment of the SOLEUS along the
medial tibia.
Most Predisposing Factor: Hyper-pronation.

• Gradual onset of pain along the postero-medial

border of the tibia.
• Pain increases with exercise or after completion
of the activity & usually last the next morning.
• Tenderness.
• Hx of running on hard surfaces, inappropriate
warm-up/footwear.
• Excessive use of plantar-flexors (jumping).

Diagnosis:
• Bone Scan (medial tibial border).
• MRI (R/O stress fracture).
Treatment:
- Icing & rest.
- Decrease weight-bearing. PERONEAL TENDON INJURY
- Return to play (modification). • Peroneus Longus inserts at the 1st MT Base.
- Orthosis (correct overpronation). • Peroneus Brevis inserts at 5th MT base.
MOI:
• Tenosynovitis or rupture.
- Repetitive Forceful Eversion -
inflammation or degeneration of the tendon
or synovium.
• Subluxation or dislocation.
- Sudden DF.
- Most common in skiing.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

TIBIALIS POSTERIOR TENDON INJURY FLEXUS HALLUCIS LONGUS (FHL)

MOI: INJURY
• Tenosynovitis or tendon rupture. • AKA Dancer's Tendonitis.
- Repetitive forceful inversion causing • Repetitive push-off maneuvers causing
inflammation or degeneration of tendon or inflammation of the synovium or tendon.
synovium along its course.
• Insidious pain on postero-medial ankle
increased during activity.
• Medial hind-foot swelling.
• Weakness Plantar-flexion & Inversion.
• (+) Too Many Toes Sign.

RETRO-CALCANEAL BURSITIS
• Inflammation of the bursae between the
posterior superior portion of the calcaneus & AT
or a bursa between the skin & AT.
• Repetitive pressure & shearing forces from an
object causing callus & bursitis.

Achilles Tendonitis / Achilles Tendon Rupture

• Repetitive eccentric overload causing
inflammation & micro-tears.
• Inflammatory
• Vascular
• Mechanical
• MC site for Rupture:
- 4 cm above the tendon insertion onto the
calcaneum.
• Risk Factors:
- Training Errors: Most Common. TIBIOFIBULAR SYNDESMOSIS INJURY
- Increase in mileage or intensity. • High ankle sprain.
- Change in recent footwear. • Injury to the following ligaments:
- Anatomic causes. - ATFL
- Increased age. - PTFL
- Interosseous Ligament
- Transverse Tibiofibular Ligament
MOI:
- Hyper-dorsiflexion & forceful eversion of the
ankle.
- Direct blow to the foot with the ankle in
External Rotation.
- (+) Squeeze Test.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

Forefoot Valgus
• Mid-tarsal Eversion of the forefoot on the hind-
foot when the subtalar joint is in the neutral
position.
• Normal Valgus Tilt (35° to 45°) of the head &
neck of the talus to its trochlea has been
exceeded.

Hindfoot Varus (Subtalar or Rearfoot Varus)

• Inversion of the calcaneus when the subtalar
joint is in the neutral position.
• Hind-foot is mildly rigid with Calcaneal
Eversion = Limited Pronation. Forefoot Varus
• Pes cavus foot. • Mid-tarsal joint Inversion of the Forefoot on
the hind-foot when the subtalar joint is in the
neutral position.
• It occurs because the normal Valgus Tilt of the
head & neck of the talus to its trochlea has not
been achieved.

Hindfoot Valgus (Rearfoot)

• Eversion of the calcaneus when the subtalar
joint is in the neutral position.
• Mobile, which may lead to Excessive
Pronation & Limited Supination.
• May result from Genu Valgum (knock knees).
• May contribute to the appearance of a pes
planus foot. Metatarsus Adducts (Hooked Forefoot)
• Most common foot deviation in children.
• May be seen at birth but often is not noticed
until the child begins to stand.
• Foot is Adducted & Supinated.
• Hind-foot may or may not be in Valgus.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

Pes Cavus ("Hollow Foot" or Rigid Foot) Splay Foot

• May be caused by a congenital or neurological • Broadening of the forefoot.
problem such as Poliomyelitis, Talipes • Caused by weakness of the intrinsic muscles &
Equinovarus, and Muscle Imbalance. inter-metatarsal ligament.
• Genetic factor. • Dropping of the anterior metatarsal arch.
• Longitudinal arches are accentuated.
• Metatarsal heads are lower in relation to the
hind-foot -› "dropping" of the Forefoot on the
hind-foot at the tarsometatarsal joints.

