FAAM for Leg, Ankle, and Foot Disorders

Self-Report Measures for Leg, Ankle, and Foot Pathologies

• Outcome measures should be selected based on the ICF framework and Movement System.
• Assessment tools should consider biological, physical, and psychosocial factors.
• Key self-report measure features include MCID (Minimal Clinically Important Difference) and MDC (Minimal Detectable Change).
• Outcome measures can guide physical examinations, interventions, prognosis, and re-evaluation.

Foot and Ankle Ability Measure (FAAM)

• Applicable to general leg, foot, and ankle disorders.
• Items are scored from 4 (no difficulty) to 0 (unable to do).
• "N/A" items are not scored, and total possible points are deducted.
• Total score is divided by the total possible score to get a percentage.
• Higher scores indicate higher ability.
• Contains a 21-item ADL (Activities of Daily Living) subscale (0-84) and an 8-item sport subscale (0-32).
• The MDC for ADL is 5.7, and for Sport, it's 12.3.
• The MCID for ADL is 8 points, and for Sport, it's 9 points.

Foot and Ankle Disability Index (FADI)

• For general foot and ankle conditions.
• A 26-item instrument.
• Items scored from 4 (no difficulty) to 0 (unable to do).
• Pain items are scored from 4 (none) to 0 (unbearable).
• Raw scoring range: 0-104.
• Total score is divided by the total possible score, after NA items are deducted, to get a percentage.
• 100% represents no dysfunction.
• MDC is 3-4.48.

Victorian Institute of Sport Assessment – Achilles (VISA-A)

• Specific to Achilles tendinopathy.
• Only given to patients diagnosed with Achilles tendinopathy
• An 8-item instrument in 3 domains: pain, function, and activity.
• Scoring range: 0-100.
• A score of 70 is the maximum if not participating in sports.
• MCID at 12 weeks in Achilles tendinopathy patients is 14 points.
• MCID at 24 weeks in Achilles tendinopathy patients is 7 points.

Achilles Tendon Total Rupture Score (ATRS)

• Specific to Achilles tendon rupture.
• A 10-item instrument.
• Range of 0-10 for each item.
• 0 = worse symptoms and greater limitations.
• 10 = no symptoms or limitations.
• MCID = 8 points.

Lower Extremity Functional Scale (LEFS)

• A 20-item instrument
• Scoring scale: 0-80.
• Higher scores indicate higher functional ability.
• Each item has a maximum score of 4.
• MDC = 9 points.
• MCID = 9 points.

Tampa Scale of Kinesiophobia (TSK)

• Assesses kinesiophobia, which is the fear of movement.
• A 17-item instrument.
• Items scored from 1-4.
• Score scale: 17-68.
• Higher scores indicate kinesiophobia.
• Scores > 37 may indicate kinesiophobia.

Numeric Pain Rating Scale (NPRS)

• Patients rate pain on a scale of 0-10.
• 0 = no pain, and 10 = worst possible pain.
• Demonstrates adequate construct validity as a measure of pain intensity.
• MCID = 1.3 points in a non-specific patient population.

Patient-Specific Functional Scale (PSFS)

• Assesses a patient’s ability to complete specific activities.
• Patients rate their ability on a scale from 0 to 10.
• “0” = unable to perform.
• “10” = able to perform at a prior level.
• The total score is the sum of activity scores divided by the number of activities.
• MDC for the average score = 2 points.
• MDC for a single activity score = 3 points.

Patient History for Leg, Ankle, and Foot Pathologies

• Assess the chief complaint, including location.
• Note symptoms in the back, buttock, thigh, or knee to identify potential proximal sources.
• Determine if symptoms radiate and whether they are localized or generalized.
• For Achilles tendinopathy, differentiate between mid-portion and insertional.
• Identify aggravating and easing factors to find movements/activities that provoke symptoms.
• Assess whether back, hip, or knee movements alter symptoms to identify the source.
• Note the 24-hour pattern of symptoms.
• Ankle stiffness in the morning may indicate ankle osteoarthritis.
• Plantar heel pain in the morning may indicate plantar fasciosis.
• Achilles pain in the morning may indicate Achilles tendinopathy.

