LIAQUAT UNIVERSITY OF

MEDICAL & HEALTH SCIENCES

DPT 4 TH YEAR 7 SEMESTER

TH

CLINICAL PRACTICE III PRESENTATION

SUBMITTED TO: DR. MUKHTAR ALI SHAH
 GROUP= F MEMBERS:
• ALISHBA 19DPL-13
• ALKA 19DPL-14
• MUMTA KANJIANI 19DPL-37
• PRERNA DODANI 19DPL-39
• ZOHA 19DPL-47
• SIKANDAR 19DPL-50
 ASSIGNMENT TOPIC : 2
ANKLE EXAMINATION:
•ANATOMY
•PATIENT HISTORY (LISTEN)
•OBSERVATION (LOOK)
•PALPATION (FEEL)
•SPECIAL TESTS
•DEFORMITIES & TREATMENT.
ANATOMY:
 ANATOMY OF FOOT:
• THE FOOT AND ANKLE FORM A COMPLEX SYSTEM WHICH CONSISTS OF 28 BONES, 33 JOINTS, 112 LIGAMENTS,
CONTROLLED BY 13 EXTRINSIC AND 21 INTRINSIC MUSCLES.
• THE FOOT IS SUBDIVIDED INTO THE REARFOOT, MIDFOOT, AND FOREFOOT.
• THE FOOT AND ANKLE PROVIDE VARIOUS IMPORTANT FUNCTIONS WHICH INCLUDES: SUPPORTING BODY
WEIGHT.
• PROVIDING BALANCE.
• SHOCK ABSORPTION.
• TRANSFERRING GROUND REACTION FORCES.
• COMPENSATING FOR PROXIMAL MALALIGNMENT.
• SUBSTITUTING HAND FUNCTION IN INDIVIDUALS WITH UPPER EXTREMITY AMPUTATION/PARALYSIS.
 HIND FOOT (REARFOOT):
• HINDFOOT: THE MOST POSTERIOR ASPECT OF THE FOOT, IS COMPOSED OF THE TALUS AND CALCANEUS, TWO
OF THE SEVEN TARSAL BONES. THE TALUS AND CALCANEUS ARTICULATION IS REFERRED TO AS THE
SUBTALAR JOINT, WHICH HAS THREE FACETS ON EACH OF THE TALUS AND CALCANEUS.

• TIBIOFIBULAR JOINT:
• THE INFERIOR DISTAL TIBIA FIBULAR JOINT IS A FIBROUS OR SYNDESMOSIS TYPE OF JOINT. IT IS
SUPPORTED BY ANTERIOR TIBIOFIBULAR, POSTERIOR TIBIOFIBULAR AND INFERIOR TRANSVERSE
LIGAMENT, AS WELL AS THE TRANSVERSE LIGAMENT. THE MOVEMENTS AT THIS JOINT ARE MINIMAL,
BUT ALLOW A SMALL AMOUNT OF SPREAD AT THE ANKLE JOINT DURING DORSI FLEXION. THE JOINT IS
SUPPLIED BY DEEP PERONEAL AND TIBIAL NERVE.
• TALOCRURAL (ANKLE) JOINT:
IT IS A UNIAXIAL MODIFIED HINGE, SYNOVIAL JOINT LOCATED BETWEEN THAT TALUS AND THE MEDIAL
MALLEOLUS THE TIBIA AND THE LATERAL MALLEUS OF THE FIBULA. IT ALLOWS LITTLE OR NO INVERSION
OR EVERSION AT THE ANKLE JOINT. IT IS SUPPLIED BY BRANCHES OF TIBIAL AND DEEP PERONEAL NERVES.
THIS JOINT IS DESIGNED FOR STABILITY, SPECIALLY IN THE DORSI FLEXION. THIS JOINT IS RESPONSIBLE FOR
INTERIOR POSTERIOR. MOVEMENTS THAT OCCURS IN THE ANKLE FOOT COMPLEX.
ON THE MEDIAL SIDE OF THIS JOIN, THE MAJOR LIGAMENT IS DELTOID, OR MEDIAL COLLATERAL
LIGAMENT, WHICH CONSISTS OF FOUR SEPARATE LIGAMENTS.
• THE TIBIONAVICULAR LIGAMENT
• TIBIOCALCANEAN LIGAMENT
• POSTERIOR TIBIOTALER LIGAMENT
• ANTERIOR TIBIOTALER LIGAMENT.
THEY RESIST TELLER ABDUCTION AND LATERAL TRANSLATION AND LATERAL ROTATION OF TALUS.
• SUBTALAR (TALOCALCANEAL) JOINT
• SUBTALAR (TALOCALCANEAL) JOINTIT IS A SYNOVIAL JOINT HAVING 3 DEGREES OF FREEDOM AND A
CLOSE PACK POSITION OF SUPINATION. LATERAL TALOCALCANEAL AND MEDIAL TALOCALCANEAL
LIGAMENTS SUPPORT THIS JOINT.THE MOVEMENTS POSSIBLE AT THE SUB TAYLOR JOINT ARE
GLIDING AND ROTATION.
• USUALLY SUBTALAR AND TALOCRURAL JOINTS BECOME INJURED. WHICH RESULTS IN SPRAIN OR
FRACTURE.

MIDFOOT:
• (MIDTARSAL JOINT):
• MIDFOOT: THE MIDFOOT IS MADE UP OF FIVE OF THE SEVEN TARSAL BONES: NAVICULAR, CUBOID,
AND MEDIAL, MIDDLE, AND LATERAL CUNEIFORMS. THE JUNCTION BETWEEN THE HIND AND
MIDFOOT IS TERMED THE CHOPART’S JOINT, WHICH INCLUDES THE TALONAVICULAR AND
CALCANEOCUBOID JOINTS.
• TALOCALCANEONAVICULAR JOINT:
• IT IS BALL IN SOCKET JOINT SYNOVIAL JOINT WITH THREE DEGREE OF FREEDOM. IT’S CLOSED PACKED POSITION IS
SUPINATION AND THE DORSAL TALONAVICULAR LIGAMENT, BIFURCATED LIGAMENT, PLANTAR
CALCANEALNAVICULAR. SPRING LIGAMENT SUPPORT THIS JOINT. MOVEMENTS POSSIBLE AT THIS JOINT ARE
GLIDING AND ROTATION.

• CALCANEOCUBOID JOINT:
• IT IS SADDLE SHAPED WITH CLOSE PACK POSITION OF SUPINATION. SUPPORTING THIS JOINT ARE BIFURCATED
LIGAMENT, THE CALCANEOCUBOID LIGAMENT AND THE LONG PLANTER LIGAMENTS. THE MOVEMENTS POSSIBLE
AT THIS JOINT IS GLIDING WITH ROTATION.
 FOREFOOT:
• THE FOREFOOT IS THE MOST ANTERIOR ASPECT OF THE FOOT. IT INCLUDES METATARSALS, PHALANGES
(TOES), AND SESAMOID BONES. THERE ARE A METATARSAL AND THREE PHALANGES FOR EACH DIGIT APART
FROM THE GREAT TOE, WHICH ONLY HAS TWO PHALANGES. THE ARTICULATION OF THE MIDFOOT AND
FOREFOOT FORMS THE LISFRANC JOINT.

• TARSOMETATARSAL JOINT :
• THEY ARE THE PLANE SYNOVIAL JOINT WITH A CLOSE PACK POSITION OF SUPINATION. THE MOVEMENT
POSSIBLE AT THESE JOINTS IS GLIDING.

• INTERMETATARSAL JOINTS:
• THE FOUR JOINTS ARE PLANE SYNOVIAL JOINTS WITH A CLOSE SPEC POSITION OF SUPINATION. THE
MOVEMENT POSSIBLE AT THIS JOINT IS GLIDING.
• METATARSOPHALANGEAL JOINT.
• THE FIVE. JOINTS ARE CONDYLOID SYNOVIAL JOINTS WITH TWO DEGREE OF FREEDOM THEIR CLOSE
PACKED POSITION IS FULL EXTENSION. THE MOVEMENTS POSSIBLE AT THIS JOINT ARE FLEXION,
EXTENSION, ABDUCTION, AND ADDUCTION.

• INTERPHALANGEAL JOINTS:
• THE INTERPHALANGEAL JOINTS ARE SYNOVIAL HINGE JOINTS WITH ONE DEGREE OF FREEDOM. THE
CLOSE PICK POSITION IS FULL EXTENSION. THE MOVEMENTS POSSIBLE AT THIS JOINT ARE FLEXION AND
EXTENSION.
SUMMARY OF JOINTS:
 MUSCLES:
• THE DORSUM OF THE FOOT HAS ONLY ONE MUSCLE (MAYBE 2 DEPENDING ON CLASSIFICATION). THIS IS THE
EXTENSOR DIGITORUM BREVIS (SOME AUTHORS NAME THE MOST MEDIAL PART OF THIS MUSCLE EXTENSOR
HALLUCIS BREVIS)
• THE PLANTAR ASPECT OF THE FOOT CONTAINS THE TOUGH FIBROUS PLANTAR APONEUROSIS COVERING MUSCLES
AND TENDONS ARRANGED IN 4 LAYERS, NUMBERED FROM 1 SUPERFICIAL TO 4 DEEP:
• LAYER 1 : CONSISTS OF THE ABDUCTOR DIGITI MINIMI, FLEXOR DIGITORUM BREVIS, ABDUCTOR HALLUCIS
• LAYER 2 : CONSISTS OF THE QUADRATUS PLANTAE, THE LUMBRICALS, AND THE LONG TENDONS OF FLEXOR
DIGITORUM LONGUS AND FLEXOR HALLUCIS LONGUS.
• LAYER 3 : CONSISTS OF THE FLEXOR HALLUCIS BREVIS, ADDUCTOR HALLUCIS AND FLEXOR DIGITI MINIMI
BREVIS.
• LAYER 4 : CONSISTS OF THE INTEROSSEOUS MUSCLES AND THE LONG TENDONS OF PERONEUS/FIBULARIS
LONGUS AND TIBIALIS POSTERIOR.
 LIGAMENTS:
• ANKLE LIGAMENT INJURY IS THE MOST FREQUENT CAUSE OF ACUTE ANKLE PAIN.
• THE LIGAMENTS AROUND THE ANKLE CAN BE DIVIDED, DEPENDING ON THEIR ANATOMIC POSITION, INTO THREE
GROUPS: THE LATERAL LIGAMENTS, THE DELTOID LIGAMENT ON THE MEDIAL SIDE, AND THE LIGAMENTS OF THE
TIBIOFIBULAR SYNDESMOSIS THAT JOIN THE DISTAL EPIPHYSES OF THE TIBIA AND FIBULA.
• THE LATERAL COLLATERAL LIGAMENT COMPLEX (LCL) CONSISTS OF[4]:

LIGAMENTS OF THE ANKLE LATERAL ASPECT :

• ANTERIOR TALOFIBULAR LIGAMENT:
• IT IS THE MOST FREQUENTLY INJURED LIGAMENT OF THE ANKLE. THIS LIGAMENT PLAYS AN IMPORTANT ROLE IN
LIMITING ANTERIOR DISPLACEMENT OF THE TALUS AND PLANTAR FLEXION OF THE ANKLE.
• POSTERIOR TALOFIBULAR LIGAMENT:
• THE POSTERIOR TALOFIBULAR LIGAMENT ORIGINATES FROM
THE MALLEOLAR FOSSA, LOCATED ON THE MEDIAL SURFACE
OF THE LATERAL MALLEOLUS, COURSING ALMOST
HORIZONTALLY TO INSERT IN THE POSTEROLATERAL TALUS.
IT IS THE STRONGEST LIGAMENT OF THE LATERAL ANKLE.
PLAYS ONLY A SUPPLEMENTARY ROLE IN ANKLE STABILITY
WHEN THE LATERAL LIGAMENT COMPLEX IS INTACT.

