Related Pathologies and Etiology

of Symptoms
The extrinsic foot musculature may develop symptoms either at or near its proximal
attachment in the leg (shin splints), or where coursing around boney prominences
in the ankle, or at its distal attachment in the foot (tendonitis/ tenosynovitis).
Symptoms also may develop in the intrinsic muscles of the foot as well as in the
plantar fascia (plantar fasciitis). Several common syndromes are described in this
section.
Heel Pain
The Heel Pain Committee of the American College of Foot and Ankle Surgeons
(ACFAS) published a revised clinical practice guideline (CPG)137 that categorizes
mechanical heel pain as: plantar heel pain (including plantar fasciitis, plantar
fasciosis, and heel spurs) and posterior heel pain (including insertional Achilles
tendinopathy, and bursitis). The Orthopaedic Section of the American Physical
Therapy Association has published two separate CPGs, one for heel pain (plantar
fasciitis)87 and one for Achilles pain, stiffness, and muscle power deficits (Achilles
tendinitis).12 Recommendations from these CPGs are included in the following
information.
Plantar fasciitis. Pain is usually experienced along the plantar aspect of the heel,
where the plantar fascia inserts on the medial tubercle of the calcaneus. The site is
very tender to palpation. Pain occurs on initial weight bearing after periods of rest,
then decreases, but returns as weight-bearing activity increases.87,137 Associated
impairments include hypomobile gastrocnemius-soleus muscles and plantar fascia
pain or restriction when extending the toes creating the windlass effect. A high
body-mass index, inappropriate footwear, and a flexible flat foot (pes planus) may
be predisposing factors. Conversely, stress forces on the fascia also may occur with
an excessively high arch (cavus foot). Pressure transmitted to the irritated site with
weight bearing or stretch forces to the fascia, as when extending the toes during
push-off, causes pain. A heel spur may develop at the site of irritation on the
calcaneus, causing pain whenever the heel is on the ground. The individual usually
avoids heel-strike during the loading response of gait.
Achilles tendinopathy (Achilles tendinitis/Achilles bursitis).
Pain is experienced at the midportion of the tendon (2 to 6 cm proximal to the
insertion on the calcaneus) or at the calcaneal insertion. Associated impairments
include decreased ankle dorsiflexion, decreased strength in ankle plantarflexion,
and increased foot pronation.36,75,112 Reported risk factors include obesity,
hypertension, and diabetes.12 Pain and stiffness in the tendon occur following a
period of inactivity and initially decrease with a return to activity but then increase
with additional activity. Symptoms may develop when the person switches from
high-heeled to low-heeled shoes followed by a lot of walking.
Tendinosis, Tendonitis, and Tenosynovitis
Any of the tendons of the extrinsic muscles of the foot may become irritated as they
approach and cross behind or over the ankle or where they attach in the foot. Pain
occurs during or after repetitive activity. When the foot and ankle are tested, pain
is experienced at the site of the lesion as resistance is applied to the muscle action
and also when the involved tendon is placed on a stretch or when palpated.13,36,98
A common site for symptoms is proximal to the calcaneus in the Achilles tendon or
its sheath (Achilles tendonitis or peritendinitis) as described in the heel pain section.
Tendon degeneration in the posterior tibial tendon is a common source of pain and
leads to impaired walking and acquired flatfoot deformity.73 Symptoms in the
anterior or posterior tibialis tendons or peroneus tendons are also associated with
athletic activities, such as running, tennis, and basketball.98
Shin Splints
This term is used to describe activity-induced leg pain along the posterior medial
or anterior lateral aspects of the proximal two-thirds of the tibia. It may include
different pathological conditions such as musculotendinitis, stress fractures of the
tibia, periosteitis, increased pressure in a muscular compartment, or irritation of the
interosseous membrane.
Anterior shin splints. Overuse of the anterior tibialis muscle is the most common
type of shin splint. A hypomobile gastrocnemius-soleus complex and a weak
anterior tibialis muscle as well as foot pronation are associated with anterior shin
splints. Pain increases with active dorsiflexion and when the muscle is stretched
into plantarflexion.
Posterior shin splints. A tight gastrocnemius-soleus complex and a weak or
inflamed posterior tibialis muscle, along with foot pronation, are associated with
posterior medial shin splints. Pain is experienced when the foot is passively
dorsiflexed with eversion and with active supination. Muscle fatigue with vigorous
exercise, such as running or aerobic dancing, may precipitate the problem.