Areas to Consider as Possible Symptom Sources

• Joint and bony structures under the area of symptoms.
• Muscles, tendons, and other soft tissue under and in the area of symptoms.
• Pain-producing structures that may refer into the area of symptoms.
• Other structures or conditions that must be considered or ruled out.
• Method to systematically think about all potential sources of symptoms.
• Generate hypotheses for likely and unlikely symptom sources.

Symptom History Details

• Note the mechanism of injury, whether traumatic or atraumatic.
• For traumatic injuries, consider the foot position during injury and contact vs. non-contact.
• For atraumatic injuries, note preceding changes in activity, footwear, or increases in running/walking.
• Record the timeline since onset and prior episodes.
• Inquire about previous tests/treatments and imaging.

Medical History

• Note additional conditions or related injuries, such as RED-S in suspected bone stress injury.
• Record related surgical history, affecting the lower extremity, lumbar.
• Note medications, such as fluoroquinolones, which contribute to Achilles tendinopathy.
• Determine if medications preclude manual therapy or exercise.

Social History and Patient Goals

• Consider the living environment.
• Evaluate the occupation (sedentary vs. active), workplace setup, and footwear.
• Assess recreational activities, such as cutting/pivoting sports, running, and prolonged standing.
• Understand the patient perceptions, expectations, and goals.

Physical Exam Planning

• Prioritize based on likely hypotheses and S.I.N.S.S. (Severity, Irritability, Nature, Stage, Stability).
• Determine the vigor of the exam.
• Examine to first onset or change in pain.
• Examine to the end of active or passive range of motion.
• Examine with overpressure to determine end feel.
• Consider sustained, repeated, or combined movements.

Screening for Medical Referral

• Evaluate signs and symptoms to determine suitability for physical therapy or need for referral.
• Analyze signs and symptoms to determine the appropriate healthcare practitioner and initial imaging, if warranted.

Red Flag Pathologies

• Traumatic fracture.
• Acute compartment syndrome.
• Gout.
• Cellulitis.
• Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE).
• Septic Arthritis.
• Peripheral Arterial Occlusive Disease (PAOD or PAD).

Ottawa Ankle and Foot Rules

• Reduce unnecessary radiographs in diagnosing acute foot and ankle injuries.

Ottawa Ankle Rule

• After acute ankle injury or ankle trauma, radiographs indicated if:
• Tender to palpation along the distal 6 cm of the posterior fibula or tip of the lateral malleolus, OR
• Tender to palpation along the distal 6 cm of the posterior tibia or tip of the medial malleolus, OR
• Inability to bear weight both immediately and in the emergency department for 4 steps.
• Rule is sensitive, meaning if negative, a fracture is unlikely.

Ottawa Foot Rule

• After acute foot injury (trauma), radiographs indicated if:
• Tender to palpation at the base of the 5th metatarsal, OR
• Tender to palpation at the navicular bone, OR
• Inability to bear weight both immediately and in the emergency department for 4 steps.

Standard Radiograph Views for Ankle

• AP view.
• Mortise view.
• Lateral view.

Standard Radiograph Views for Foot

• AP.
• Oblique.
• Lateral.

Acute Compartment Syndrome

• Increased pressure within a lower leg compartment diminishes blood flow to nerves and muscles.
• Can be acute (direct trauma) or chronic exertional (repetitive overuse).

Lower-Leg Compartment Contents

• Anterior: tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius; deep peroneal nerve; anterior tibial artery.
• Lateral: peroneus brevis and longus; superficial peroneal nerve, proximal part of deep peroneal nerve; peroneal artery.
• Posterior superficial: gastrocnemius, soleus, plantaris; tibial nerve branches; posterior tibial artery, popliteal artery, peroneal artery, sural arteries.
• Posterior deep: popliteus, tibialis posterior, flexor hallucis longus, flexor digitorum longus; tibial nerve; posterior tibial artery, peroneal artery.

Acute Compartment Syndrome Presentation (6 P’s)

• Pain: Out of proportion to the injury; increased with passive stretching.
• Pulselessness: A late finding distal to the compartment.
• Pallor: Loss of distal color in the foot.
• Paresthesia: Due to nerve ischemia.
• Paralysis.
• Poikilothermia: Change in temperature or coolness in the affected extremity.
• Monitor those with increased risk.
• Symptoms will vary depending on time lapsed since injury, rate of intercompartmental pressure increase, patients’ blood pressure, and the amount of damage within that compartment

Acute Compartment Syndrome Diagnosis

• Intracompartmental Pressure: Needle measures intercompartmental pressure.
• MRI.