DISORDERS OF THE TOES

Morton’s Neuroma
• Irritation & degeneration of the distal
interdigital nerves with eventual enlargement
due to perineural fibrosis.
• Metacarpal in 3rd inter-metatarsal space.
Pes Planus (Flatfoot or Mobile Foot)
• May be congenital, or it may result from
trauma, muscle weakness, ligament laxity,
"dropping" of the talar head, paralysis, or a
pronated foot.
• Normal until age of 2 year old.

MTP Strain
• AKA Turf Toe.
• Hyperextension on injury combined with
compressive loading to the metatarsophalangeal
joint of the hallux.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

Hallux Valgus Claw Toes

• Lateral deviation of the first toe >20° between • Characterized by hyperextension of the
the tarsus & metatarsus. metatarsophalangeal (MTP) & flexion of the
• May lead to bunion. proximal interphalangeal (PIP) and distal
interphalangeal (DIP) joints.
• Weakness of foot intrinsics associated with
neurologic disorders.

Hallux Rigidus
• Degenerative joint disease of the first Mallet Toes
metatarsophalangeal joint leading to pain & • Flexion deformity at the distal interphalangeal
stiffness. (DIP) joint with normal alignment at the
proximal interphalangeal (PIP) &
metatarsophalangeal (MTP) joints.
• Usually the result of jamming type injury or
wearing tight shoes.

Hammer Toes
• Consists of an extension contracture at the
metatarsophalangeal joint & flexion contracture
at the proximal interphalangeal joint.
• DIP joint may be flexed, straight, or
hyperextended.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

Plantar Fasciitis BALANCE ASSESSMENTS

• Medial plantar heel pain caused by
inflammation of the plantar fascia. 1. STATIC
• Romberg Test
MECHANISM OF INJURY: • Sharpened Romberg
• Increased tension on the plantar fascia leads to • Single-Leg Balance Stance Test
chronic inflammation most commonly at its • Stork Stand Test
origin.
• Disorders causing tension include: pes cavus, 2. DYNAMIC
pes planus, obesity, tight Achilles tendon, bone • Five-times-sit-to-stand Test (5x STS).
spur.
• Other associations: HLA-B27; seronegative 3. ANTICIPATORY POSTURAL CONTROL
spondyloarthropathy. TESTS
- Heel spurs may contribute to the etiology: • Functional Reach Test
50-75% with heel spurs have plantar • Star Excursion Balance Test
fasciitis.
4. REACTIVE POSTURAL CONTROL
CLINICAL FEATURES: TESTS
• Tenderness over the medial aspect of the heel & • Pushes (small or large, slow or rapid,
the entire plantar fascia. anticipated and unanticipated).
• Pain worse in the morning or at start of weight- • Pull Test
bearing activities & decreases during activity. • Push and Release Test
• Tight Achilles Tendon is frequently associated • Postural Stress Test
with plantar fasciitis.

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 OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHYSICAL THERAPY
Km. 23 Sumulong Highway, Sta. Cruz, Rizal
ANTIPOLO CAMPUS

THE FOOT POSTURE INDEX (FPI-6)

The patient should stand in their relaxed

stance position with double limb support. The
patient should be instructed to stand still, with
their arms by the side and looking straight ahead.
It may be helpful to ask the patient to take several
steps, marching on the spot, prior to settling into a
comfortable stance position. During the
assessment, it is important to ensure that the
patient does not swivel to try to see what is
happening for themself, as this will significantly
affect the foot posture. The patient will need to
stand still for approximately two minutes in total
in order for the assessment to be conducted. The
assessor needs to be able to move around the
patient during the assessment and to have
uninterrupted access to the posterior aspect of the
leg and foot.

If an observation cannot be made (e.g.

because of soft tissue swelling) simply miss it out
and indicate on the data sheet that the item was
not scored.

If there is genuine doubt about how high

or low to score an item always use the more
conservative score.

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