Lower leg, ankle, and foot pathologies | NPTE-PTA Comparing clinical presentation and interventions for lower extremity

Acetaminophen and NSAIDs are the standard first-line analgesic/anti-inflammatory management for the conditions on this page; additional or different medical management is called out where it applies.

Conditions of the lower leg

Acute compartment syndrome

Increased compartment pressure of the lower leg (specifically, the anterior, lateral, and posterior areas)
- Commonly caused by direct trauma or fracture
Symptoms (six P’s)
- Pain in the lower leg, out of proportion to the injury and worse with passive stretch of the compartment muscles
- Poikilothermia (coolness) in the lower leg
- Paresthesia to the lower leg - specifically to the deep peroneal nerve
- Paralysis/paresis of the lower leg, specifically of the deep peroneal nerve
- Pallor to the lower leg
- Pulselessness in the dorsal pedal artery

Pain and paresthesia are the earliest signs to appear. A palpable pulse does not rule out compartment syndrome - pulselessness is a late sign.

Diagnosis
- Clinical presentation
Medical management
- Medical emergency: immediate fasciotomy is indicated to relieve pressure and decrease the likelihood of prolonged neurovascular compromise
Physical therapy management
- Post-operatively, physical therapy to ensure return to normal function

PTA role and pitfall: Acute compartment syndrome is a medical emergency, not a condition to treat with exercise. If any of the six P’s emerge or worsen during a session, stop the activity, take vital/neurovascular measurements, and notify the supervising PT or physician immediately rather than continuing the plan of care. This is different from chronic exertional compartment syndrome (below), which develops gradually with activity and resolves with rest.

Cross-sectional view of lower leg compartments and bones. — Cross-sectional view of lower leg

Chronic exertional compartment syndrome

Increased compartment pressure of the lower leg (specifically, the anterior, lateral, and posterior areas), causing a restriction in blood flow
- Develops gradually over a period of time due to repetitive movements and exertional activities
- Most often involves the anterior compartment and is frequently bilateral
Symptoms
- Pain
- Numbness and tingling
- Weakness
- Swelling
- Tightness
- Foot drop
Diagnosis
- Clinical presentation
- Compartment pressure testing before and after exercise
Medical management
- Fasciotomy if symptoms persist despite activity modification
Physical therapy management
- Functional training, proprioceptive training
- Decrease exacerbating activity
- May require the use of orthoses

Stress fractures

Microfractures to the tibia, fibula, or bones of the foot and ankle due to overuse (repetitive micro-traumas to the tibia or fibula)
- Commonly due to poor alignment of the lower extremity when performing activity, deconditioning, or improper training
Symptoms
- Localized sharp pain that gradually worsens with activity
- Mild swelling may occur around the fracture site
- The affected area may feel weak or unstable
- Difficult to put weight on the injured area
- Early pain eases with rest; pain at rest develops as the injury progresses
Diagnosis
- Clinical presentation reproduced with percussion
- X-rays are often negative for the first 2-3 weeks; bone scan or MRI confirms the diagnosis
Physical therapy management
- Initially decreased exacerbating activity
- Correction of malalignment and biomechanical issues
- Strengthening and coordinating activities

Medial tibial stress syndrome (shin splints) causes similar activity-related pain but is diffuse along the tibia without a focal point, unlike the localized point tenderness of a stress fracture. Treatment of shin splints begins with several weeks of rest from the activity that caused the pain and cold packs for 20 minutes at a time, several times a day.

Ankle and foot conditions

Ligament sprains

Classification of sprains
- Grade 1
  - A mild sprain where the ligament is stretched or slightly torn
  - Symptoms include minor swelling, tenderness, and bruising
  - Recovery time is usually 1-3 weeks
- Grade 2
  - A moderate sprain where the ligament is partially torn
  - Symptoms include swelling, bruising, pain, and difficulty walking
  - Recovery time is usually 3-6 weeks
- Grade 3
  - A severe sprain where the ligament is completely torn
  - Symptoms include severe pain, swelling, bruising, and instability
  - Recovery time can be several months
A high ankle sprain injures the ligaments between the tibia and fibula when the foot is flexed upward and then twisted; squeezing the tibia and fibula together causes pain higher up the leg
Symptoms
- See specific grade for symptoms associated
Diagnosis
- Clinical presentation, ligament laxity
  - Special tests:
    - Anterior drawer (Anterior talofibular ligament)
    - Talar tilt (inversion stresses the calcaneofibular ligament; eversion stresses the deltoid ligament)
Medical management
- Grade 2: immobilization device may be recommended
- Grade 3 sprains are usually managed conservatively with immobilization/bracing and functional rehabilitation; surgery is reserved for chronic instability or failed conservative care
Physical therapy management
- Grade 1: conservative management of rest, ice, compression, and elevation acutely; then functional mobility training
- Grades 2 and 3:
  - Functional mobility training
  - Biomechanical fault realignment
  - Joint protection and mobility
  - Post-surgical protocols if surgery is indicated