Acute Compartment Syndrome Treatment

• Medical emergency!

• 8 hours may cause irreversible damage.

• Emergent fasciotomy: Incision to relieve pressure.

Gout

• Inflammatory metabolic joint disease with hyperuricemia and monosodium urate crystals in synovial fluid.
• Risk factors: Family history, heavy alcohol consumption, chronic kidney disease, obesity, renal insufficiency, hypertension.
• Symptomatic at 40-50 years old, but may be asymptomatic for years.
• Characterized by exquisite joint pain.
• Red, shiny, tense, warm skin at the joint.
• 1st MTP is the most common site.

Acute Ankle Sprains

• Lateral ankle sprains.
• Medial ankle sprains.
• “High” ankle sprains.

Lateral Ankle Sprain

• An acute injury to the lateral ankle ligaments.
• The anterior talofibular ligament (ATFL) is the most commonly injured.
• Calcaneofibular ligament is the second most common.
• Posterior talofibular ligament is the least common.
• Mechanism of injury: forced plantarflexion/inversion.

Lateral Ankle Sprain Prevalence

• The most prevalent musculoskeletal injury in active populations.
• ~50% of individuals who sustain a lateral ankle sprain seek medical attention.
• Prevalence of 11.88% in the general population.
• Decreasing risk with increased age.
• Most common in indoor court sports.

Acute Lateral Ankle Sprain Risk Factors

• Previous history of ankle sprain.
• Female.
• Decreased ankle dorsiflexion range of motion.
• Hip abductor and extensor weakness.
• Poor performance on balance and hopping tests.
• Participating in court sports.

Ankle Sprain Classification: Severity

• Grade 1 (mild): stable.
  • Pathology: Mild stretch, no instability, single ligament involved (usually ATFL).
  • Signs/symptoms: No hemorrhage, minimal swelling, point tenderness, no anterior drawer sign, no varus laxity.
  • Disability: No or little limp, minimal functional loss, difficulty hopping, recovery 8 days.
• Grade 2 (moderate): stable.
  • Pathology: Large spectrum of injury, mild to moderate instability, complete tearing of ATFL or partial tearing of ATFL + CFL.
  • Signs/symptoms: Some hemorrhage, localized swelling, anterior drawer sign may be present, no varus laxity.
  • Disability: Walking with a limp, unable to toe raise, unable to hop, unable to run, recovery 20 days.
• Grade 3 (severe): two-ligament, unstable.
  • Pathology: Significant instability, complete tear of anterior capsule, ATFL, and CFL.
  • Signs/symptoms: Diffuse swelling on both sides of the Achilles tendon, early hemorrhage, possible tenderness medially and laterally, positive anterior drawer sign, positive varus laxity.
  • Disability: Unable to bear weight fully, significant pain inhibition, initially almost complete range of motion loss, recovery 40 days.

Lateral Ankle Sprain Clinical Findings

• Sudden onset of symptoms with acute ankle inversion-related injury.
• Bruising.
• Swelling.
• Difficulty weightbearing.
• Can they weight bear for 4 consecutive steps?

Lateral Ankle Sprain Physical Examination

• Negative Ottawa Ankle and Foot Rules.
• Pain and/or reported instability with weight-bearing.
• Decreased ankle range of motion.
• Decreased postural control and strength.
• Positive Anterior Drawer Test.
• Positive Tilt Test.
• Tenderness to palpation over ATFL and possibly also CFL.

Associated Injuries: Cuboid Syndrome

• Pain at the calcaneocuboid joint.
• Clinical presentation:
• Plantar lateral midfoot pain and feeling of a “rock” under cuboid when walking.
• Pain with palpation and joint mobility assessment of cuboid.
• Pain with resisted eversion.
• Management:
• Cuboid mobilization and manipulation.
• Cuboid sling taping technique.

Lateral Ankle Sprain Associated Injuries

• Lisfranc injuries.
• Talar dome lesion (osteochondral defect, Fracture).
• Fractures.
• Fibular nerve/sural nerve injury.
• Clinical presentation: positive slump or straight leg raise.
• Management: nerve mobilizations.

