Research outcome measures related to ankle foot complex indications of delorme boot

This presentation is about commonly used outcome measures of ankle foot complex. It also has information about delorme boot which a tool for progressive resisted exercise training

1. RESEARCH OUTCOME MEASURES RELATED TO ANKLE FOOT COMPLEX. INDICATIONS OF DELORME BOOT Presented by: Antu Anna Roy BPT Intern Medical Trust Institute of Medical Sciences , Kochi

2. JOINTS OF ANKLE FOOT COMPLEX The joints of the foot is divided into three sections: hind foot, mid foot and fore foot

3.  Hindfoot ( Rearfoot ) 1. Talocrural (Ankle) Joint. 2. Subtalar ( Talocalcanean ).  Midfoot 1. Talocalcaneonavicular joint. 2. Cuneocuboid Joint. 3. Cuneonavicular Joints 4. Cuboideonavicular joint 5. Calcaneocuboid Joint.  Fore foot 1. Tarsormetatarsal Joints. 2. Metatarsophalangeal Joints. 3. Interphalangeal joints.

4. IMPORTANT JOINTS Ankle Joint ( Talocrural ): The talocrural joint is a uniaxia (modified hinge, synovial joint) located between the talus, the medial malleolus of the tibia, and the lateral malleolus of the fibula. The movements possible at this joint are dorsiflexion and plantar flexion. Subtalar ( Talocalcaneal ) Joint: A gliding multiaxial synovial joint which consists of the talus on top and calcaneus on the bottom. The subtalar joint allows movements about an oblique axis, allowing the foot to side to side motion (inversion and eversion ).

5. Transverse tarsal joint: It is formed of 2 joints that lie side by-side. These are the talo-navicular joint (between the head of talus and navicular ), and calcaneo-cuboid joint (between the caleaneus and cuboid ). It is little to no motion and assists in eversion and inversion.

6. LIGAMENTS OF ANKLE JOINT The joint is supported by: Fibrous capsule Deltoid or medial ligament Anterior or tibionavicular fibers Middle or tibiocalcaneal fibers Posterior or tibiotalar fibers Lateral ligament Anterior talofibular ligament Posterior talofibular ligament Calcaneofibular ligament

7. MEDIAL LIGAMENT Deltoid ligaments: supports the medial side of ankle. It is triangular shapedwith apex at tip of medial malleolus and base at talus, navicular , calcaneus It has two major components

8. Superficial deltoid ligament which resist talar abduction and primarily resists eversion of hindfoot . Tibionavicular portion prevents inward displacement of head of talus, while tibiocalcaneal portion prevents valgus displacement. Deep deltoid ligament prevents lateral displacement of talus & prevents external rotation of the talus and latter effect is pronounced in plantar flexion, when deep deltoid tends to pull talus into internal rotation.

9. LATERAL LIGAMENTS Talofibular ligaments: from the lateral malleolus of the fibula to connects the talus and support the lateral side of the joint . Anterior Talofibular Ligament: It prevents anterior subluxation of talus when ankle is in plantar flexion. Posterior Talofibular Ligament: it prevents posterior and rotatory subluxation of the talus. Calcaneofibular : connecting lateral malleolus to calcaneus .It acts primarily to stabilize sub- talar joint & limit inversion. it is lax in normal, standing position due to relative valgus orientation of calcaneus

10. LIGAMENTS OF FOOT Spring ligament: attaches from calcaneus to navicular . It supports longitudinal arch and the head of talus especially in standing. Plantar aponeurosis : runs from calcaneus to proximal phalanges, ties posterior and anterior sections together and windlass action in ankle, where full dorsflexion is limited by plantar aponeurosis .

11. MOVEMENTS OF ANKLE JOINT Active movements of ankle joint are dorsiflexion and plantar flexion. In dorsiflexion , the forefoot is raised, and the ankle between the front of the leg and the dorsum of the foot is dimininshed . In plantar flexion, the forefoot is depressed, and the ankle between the leg and the foot is increased.

12. MUSCLES PRODUCING MOVEMENT Dorsi flexion Principal muscle : Tibialis Anterior Accessory muscles : Extensor Digitorum Longus , Extensor Hallucis Longus , Peroneus Tertius Plantar flexion Principal muscle : Soleus , Gastrocnemius Accessory muscles : Plantaris , Tibialis Posterior, Flexor Hallucis Longus , Flexor Digitorum Longus

13. MOVEMENTS OF FOOT The active movements taking place in the subtalar and talocalcaneonavicular joint is inversion and eversion . Inversion is a movement in which the medial border of the foot is elevated, so that sole faces medially. Eversion is a movement in which the lateral border of foot is elevated, so that the sole faces laterally. In inversion and eversion , the entire part of the foot below the talus moves together. The calcaneum and navicular bones move medially or laterally round the talus carrying the forefoot with them.

