As with the hip and knee, acetaminophen and NSAIDs are the standard first-line analgesic/anti-inflammatory management here; additional or different medical management is called out where it applies.

Conditions of the lower leg

Acute compartment syndrome
- Increased compartment pressure of lower leg (specifically- anterior, lateral, and posterior areas)
  - Commonly caused by direct trauma or fracture
Symptoms (six P’s)
- Pain in the lower leg
- Palpable tenderness in the lower leg
- Paresthesia to the lower leg - specifically to the deep peroneal nerve
- Paresis of the lower leg, specifically of the deep peroneal nerve
- Pallor to the lower leg
- Pulselessness in the dorsal pedal artery
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
  - Typically occurring in only one compartment of the lower leg
Symptoms
- Pain
- Numbness and tingling
- Weakness
- Swelling
- Tightness
- Foot drop
Diagnosis
- Clinical presentation
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
- Pain may be more severe at night or when resting
Diagnosis
- Clinical presentation reproduced with percussion
- Bone scan
- MRI
Physical therapy management
- Initially decreased exacerbating activity
- Correction of malalignment and biomechanical issues
- Strengthening and coordinating activities

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
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
- Corticosteroids
- Management of rheumatoid arthritis or gout
Physical therapy management
- Determine the phase (acute vs subacute vs chronic) and make an appropriate selection of interventions based on the phase of healing
Tarsal tunnel syndrome
- Entrapment of the posterior tibial nerve within the tarsal tunnel
  - Overuse injury due to tendonitis of the posterior tibialis
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
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
Symptoms
- Observation of the foot as noted above
Diagnosis
- Clinical presentation and observation
Medical management
- Management of underlying causes as appropriate
Physical therapy management
- Improved biomechanical alignment
- Orthoses as appropriate
- Joint mobility
- Patient education
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
Physical therapy management
- Progressive disorder with no cure, so physical therapy interventions are centered around patient education, skin assessments for possible development of wounds, contracture prevention/management, and functional mobility assessment/training
Foot deformities
- Rearfoot varus
  - Inversion of calcaneus when the subtalar joint is in neutral
- Rearfoot valgus
  - Eversion of calcaneus when the subtalar joint is in neutral
- Forefoot varus
  - Inversion of the forefoot when the subtalar is in neutral
- Forefoot valgus
  - Eversion of forefoot when the subtalar is in neutral
Diagnosis of foot deformities
- Clinical presentation and observation
Symptoms
- Abnormalities in gait due to uneven levers
Medical management
- None indicated
Physical therapy management
- Improving foot alignment
- Orthoses as appropriate
- Strengthening as appropriate

Acute compartment syndrome

Increased pressure in lower leg compartments (anterior, lateral, posterior); caused by trauma/fracture
Six P’s: Pain, Palpable tenderness, Paresthesia (deep peroneal nerve), Paresis, Pallor, Pulselessness (dorsal pedal artery)
Medical emergency — requires immediate fasciotomy
PTA pitfall: never treat with exercise; if six P’s appear/worsen, stop and notify PT/physician immediately

Chronic exertional compartment syndrome

Gradual pressure increase from repetitive activity, usually one compartment
Symptoms: pain, numbness/tingling, weakness, swelling, tightness, foot drop
PT management: functional/proprioceptive training, activity modification, orthoses
Resolves with rest (unlike acute form)

Stress fractures

Microfractures of tibia/fibula/foot bones from overuse, malalignment, deconditioning
Symptoms: localized sharp pain worsening with activity, mild swelling, instability, worse at night
Diagnosis: percussion reproduces pain, bone scan, MRI
PT management: decrease aggravating activity, correct malalignment, strengthening/coordination

Ligament sprains

Graded 1 (mild, stretch) to 3 (severe, complete tear); recovery ranges 1-3 weeks to several months
Diagnosis: anterior drawer (ATFL), talar tilt (inversion=calcaneofibular, eversion=deltoid)
Medical management: Grade 2 may need immobilization; Grade 3 usually conservative, surgery only for chronic instability
PT management: RICE acutely (Grade 1), functional mobility training, biomechanical correction, post-surgical protocols as needed

Achilles tendinopathy

Chronic tendon degeneration (tendinosis) from overuse, age, RA, or gout
Symptoms: heel pain/tenderness/stiffness, swelling, worsens with activity
Diagnosis: Thompson’s test (rules out rupture)
Medical management: corticosteroids, treat underlying RA/gout
PT management: intervention selection based on healing phase (acute/subacute/chronic)