Associated Injuries: Fibularis Dysfunction

• Fibularis dysfunction (subluxation, tendinopathy).
• Ruptured retinaculum leading to tendon subluxation.
• Clinical presentation:
• Posterolateral ankle pain and potential swelling.
• Pain to palpation of the fibularii tendons.
• Supinated foot position during gait.
• Pain with AROM and resisted eversion.
• Positive peroneal (fibularis) subluxation test.
• Management:
• Impairment-based interventions.
• Acute subluxation: boot for up to 6 weeks.
• Tendinopathy: isometric loading for symptom modulation followed by progressive loading.
• Failed non-operative management leads to surgical repair of retinaculum.

Imaging for Lateral Ankle Sprain

• Acute trauma, negative Ottawa Ankle Rules, typically, no imaging indicated.
• Positive Ottawa ankle or foot rules: ankle radiographs.
• If radiographs demonstrate potential osteochondral injury or negative radiographs with persistent symptoms (1-3 weeks):
• MRI or CT scan without contrast.
• Negative ankle radiographs, suspected syndesmotic injury:
• Leg radiographs.
• Ankle stress radiographs.
• MRI without contrast.
• CT scan without contrast.

Lateral Ankle Sprain Management

• Protected Motion Phase.
• Controlled Motion Phase.
• Return to Function Phase.

Protected Motion Phase

• Protect injured structures.
• Manage pain, inflammation, effusion.
• Early, low grade range of motion and mobilizations.
• Physical agents.
• Therapeutic exercise.
• Manual therapy.
• Optimal Loading.

Protected Motion Physical Agents

• Grade C: cryotherapy, diathermy, low-level laser therapy.

Protected Motion Therapeutic Exercise

• Grade A: Protected (pain-free) active range of motion, stretching exercises, strengthening.
• Initially sagittal plane motion, protecting frontal and transverse planes.
• Progress from non-weightbearing to weightbearing.
• Open chain strengthening in the sagittal plane, isometrics in frontal plane.

Protected Motion Manual Therapy

• Grade A: lymphatic drainage, joint mobilizations; anterior-to-posterior talar glides.

Protected Motion Optimal Loading

• Grade A: braces or taping, and progressive weightbearing.
• Severity, phase of tissue healing, and patient preference should dictate the assistive device.
• In more severe sprains, semi-rigid bracing to casting may be indicated for up to 10 days post injury.

Controlled Motion Phase; Manual Therapy

• Graded mobilizations/manipulations, mobilization with movement (MWM).

Controlled Motion Phase; Therapeutic Exercise

• Range of motion in all planes.
• Open chain strengthening in all planes.
• Closed chain strengthening in sagittal plane, progressing to all planes.
• Weightbearing functional exercises.
• Single limb balance activities progressive from stable to unstable surfaces.

Return to Function Phase

• The ankle should be pain-free and feel stable, with no giving way episodes.
• Practice and game-specific loads should not be a novel experience upon return to sport and functional activity.

Lateral Ankle Sprains: Bracing

• Primary prevention of 1st time lateral ankle sprains.
• Grade A: clinicians should recommend the use of prophylactic bracing to reduce the risk of a first-time lateral ankle sprain, particularly for those with risk factors.
• Secondary prevention of recurrent lateral ankle sprains following initial sprain.
• Grade A: clinicians with prescribe prophylactic bracing and use proprioceptive and balance-focused therapeutic exercise training programs to address impairments identified on physical examination to reduce the risk of a subsequent injury in patients with a first-time lateral ankle sprain.

Lateral Ankle Sprains Prevention

• Tertiary prevention (Acute)
  • Should do: early weight bearing with support, therapeutic exercise (in clinic and home), manual therapy procedures.
  • Should not do: therapeutic ultrasound.
• Tertiary prevention (Chronic)
  • Should do: therapeutic exercise (proprioceptive and neuromuscular exercise), manual therapy procedures, combined treatment programs.
  • Should not do: external support as a stand-alone treatment.

Lateral Ankle Sprains Prognosis

• Full return to participation from 1 day to ~3 weeks after injury, depending on the demands of sport.
• Full, asymptomatic recovery may take months to years.
• ~40% develop Chronic Ankle Instability (CAI).
• Variables associated with an increased risk of developing CAI.
  • Inability to perform single-leg drop landing and drop vertical jump 2 weeks post lateral ankle sprain.
  • Increased BMI.
  • High-level sport participation.
  • Not participating in an exercise-balance program.
  • Not using prophylactic bracing.