Common Structural and Functional
Impairments, Activity Limitations, and
Participation Restrictions (Functional
Limitations/Disabilities)
Pain with repetitive activity, on palpation of the involved site, when the involved
musculotendinous unit is stretched, and with resistance to the involved muscle
Pain on initial weight bearing and with repetitive weightbearing activities and
gait
Muscle length-strength imbalances, especially tight gastrocnemius-soleus muscle
group
Abnormal foot posture (may be from faulty footwear)
Decreased length of time the individual can stand and decreased distance or speed
of ambulation, which may restrict associated community and work activities and
recreational and sports activities

Leg, Heel, Foot Pain:

ManagementProtection Phase
If signs of inflammation are present, treat as an acute condition, with rest and
appropriate modalities. (See Chapter 10 for general principles and guidelines.)
Immobilization in a cast or splint with the foot slightly plantarflexed or use of a
heel lift or custom orthotic inside the shoe may relieve stress.26,75,112
Apply cross-friction massage to the site of the lesion.
Initiate gentle muscle-setting contractions or electrical stimulation to the involved
muscle in pain-free positions.
 Teach active ROM within the pain-free ranges.
Instruct the patient to avoid activity that provokes pain.
Use supportive taping or orthotic shoe insert to provide relief of
symptoms.12,53,73,87,101,137
Leg, Heel, Foot Pain: Management
Controlled Motion and Return to
Function Phases
When symptoms become subacute, the entire lower extremity as well as the foot
should be examined for impaired alignment or muscle flexibility and strength
imbalances. Eliminating or modifying the cause is important to improve outcomes
and prevent recurrences.16,152 Orthotic devices may be necessary to correct
alignment.75,77,112 Therapeutic exercises may be helpful to increase flexibility
and improve general muscle performance. Detailed descriptions of stretching and
strengthening exercises for the ankle and foot are in the last section of this chapter.
FOCUS ON EVIDENCE
A multicenter, randomized study of 60 subjects with plantar heel pain compared
two treatment groups, one receiving electrophysical agents and exercise, and the
other treated with manual interventions (vigorous soft tissue techniques and joint
mobilization directed at the hip, knee, and ankle/foot as needed) and exercise. There
was a significant improvement in both groups in functional measures and pain, with
those receiving the specific manual interventions and exercise showing greater
differences at 4-week and 6-month follow-up.16
Educate the Patient and Provide Home
Exercises
Help the patient incorporate home exercises and soft tissue and joint mobilization
into his or her daily routine.
If the patient experiences pain when first bearing weight, especially in the
morning and after prolonged sitting, teach the patient to do ROM exercises
(especially dorsiflexion) or alphabet writing with the foot for several minutes before
standing.
Teach prevention, including the following principles.
 Before intense exercise, use gentle repetitive warm-up activities followed by
stretching of tight muscles.
Use proper foot support for the ground conditions (this cannot be
overemphasized).
Allow time for recovery from microtrauma after highintensity workouts
Stretch Range-Limiting Structures
The gastrocnemius-soleus muscle complex is frequently hypomobile in cases of
foot problems and should be stretched if limiting dorsiflexion. Restricted mobility
causes the foot to pronate when the ankle dorsiflexes.
CLINICAL TIP
Instruct patients with pes planus to wear supportive shoes with medial arch support
when performing standing gastrocnemius-soleus stretches to protect the foot.56
With heel pain (fasciitis, heel spurs), apply joint and soft tissue mobilization
techniques.16
Deep massage to the insertion of the plantar fascia at the medial calcaneal tubercle
and the gastrocnemius-soleus tendon.
Joint mobilization directed to specific limitations such as lateral glide to the
subtalar joint to improve rearfoot inversion and posterior glide to the talus to
improve ankle dorsiflexion.
Stretching exercises to the plantar fascia
Stretching exercises to any lower extremity region that may affect alignment and
function of the foot and ankle.
Improve Muscle Performance
Begin with resistive isometric and progress to resistive dynamic exercises to the
foot and ankle in open- and closed-chain activities.
For medial and lateral support, develop a balance in strength between the muscle
groups, especially the invertors and evertors.
Emphasize muscular endurance, and train the muscles to respond to eccentric
loading.12,73
 With plantar fasciitis, the intrinsic muscles need to be strengthened. Include
exercises that require toe control, such as scrunching tissue paper or a towel and
picking up marbles and other small objects with the toes.
