5/19/2018 The Foot and ankle complex: understanding the science behind both movement and dysfunction By Chris Gellert, PT, MMusc & Sportsphysio, M

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The Foot and ankle complex: understanding the sciencebehind both movement and dysfunction

By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS

IntroductionThe foot is where movement begins, from the initiating of simple functional movementssuch as sit to stand or walking, to climbing stairs, to more complex dynamic sportmovements such as playing soccer, football, rugby, and tennis. The ankle and foot complexrequire proper mobility in order for the body to initiate movement or change direction. Inthis article, we will review the anatomy of the ankle, common injuries to the ankle, functionalassessments and training strategies to work with clients with previous injuries.

Figure 1. Walking requires adequate ankle mobility

Basic anatomyLets 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 forefootis composed of the five toes (called phalanges) and their connecting long bones(metatarsals). The midfoothas five irregularly shaped tarsal bones that forms the foot's arch,serving as a shock absorber. The rear footis comprised of top of the talus is connected to thetwo long bones of the lower leg (tibia and fibula), forming a hinge that allows the foot to moveup and down. The heel bone (calcaneus) is the largest bone in the foot. It joins the talus to formthe subtalar joint.

Metatarsals/phalanges(forefoot) Midfoot Rear foot

Figure 2. Functional areas of the ankle

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When we look at the support and stability within the ankle, the primary support comes fromthe ligaments within the ankle. There are several important ligaments that stabilize, and afew, 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 ligamentand the deltoid ligament. These ligaments can be seen in figure 3.a. Anterior talofibular(ATFL) ligament originates on front aspect of the fibula, 1 cm fromthe tip of the lateral malleolus and inserts along the outside aspect of the talar neck.

b. Calcaneofibular ligament(CFL) originates on the tip of the fibula, and inserts on theoutside of the calcaneous(heel bone). It is the most often l ig ment injured due to beingthe we kness of l ig ment and because most ankle sprains involve inversion of the foot.(toe going inward). This is seen in figure 4.

c. Deltoid ligament originates from front & below aspects of medial malleolus andinserts on medial and posteromedial aspect of the talus. It resists eversion motion of the foot.

Figure 3. Ligaments of the foot

Common injuries and causesThere are different types of injuries the ankle can sustain. The most common are the anklesprain, plantar fasciitis and achilles tendonitis. In this next section, we will review each conditionproviding a deeper understanding of each.a. Ankle SprainsMechanism of injury/pathophysiology: occurs as a result of direct trauma where85-90% 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 theanterior talofibular ligament (ATFL)initially, with the calcaneofibular ligament(CFL).

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Figure 4. Inversion of the ankle Figure 5. Ankle sprainSprains 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 ligamentand mild swelling visibly present.Grade 2:There is moderate loss of function, particularly with walking and negotiating unevensurfaces. Anatomically, there is partial tearing of the anterior talofibular ligament(ATFL)

and calcaneofibular(CFL) ligaments, presenting moderate amount of swelling throughout theankle.Grade 3:There is severe loss of function, affecting a persons ability to bear weight and walkdue to severe pain and the complete tearing of the anterior talofibular ligament, calcaneofibularligament and posterior talofibular ligaments. Clinically, there is a significant amount of swellingthroughout 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 andmay require surgical intervention.

b. Plantar fascitisMechanism of injury/pathophysiology: Plantar fascitis is caused by repetitive mechanicalloading of the plantar fascia, due to excessive pronation of the foot, resulting in an irritationand inflammation of the plantar fascia.

Risk Factors:Excessive pronation, decreased arch, unsupported shoes, muscle imbalancebetween the evertors and invertors.

Sign and symptoms: Pain occurs along the plantar fascia(typically along the medial aspect), withsymptoms of gradual, insidious onset, with pain being worst in weight bearing, and localizedheel pain as well.

Medical treatment: In the acute phase, physical therapy utilizes modalities to decreaseinflammation and assist with tissue healing. In addition, taping, stretching, manual therapy andstabilization/strengthening exercises are utilized.

c. Achiles tendonitisMechanism of injury:The achilles tendon is among the most prone to overuse injury, withtendon problems accounting for up to 18% of injuries in runners (Magnussen et al 2009).

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Achilles tendonitis is defined as the acute inflammation of the tendon while an achillestendinopathy, is defined as chronic pain in the achilles tendon. Injury to the Achilles tendoncan 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 mainpathological stimulus or cause.

Achilles ruptures, typically affect younger individuals, in which running, jumping, and agilityactivities involving explosive, eccentric loading to the Achilles tendon. Natural aging allowspredisposing chronic degeneration of the tendon. Blood flow decreases and stiffnessincreases with aging to decrease the ability to withstand stress(Hess, G 2010).

Pathophysiology:An overuse tendon injury, is caused by repetitive strain of the affectedtendon such that the tendon can no longer endure tensile stress. As a result, tendon fibersbegin 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 toointense, 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 thoughtto 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 atender, nodular swelling and pain again with dorsiflexion of the foot.

Medical treatment: Patients may be given initially NSAIDS for pain relief, are advised torest, use ice and decrease the load to the foot complex. The role of corticosteroid injectionsin the treatment is controversial. Gentle stretching of gastrocnemius and conservativemanagement is used for achilles tendonopathies. Diagnostically, ultrasound and MRI

may be used to rule out tears.