Medial Ankle Sprains

• An acute injury to the medial ankle ligaments.
• Deltoid ligaments are usually injured.
• Strong fan-shaped ligament that runs form the distal aspect of the tibia down to the navicular, calcaneus, and talus.
• Can be separated into three ligaments.
• Less commonly injured than the lateral ankle ligaments.
• Mechanism of injury: forced eversion.

Medial Ankle Sprain: Epidemiology and Risk Factors

• Incidence in athletes is 0.06 per 1000 athlete exposures.
• 3-5% of all ankle sprains.
• Males > females.
• Sports with higher injury rates:
• Women's gymnastics.
• Men's rugby.
• Men's and women’s soccer.
• Men's American football.

Medial Ankle Sprain: Clinical Findings

• Patient History: Acute or recent traumatic injury, medial ankle swelling, bruising, and difficulty weightbearing.
• Physical Examination: Tenderness to palpation of deltoid ligament, pain/apprehension with passive eversion, and often occur with fractures.

Medial Ankle Sprain: Management

• Limited evidence specifically for medial ankle sprain.
• Initially protect the medial ankle ligaments.
• Similar to the lateral ankle sprain after the acute phase.

“High” Ankle Sprains

• Acute injury to the tibiofibular ligaments and the interosseous ligament.
• Mechanism of injury: forced external rotation of the foot/ankle and/or hyper-dorsiflexion.
• Important to not confuse the anteroinferior tibiofibular ligament (AITFL) with the ATFL.
• AITFL is usually the ligament that is injured in ''high'' or syndesmotic ankle sprains.
• May injure: Posterior Inferior Tibiofibular Ligament (PITFL).

Grading of “High” Ankle Sprain: Injury Severity Based on Clinical Presentation

• Grade 1: Sprain without diastasis.
  • Symptoms: Mild point tenderness over tibiofibular ligaments.
  • Stability: Mild laxity with a stable endpoint to stress.
  • Plain radiograph imaging: Stable with stress on plain radiographs.
  • Management strategy weight bearing: Weight bearing to tolerance.
  • Immobilization: 0-3 days.
• Grade 2: Sprain with latent diastasis.
  • Symptoms: Point tenderness extends proximally over the IOM.
  • Stability: Moderate laxity with a soft endpoint to stress.
  • Plain radiograph imaging: Mild laxity present with stress but absent with plain radiographs.
  • Management strategy weight bearing: Progress to full weight bearing after 1-2 weeks.
  • Immobilization: 3-7 days.
• Grade 3: Sprain with frank diastasis.
  • Symptoms: Significant tenderness and an inability to weight bear.
  • Stability: Notable laxity with the absence of endpoint.
  • Plain radiograph imaging: Instability and/or fracture evident on plain radiograph.
  • Management strategy weight bearing: Minimum 2-3 weeks non-weight bearing.
  • Immobilization: 7+ days.

“High” Ankle Sprain: Prevalence

• ~10% of ankle sprains.
• Often occur with medial ankle sprains.
• Male > female.
• Highest risk in American football, wrestling, ice hockey.

“High” Ankle Sprain: Clinical Findings

• Anterior or posterior talocrural region pain.
• Pain with weightbearing, especially mid and late terminal stance (dorsiflexion).
• Pain and limited active range of motion/passive range of motion in dorsiflexion.
• Pain with active range of motion eversion.
• Positive syndesmosis squeeze test.
• Positive Kleiger’s test.
• Tenderness to palpation over the anterior inferior tibiofibular ligament.

“High” Ankle Sprains: Diagnostic Imaging

• Views: Anteroposterior, Lateral, and Mortise.
• Greater space and less overlap between the fibula and tibia can indicate a rupture of that syndesmosis.