Ligamentous Injuries:
Nonoperative Management
After trauma, the ligaments of the ankle may be stressed or torn. First- and second-
degree (grades I and II) sprains are usually treated conservatively. The most
common type of ankle sprain is caused by an inversion stress and can result in a
partial or complete tear of the anterior talofibular (ATF) ligament and often the
calcaneofibular (CF) ligament (see Fig. 22.2).51,114 The posterior talofibular
(PTF) ligament, the strongest of the lateral ligaments, is torn only with massive
inversion stresses. If the inferior tibiofibular ligaments are torn after stress to the
ankle, the mortise becomes unstable. Rarely do the components of the deltoid
ligament become stressed; there is greater likelihood of an avulsion from or fracture
of the medial malleolus with an eversion stress. Depending on the severity of injury,
the joint capsule also may be involved, and intraarticular pathology, including
articular cartilage lesions, may occur,70 resulting in symptoms of acute (traumatic)
arthritis.
Common Structural and Functional
Impairments, Activity Limitations,
and Participation Restrictions
(Functional Limitations/Disabilities)
Pain when the injured tissue is stressed in mild to moderate injuries.
Excessive motion or instability of the related joint in the case of complete tears.
Proprioceptive deficit manifested as decreased ability to perceive passive motion
and development of balance impairments.32
Related joint symptoms and reflex muscle inhibition.
Possible decreased ROM of the talocrural joint in recurrent lateral ankle sprains
due to anterior subluxation and impaired tracking of the talus in the mortise.147
Postural control deficits following an acute lateral ankle sprain in both the injured
and uninjured limb.84
 Restricted ambulation (requiring an assistive device) during the acute and
subacute phases. With chronic instability, the individual may have difficulty
walking or running on uneven surfaces or making quick changes in direction. He or
she may be unable to land safely when jumping or hopping or may fall more
frequently.
FOCUS ON EVIDENCE
A study of recreational athletes with chronic ankle instability (n=15) and matched
healthy athletes without instability (n=15) tested single limb postural stability on a
moving surface while simultaneously performing a cognitive activity. Results
showed when the cognitive activity was performed, there was significantly poorer
postural stability in those with chronic instability than in those without instability.
The authors suggest that this demonstrated decreased automaticity of postural
control in the group with ankle instability.109
Acute Ankle Sprain:
ManagementProtection Phase
See Chapter 10 for principles of treatment during stages of inflammation and repair.
If possible, examine the ankle before joint effusion occurs. To minimize the
swelling, use compression, elevation, and ice. The ankle should be immobilized in
neutral or in slight dorsiflexion and eversion.
Use gentle joint mobilization techniques to maintain mobility and inhibit pain.
Educate the patient.
Teach the patient the importance of RICE (rest, ice, compression, and elevation),
and instruct the patient to apply ice every 2 hours during the first 24 to 48 hours.
Teach partial weight bearing with crutches to decrease the stress of ambulation.34
Teach muscle-setting techniques and active toe curls to help maintain muscle
integrity and assist with circulation.
FOCUS ON EVIDENCE
Green and associates35 studied 38 individuals following acute ankle sprain (within
72 hours of injury and requiring partial weight bearing). All subjects received RICE
intervention. Those randomly assigned to the experimental group (n=19) also
received gentle anterior-posterior (AP) joint mobilization techniques to the
talocrural joint with the foot positioned in dorsiflexion. Range of pain-free ankle
dorsiflexion, gait speed, step length, and single support time were measured. The
majority of those in the experimental group were discharged after fewer treatments
(13 of 19 subjects by the fourth treatment), having gained full range of dorsiflexion,
whereas only three subjects in the control group met this criterion and required
additional treatment. Also, subjects in the experimental group demonstrated
improved stride speed compared to the control group.
Ankle Sprain: Management
Controlled Motion Phase
As the acute symptoms subside, continue to provide protection for the involved
ligament with a splint during weight bearing. Fabricating a stirrup out of
thermoplastic material and holding it in place with an elastic wrap or Velcro straps
provides stability to the joint structures while allowing for the stimulus of weight
bearing for proprioceptive feedback and proper healing. Commercial splints, such
as an air splint, are also available to provide medial-lateral stability while allowing
dorsiflexion and plantarflexion.40,63
Apply cross-fiber massage to the ligaments as tolerated.
Use grade II joint mobilization techniques to maintain mobility of the joint.
Teach the patient exercises to be done within tissue tolerance at least three times
per day. Suggestions include:
Nonweight-bearing AROM into dorsiflexion and plantarflexion, inversion and
eversion, toe curls, and writing the alphabet in the air with the foot.
Sitting with the heel on floor and scrunching paper or a towel and picking up
marbles with the toes.