• CALCANEOFIBULAR LIGAMENT:
• THE CALCANEOFIBULAR LIGAMENT ORIGINATES FROM THE
ANTERIOR PART OF THE LATERAL MALLEOLUS. ITS PRIMARY
ROLE IS TO RESTRAIN INVERSION IN A NEUTRAL OR
DORSIFLEXED POSITION, RESTRAINS SUBTALAR INVERSION,
THEREBY LIMITING TALAR TILT.
 LIGAMENTS OF THE ANKLE MEDIAL ASPECT:
• THE MEDIAL COLLATERAL LIGAMENT
(MCL):
• ALSO KNOWN AS DELTOID LIGAMENT, IS COMPOSED
OF TWO LAYERS; SUPERFICIAL AND DEEP. THE MCL IS
A MULTIFASCICULAR LIGAMENT, ORIGINATING FROM
THE MEDIAL MALLEOLUS TO INSERT IN THE TALUS,
CALCANEUS, AND NAVICULAR BONE. IT PRIMARY
RESTRAINS TO VALGUS TILTING OF THE TALUS. BOTH
THE SUPERFICIAL AND DEEP LAYERS INDIVIDUALLY
RESIST EVERSION OF THE HINDFOOT. IT ALSO
STABILIZES ANKLE AGAINST PLANTAR FLEXION,
EXTERNAL ROTATION, AND PRONATION.
PATIENT HISTORY
(LISTEN) :
 ANKLE PATIENT HISTORY:
1. MOI?
• INVERSION: • DORSIFLEXION:
• ANTERIOR TALO-FIBULAR LIGAMENT • FX OF TALAR
• CALCANEOFIBULAR LIGAMENT • DISLOCATION OF PERONEI

• FX OF 5TH METATARSAL
• FX OF ANTERIOR PROCESS OF CALCANEUS • HYPER PLANTER FLEXION:
• EVERSION: • FX OF LATERAL TUBERCLE OF POSTERIOR PROCESS
OF TALUS
• DELTOID LIGAMENT
• SYNDESMOSES LIGAMENT
 2. LOCATION OF PAIN:
• MEDIAL SIDE : • GENERALIZED PAIN:
• DELTOID LIGAMENT INJURY • DEGENERATIVE CHANGES
• FX OF MEDIAL MALLEOLUS • OSTEOCHONDRITIS DISSECANS

• TIBIALIS POSTERIOR TENDINITIS • NERVE INJURY (LIKE SUPERFICIAL PERONEAL

NERVE TRACTION INJURY)
• COMPLEX REGIONAL PAIN SYNDROME
• LATERAL SIDE :
• CALCANEO-FIBULAR LIGAMENT INJURY
• FX OF LATERAL MALLEOLUS.
 3. TYPE OF PAIN:
• ACHING PAIN: • PAIN AFTER ACTIVITY:
• DEGENERATIVE CHANGES
• INFLAMMATORY ARTHROPATHY
• SHARP/CATCHING PAIN: • TENDINOSIS
• MECHANICAL PAIN • ARTHRITIS
• LIGAMENT SPRAIN
• LOOSE BODY.
• PAIN AT REST:
• PAIN DURING ACTIVITY: • NOT MECHANICAL ORIGIN SOMETIMES SEEN IN
• STRUCTURAL ABNORMALITY LIKE LIGAMENT ADVANCED ARTHRITIS
SPRAIN • PERIPHERAL NERVE INJURY, LUMBER SPINE OR
• ARTHRITIS COMPLEX REGIONAL PAIN SYNDROME.
 4. AGGRAVATING FACTORS?
• WEIGHT BEARING
• WEARING FOOTWEAR
• WALKING ON UNEVEN SURFACES
• STAIRS CLIMBING
• STAIRS DESCENDING.

5. RELIEVING FACTORS?
• WEARING BOOT OR BRACES
 6. ANY SWELLING OR BRUISING?
• LOCALIZED SWELLING : • IF SWELLING OCCUR WITHIN MINUTES:
• FX
• MEDIAL SIDE:
• LIGAMENT SPRAIN
• DELTOID LIGAMENT INJURY
• FX OF MEDIAL MALLEOLUS
• IF SWELLING OCCUR WITHIN HOURS :
• LIGAMENT SPRAIN
• TIBIALIS POSTERIOR TENDINITIS • ARTICULAR CARTILAGE
• LATERAL SIDE :
• NO INJURY :
• CALCANEO-FIBULAR LIGAMENT INJURY • O.A / R.A / SEPTIC ARTHRITIS
• FX OF LATERAL MALLEOLUS • DVT
• PERONEAL TENDON • TUMOR
 6. ANY DEFORMITY?
• CONGENITAL :
• CLUB FOOT ( TALLIPES EQUINOVARUS)
• HIGH ARCHES ( PES CAVES)
• FLATFOOT (PES PLANUS)

• ACQUIRED:
• MALLET TOES
• HALLUX VARUS
 7. TYPE OF INJURY AND IT COMPLICATION?
• SUPINATION-LATERAL ROTATION INJURY :
• STAGE : 1 RUPTURE OF ANTERIOR TIBIOFIBULAR LIGAMENT
• STAGE : II SHORT OBLIQUE FX OF DISTAL PORTION OF FIBULA
• STAGE : III FX OF POSTERIOR ASPECT OF TIBIA
• STAGE : IV FX OF MEDIAL MALLEOLUS.

• SUPINATION-ADDUCTION INJURY
• STAGE : I FX OF FIBULA / RUPTURE OF LATERAL MALLEOLUS
• STAGE : II FX OF MEDIAL MALLEOLUS / RUPTURE OF DELTOID LIGAMENT.
• PRONATION-LATERAL ROTATION INJURY:
• STAGE : I FX OF MEDIAL MALLEOLUS / RUPTURE OF DELTOID LIGAMENT
• STAGE : II ANTERIOR TIBIOFIBULAR LIGAMENT RUPTURE
• STAGE : III HIGH FIBULAR FX

• PRONATION-ABDUCTION INJURY:
• STAGE : I AND II ARE SIMILAR OF PRONATION-LATERAL ROTATION
• STAGE : III TRANSVERSE SUPRAMALLEOLAR FIBULAR FX.
8. WHAT IS PT. OCCUPATION?
9. WHAT EXERCISES PT. PERFORM USUALLY?
10. WAS PT. ABLE TO CONTINUE ACTIVITY AFTER INJURY?
11. IS PT. ABLE TO PUT FULL WEIGHT BEARING ON AFFECTED FOOT? OR PARTIAL
WEIGHT BEARING?
12. WHAT TYPES OF SHOES PT. WEAR?
13. ANY PREVIOUS HX OF INJURY, AFFLICTION OR SX?
14. WHAT ADLS AFFECTED TO PT. AFTER INJURY?
OBSERVATION
(LOOK):
 OBSERVATION:
• OBSERVATION OF FOOT IS EXTENSIVE. BECAUSE OF HIS STRESS IS THE FOOT IS SUBJECTED
TO AND BECAUSE OF IT LIKE THE HAND CAN PROJECT SIGNS OF SYMPTOMATIC PROBLEMS
AND DISEASE THE EXAMINER SHOULD CAREFULLY INSPECT FOOT.
• THE PT SHOULD REMOVE SHOES AND SOX AND TROUSERS UPTO KNEE JOINT.
• WHEN PERFORMING THE OBSERVATION THE EXAMINER SHOULD REMEMBER TO
COMPARE THE WEIGHT BEARING CLOSED CHAIN WITH NON WEIGHT BEARING OPEN
CHAIN POSTURE OF THE FOOT.
• DURING OPEN PACKED MOTION THAT TALUS IS CONSIDERED FIXED. AND DURING CLOSE
CHAIN MOTION THE TALUS MOVES TO HELP THE FOOT.
 ALIGNMENT:
• ASK THE PATIENT STAND FACING YOU.
• NORMALLY THE PATIENT IS IN SLIGHT ER FROM SAGITTAL AXIS OF BODY. THIS IS CALLED THE FICK
ANGLE(NORMAL RANGE 5°-18°)
• ROTATION ABNORMALITIES CAN ARRIVE FROM VARIOUS LOCATIONS.
• CAUSES OF TOE IN:
• FOOT-ANKLE:
• PRONATED FEET
• METATARSUS VARUS
• TALLIPES VARUS AND EQUINOVARUS.

• LEG-KNEE:
• TIBIA VARA (BLOUNT'S DISEASE) AND DEVELOPMENTAL GENU VARUM
• EXCESSIVE INTERNAL TIBIAL ROTATION.
• GENU VARUM WITH COMPENSATORY IR OF TIBIA TO SHIFT THE CENTRE OF GRAVITY MEDIALLY.
• CAUSES OF TOE OUT:
• FOOT-ANKLE:
• PES VALGUS
• TALIPES CALCANEOVALGUS
• CONGENITAL CONVEX PES PLANOVALGUS.