“High” Ankle Sprains: Non-Operative Management - Acute, Stable Sprains

• Acute phase: Emphasis on protection and controlling the inflammatory response.
  • Non-weightbearing (up to 2 weeks) then partial weightbearing.
  • Manage pain, inflammation, effusion.
  • Proximal hip/knee strengthening.
  • Foot intrinsic strengthening.
  • Limit dorsiflexion range of motion (especially weightbearing).
• Subacute phase: Emphasis on restoring strength, mobility, and neuromuscular control.
  • Gradually increase weightbearing and normalize gait pattern.
  • Manual therapy to improve range of motion.
  • Progressive pain-free ankle strengthening.
  • Progressive proprioceptive exercises.
• Return to activity phase: Emphasis on restoring activity-specific skills.
  • Progressive strengthening.
  • Functional and proprioceptive exercises.
  • Progressive sport-specific exercises.
• Introduce Dorsiflexion Conscientiously.
• Limit dorsiflexion in the early phases of rehab.

“High” Ankle Sprains: Operative Management

• Screw fixation.
• Knotless suture button fixation.

“High” Ankle Sprains: Prognosis

• 2-4x as long to recover as a lateral ankle sprain.
• Mean time to return to sport is 46.4 days (non-operative) and 55.2 days (operative).
• 15% of college athletes will miss > 21 days of sport, and 47% will miss > 7 days of sport.

Chronic Ankle Instability (CAI)

• A patient with a history of at least 1 ankle sprain, who has perceived of episodic "giving way" of the ankle that persists greater than a year after the initial sprain, and causes resultant activity limitation.
• Two Primary Components: Functional Ankle Instability and Mechanical ankle instability.

Components of Ankle Instability

• Functional Ankle Instability
  • Subjective feelings of instability.
  • Can have functional ankle instability or feeling of “giving way” without mechanical laxity.
• Mechanical ankle instability
  • Mechanical laxity = injury to the ATFL or CFL
  • Positive special test for anterior drawer test of the ankle and talar tilt test.
  • Can have mechanical ankle instability without feeling unstable.
  • Oftentimes both are present.

Chronic Ankle Instability Prevalence

• 20% in adolescent athletes.
• 23.4% in high school and collegiate athletes.
• 40% in patients who sought care for a first-time lateral ankle sprain.

Risk Factors for Chronic Ankle Instability

• Not using prophylactic bracing.
• Not participating in an exercise-balance program.
• Poor functional performance after a lateral ankle sprain.
• Participating in sports.
• Higher BMI.

Chronic Ankle Instability: Clinical Findings

• Recurrent ankle sprains and/or feelings of instability; giving way.
• Impaired postural control.
  • Static (BESS).
  • Dynamic (y-balance test).
• Muscle weakness.
  • Hip abductors, extensors, external rotators.
  • Ankle invertors, evertors, and plantar flexors.
• Limited ankle dorsiflexion ROM (open chain and closed chain).
• Decreased talocrural joint mobility (anterior-to-posterior glide).
• Deficits with hopping and jumping (longer time to stabilize and loss of balance).
• Altered movement patterns during functional activities including a lateral shift in pressure in the stance phase.

Chronic Ankle Instability: Two Pathways After an Acute Lateral Ankle Sprain

• They can go on to develop chronic ankle instability.
• Or they can be a “coper”.

Chronic Ankle Instability: Management

• External support (Grade B).
• Do not use external support, including braces or taping, as a stand-alone intervention to improve balance and postural stability in individuals with CAI.
• Therapeutic exercise and activity (Grade A).
  • Proprioceptive and neuromuscular therapeutic exercise to improve dynamic postural stability and patient-perceived stability during function in individuals with CAI.
• Manual therapy (Grade A).
  • Joint mobilizations/manipulations and mobilization with movement, to improve weight-bearing ankle dorsiflexion and dynamic balance in the short term for individuals with CAI.
• Operative Management (Rehabilitation Precautions):
  • Initial period of Non-weight bearing.
  • Avoid Active range of motion and passive range of motion inversion for 6 weeks.
• The outcomes of this are that most patients report "good'' or "excellent'' ankle function ~2 years post surgery.
• Techniques: Brostrom procedure, Brostrom-Gould procedure, and Carlson procedure.

Chronic Ankle Instability: Prognosis

• Increased risk of ankle osteoarthritis in patients with chronic ankle instability.
• Diminished quality of life and physical activity leading to compromised health and wellness.
• Increased levels of fear and kinesiophobia.
• Highlights the importance of early intervention.