14. Pronation is composed of three cardinal plane components:  subtalar eversion , ankle dorsiflexion , and forefoot abduction. Supination is composed of inversion, ankle plantar flexion and adduction.

15. COMMON PATHOLOGIES OF ANKLE FOOT COMPLEX Injury to ligament Paralysis or spasticity Soft tissue injuries Fractures Neurological conditions

16. INJURIES OF LIGAMENTS ANKLE SPRAIN Injuries of the lateral ligament Ankle sprains usually occur on the lateral side because the joint capsule and ligaments are stronger on the medial side of the ankle. Mechanism of injury of ankle sprain is inversion of the supinated , plantarflexed foot . It usually occurs when the foot rolls over on the outside of the ankle. When the ligament is completely torn or detached from the fibula, the talus is free to tilt in the mortice of the tibia and fibula.

17. Injuries of Medial Ligament The medial ligament is immensely strong and if stressed in ankle joint injuries generally avulses the medial malleolus rather than itself tearing. Nevertheless tears do occur, and are seen particularly in conjunction with lateral malleolar fractures. A mechanism is combination of external rotation at ankle, abduction of hindfoot ,& eversion of forefoot while the upper body externally rotates over the fixed foot.

18. PARALYSIS OR SPASTICITY Tibialis Posterior : Paralysis of tibialis posterior alone causes a planovalgus deformity. Spasticity of Tibialis Posterior cause dynamic varus deformities of foot. Tibialis Anterior : Paralysis (polio) results in development of equinovalgus deformity. This is seen initially during swing phase of gait. Failure to raise the foot sufficiently during the early swing phase causes Toe drag.

19. Gastrocnemius-soleus paralyzed: The patient cannot rise on tiptoes, and the gait is severely affected because of inability to increase walking speeds beyond the normal pacing. However, despite uneven step lengths, patient will have uniform forward progression. Patient will have excessive dorsiflexion of the ankle and diminished plantar flexion on the involved side . The act of climbing stairs is awkward and slow, and activities such as running and jumping are all but impossible.

20. SOFT TISSUE INJURIES Footballer’s ankle: Repeated incidents of forced plantar flexion of the foot which result in tearing of the anterior capsule of the ankle joint. These may lead to mechanical restriction of dorsiflexion . Peroneal tendon disruption ( peroneus brevis tear): Mechanism of this injury is forced dorsiflexion with slight inversion and concomitant eccentric contraction of the peroneal muscles may produce a subluxation or dislocation of the peroneal tendons. Anterior ( Talotibial ) Impingement Syndrome: The mechanism of injury is repetitive forced dorsiflexion as demiplie position in ballet can lead to impingement of anterior lip of tibia on talar neck.

21. Posterior ( Talotibial ,) Impigement Syndrome: The mechanism of injury is repetitive, forced plantarflexion such as may occur with practicing karate kicks or dancing . Shortening of the Achilles tendon Mechanisms for tendinitis have been proposed by repeated tension or repeated loading .Shortening results in plantar flexion of the foot and clumsiness of gait as the heel fails to reach the ground (Insufficient push off).

22. Plantar Fasciltis : Mechanism of Injury are overuse or repetitive stretching of the plantar fascia associated with training errors or associated with incomplete rehabilitation (strengthening) following a previous ankle injury because weak peroneal muscles may inadequately support the arch. Thus placing additional stress on the plantar fascia. All of which reduce the foot’s shock absorbing capability.

23. FRACTURES Pott’s Fracture It is the fracture of both malleoli . It is caused by forced abduction or adduction force.

24. Fracture of Talus Injuries of talus are rare and result from fall from height or forced dorsiflexion injury to the ankle.

25. Fracture of Calcaneum Fracture of calcaneum results from a fall from height. The calcaneum is pushed up against talus and gets crushed.

26. Fracture of Metatarsals Fracture of metatarsals occurs due to fall of a heavy object on the foot or in road side accidents. The base of fifth metatarsal may be fractured by sudden pull of peroneus brevis muscle, due to forced inversion and plantar flexion of foot.