Tarsal tunnel syndrome

Posterior tibial nerve entrapment, often from posterior tibialis tendonitis
Symptoms: numbness/tingling in sole/arch/toes, burning pain radiating ankle to foot/calf
Diagnosis: Tinel’s sign, electrodiagnostic testing
Medical management: surgery if conservative care fails
PT management: joint mobility, functional training, orthoses, neurotension stretching

Foot deformities (general)

Types: pes cavus (high arch), pes planus (flat/overpronation), equinus (plantar flexed), talipes equinovarus (clubfoot)
Diagnosis: clinical observation
PT management: biomechanical alignment, orthoses, joint mobility, patient education

Charcot-Marie-Tooth disease

Genetic, progressive peroneal muscular atrophy causing motor/sensory deficits
Symptoms: foot/leg weakness, high arches/hammertoes/flat feet, foot drop with steppage gait, numbness/tingling, muscle atrophy
Diagnosis: electrodiagnostic exam, genetic testing
No cure — PT focuses on education, skin checks, contracture prevention, functional mobility

Foot deformities (rearfoot/forefoot varus-valgus)

Rearfoot varus/valgus: calcaneal inversion/eversion with subtalar neutral
Forefoot varus/valgus: forefoot inversion/eversion with subtalar neutral
Symptoms: gait abnormalities from uneven levers
No medical management indicated
PT management: alignment correction, orthoses, strengthening

Next | 5.10 Spine and pelvis anatomy

Lower leg, ankle, and foot pathologies

As with the hip and knee, acetaminophen and NSAIDs are the standard first-line analgesic/anti-inflammatory management here; additional or different medical management is called out where it applies.

Conditions of the lower leg

Acute compartment syndrome
- Increased compartment pressure of lower leg (specifically- anterior, lateral, and posterior areas)
  - Commonly caused by direct trauma or fracture
Symptoms (six P’s)
- Pain in the lower leg
- Palpable tenderness in the lower leg
- Paresthesia to the lower leg - specifically to the deep peroneal nerve
- Paresis of the lower leg, specifically of the deep peroneal nerve
- Pallor to the lower leg
- Pulselessness in the dorsal pedal artery
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

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
  - Typically occurring in only one compartment of the lower leg
Symptoms
- Pain
- Numbness and tingling
- Weakness
- Swelling
- Tightness
- Foot drop
Diagnosis
- Clinical presentation
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
- Pain may be more severe at night or when resting
Diagnosis
- Clinical presentation reproduced with percussion
- Bone scan
- MRI
Physical therapy management
- Initially decreased exacerbating activity
- Correction of malalignment and biomechanical issues
- Strengthening and coordinating activities

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
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
- Corticosteroids
- Management of rheumatoid arthritis or gout
Physical therapy management
- Determine the phase (acute vs subacute vs chronic) and make an appropriate selection of interventions based on the phase of healing
Tarsal tunnel syndrome
- Entrapment of the posterior tibial nerve within the tarsal tunnel
  - Overuse injury due to tendonitis of the posterior tibialis
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
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
Symptoms
- Observation of the foot as noted above
Diagnosis
- Clinical presentation and observation
Medical management
- Management of underlying causes as appropriate
Physical therapy management
- Improved biomechanical alignment
- Orthoses as appropriate
- Joint mobility
- Patient education
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
Physical therapy management
- Progressive disorder with no cure, so physical therapy interventions are centered around patient education, skin assessments for possible development of wounds, contracture prevention/management, and functional mobility assessment/training
Foot deformities
- Rearfoot varus
  - Inversion of calcaneus when the subtalar joint is in neutral
- Rearfoot valgus
  - Eversion of calcaneus when the subtalar joint is in neutral
- Forefoot varus
  - Inversion of the forefoot when the subtalar is in neutral
- Forefoot valgus
  - Eversion of forefoot when the subtalar is in neutral
Diagnosis of foot deformities
- Clinical presentation and observation
Symptoms
- Abnormalities in gait due to uneven levers
Medical management
- None indicated
Physical therapy management
- Improving foot alignment
- Orthoses as appropriate
- Strengthening as appropriate

Achievable NPTE-PTA

5. Musculoskeletal system

5.9. Comparing clinical presentation and interventions of lower extremity

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