Anterior Ankle Impingement

• Anterior ankle pain with dorsiflexion, especially weighted dorsiflexion.
• May result in bony exostoses on the anterior rim of the tibia and talus.
• Prevalence: Up to 25% of individuals with chronic ankle instability present with anterior ankle impingement.

Anterior Ankle Impingement: Patient History. and Exam

• Patient History: History of recurrent ankle sprains, pain/limited mobility with squat, and pain/limited mobility with descending stairs/ascending hills.
• Physical Examination: Limited and painful ankle dorsiflexion range of motion in a closed chain, decreased talocrural joint mobility, and pain/limited mobility with single-leg squat.

Anterior Ankle Impingement: Management

• Nonoperative: Relative rest, activity modification, heel lift in an acute phase, manual therapy , NSAIDs, and corticosteroid injection.
• Depends on severity and bony exostoses.
• Operative: Arthroscopic debridement.

Ankle Osteoarthritis (OA)

• Progressive gradual loss of cartilage results in joint-related changes, stiffness, and pain.
• patients can have radiographic findings of OA without pain.

Ankle Osteoarthritis: Prevalence

• 13.9% prevalence ofradiographic ankle OA in patients > 50 years old.
• 1.2-3.4% prevalence of symptomatic radiographic ankle OA.
• Epidemiology of Ankle OA: 70% were post-traumatic, 12% were rheumatoid disease, and 7% were idiopathic.

Ankle Osteoarthritis: Clinical Presentation

• Typically a post-traumatic onset, especially rotational injuries.
• patients may report having a significant injury to their ankle earlier in their life.
• Gradual worsening over time.
• Stiffness after prolonged rest, especially in the morning.
• Pain with weight-bearing activities, like walking and stairs.
• Limited ankle range of motion.
• Stiffness with passive range of motion.
• Hypomobility with joint passive accessory examination.

Ankle Osteoarthritis: Management

• Patient education, strengthening and proprioception exercises of ankle muscles, talocrural joint mobilizations, rocker bottom footwear, and orthoses or taping.
• Pharmacological Management: NSAIDs, low dose paracetamol, intra-articular corticosteriods, hyaluronic acid injection, and platelet-rich plasma.
• Operative Management: Ankle arthroscopy and debridement, as well as ankle arthrodesis.

Medial Ankle Pain

• Posterior Tibial Tendinopathy.
• Tarsal Tunnel Syndrome.

Posterior Tibial Tendinopathy

• Is also referred to as posterior tibial tendon dysfunction (PTTD).
• Progressive microtrauma and insufficiency of the posterior tibialis tendon.
• Classified into 4 stages.
• 5-15% of general population.
• Risk factors: Caucasian, women, age > 40 years old, obesity, diabetes, and hypertension.

Posterior Tibial Tendinopathy: Body chart

• Localized, achy.
• Superficial.

Posterior Tibial Tendon Dysfunction Stages

• Stage 1: no deformity; mild pain and swelling at the medial ankle; normal heel raise test, but weakness with endurance testing; normal tendon length; and tenosynovitis present.
• Stage 2: deformity is flexible; moderate medial ankle and foot pain; pain and/or weakness with heel raise test; increased tendon length; and longitudinal tears in the tendon.
• Stage 3: deformity is rigid; severe pain, both medially and laterally at the ankle and foot; abnormal heel raise test; and tendon tearing.
• Stage 4: Talus is tilted laterally; flexible ankle valgus; no severe arthritic changes; and rigid ankle valgus.

Posterior Tibial Tendinopathy: Clinical Presentation - Early Stages

• Pain increased with waling and standing.
• Pain and, or swelling along the medial foot and ankle.
• Standing on toes may be painful and difficult.
• Inability to invert the heel with single limb heel raise.
• Pain and weakness with resisted plantarflexion and inversion.
• Forefoot may be abducted ''too many toes sign''.
• Pronatory foot type on FPI-6.
• Positive navicular drop test.

Posterior Tibial Tendinopathy: Management - Early Stages

• Patient education, relative rest, orthotics and taping, foot intrinsic strengthening, gastrocnemius/Soleus flexibility, and talocrurla joint mobilization.

Posterior Tibial Tendinopathy: Clinical Presentation - Later Stages

• Pain may shift laterally because of calcaneofibular or lateral subtalar impingement
• Medial pain may disappear.
• Progressive collapse of the medial longitudinal arch.
• Development of severe hindfoot valgus.