27. NEUROLOGICAL CONDITIONS Foot Drop It is a gait abnormality in which the dropping of the forefoot happens due to weakness, irritation or damage to the common fibular nerve including the sciatic nerve, or paralysis of the muscles in the anterior portion of the lower leg. It is usually a symptom of a greater problem, not a disease in itself. It is characterized by inability or impaired ability to do dorsiflexion . Person shows high stepping gait.

28. Diabetic Foot A diabetic foot is a foot that exhibits any pathology that results directly from diabetes mellitus or any long-term (or "chronic") complication of diabetes mellitus. Due to the peripheral nerve dysfunction associated with diabetes (diabetic neuropathy), patients have a reduced ability to feel pain.  In diabetes, peripheral nerve dysfunction can be combined with peripheral artery disease(PAD) causing poor blood circulation to the extremities (diabetic angiopathy ).

29. RESEARCH OUTCOME MEASURES RELATED TO ANKLE FOOT COMPLEX

30. WHAT IS AN OUTCOME MEASURE? An  outcome measure  is the result of a test that is used to objectively determine the baseline function of a patient at the beginning of treatment. Once treatment has commenced, the same instrument can be used to determine progress and treatment efficacy. With the move towards Evidence Based Practice (EBP) in the health sciences, objective measures of outcome are important to provide credible and reliable justification for treatment. The instrument should also be convenient to apply for the therapist and comfortable for the patient.

31. OUTCOME MEASURES OF ANKLE FOOT COMPLEX Foot and Ankle Disability Index(FADI) Foot and Ankle Ability Measure(FAAM) American Orthopedic Foot and Ankle Society Score(AOFAS) Foot Function Index(FFI) Foot and Ankle Outcome Score(FAOS) Manchester Foot Pain and Disability Index Olerud and Molander Ankle Score Lower Extremity Functional Scale(LEFS)

32. FOOT AND ANKLE DISABILITY INDEX(FADI) FADI is a region specific self report of function. It is a 34 item questionnaire divided into 2 subscales: FADI & FADI sports The FADI has 26 items in which 4 are pain related and 22 activity related. FADI sport has 8 items FADI has a total point value of 104 points Each of the 26 items is scored on a 5 point Likert scale from : 4 – no difficulty at all 3 – slight difficulty 2 – moderate difficulty 1 – extreme difficulty 0 – unable to do

33. FOOT AND ANKLE ABILITY MEASURE(FAAM) FAAM is a self reported outcome instrument developed to assess physical function for individuals with foot and ankle related impairment. It is a 29 item questionnaire divided into 2 subscales: FAAM, 21 item activities of daily life & FAAM, 8 items sports subscale. FAAM is identical to FADI except for an additional 5 items found on the FADI. Each item is scored on a 5 point Likert scale. Items score total ranges from 0-84 in ADL subscale and 0-32 for sports subscale, and transformed to percentage scores..

34. Foot and Ankle Ability Measure (FAAM) Activities of Daily Living Subscale Please Answer every question with one response that most closely describes your condition within the past week. If the activity in question is limited by something other than your foot or ankle mark “Not Applicable” (N/A). No Slight Moderate Extreme Unable N/A Difficulty Difficulty Difficulty Difficulty to do Standing 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Walking on even Ground 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Walking on even ground 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 without shoes Walking up hills 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Walking down hills 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Going up stairs 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Going down stairs 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Walking on uneven ground 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Stepping up and down curbs 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Squatting 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Coming up on your toes 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Walking initially 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Walking 5 minutes or less 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 Walking approximately 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 10 minutes Walking 15 minutes or 􀀀 􀀀 􀀀 􀀀 􀀀 􀀀 greater

35. AMERICAN ORTHOPEDIC FOOT AND ANKLE SOCIETY SCORE (AOFAS) It is one of the most commonly used clinician reporting tools for foot and ankle conditions. It measures outcomes on four different anatomical areas of the foot:- the ankle- hindfoot , midfoot , metatarsophalangeal (MTP)- interphalangeal (IP) for the hallux and MTP-IP for the lesser toes. The four anatomic regions of the foot are all represented by a different version of the survey with each tool designed to be used independently. The questionnaire consists of nine items that are distributed over three categories: Pain (40 points), function (50 points) and alignment (10 points). These are all scored together for a total of 100 points.

36. FOOT FUNCTION INDEX(FFI) A Foot Function Index (FFI) was developed to measure the impact of foot pathology on function in terms of pain, disability and activity restriction. It has been shown to be a reasonable tool for use with low functioning individuals with foot disorders and patients with rheumatoid arthritis and non-traumatic foot or ankle problems. It may not be appropriate for individuals who function at or above the level of independent activities of daily living. 