• LEG-KNEE:
• EXCESSIVE EXTERNAL TIBIAL ROTATION
• CONGENITAL ABSENCE/HYPOPLASIA OF FIBULA.
HALLUX VALGUS PRONATION OF BIG TOE
• OTHER DEFORMITIES ARE:
• HAMMER TOE
• MALLET TOE
• CLAW TOES
• PES CAVUS
• PES PLANUS
THESE ALL ARE DISCUSSED LATER.
• WEIGHT BEARING POSITION, ANTERIOR VIEW:
• WITH THE PATIENT IN A STANDING POSITION, THE EXAMINER SHOULD OBSERVE WHETHER THE PATIENTS
HIP AND TRUNK ARE IN NORMAL POSITION. EXCESSIVE LATERAL ROTATION OF THE HIP OR ROTATION OF THE
TRUNK AWAY FROM THE OPPOSITE HIP. ELEVATES THE MEDIA LONGITUDINAL ARCH. OF THE FOOD.
• IF THE ILIOTIBIAL BAND IS TIGHT, THE TIGHTNESS MAKERS THE INVERSION AND THE LATERAL ROTATION OF
THE FOOT. THE EXAMINER SHOULD ALSO LOOK AT THE TIBIA TO NOTE ANY LOCAL OR GENERAL BONE
SWELLING.
• SUPINATION OF THE FOOT PRODUCED BY THE LATERAL ROTATION OF THE TIBIA
• PRONATION OF FOOD PRODUCED BY THE MEDIAL TORSION OF THE TIBIA.
• IN WEIGHT BEARING IF THE RELATION OF THE FOOT TO THE ANKLE IS NORMAL, ALL OF THE METATARSAL
BONE, BEAR WEIGHT, AND ALL THE METATARSAL HEADS LIE IN THE SAME TRANSVERSE PLANE. THE
FOREFOOT AND THE HINDFOOT SHOULD BE PARALLEL TO EACH OTHER TO THE FLOOR. THE MIDTARSAL
JOINTS ARE IN MAXIMUM PRONATION AND THE SUB TALLER JOINTS IS IN NEUTRAL POSITION. THE SUB TALAR
AND TALO CRUELER JOINT SHOULD BE PARALLEL TO THE FLOOR. FINALLY, THE POSTERIOR BY SECTION OF
THE CALCANEUS AND THE DISTAL 1/3 OF THE LAKE SHOULD FORM TWO VERTICAL PARALLEL LINES.
• IF THE EXAMINER HAS NOTED ANY ASYMMETRY IN HIS STANDING, THE EXAMINER SHOULD PLACE THE TALUS
OR FOOT IN NEUTRAL TO SEE IF THE ASYMMETRY DISAPPEARS. IF THERE ARE SYMMETRIES PRESENT IN
NORMAL STANDING, IT IS A FUNCTIONAL ASYMMETRY. IF IT IS STILL PRESENT WHEN THE FOOT IS IN
NEUTRAL, IT IS ANATOMICAL OR A STRUCTURAL ASYMMETRY.
 WEIGHT, BEARING, POSITION, POSTERIOR VIEW.
• FROM BEHIND, THE EXAMINER COMPARES THE BULK OF THE CALF MUSCLES AND NOTES ANY DIFFERENCES.
VARIATION MAY BE CAUSED BY THE PERIPHERAL NERVE LESION, NERVE ROOT PROBLEMS AND ATROPHY
RESULTING FROM THE DISEASE AFTER INJURY. THE EXAMINER SHOULD. OBSERVE THE ACHILLES TENDON IF
THE TENDON APPEARS TO CARVE OUT, IT MAY INDICATE A FALLEN MEDIA. LONGITUDINAL HOURS RESULT IN
PES PLANUS. (HELBING SIGN).
• IF THE EXAMINER OBSERVED THE CALCANEUS FOR NORMALITY OF THE SHAPE AND POSITION. RUNNERS
OFTEN BUILT UP A BONE AND CARELESS ON THE HEEL, PRODUCING A PUMP BUMP. AS A RESULT OF PRESSURE.
( DISEASE OR DEFORMITY?)
• THE MALLEOLI ARE COMPARED FOR POSITIONING. NORMALLY THE LATERAL MALLEOLUS EXTENDS FURTHER
DISTALLY THAN THE MEDIAL.
• WEIGHT, BEARING POSITION, LATERAL VIEW.
• THE LONGITUDINAL ARCHES OF THE FOOT CAN BE EXAMINED. THE EXAMINER SHOULD NOTE. WHETHER THE
MEDIAL ARCH IS HIGHER THAN THE LATERAL.

• NON WEIGHT BEARING POSITION.

• WITH THE PATIENT IN SUPINE THE NON WEIGHT BEARING POSITION, THE EXAMINER SHOULD LOOK FOR
ABNORMALITIES SUCH AS.HOLLOW SITES. PLANTER WARTS, SCARS, AND SINUS OR PRESSURE SORES ON THE
SOLES OF THE FEET, AS WELL AS THE SWELLING WHICH IS MORE PROMINENT ON THE DORSUM OF THE FOOT.
ALONG WITH THAT, THE EXAMINER CAN OBSERVE WHETHER THE PATIENT HAS FALLEN METATARSAL ARCH.
NORMALLY IN NON WEIGHT BEARING POSITION THE ARCH IS VISIBLE. IF ARCH FALLS, CALLOSITIES ARE OFTEN
FOUND.
PALPATION
(FEEL):
 SKIN TEMPERATURE:
RUN THE BACK OF YOUR FINGERS FROM DORSUM OF THE FOOT TO MID CALF. IN THIS WAY AN EXAMINER CAN
COMPARE THE TEMPERATURE OF NORMAL SKIN AND FEEL THE RISE OF TEMPERATURE IF PRESENT.
• CAUSES OF RISE IN TEMPERATURE:
• SEPTIC ARTHRITIS
• BURSITIS
• CRYSTAL INDUCED ARTHROPATHIES CELLULITIS
• CHARCOT ARTHROPATHY
 ANTERIOR ASPECT:
• TIBIALIS ANTERIOR TENDON:
• ASK THE PATIENT TO DORSIFLEX THE ANKLE. TIBIALIS ANTERIOR CAN BE SEEN AND PALPATED AT THE LEVEL OF
ANKLE AS IT CROSSES THE JOINT. IT IS THE LARGEST AND MOST MEDIAL TENDON AT THE JOINT LEVEL.

• MEDIAL CUNEIFORM:
• TRACE THE TIBIALIS ANTERIOR TENDON TO ITS INSERTION AT THE BASE OF THE FIRST METATARSAL AND FIRST
CUNEIFORM.

• EXTENSOR HALLUCIS LONGUS TENDON :

• THIS IS THE NEXT BIG TENDON OVER THE DORSUM OF THE FOOT AND AT THE LEVEL OF THE ANKLE JOINT. ASK THE
PATIENT TO EXTEND THE BIG TOE, THE TENDON BECOMES PROMINENT JUST LATERAL TO THE TIBIALIS ANTERIOR
TENDON.
TIBIALIS ANTERIOR TENDON (BLACK ARROWS); EXTENSOR HALLUCIS LONGUS TENDON (WHITE ARROWS).
• DORSALIS PEDIS ARTERY:
• THIS IS A CONTINUATION OF THE ANTERIOR TIBIAL
ARTERY WHICH, AFTER CROSSING THE ANKLE
JOINT, BECOMES THE DORSALIS PEDIS. TO PALPATE,
ASK THE PATIENT TO EXTEND THE BIG TOE AND
OBSERVE THE EXTENSOR HALLUCIS TENDON. IT
CAN BE FELT JUST LATERAL TO THE EHL AND
PROXIMAL TO THE PROMINENCE OF THE
METATARSOCUNEIFORM JOINT.

PALPATION OF DORSALIS PEDIS ARTERY.

• EXTENSOR DIGITORUM LONGUS TENDON:
• ASK THE PATIENT TO DORSIFLEX THE TOES. IT BECOMES PROMINENT AT THE ANKLE
JOINT LATERAL TO THE EHL TENDON.
 MEDIAL SIDE:
• MEDIAL MALLEOLUS :
• IT IS THE MOST PROMINENT STRUCTURE ON THE MEDIAL SIDE OF THE ANKLE JOINT. CHECK FOR
TENDERNESS (FRACTURE/NONUNION) OF THE MEDIAL MALLEOLUS.

• DELTOID LIGAMENT:
• BROAD STRUCTURE ATTACHED TO THE TIP OF THE MEDIAL MALLEOLUS, WHICH RUNS INFERIORLY AND
BOTH ANTERIORLY AND POSTERIORLY. IT IS OFTEN DIFFICULT TO DEFINE THE EDGES BUT TENDERNESS
(ESPECIALLY UPON EVERSION OF THE CALCANEUS) MAY BE DUE TO SPRAIN/RUPTURE OF THE LIGAMENT.
WITHIN THE DEPRESSION BETWEEN THE MEDIAL MALLEOLUS AND THE ACHILLES TENDON
POSTERIORLY LIE THE FOLLOWING STRUCTURES: TIBIALIS POSTERIOR TENDON, FLEXOR DIGITORUM
LONGUS TENDON, POSTERIOR TIBIAL ARTERY AND NERVE, AND FLEXOR HALLUCIS LONGUS TENDON
(THE ORDER CAN BE REMEMBERED WITH THE MNEMONIC: (TALL DOCTORS ARE NEVER HUNGRY).
• TIBIALIS POSTERIOR TENDON:
• THIS IS THE LARGEST TENDON BEHIND THE MEDIAL MALLEOLUS. IT BECOMES MORE PROMINENT WITH PLANTAR
FLEXION AND INVERSION OF THE FOOT.

TIBIALIS POSTERIOR TENDON (BLACK ARROW). TIBIALIS ANTERIOR TENDON (WHITE ARROW) IS ALSO VISIBLE.
• FLEXOR DIGITORUM LONGUS TENDON:
• THIS IS THE NEXT TENDON TO THE TIBIALIS POSTERIOR TENDON. IT BECOMES MORE EASILY PALPABLE WHEN
APPLYING RESISTANCE TO THE TOES WHICH YOU HAVE ASKED THE PATIENT TO FLEX. MOVEMENT OF THE
TENDON IS FELT
• IF EITHER SIDE OF THE ACHILLES TENDON IS HELD BETWEEN THE THUMB AND INDEX FINGER.
• NOTE: IN THE CASE OF SYNOVITIS OF THE TENDONS BEHIND THE MEDIAL MALLEOLUS, PALPATION MAY GIVE
A CLUE AS TO THE ORIGIN OF THE PAIN. APART FROM THE TIBIALIS POSTERIOR TENDON, THE OTHER
TENDONS ARE DIFFICULT TO PALPATE.