Posterior Tibial Tendinopathy: Management - Later Stages

• Orthotics and ankle-foot orthosis, foot intrinsic strengthening, and talocrural joint mobilizations..
• Operative Management may be warranted if continued pain and disability: Tendon transfer, triple arthrodesis, and total ankle arthroplasty.

Tarsal Tunnel Syndrome

• Tibial nerve irritation or entrapment neuropathy in the tarsal tunnel.
• Made up of flexor retinaculum that runs from the medial malleolus posteriorly to the calcaneus.
• Tibial nerve runs underneath the roof of the flexor retinaculum.

Tarsal Tunnel Syndrome: Body Chart

• Generalized.
• Achy, numbness.
• Superficial.

Tarsal Tunnel Syndrome: Clinical Presentation

• Patient History: Pain and paresthesias in medial ankle, heel, and/or foot;Aggravating factors: walking, running, standing; onset may be slow and insidious or post-traumatic
• Poorly localized burning sensation, pain, and/or paresthesias, possible numbness and/ or weakness in ankle or foot.
• Physical Examination: Patient symptoms with passive eversion, Positive Tinel's sign, Positive dorsiflexion-eversion test, Positive triple compression test, and Positive straight leg raise with dorsiflexion/eversion.

Tarsal Tunnel Syndrome: Management

• Orthoses and/or taping to limit excessive pronation, gastrocnemius and soleus flexibility, talocrural mobilization, nerve mobilization, and posterior tibialis and foot intrinsic strengthening.
• Operative management if failed non-operative management: Decompression of the tarsal tunnel.

Leg Pain (BSI, MTSS, CECS)

• BSI (Bone stress injury)
• MTSS (Medial tibial stress syndrome)
• CECS (Chronic exertional compartment syndrome)

Bone Stress Injury (BSI): Pathophysiology

• Bone loading → Bone strain → no damage or strain-related remodeling OR bone damage (damage-related remodeling).
• Imbalance between damage and remodeling → accumulation of damage →stress reaction
• Stress fracture.
• Complete bone fracture.

Pathophysiology: Schematic Representation

• Micro cracks in bone form initiating osteocyte apoptosis or cell program death.
• Calcium channeling signaling attracting osteoclasts.
• Osteoclast forming reabsorption cavities at the side of the micro damage, clearing the damage but temporarily weakening the bone.
• Create a callous to repair the micro damage.
• With a bone stress injury, more damage occurs at a faster rate than osteoblasts can lay down new bone.

BSI: High-and-Low-Risk

• Low risk tends to heal well with activity modification with continued weight bearing.
• High-risk stress fractures may require more aggressive treatment, such as restricted weight bearing or surgery.

Epidemiology

• 1/3 to 2/3 of competitive cross-country and long-distance runners have a history of BSI.
• Recurrence rate in cross country and track athletes = 10.3 - 12.6%.

Risk Factors for Bone Stress Injury (BSI)

• Prior BSI & BMI < 19 kg/m^2, menarche greater than or equal to 15 years, and past participation in dance or gymnastics (for women only)..
• If they have two of these risk factors, it increases their risk to 13%
• If having all four increases the risk of BSI to 36%
• For Men Risk Factors: Prior BSI and lack of playing ball sports..
• With one RF there Is a 7% risk of BSI, with both RF= 33%.

Relative Energy Deficiency in Sport (RED-S)

• Reduced energy availability (LEA): inadequate energy availability
• CAN lead to increased detrimental health outcomes (RED-S).
• One component of screening is performed using the RED-S Clinical Assessment Tool (CAT-2).

Bone Stress Injury Medical History

• Gradual onset of localized pain.
• Recent increase in weight-bearing activity.
• Pain worsened during and/or after weight-bearing activity
• Demonstrate risk factors for BSI.
• May report findings consistent with RED-S.

Military Study and Stress Fractures

• Peak occurrence weeks 5-8.
• Highlights the importance of training variability within the first two months of establishing a new training program. Training should include relative rest days and rest weeks where mileage is decreased for athletes.

Bone Stress Injury (BSI): Point Tenderness

• < 10 cm of bone tenderness.
• Additional literature suggests