Common assessmentsThe ankle is where all movement begins, therefore, possessing proper mobility is vital.Limitations in dorsiflexion can impair functional as well as sport movements. Several studiespublished have shown that limited dorsiflexion impacts the squat, step down(stairs), andlanding from a jump. Therefore, lacking ankle mobility, particularly in the elderly predisposesthem biomechanically to a fall.

One simple test to assess ankle mobility. It is the standing wall test,as seen in the figurebelow. 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, thisis 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 canmeasure the distance of the knee cap from the wall or measure the clients great toe to thewall, watching for the heel to come off the floor.

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Figure 6. Standing wall test

Another great test to assess a clients movement pattern, is the squat.The squat is a classicfundamental primal movement that someone typically performs almost on a daily basis. Withthis test, you can observe how the clients ankle, knee, hip and back moves compared tonormal movement patterns. This is seen in the figure below. If the client demonstrates

excessive pronation of the foot, potential reason is due to weak evertors or is due tostructural issue(pes plannus or flat feet). If the client demonstrates excessive supination ofthe foot, this could be due to tightness of peroneals and gastrocnemius, tightness ofperoneals & iliotibilal band(ITB), structural changes of the foot(high arch).

Figure 7. Squat in frontal view Squat in side view

Lastly, an in place lungelooks at ones control through the entire kinematic chain. The lungeis another fundamental primal movement. The lunge is a dynamic movement that is typicallyperformed during daily activities(stooping down to pick something up) or as part of anathletic movement. This test examines ankle control, knee control and pelvic stability.

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Figure 8. In place lunge

Training strategies and programming for ankle injuriesWith any injury, the most important thing to remember is the type of injury, healing timeand prior level of function of the client. Lets begin with ankle sprains.

a. Ankle sprainsRecommendations for training:A client with a chronic ankle sprain would benefitfrom continued functional strengthening exercises that target the invertors, evertors anddorsiflexors. Exercises such as diagonal forward, diagonal reverse(as seen in figure 9,target the glute medius and minimus). In addition forward traveling lunges areeffective in strengthening not only the ankle, but the knee and hip complex.

Figure 9. Diagonal lunge

b. Plantar fascitisRecommendations for training: Strengthening the intrinsic and extrinsic muscles(evertors and invertors), is important. It is also important to continue stretching tighthip flexors, quadriceps, ITB and gastrocnemius. Core strengthening should always bepart of the training program, begin teaching static exercises, such as planks, trunkrotation with tubing, then progress to dynamic exercises such as traveling lungeswith trunk rotation and diagonal lunge with wood chop.

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c. Achilles tendonitisRecommendations for training: It has been shown through the research, that12 weeks of eccentric resistance training can reduce pain in those suffering fromchronic achilles tendinosis. Physiologically, eccentric training stimulates type I collagensynthesis, whereby strengthening the tendon, resulting in also reduction in pain in the

tendon during loading.(Langberg, H et al 2007). An effective eccentric exercise for theachilles, is to place a strong resistance based band under the clients ball of their foot,and step down(dorsiflexion of foot) off a 6-8 step, or something that is comfortable.Continued strengthening the entire kinematic chain is effective as well as recommendingto the client to cross train with such interventions such as yoga, pilates, swimming,cycling and hiking.

SummaryThe ankle is a complex unit that is comprised of a multitude of ligaments, tendons,connective tissue, muscles that synergistically initiate and correct movement, and stabilizewhen an unstable environment. Understanding the anatomy, biomechanics and weak linksof the ankle, common injuries and evidenced based training strategies, should provide youwith the insight to better understand and work with clients with these kind of injuries moreconfidently.

Chris is the CEO of Pinnacle Training & Consulting Systems(PTCS). A continuingeducation company, that provides educational material in the forms of home study courses,live seminars, DVDs, webinars, articles and min books teaching in-depth, the foundationscience, functional assessments and practical application behind Human Movement, that isevidenced based. Chris is both a dynamic physical therapist with 14 years experience, and apersonal trainer with 17 years experience, with advanced training, has created over 10courses, is an experienced international fitness presenter, writes for various websites and

international publications, consults and teaches seminars on human movement. For moreinformation, please visit www.pinnacle-tcs.com

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REFERENCES

Hess, G., 2010,Achilles Tendon Rupture: A Review of Etiology, Population, Anatomy, RiskFactors, and Injury Prevention, Foot Ankle Specialist,vol. 3, no.1, pp. 29-32.

Langberg, H., et al 2007, Eccentric rehabilitation exercise increases peritendinous type Icollagen synthesis in humans with Achilles tendinosis, Scandavian Journal Medicine ScienceSports, vo1. 17, pp. 6166

Magnussen, R., et al., 2009, Nonoperative Treatment of Midportion Achilles Tendinopathy:A Systematic Review, Clinical Journal Sports Medicine,vol. 19, number 1, pp. 54-63.

Mcpoil, T., et al 2008, Heel PainPlantar Fasciitis: Clinic Practice Guidelines Linked to theInternational Classification of Functioning, Disability, and Health from the AmericanPhysical Therapy Association, JOSPT,vol. 38, issue, 4, pp. 2-17.

Paavola, M., et al 2002,

Current Concepts Review: Achilles Tendinopathy, The Journal ofBone and Joint Surgery,pp. 2062-2073.

Wearing et al., 2006, The pathomechanics of plantar fasciitis, Sports Medicine,vol. 36,issue 7, pp. 585611.