• FLEXOR HALLUCIS LONGUS:

• THIS HAS THE LOWEST-LYING MUSCLE BELLY OF THE EXTRINSICS. NOTICE THAT WHEN THE FOOT IS HELD
DORSIFLEXED, THE RANGE OF DORSIFLEXION OF GREAT TOE DIMINISHES AS THE FHL MUSCLE BELLY IS FORCED
INTO THE TENDON SHEATH WHERE IT IS VULNERABLE TO TENDINITIS (THOMASEN’S SIGN).
• POSTERIOR TIBIAL ARTERY :
• THE PULSE CAN USUALLY BE PALPATED BY GENTLE PRESSURE ROUGHLY HALFWAY BETWEEN THE POSTERIOR BORDER
OF THE MEDIAL MALLEOLUS AND THE ACHILLES TENDON WHILE THE FOOT IS RELAXED. IT CAN BE DIFFICULT TO FIND
AT TIMES, BUT PERSEVERE BEFORE YOU CONCLUDE IT IS NOT PALPABLE. IT IS THE MAIN BLOOD SUPPLY OF THE FOOT.
ITS ABSENCE USUALLY INDICATES ARTERIAL INSUFFICIENCY.

• TIBIAL NERVE:
• THIS LIES BEHIND THE POSTERIOR TIBIAL ARTERY AND FOLLOWS ITS COURSE TO THE FOOT. IT DIVIDES INTO A
CALCANEAL BRANCH AND THE MEDIAL AND LATERAL PLANTAR NERVES. ALTHOUGH IT CAN BE DIFFICULT TO
PALPATE AS AN ISOLATED STRUCTURE, ITS COURSE HAS CLINICAL SIGNIFICANCE; IF ENTRAPPED BEHIND THE FLEXOR
RETINACULUM DIRECT PRESSURE OVER THE NERVE JUST BEHIND THE MEDIAL MALLEOLUS IS PRODUCED AND DIRECT
PERCUSSION OVER THE NERVE (TINEL’S TEST) MAY BE POSITIVE.
• TARSAL TUNNEL SYNDROME:
• CAUSES
• SWELLING AND INFLAMMATION
• ANKLE DEFORMITIES
• SEVERE PES PLANUS
• VALGUS DEFORMITY OF THE HEEL
• MASS EFFECT: LIPOMA, GANGLION CYST, VARICOSITIES.

• SUSTENTACULUM TALI:
• THIS CAN BE PALPATED ONE FINGER BREATH PLANTARWARD FROM THE DISTAL END OF THE MEDIAL MALLEOLUS. SPRING
LIGAMENT ATTACHES TO THE SUSTENTACULUM TALI.
• LATERAL PLANTAR NERVE:
• ENTRAPMENT OF THE FIRST BRANCH OF THE LPN BETWEEN THE DEEP FASCIA OF THE ABDUCTOR HALLUCIS AND
QUADRATUS PLANTAE MAY LEAD TO CHRONIC HEEL PAIN ON THE MEDIAL SIDE (BAXTER’S NERVE SYNDROME).
PAIN CAN BE ELICITED IN THE ENTRAPPED NERVE BY PALPATING ABOUT 2.5 CM BELOW THE MEDIAL MALLEOLUS
OVER THE PROXIMAL ASPECT OF THE ABDUCTOR HALLUCIS MUSCLE BELLY.

SITE OF ENTRAPMENT OF LATERAL PLANTAR NERVE.

• MEDIAL HEAD OF TALUS:
• THIS CAN BE EASILY PALPATED 1 CM DISTAL TO THE ANTERIOR EDGE OF THE MEDIAL MALLEOLUS IN LINE WITH
THE FIRST METATARSAL. ABDUCTION AND ADDUCTION OF THE FOREFOOT MAKE THE GAP BETWEEN THE TALUS
AND NAVICULAR PALPABLE.

• MEDIAL NAVICULAR TUBERCLE:

• THIS IS DISTAL TO THE HEAD OF THE TALUS IF PALPATED FROM PROXIMAL TO DISTAL. ABDUCTION AND
ADDUCTION OF THE FOREFOOT MAKE THE GAP BETWEEN THE TALUS AND NAVICULAR PALPABLE.
• MEDIAL PLANTAR NERVE:
• CAN BE ENTRAPPED AT MASTER KNOT OF HENRY (WHERE THE FLEXOR HALLUCIS LONGUS AND FLEXOR
DIGITORUM LONGUS TENDONS CROSSOVER) GIVING RISE TO PAIN ON THE MEDIAL SIDE OF THE ARCH
(JOGGER’S FOOT). PAIN CAN BE ELICITED FROM THE ENTRAPPED NERVE BY PALPATING THE REGION OF
HENRY’S KNOT (PLANTAR TO THE 1ST TMT JOINT)

SITE OF ENTRAPMENT OF MEDIAL PLANTAR NERVE.

• HEAD OF THE FIRST METATARSAL:
• THIS FORMS THE BALL OF THE FOOT. IT ARTICULATES DISTALLY WITH THE PHALANX OF THE
GREAT TOE TO FORM THE METATARSOPHALANGEAL JOINT. IT IS OFTEN PAINFUL IN GOUT AND
BUNIONS. IF THE 1ST METATARSAL IS TRACED PROXIMALLY, THE METATARSOCUNEI FORM (OR
1ST TARSOMETATARSAL) JOINT CAN BE PALPATED. FORWARD AND BACKWARD MOVEMENT OF
THE JOINT MAKES PALPATION EASIER.
 LATERAL SIDE:
• LATERAL MALLEOLUS:
• THIS FORMS THE DISTAL END OF THE FIBULA, AND EXTENDS DISTAL AND LIES POSTERIOR TO THE MEDIAL
MALLEOLUS.

• ANTEROLATERAL DOME OF TALUS:

• PLACE YOUR THUMB OVER THE ANTERIOR PART OF THE LATERAL MALLEOLUS AND THEN PLANTAR FLEX THE
FOOT. YOU CAN FEEL THE ANTEROLATERAL PORTION OF THE TALUS MOVE UNDER YOUR THUMB.

• SINUS TARSI:
• SINUS TARSI IS THE SPACE BETWEEN THE LATERAL TALUS AND THE CALCANEUS. IT IS SITUATED ONE FINGER
BREATH ANTERIOR TO THE TIP OF THE LATERAL MALLEOLUS. CONTRACTION OF THE EXTENSOR DIGITORUM
BREVIS CAN BE FELT IF THE PATIENT EXTENDS HIS TOES.
• ANTERIOR INFERIOR TIBIOFIBULAR LIGAMENT:
• RUN YOUR FINGER ABOUT 1 CM ABOVE AND MEDIAL TO THE LATERAL MALLEOLUS AT THE LEVEL OF THE ANKLE
JOINT. THE LIGAMENT CANNOT BE FELT AS A DISTINCT STRUCTURE BUT IT IS OFTEN TENDER WITH INJURIES TO
THE TIBIOFIBULAR SYNDESMOSIS.

• ANTERIOR TALOFIBULAR LIGAMENT:

• THE LIGAMENT CANNOT BE FELT DISTINCTLY BUT TENDERNESS IS OFTEN ELICITED OVER THE SINUS TARSI,
ESPECIALLY UPON INVERSION OF THE FOOT.
• CALCANEOFIBULAR LIGAMENT:
• THIS RUNS FROM THE TIP OF THE LATERAL MALLEOLUS POSTERIORLY TO THE LATERAL
WALL OF THE CALCANEUS. AGAIN, IT IS NOT PALPATED AS A DISTINCT STRUCTURE EASILY
BUT IT BECOMES TENDER IN SEVERE ANKLE SPRAIN AFTER RUPTURE OF THE ANTERIOR
TALOFIBULAR LIGAMENT.
• POSTERIOR TALOFI BULAR LIGAMENT:
• THIS IS ATTACHED TO THE POSTERIOR EDGE OF THE LATERAL MALLEOLUS AND PASSES
POSTERIORLY TO THE LATERAL TUBERCLE ON THE POSTERIOR EDGE OF THE TALUS.
AGAIN, THIS LIGAMENT CANNOT BE FELT DISTINCTLY BUT TENDERNESS ESPECIALLY
UPON INVERSION IS DUE TO THE SPRAIN OR RUPTURE.
• PERONEUS LONGUS AND BREVIS TENDONS:
• THESE PASS BEHIND THE LATERAL MALLEOLUS, THE BREVIS TENDON BEING CLOSER TO THE
BONE. PERONEUS LONGUS PASSES PLANTAR TO THE CUBOID IN THE CUBOID TUNNEL (WHERE
AN OS PERONEAL MAY BE PRESENT) TO INSERT IN THE PLANTAR BASE OF THE FIRST
METATARSAL. PERONEUS BREVIS INSERTS INTO THE BASE OF THE 5TH METATARSAL. BOTH
TENDONS BECOME MORE PROMINENT UPON RESISTED EVERSION OF THE FOOT. THE TENDONS
CAN DISLOCATE ANTERIORLY, WHICH IS PALPABLE AND, AT TIMES, AUDIBLE.