Achilles tendinopathy

Chronic degeneration (tendinosis) of the Achilles tendon due to overuse, age, rheumatoid arthritis, or gout
Symptoms
- Pain, typically located in the back of the heel or just above it
- Tenderness and stiffness in the Achilles tendon
- Swelling and redness around the tendon
- Pain that worsens with activity and improves with rest
Diagnosis
- Clinical presentation
  - Thompson’s test to rule out Achilles tendon rupture
Medical management
- Corticosteroid injection is generally avoided (risk of tendon weakening and rupture)
- Management of rheumatoid arthritis or gout
Physical therapy management
- Interventions follow the PT’s plan of care for the stage of healing (for example, relative rest and pain control acutely, then progressive tendon loading - eccentric or heavy slow resistance calf exercise, the first-line evidence-based intervention)
- The PTA monitors the pain response to loading and reports any worsening, or a sudden pop or loss of push-off strength, to the supervising PT

Peroneal tendon subluxation

Peroneal tendon subluxation is linked to laxity or rupture of the superior peroneal retinaculum and causes painful clicking or popping at the lateral malleolus

Plantar fasciitis

Degeneration or irritation of the plantar fascia at its origin on the medial calcaneal tubercle, caused by overuse, tight calf musculature, or biomechanical faults such as pes planus or pes cavus
Symptoms
- Classic first-step pain: sharp heel pain with the first steps in the morning or after rest, which eases somewhat with continued activity
- Tenderness at the medial calcaneal tubercle
Diagnosis
- Clinical presentation and palpation at the medial calcaneal tubercle
Medical management
- NSAIDs; corticosteroid injection only for refractory cases (risk of fascia rupture or fat pad atrophy)
Physical therapy management
- Plantar fascia and calf stretching
- Taping or orthoses
- Night splints

Plantar fasciitis and tarsal tunnel syndrome both cause plantar foot pain but present differently: plantar fasciitis produces localized first-step heel pain at the medial calcaneal tubercle, while tarsal tunnel syndrome produces neural burning or tingling with a positive Tinel’s sign.

Tarsal tunnel syndrome

Entrapment of the posterior tibial nerve within the tarsal tunnel
- Caused by compression from overpronation/flat foot, trauma, space-occupying lesions (ganglion, varicosities), or tenosynovitis of the medial ankle tendons
Symptoms
- Numbness and tingling in the sole, arch, or toes.
- Burning or shooting pain may radiate from the ankle to the foot or calf
- Swelling or redness
- Pain that improves with rest
Diagnosis
- Clinical presentation
  - Special test: Tinel’s sign
- Electrodiagnostic testing
Medical management
- Surgical intervention if conservative management is not effective
Physical therapy management
- Joint mobility
- Functional exercise training
- Orthoses
- Neurotension stretching

Posterior tibial tendon dysfunction

Posterior tibial tendon dysfunction is the most common cause of adult-acquired flatfoot; it begins with medial ankle and foot pain, and collapse of the medial longitudinal arch follows

Foot deformities

Pes cavus - high arch foot
- Due to genetics or biomechanical faults
Pes planus - absent arch foot, overpronation
- Due to genetics, age, obesity, or biomechanical faults
Equinus - plantar flexed foot
- Can be due to genetics, bone deformity, or neurological conditions
Talipes equinovarus - club foot (plantar flexion and inversion)
- Due to congenital deformity
Rearfoot varus - inversion of the calcaneus when the subtalar joint is in neutral
Rearfoot valgus - eversion of the calcaneus when the subtalar joint is in neutral
Forefoot varus - inversion of the forefoot when the subtalar joint is in neutral
Forefoot valgus - eversion of the forefoot when the subtalar joint is in neutral
Symptoms
- Observation of the foot as noted above; abnormalities in gait due to uneven levers
Diagnosis
- Clinical presentation and observation
Medical management
- Management of underlying causes as appropriate; congenital clubfoot (talipes equinovarus) is corrected with serial stretching and casting (Ponseti method) starting shortly after birth
Physical therapy management
- Improved biomechanical alignment
- Orthoses as appropriate
- Joint mobility
- Patient education

Tarsal coalition

A tarsal coalition is an abnormal connection of two or more foot bones that can cause a severe, rigid flatfoot, with symptoms usually appearing in late childhood or early adolescence as the connection hardens

Charcot-Marie-Tooth disease

Progressive disorder causing peroneal muscular atrophy and involvement of the peroneal nerves - causing motor and sensory deficits
- Genetic disorder
- Begins in the lower legs but can progress to the forearm and hands
Symptoms
- Foot and leg weakness
- Foot abnormalities: high arches, hammertoes, and flat feet
- Foot drop with a steppage gait due to weakness of the ankle dorsiflexors
- Numbness, tingling, and burning sensations in the lower leg
- Muscle atrophy in the feet and legs
- Clumsiness and difficulty with fine motor skills
Diagnosis
- Clinical presentation
- Electrodiagnostic exam
- Genetic testing
Medical management
- Surgical correction of joint abnormalities as deemed appropriate
- Chronic inflammatory demyelinating polyneuropathy (CIDP), an acquired peripheral neuropathy, is treated with intravenous immune globulin and glucocorticoids
Physical therapy management
- Progressive disorder with no cure, so physical therapy follows the PT’s plan of care and centers on patient education, skin assessments for possible development of wounds, contracture prevention/management, and functional mobility training