• 5TH METATARSAL BASE AND HEAD PALPATE:

• THE BASE OF 5TH METATARSAL FOR TENDERNESS. TRACE THE SHAFT OF THE 5TH METATARSAL
DISTALLY. INFLAMMATION OF THE BURSA OVERLYING THE LATERAL ASPECT OF THE 5TH
METATARSAL IS CALLED TAILOR’S BUNION.
 SOLE OF FOOT:
• SESAMOID BONES:
• PASSIVELY DORSIFLEX THE BIG TOE AND PRESS FIRMLY ON THE FIRST METATARSAL. SESAMOID
BONES MAY NOT BE FELT DISTINCTLY, HOWEVER TENDERNESS MAY BE EVIDENT.
• CAUSES OF TENDERNESS
• FRACTURE
• SESAMOIDITIS
• ARTHRITIS
• METATARSAL HEADS:
PLACE YOUR THUMB OVER THE PLANTAR SURFACE AND YOUR INDEX FINGER OVER THE DORSUM
OF THE METATARSAL HEAD. MOVEMENT OF THE EACH TOE MAKES THE PALPATION OF THE JOINT
EASIER.
• CAUSES OF TENDERNESS
• SYNOVITIS →INSTABILITY INFLAMMATORY CONDITIONS
• DORSAL SUBLUXATION/DISLOCATION
• FREIBERG’S DISEASE → TENDERNESS OF THE SECOND METATARSAL HEAD IS MOST COMMON.
• MORTON’S NEUROMA:
• PAIN FROM MORTON’S NEUROMA IS IN THE PLANTAR FOREFOOT. THE NEUROMA IS MOST
COMMONLY LOCATED BETWEEN THE 3RD AND 4TH METATARSAL HEADS (80% TO 90%) OR 2ND
AND 3RD METATARSAL HEADS. THE PAIN IS OFTEN WORSENED BY FOOTWEAR AND RELIEVED BY
REMOVING THE SHOE. OTHER SYMPTOMS INCLUDE NUMBNESS OR PARESTHESIA IN THE TOE(S)
AND THE SENSATION THAT THE PATIENT IS WALKING ON A PEBBLE OR CRUMPLED SOCK.
TENDERNESS TO COMPRESSION (MULDER’S SIGN) IN THE SECOND OR THIRD WEB SPACE CAN BE
DUE TO A PAINFUL NEUROMA.
• PLANTAR FASCIA:
• FEEL THE PLANTAR FASCIA, WHICH IS A TOUGH STRUCTURE EXTENDING FROM METATARSAL
HEADS TO THE CALCANEAL TUBEROSITY. DORSIFLEXION OF THE BIG TOE MAKES THE MEDIAL
BAND OF THE FASCIA TAUT AND EASIER TO PALPATE. PAIN AT ITS INSERTION TO THE
CALCANEAL TUBEROSITY CAN BE ASSOCIATED WITH PLANTAR FASCIITIS.

NODULES OVER THE PLANTAR FASCIA.

 HEEL:
• THE ACHILLES’ TENDON INSERTS TO THE POSTERIOR TUBEROSITY OF THE CALCANEUS.

• SUBCUTANEOUS (PRE-ACHILLES) BURSA:

• THIS LIES BETWEEN OVERLYING SKIN AND THE INSERTION OF THE ACHILLES TENDON. PINCH AND LIFT
THE SKIN AT THE INSERTION AND THE BURSA IS BETWEEN YOUR FI NGERS. INFLAMMATION OF THIS
BURSA IS ONE OF THE CAUSES OF PAIN IN THIS AREA.

• RETROCALCANEAL BURSA
• THE RETROCALCANEAL BURSA IS SITUATED BETWEEN THE POSTERIOR TUBEROSITY OF THE CALCANEUS
AND THE ANTERIOR SURFACE OF THE ACHILLES TENDON. TENDERNESS OVER THE INSERTION AS WELL
AS ON BOTH SIDES OF THE ACHILLES TENDON MAY BE DUE TO BURSITIS. IF PAIN IS ELICITED ONLY AT
THE INSERTION, INSERTIONAL TENDINOSIS OF THE ACHILLES TENDON MAY BE THE CAUSE.
• NOTE: OFTEN TENDINOSIS AND BURSITIS COEXIST.
• HAGLUND’S DEFORMITY:
• THIS IS A PROMINENCE OVER THE DORSOPOSTERIOR CALCANEAL TUBEROSITY THAT CAN LEAD
TO RETROCALCANEAL BURSITIS WITH RUBBING AGAINST THE HEEL COUNTER OF A SHOE

. HAGLUND’S DEFORMITY
SPECIAL TESTS:
 TESTS FOR NEUTRAL OR BALANCED POSITION OF
THE TALUS:
• THE NEUTRAL POSITION IS AN IDEAL POSITION THAT, IN REALITY, IS NOT COMMONLY FOUND IN PEOPLE IN
NORMAL WEIGHT BEARING. FOR MOST PATIENTS, THE SUBTALAR JOINT IS NORMALLY IN SLIGHT VALGUS
WITH FOREFOOT IN SLIGHT VARUS AND THE CALCANEUS IN SLIGHT VALGUS. THE TIBIA IN SLIGHT VARUS, SO
EACH JOINT SLIGHTLY COMPENSATES FOR ADJACENT ONE.
• THE INDICATIONS FOR THE FOLLOWING TESTS ARE TO DETERMINE THE NEUTRAL POSITION OF THE TALUS,
WHICH OFTEN IS REFERRED TO AS THE NEUTRAL (SUBTALAR NEUTRAL) OR BALANCED POSITION OF THE
FOOT.
 NEUTRAL POSITION OF THE TALUS (PRONE-NON
WEIGHT-BEARING POSITION):
• PROCEDURE:
• THE PATIENT LIES PRONE WITH THE FOOT EXTENDED OVER THE END OF EXAMINING TABLE. THE
EXAMINER GRASP THE PATIENTS FOOT OVER THE 4TH AND 5TH METATARSAL HEADS WITH THE INDEX
FINGER AND THUMB OF ONE HAND. THE EXAMINER PALPATES BOTH SIDES OF THE TALUS ON THE
DORSUM OF FOOT USING THE THUMB AND INDEX FINGER OF THE OTHER HAND. THE EXAMINER THEN
PASSIVELY AND GENTLY DORSIFLEXES THE FOOT UNTIL RESISTANCE IS FELT. WHILE MAINTAINING THE
DORSIFLEXED POSITION, THE EXAMINER MOVE THE FOOT BACK AND FORTH THROUGH AN ARC OF
SUPINATION AND PROBATION.
• INTERPRETATION:
• AS THE ARC OF MOVEMENT IS PERFORMED, THERE IS A POINT IN THE ARC AT WHICH THE FOOT APPEARS TO FALL
OFF TO THE ONE SIDE OR THE OTHER MORE EASILY. THEN THE TEST IS POSITIVE.

• CLINICAL NOTE:
• THIS PRONE TEST POSITION IS BEST FOR DETERMINING THE RELATION OF THE HINDFOOT (REARFOOT) TO THE
LEG.
 NEUTRAL POSITION OF THE TALUS (SUPINE-NON
WEIGHT-BEARING POSITION):
• PROCEDURE:
• THE PATIENT LIES SUPINE WITH THE FOOT EXTENDED OVER THE END OF EXAMINING TABLE. THE
EXAMINER GRASP THE PATIENTS FOOT OVER THE 4TH AND 5TH METATARSAL HEADS WITH THE INDEX
FINGER AND THUMB OF ONE HAND. THE EXAMINER PALPATES BOTH SIDES OF THE TALUS ON THE
DORSUM OF FOOT USING THE THUMB AND INDEX FINGER OF THE OTHER HAND. THE EXAMINER THEN
PASSIVELY AND GENTLY DORSIFLEXES THE FOOT UNTIL RESISTANCE IS FELT. WHILE MAINTAINING THE
DORSIFLEXED POSITION, THE EXAMINER MOVE THE FOOT BACK AND FORTH THROUGH AN ARC OF
SUPINATION AND PROBATION.
• INTERPRETATION:
• IF THE FOOT IS POSITIONED SO THAT THE TALAR HEAD DOES NOT APPEAR TO BULGE TO EITHER SIDE (MEDIAL OR
LATERAL), THE SUBTALAR JOINT IS IN ITS NEUTRAL NON-WEIGHT-BEARING POSITION.

• CLINICAL NOTE:
• THIS SUPINE TEST POSITION IS BEST FOR DETERMINING THE RELATION OF THE FOREFOOT TO THE HINDFOOT.
 NEUTRAL POSITION OF THE TALUS (WEIGHT-
BEARING POSITION) :
• PROCEDURE:
• THE PATIENT STANDS WITH THE FEET IN A RELAXED STANDING POSITION SO THAT THE BASE
WIDTH AND FICK ANGLE (NORMALLY, THE PATELLA FACES STRAIGHT AHEAD WHILE THE FOOT
FACES SLIGHTLY LATERALLY) ARE NORMAL FOR THE PATIENT. THE EXAMINER PALPATES THE
HEAD OF THE TALUS ON THE DORSAL ASPECT OF THE FOOT WITH THE THUMB AND FOREFINGER
OF ONE HAND (THE THUMB IS PLACED ON THE LATERAL ASPECT OF THE TALUS AND THE
FOREFINGER IS PLACED ON THE MEDIAL ASPECT OF THE TALUS). THE PATIENT THEN ACTIVELY
(OR THE EXAMINER PASSIVELY) SLOWLY ROTATES THE TRUNK TO THE RIGHT AND THEN TO THE
LEFT, WHICH CAUSES THE TIBIA TO MEDIALLY AND LATERALLY ROTATE SO THAT THE TALUS
SUPINATES AND PRONATES.
• INTERPRETATION:
• IF THE FOOT IS POSITIONED SO THAT THE TALAR HEAD DOES NOT APPEAR TO BULGE TO EITHER
SIDE (MEDIAL OR LATERAL), THE SUBTALAR JOINT IS IN ITS NEUTRAL POSITION IN WEIGHT
BEARING.
 TESTS FOR LIGAMENTOUS INSTABILITY:
ANTERIOR DRAWER TEST OF THE ANKLE:
• INDICATION:
• THIS IS PERFORMED TO TEST THE INJURIES TO THE ANTERIOR TALOFIBULAR LIGAMENT, THE MOST
FREQUENTLY INJURED LIGAMENT IN THE ANKLE.

• PROCEDURE:
• THE PT LIES IN SUPINE POSITION WITH THE KNEE JOINT SLIGHTLY FLEXED AND ANKLE JOINT IS HELD IN
10 TO 15° OF PLANTER FLEXION THEN GRASP THE PT HEEL WITH CONTRALATERAL HAND WHILE THE PT’S
FOOT LIES ON ANTERIOR ASPECT OF YOUR FOREARM. WITH THE OTHER HAND FIXATES THE PT’S TIBIA AS
CLOSE AS POSSIBLE TO THE JOINT LINE AND THEN DRAW THE FOOT ANTERIORLY .
• ALTERNATIVELY YOU CAN PLACE THE PT’S FOOT ON THE TABLE USE A PLINTH TO PUT THE PT’S FOOT
INTO 10 TO 15° OF PLANTER FLEXION THEN FIXATE THE FOOTS POSITION, GRASP THE TIBIA WITH OTHER
HAND AN PUSH THE TIBIA POSTERIORLY.
• INTERPRETATION:
• IN A POSITIVE TEST THE THERAPIST FEEL INCREASED ANTERIOR TRANSLATION COMPARED WITH THE
UNAFFECTED ANKLE AND MIGHT BE ABLE TO OBSERVE A DIMPLE APPEARING ON ANTEROLATERAL
ASPECT OF THE TALUS.
 TALAR TILT:
• INDICATION:
• TO EXAMINE THE ANKLE FOR THE INJURY OF ANTERIOR, POSTERIOR TALOFIBULAR LIGAMENT
,CALCANEOFIBULAR LIGAMENT AS WELL AS THE DELTOID LIGAMENT.

• PROCEDURE:
• PT SITTING WITH THE KNEE HANGING OFF OF THE TABLE. IN ORDER TO TEST THE ANT: TALOFIBULAR
LIGAMENT, BRING PT’S FOOT INTO PLANTER FLEXION SO THAT THE ATFL IS PERPENDICULAR TO THE
MOVEMENT THAT THE THERAPIST GOING TO PERFORM. THEN GRAB THE CALCANEUS AND PERFORM
INVERSION.
 • IN ORDER TO TEST CALCANEOFIBULAR LIGAMENT, BRING PT’S FOOT INTO THE ANATOMICAL POSITION
SO THAT THE LIGAMENT IS PERPENDICULAR TO THE LONG AXIS OF TALUS, THEN BRING THE FOOT INTO
INVERSION AND EVERSION. THE EVERSION PART OF THIS TEST STRESSES THE DELTOID LIGAMENT
COMPLEX ON MEDIAL SIDE.
• AND LASTLY TO PUT MOST STRESS ON POSTERIOR TALOFIBULAR LIGAMENT BRING THE FOOT INTO
MAXIMUM DORSIFLEXION AND PERFORM THE EVERSION AND INVERSION AGAIN.

• INTERPRETATION:
• THIS TEST IN DIFFERENT POSITION IS CONSIDERED POSITIVE IF PT COMPLAIN ABOUT PAIN OR IF FIND
EXCESSIVE GAPPING COMPARED WITH THE UNAFFECTED SIDE.
TALAR TILT TEST
 THOMPSON’S (SIMMONDS) TEST:
• INDICATION:
• EVALUATES THE INTEGRITY OF THE ACHILLES TENDON.

• PROCEDURE:
• PATIENT LIES PRONE WITH FOOT OFF EDGE OF TABLE. WHILE PT IS RELAXED SQUEEZE CALF MUSCLES.

• INTERPRETATION:
• THE ABSENCE OF PLANTER FLEXION WHEN THE MUSCLE IS SQUEEZD INDICATES A POSITIVE TEST AND
RUPTURE OF ACHILLES TENDON.
THOMPSON'S TEST
 TINEL'S SIGN
(PERCUSSION SIGN)
• INDICATION:
• IDENTIFIES DYSFUNCTION OF POSTERIOR TIBIAL NERVE POSTERIOR TO THE MEDIAL MALLEOLUS OR
DEEP FIBULAR NERVE ANTERIOR TO TALOCRURAL JOINT.

• PROCEDURE:
• PATIENT SUPINE WITH FOOT SUPPORTED ON THE TABLE. TAP OVER REGION OF POSTERIOR TIBIAL NERVE
AS IT PASSES POSTERIOR TO MEDIAL MALLEOLUS. TAP OVER REGION OF DEEP FIBULAR NERVE AS IT
PASSES UNDER DORSAL RETINACULUM (ANTERIOR TO ANKLE JOINT).

• INTERPRETATION:
• REPRODUCES TINGLING AND/OR PARESTHESIA INTO THE RESPECTIVE NERVE DISTRIBUTIONS.
TINEL‘S SIGN
 MORTON’S TEST (METATARSAL SQUEEZE TEST) :
• INDICATION:
• IDENTIFIES STRESS FRACTURE OR NEUROMA IN FOREFOOT.

• PROCEDURE:
• PATIENT LIES SUPINE WITH FOOT SUPPORTED ON TABLE. THERAPIST GRASP AROUND THE METATARSAL HEADS AND
SQUEEZE. THE HEAD TOGETHER.

• INTERPRETATION:
• POSITIVE FINDING IS PAIN IN FOREFOOT.
 WINDLASS TEST:
• INDICATION:
• TEST TO ASSESS THE PLANTER FASCIITIS.

• PROCEDURE:
• PT STAND ON STOOL OR CHAIR WITH THE FOOT POSITIONED, METATARSAL HEADS REST ON THE EDGE
OF THE STOOL WHILE PT MAINTAIN WEIGHT THROUGH THE LEG. THE EXAMINER THEN PASSIVELY
DORSIFLEXES THE BIG TOE.

• INTERPRETATION:
• PAIN OR INCREASED PAIN AT THE INSERTION OF PLANTER FASCIA INDICATES A POSITIVE TEST FOR
PLANTER FASCIITIS.
WINDLASS TEST
 EXTERNAL (LATERAL) ROTATION STRESS TEST
(KLEIGER TEST) :
• INDICATION:
• TO DIAGNOSE ANKLE SYNDESMOSIS INJURY.

• PROCEDURE:
• THE PATIENT IS SEATED WITH THE LEG HANGING OVER THE EXAMINING TABLE WITH THE KNEE AT 90°.
THE EXAMINER STABILIZE THE LEG WITH ONE HAND. WITH THE OTHER HAND, THE EXAMINER HOLDS
THE FOOT IN DORSIFLEXION (90) ° AND APPLIES A PASSIVE LATERAL ROTATION STRESS TO THE FOOT
AND ANKLE.

• INTERPRETATION:
• THE TEST IS POSITIVE FOR A SYNDESMOSIS (”HIGH ANKLE”) INJURY IF PAIN IS PRODUCED OVER THE
ANTERIOR OR POSTERIOR TIBIOFIBULAR LIGAMENTS AND INTER OSSEOUS MEMBRANE.
EXTERNAL (LATERAL) ROTATION STRESS TEST (KLEIGER TEST) :
 SQUEEZE TEST OF THE LEG:
• INDICATION:
• THIS TEST IS USED FOR THE DETECTION OF DISTAL ANKLE SYNDESMOSIS INJURY.
• ALSO CALLED DISTAL TIBIOFIBULAR COMPRESSION TEST.

• PROCEDURE:
• PT LIES SUPINE, EXAMINER GRASPS THE LOWER LEG AT MIDCALF AND SQUEEZES THE TIBIA AND FIBULA
TOGETHER. THE EXAMINER THEN APPLIED THE SAME LOAD AT MORE DISTAL LOCATIONS MOVING
TOWARDS THE ANKLE.

• INTERPRETATION:
• PAIN IN THE LOWER LEG MAY INDICATE A SYNDESMOSIS INJURY, PROVIDE THAT FRACTURE, CONTUSION
AND COMPARTMENT SYNDROME HAVE BEEN RULED OUT.
SQUEEZE TEST
 JACK TEST:
• INDICATION:
• THIS TEST IS USED TO DIFFERENTIATE BETWEEN RIGID AND FLEXIBLE FLAT FOOT.

• PROCEDURE:
• PT IS STANDING, NOTE THE MEDICAL ARCH, THEN DORSIFLEX THE BIG TOE AND
THEN NOTE IF THERE IS ANY DIFFERENCE IN THE HEIGHT OF MEDICAL ARCH.
• INTERPRETATION:
• IN FLEXIBLE FLAT FOOT, DORSIFLEXION OF BIG TOE RESULTS IN RECONSTITUTION OF THE MEDIAL ARCH.
• IN RIGID FLAT FOOT, DORSIFLEXION OF BIG TOE DOES NOT HAVE ANY EFFECT ON THE HEIGHT OF MEDICAL ARCH.
JACK TEST
DEFORMITIES AND
TREATMENT:
 BUNION:
• A BUNION IS A BONY BUMP THAT FORMS ON THE JOINT AT THE BASE OF BIG TOE.

• PATHOPHYSIOLOGY:
• A BUNION FORMS WHEN BONES THAT MAKE UP THE MTP JOINT MOVE OUT OF ALIGNMENT. THE LONG
METATARSAL BONE SHIFTS TOWARD THE INSIDE OF FOOT AND PHALANX BONES OF BIG TOE ANGLE
TOWARD SECOND TOW. THE MTP JOINT GETS LARGER AND PROTRUDES FROM INSIDE OF FOREFOOT.
• CAUSES:
• INHERITED FOOT TYPE.
• •WEARING TIGHT(FIT SHOES)
• NARROW SHOES
• HIGH HEELS.
• IT MAY OCCUR WHEN SOME OF THE BONES IN THE FRONT OF YOUR FOOT MOVE OUT OF PLACE.
• MIGHT BE ASSOCIATED WITH ARTHRITIS PARTICULARLY INFLAMMATORY TYPE SUCH AS RA
• SYMPTOMS:
• BULGING BUMP ON OUTSIDE OF BASE OF BIG TOE.
• SWELLING REDNESS SORENESS AROUND BIG TOE JOINT.
• CORNS AND CALLUSES – OFTEN DEVELOP WHERE THE FIRST AND SECOND TOES RUB AGAINST EACH
OTHER.
• ONGOING PAIN OR PAIN THAT COMES AND GOES.
• LIMITED MOVEMENT OF BIG TOE.
• PHYSIOTHERAPY MANAGEMENT:
• PAIN MANAGEMENT
• ICING
• ROM EXERCISE
• MUSCLE STRENGTHENING
• FUNCTIONAL TRAINING
– RESTORE WALKING ABILITY.
 PLANTER FASCIITIS:
• ONE OF THE MOST COMMON CAUSE OF HEEL PAIN. IT INVOLVES INFLAMMATION OF A THICK BAND OF
FIBROUS TISSUE (PLANTAR FASCIA) THAT RUNS ACROSS THE BOTTOM OF EACH FOOT AND CONNECTS
THE HEEL BONE TO THE TOES.
• PATHOPHYSIOLOGY:
• THIS CONDITIONS STARTS WITH MICROTEARS DUE TO REPETITIVE STRESS ASSOCIATED WITH STANDING
UPRIGHT AND WEIGHT BEARING. THE CONSTANT STRETCHING OF PLANTAR FASCIA RESULTS IN
DEGENERATION OF FASCIA EVENTUALLY LEADING TO PAIN DURING SLEEP OR AT REST.

• CAUSES:
• THIS IS OFTEN AN OVERUSE INJURY.
• TYPE OF SHOES YOU WEAR.
• A LOT OF PRESSURE ON ON ARCH OF FOOT.
• MORE COMMON IN RUNNERS.
• OVERWEIGHT PEOPLE.
• TENSION AND STRESS ON FASCIA.
• SYMPTOMS:
• STABBING PAIN (AT THE BOTTOM OF FOOT NEAR THE HEEL) THAT OCCURS WITH FIRST
FEW STEPS AFTER GETTING OUT OF BED IN MORNING OR AFTER LONG PERIOD OF REST.
• GREATER PAIN AFTER (NOT DURING) EXERCISE OR ACTIVITY.
• PAIN WORSE WHEN BAREFOOT ON HARD SURFACES AND WITH STAIR CLIMBING.
• TENDERNESS
• A LUMP MAY BE PRESENT OR MAY HAVE A PREFERENCE TO TOE WALKING.
• LIMITED DORSIFLEXION AND TIGHT ACHILLES TENDON.
• PHYSIOTHERAPY MANAGEMENT:
• STRENGTH TRAINING
• STRECHING
• MOBILIZATIONS
• FOOT ORTHOSES, TAPING, NIGHT SPLINTS.
 CLAW TOES:
• IT IS A LESSER TOE DEFORMITY CHARACTERIZED BY MTP HYPEREXTENSION AND
RESULTING PIP AND DIP FLEXION.

• PATHOPHYSIOLOGY:
• MTP HYPEREXTENSION IS THE PRIMARY
PATHOLOGY. MTP PLANTAR PLATE
BECOME INSUFFICIENT OVERTIME.
BASE OF PROXIMAL PHALANX TRANSLATES
DORSALLY. INTROSSEI AND LUMBRICALS
MORE DORSALLY.
• CAUSES:
• INHERITED
• SYMPTOM OF NEUROLOGICAL DISEASE
• IMBALANCE OF FOOT MUSCLES
• ILL FITTING SHOES
• NERVE DAMAGE BY DIABETES
• RA OR OA
• TRAUMA

• SYMPTOMS:
• PAIN AT THE LEVEL OF UNSTABLE MTP JOINT
• CALLUSES
• BLISTERS
• SWELLING
• ULCERS (RARE)
• TREATMENT AND MANAGEMENT:
• WEARING SHOES THAT HAVE ROOMY TOE BOXES LOW HEELS AND GOOD ARCH SUPPORT.
• WEARING PADS ARCH SUPPORTS OR OTHER SHOE INSERTS TO CUSHION THE TOE.
• STRENGTHENING AND STRETCHING TOE MUSCLES THROUGH EXERCISES.
• EX BY TOWELS, MARBLES AND SMALL BALLS.
• A SPLINT OR TAPE TO HOLD YOUR TOES WHERE THEY’RE SUPPOSED TO BE.
• AVOID HIGH HEEL AND TIGHT SHOES.
 PES PLANUS:
• ALSO CALLED FLAT FOOT. THE LOSS OF THE MEDIAL LONGITUDINAL ARCH OF THE FOOT
HEEL VALGUS DEFORMITY AND MEDIAL TALAR PROMINENCE. ARCHES ON INSIDE OF FEET
ARE FLATTENED ALLOWING ENTIRE SOLES OF YOUR FEET TO TOUCH THE FLOOR WHEN
YOU STAND UP.
• CAUSES: CONGENITAL AND ACQUIRED.
• CONGENITAL:
• ABNORMAL DEVELOPMENT OF FOOT, PRODUCING PES PLANUS, MAY BE DUE TO
NEUROLOGICAL PROBLEMS (E.G: CP, POLIO) BONY ABNORMALITIES (E.G: TARSAL
CONDITION -FUSION OF TARSAL BONES)
• ACQUIRED:
• MAY ARISE FROM DIABETES, RA, TRAUMATIC INJURY, OBESITY, AGING, PREGNANCY.
• SYMPTOMS:
• IN SYMPTOMATIC PATIENTS THERE MAY BE COMPLAINTS OF MIDFOOT, HEEL, LOWER
LEG, KNEE, HIP OR BACK PAIN. PTS WITH MORE ADVANCED CHANGES MAY COMPLAIN OF
AN ALTERED GAIT PATTERN.
• FOOT POINTING INWARDS (OVER PRONATION) LEADING TO INJURIES AND SHOES
WEARING OUT.
• WEAKNESS AND NUMBNESS OR STIFF FOOT.
• TREATMENT AND MANAGEMENT:
• PAIN MANAGEMENT
( REST, ACTIVITY MODIFICATION, CRYOTHERAPY, MASSAGE, NSAIDS)
• FLEXIBILITY EXERCISE
( PROM, STRETCHING)
• STRENGTHENING EXERCISE.
 PES CAVUS:
• ALSO CALLED HOLLOW FEET. A DEFORMITY THAT IS TYPICALLY CHARACTERIZED BY
CAVUS (ELEVATION OF LONGITUDINAL PLANTAR ARCH OF FOOT) A FOOT WITH AN
ABNORMALLY HIGH PLANTAR LONGITUDINAL ARCH. PEOPLE WITH THIS CONDITION
PLACE TO MUCH WEIGHT AND STRESS ON BALL AND HEEL OF FOOT WHILE STANDING OR
WALKING.
• CAUSES:
• NEUROMUSCULAR
• MUSCULAR DYSTROPHY
• CHARCOT MARIE TOOTH DISEASE
• POLYNEURITIS
• SPINAL TUMOR
• CONGENITAL
• ARTHROGRYPOSIS RESIDUAL CLUB FOOT
• IDIOPATHIC
• TRAUMA
• CRUSH INJURY
• RESIDUAL COMPARTMENT SYNDROME
• MALUNION OF FRACTURES OF FOOT.
• CLINICAL PRESENTATION:
• PT COMPLAINS PAIN, ANKLE INSTABILITY, DIFFICULTY IN WALKING AND PROBLEMS WITH
FOOT WEAR.
• ALSO CAN PRESENT WITH LATERAL FOOT PAIN FROM INC WEIGHT BEARING ON LATERAL
FOOT.
• LOSS OF SENSATION (LOWER LEG)
• DRAGGING ONE’S AFFECTED FOOT.
• TREATMENT AND MANAGEMENT:
• PATIENT WITH PAINFUL PES CAVUS TYPICALLY INVOLVES STRATEGIES TO REDUCE AND
REDISTRIBUTE PLANTAR PRESSURE LOADING WITH THE USE OF FOOT ORTHOSES AND
SPECIALIZED CUSHIONED FOOTWEAR.
• STRETCHING OF TIGHT MUSCLES.
• STRENGTHEN WEAK MUSCLES MAY PROVIDE EARLY RELIEF.
 ANKLE SPRAIN:
• ANKLE SPRAINS ARE COMMON INJURIES THAT OCCUR WHEN THE FOOT TWISTS OR TURNS BEYOND ITS
NORMAL RANGE OF MOVEMENT (INVERTED), CAUSING THE LIGAMENTS OF THE ANKLE TO
OVERSTRETCH OR TEAR. OR AN ANKLE SPRAIN IS WHERE ONE OR MORE OF THE LIGAMENTS OF THE
ANKLE ARE PARTIALLY OR COMPLETELY TORN.

• MECHANISM OF INJURY/ PATHOLOGICAL PROCESS:

• LATERAL ANKLE SPRAINS USUALLY OCCUR DURING A RAPID SHIFT OF BODY CENTER OF MASS OVER THE
LANDING OR WEIGHT-BEARING FOOT. THE ANKLE ROLLS OUTWARD, WHILST THE FOOT TURNS INWARD
CAUSING THE LATERAL LIGAMENT TO STRETCH AND TEAR. A LESS COMMON MECHANISM OF INJURY
INVOLVES FORCEFUL EVERSION MOVEMENT AT THE ANKLE INJURING THE STRONG DELTOID LIGAMENT.
• CAUSES:
• IN AN INVERSION INJURY THE ANKLE TILTS INWARD, MEANING THE BOTTOM OF THE FOOT ANGLES
TOWARD THE OTHER FOOT. THIS FORCES ALL THE PRESSURE OF YOUR BODY WEIGHT ONTO THE
OUTSIDE EDGE OF THE ANKLE. AS A RESULT, THE LIGAMENTS ON THE OUTSIDE OF THE ANKLE ARE
STRETCHED AND POSSIBLY TORN. A SEVERE FORM OF ANKLE SPRAIN, CALLED AN ANKLE SYNDESMOSIS
INJURY, INVOLVES DAMAGE TO OTHER SUPPORTIVE LIGAMENTS IN THE ANKLE. THIS TYPE OF INJURY IS
SOMETIMES CALLED A HIGH ANKLE SPRAIN BECAUSE IT INVOLVES THE LIGAMENTS ABOVE THE ANKLE
JOINT. IN AN ANKLE SYNDESMOSIS INJURY, AT LEAST ONE OF THE LIGAMENTS CONNECTING THE TIBIA
AND FIBULA BONES (THE LOWER LEG BONES) IS SPRAINED. RECOVERING FROM EVEN MILD INJURIES OF
THIS TYPE TAKES AT LEAST TWICE AS LONG AS FROM A TYPICAL ANKLE SPRAIN.
• CLASSIFICATION GRADING SYSTEM
• CLASSIFICATION BASED ON THE SEVERITY OF SPRAIN INJURY
• GRADE I MILD - LITTLE SWELLING AND TENDERNESS WITH LITTLE IMPACT ON FUNCTION
• GRADE II MODERATE - MODERATE SWELLING, PAIN AND IMPACT ON FUNCTION. REDUCED
PROPRIOCEPTION, ROM AND INSTABILITY
• GRADE III SEVERE - COMPLETE RUPTURE, LARGE SWELLING, HIGH TENDERNESS LOSS OF FUNCTION AND
MARKED INSTABILITY
• DEPENDING ON HOW BADLY A LIGAMENT IS DAMAGED, OR HOW MANY LIGAMENTS ARE INJURED, YOUR
ANKLE SPRAIN MAY BE CLASSIFIED AS:
• GRADE 1 (MILD). THE LIGAMENT IS OVERSTRETCHED.
• GRADE 2 (MODERATE). THE LIGAMENT IS OVERSTRETCHED OR PARTIALLY TORN.
• GRADE 3 (SEVERE). THE LIGAMENT IS COMPLETELY TORN.
• THE TRADITIONAL GRADING SYSTEM FOR LIGAMENT INJURIES FOCUSES ON A SINGLE
LIGAMENT
• GRADE I REPRESENTS A MICROSCOPIC INJURY WITHOUT STRETCHING OF THE LIGAMENT ON A
MACROSCOPIC LEVEL.
• GRADE II HAS MACROSCOPIC STRETCHING, BUT THE LIGAMENT REMAINS INTACT.
• GRADE III IS A COMPLETE RUPTURE OF THE LIGAMENT.
• SIGN AND SYMPTOMS:
• PAIN
• SWELLING
• INABILITY TO STAND OR WALK ON THE AFFECTED FOOT
• THROBBING
• STIFFNESS
• WEAKNESS
• A FEELING OF INSTABILITY IN THE ANKLE JOINT
• OFTEN, THE ANKLE STARTS TO SWELL IMMEDIATELY AND MAY BRUISE. THE ANKLE AREA USUALLY IS TENDER TO THE TOUCH, AND WHEN YOU
MOVE THE ANKLE, IT HURTS. IN MORE SEVERE SPRAINS, YOU MAY HEAR OR FEEL SOMETHING TEAR, ALONG WITH A "POP" OR "SNAP.
• "PATIENT PRESENTS WITH INVERSION INJURY OR FORCEFUL EVERSION INJURY TO THE ANKLE. MAY HAVE PREVIOUS HISTORY OF ANKLE INJURIES OR
INSTABILITY.
• ABLE TO PARTIAL WEIGHT-BEAR ONLY ON THE AFFECTED SIDE.
• IF PATIENT PRESENTS WITH DESCRIPTION OF COLD FOOT OR PARESTHESIA, SUSPECT NEUROVASCULAR COMPROMISE OF PERONEAL NERVE.
• TENDERNESS, SWELLING AND BRUISING CAN OCCUR ON EITHER SIDE OF THE ANKLE.
• NO BONY TENDERNESS, DEFORMITY OR CREPITUS PRESENT.

• PASSIVE INVERSION OR PLANTAR FLEXION WITH INVERSION SHOULD REPLICATE SYMPTOMS FOR A LATERAL LIGAMENT SPRAIN. PASSIVE EVERSION
SHOULD REPLICATE SYMPTOMS FOR A MEDIAL LIGAMENT SPRAIN.
• INVESTIGATION: X-RAY TO RULE OUT OTHER DISEASE
• SPECIAL TESTS:
• ANTERIOR DRAW - TESTS THE ATFL
• TALAR TILT - TESTS THE CFL
• POSTERIOR DRAW - TESTS THE PTFL
• SQUEEZE TEST - FOR SYNDESMOTIC SPRAIN
• EXTERNAL ROTATION STRESS TEST (KLEIGER’S TEST) -SYNDESMOTIC SPRAIN
• IT IS RECOMMENDED THAT THESE TESTS BE PERFORMED AT 4-7 DAYS POST ACUTE INJURY TO ALLOW
THE INITIAL SWELLING AND PAIN TO SETTLE, ENABLING THE THERAPIST TO GAIN A MORE ACCURATE
DIAGNOSIS.
• PALPATION IS USED TO FEEL FOR THE STRUCTURES THAT MAY BE INVOLVED IN THE INJURY, INCLUDING
BONE, MUSCLE AND LIGAMENTOUS STRUCTURES, FOLLOWED BY AN ACTIVE AND PASSIVE RANGE OF
MOVEMENT ASSESSMENT.
• PHYSICAL THERAPY MANAGEMENT:
• AN ANKLE SPRAIN USUALLY TAKES BETWEEN 2 WEEKS TO 2 MONTHS TO HEAL. THE ANKLE WILL FEEL
BETTER AFTER A FEW WEEKS, AND BE FULLY STRENGTHENED IN A FEW MONTHS. A SEVERELY SPRAINED
LIGAMENT, HOWEVER, CAN TAKE 9 MONTHS TO 1 YEAR TO HEAL.
• SWELLING AND PAIN ARE TREATED WITH MODALITIES LIKE ICE OR ELECTRICAL STIMULATION.
• IF SWELLING IN THE ANKLE IS SEVERE, APPLY MASSAGE STROKES FROM THE ANKLE TOWARD THE KNEE
WITH YOUR LEG KEPT IN AN ELEVATED POSITION.
• A COMPRESSION WRAP MAY USE TO WRAP ANKLE AND LOWER LIMB AND TO ELEVATE LEG.
• MILD ANKLE SPRAIN :
• NATURAL FULL RECOVERY WITHIN 14 DAYS
• TAPING
• FIRST TIME LATERAL LIGAMENT SPRAINS CAN BE INNOCUOUS INJURIES THAT RESOLVE QUICKLY WITH MINIMAL
INTERVENTION .
• TO REDUCE SWELLING INCLUDING ICE, HEAT, ULTRASOUND, ELECTRICAL STIMULATION, TAPING, SPECIFIC
EXERCISES, AND HANDS-ON THERAPY, SUCH AS SPECIALIZED MASSAGE.

• SEVERE ANKLE SPRAIN:

• PHYSIOTHERAPY IS REQUIRED WITH FUNCTIONAL THERAPY OF THE ANKLE SHOWN TO BE MORE EFFICIENT THAN
IMMOBILIZATION. FUNCTIONAL THERAPY TREATMENT CAN BE DIVIDED IN 4 STAGES, MOVING ONTO TO THE
NEXT STAGE AS TISSUE HEALING ALLOWS .
• INFLAMMATORY PHASE,
• PROLIFERATIVE PHASE,
• EARLY REMODELING,
• LATE MATURATION AND REMODELING.
• INFLAMMATORY PHASE (0-3 DAYS):
• THE MOST COMMON APPROACH TO MANAGE ANKLE SPRAIN IS THE PRICE PROTOCOL: PROTECTION, REST, ICE,
COMPRESSION, AND ELEVATION.
• RECOMMENDATIONS FOR THE PATIENT:
• PROTECTION: BY RESTING AND AVOIDING ACTIVITIES THAT MAY CAUSE FURTHER INJURY AND/OR PAIN
• REST: ADVISE REST FOR THE FIRST 24 HOURS AFTER INJURY, POSSIBLY WITH CRUTCHES TO OFFLOAD THE
INJURED ANKLE OR BY CRUTCHES WILL PREVENT TOO MUCH WEIGHT FROM BEING PLACED ON THE
ANKLE IN THE EARLY DAYS AFTER INJURY.
• ICE: APPLY A COLD APPLICATION (15 TO 20 MINUTES, ONE TO THREE TIMES PER DAY) OR APPLY ICE PACKS
TO THE AREA FOR 15 TO 20 MINUTES EVERY 2 HOURS.
• COMPRESSION: APPLY COMPRESSION BANDAGE TO CONTROL SWELLING CAUSED BY THE ANKLE SPRAIN. THIS
IS USUALLY ACCOMPLISHED BY USING AN ELASTIC WRAP OR COMPRESSION SOCK.
• ELEVATION: IDEALLY ELEVATE ANKLE ABOVE THE LEVEL OF THE HEART, BUT AS A MINIMUM, AVOID
POSITIONS WHERE THE ANKLE IS IN A DEPENDENT POSITION RELATIVE TO THE BODY
• FOOT AND ANKLE ROM:
• PATIENT PERFORMS ACTIVE MOVEMENTS WITH THE TOES AND ANKLE WITHIN PAIN FREE LIMITS TO
IMPROVE LOCAL CIRCULATION.
• MANUAL THERAPY IN THE ACUTE PHASE COULD ALSO EFFECTIVELY INCREASE ANKLE DORSIFLEXION.
• ANTEROPOSTERIOR MANIPULATION AND RICE RESULTS IN GREATER IMPROVEMENT IN RANGE OF
MOVEMENT THAN THE APPLICATION OF RICE ALONE.
• PROLIFERATIVE PHASE (4-10 DAYS)
1. PATIENT EDUCATION REGARDING GRADUAL INCREASE IN ACTIVITY LEVEL, GUIDED BY SYMPTOMS.
2. PRACTICE FOOT AND ANKLE FUNCTIONS
• RANGE OF MOTION
• ACTIVE STABILITY
• MOTOR COORDINATION
• IT IS IMPORTANT TO BEGIN EARLY WITH THE REHABILITATION OF THE ANKLE. FIRST WEEK EXERCISES PRODUCE
SIGNIFICANT IMPROVEMENTS TO SHORT TERM ANKLE FUNCTION.

3. TAPE/BRACE :APPLY TAPE AS SOON AS THE SWELLING HAS DECREASED. TAPE OR A BRACE USE DEPENDS ON
PATIENT PREFERENCE
• EARLY REMODELING (11 -21 DAYS)
• PRACTICE BALANCE, MUSCLE STRENGTH, ANKLE/FOOT MOTION AND MOBILITY (WALKING, STAIRS,
RUNNING).
• LOOK FOR A SYMMETRIC WALK PATTERN.
• FOCUSING ON BALANCE AND COORDINATION EXERCISES. GRADUALLY PROGRESS THE LOADING, FROM STATIC TO
DYNAMIC EXERCISES, FROM PARTIALLY LOADED TO FULLY LOADED EXERCISES AND FROM SIMPLE TO
FUNCTIONAL MULTI-TASKING EXERCISES.

• TAPING/BRACING
• ADVISE WEARING TAPE OR A BRACE DURING PHYSICAL ACTIVITIES UNTIL THE PATIENT IS ABLE TO CONFIDENTLY
PERFORM STATIC AND DYNAMIC BALANCE AND MOTOR COORDINATION EXERCISES.
• IMPROVE STRENGTH.
• ANKLE SPRAINS MAY BE RELATED TO WEAK, INJURED, OR UNCOORDINATED LEG MUSCLES. INCLUDE USING CUFF
WEIGHTS, STRETCH BANDS, AND WEIGHT-LIFTING EQUIPMENT.
• IMPROVE ENDURANCE.
• CARDIO-EXERCISE EQUIPMENT MAY BE USED, SUCH AS TREADMILLS OR STATIONARY BICYCLES.

• IMPROVE BALANCE.
• REGAINING YOUR SENSE OF BALANCE IS IMPORTANT AFTER AN INJURY.
• DISC TRAINING
• USING A CIRCULAR PLATFORM WITH A SMALL SPHERE UNDER IT. WHILE SITTING OR STANDING, PATIENTS PLACE
THEIR FEET ON THE PLATFORM AND WORK THE ANKLE BY TILTING THE DISC IN VARIOUS DIRECTIONS. THIS FORM
OF EXERCISE STRENGTHENS THE MUSCLES AROUND THE ANKLE, AND IMPROVES BALANCE AND JOINT POSITION
SENSE.
• LATE REMODELING AND MATURATION:
• PRACTICE MOTOR COORDINATION SKILLS WHILE PERFORMING MOBILITY EXERCISES
• INCREASE THE COMPLEXITY OF MOTOR COORDINATION EXERCISES IN VARIED
SITUATIONS UNTIL THE PRE-INJURY LEVEL IS REACHED.