37. The FFI (questionnaire) consists of 23 self-reported items divided into 3 subcategories, namely: pain, disability and activity limitation. The patient has to score each question on a scale from 0 (no pain or difficulty) to 10 (worst pain imaginable or so difficult it requires help), that best describes their foot over the past week. The pain subcategory consists of 9 items and measures foot pain in different situations, such as walking barefoot versus walking with shoes. The disability subcategory consists of 9 items and measures difficulty performing various functional activities because of foot problems, such as difficulty climbing stairs. The activity limitation subcategory consists of 5 items and measures limitations in activities because of foot problems, such as staying in bed all day. Recorded on a visual analogue scale (VAS), scores range from 0 to 100, with higher scores indicating worse pain.

38. Foot Function Index No Pain 1 2 3 4 5 6 7 8 9 10 Worst Pain Imaginable Pain Subscale: How severe is your foot pain: Foot pain at its worst? Pain standing with shoes? Foot pain in morning? Pain walking with orthotics? Pain walking barefoot? Pain standing with orthotics? Pain standing barefoot? Foot pain at end of day? Pain walking with shoes?

39. Disability Subscale: How much difficulty did you have: Difficulty walking in house? Difficulty standing tip toe? Difficulty walking outside? Difficulty getting up from chair? Difficulty walking 4 blocks? Difficulty climbing curbs? Difficulty climbing stairs? Difficulty walking fast? Difficulty descending stairs?

40. Activity Limitation Subscale: How much of the time do you: Stay inside all day because of feet? Use assistive device indoors? Stay in bed because of feet? Use assistive device outdoors? Limit activities because of feet? Score: ____/230 points (MDC: 7 points; No Disability “0”)

41. FOOT AND ANKLE OUTCOME SCORE(FAOS) FAOS was developed to assess the patients opinion about a variety of foot and ankle related problems. FAOS has this far been used in patients with lateral ankle instability, Achilles tendinitis, and plantar fasciitis. FAOS is a 42 item questionnaire consists of 5 subscales; Pain, other Symptoms, Function in daily living (ADL), Function in sport and recreation (Sport( Rec ), and foot and ankle-related Quality of Life (QOL). The last week is taken into consideration when answering the questionnaire. Standardized answer options are given (% Likert boxes) and each question gets a score from 0 to 4. A normalized score (100 indicating no symptoms and 0 indicating extreme symptoms) is calculated for each subscale.

42. MANCHESTER FOOT PAIN AND DISABILITY INDEX The Manchester Foot Pain and Disability Index (MFPDI) is a Patient Reported Outcome (PRO) measure developed and validated to measure pain specifically related to a foot disability. The MFPDI is a suitable instrument for assessing the impact of painful foot conditions in community and clinical populations. The MFPDI is a self-administered, paper based PRO consisting of 19-items assessing foot pain and disability. The PRO contains three constructs (four subscales) which reflect disabilities associated with foot pain and two additional items relating to work and leisure

43. The three constructs identified within the MFPDI are: Functional limitation (10 items) Pain intensity (7 items) Personal appearance (2 items) Responses are recorded on a three point scale: None of the time On some days On most /every day(s)

44. MANCHESTER FOOT PAIN AND DISABILITY INDEX – ENGLISH VERSION Below are some statements about problems people have because of pain in their feet. For each statement indicate if this has applied to you during the past month. If so, was this only on some days or on most or every day in the past month? None of On some On most/ the time days every day/s Because of pain in my feet: I feel self-conscious about my feet    I get self-conscious about the shoes I have to wear    I have constant pain in my feet    My feet are worse in the morning    My feet are more painful in the evening    I get shooting pains in my feet    I still do everything but with more discomfort   

45. None of On some On most/ the time days every day/s Because of pain in my feet: I avoid walking outside at all    I avoid walking long distances    I don’t walk in a normal way    I walk slowly    I have to stop and rest my feet    I avoid hard or rough surfaces when possible    I avoid standing for a long time    I catch the bus or use the car more often    I need help with housework / shopping    I get irritable when my feet hurt   

46. None of On some On most/ Not the time days day/s applicable Because of pain in my feet: I am unable to carry out my previous     work I no longer do all my previous activities     (sport, dancing, hill-walking, etc)

47. OLERUD-MOLANDER AN KLE SCORE(OMAS) Olerud-Molander Ankle Score (OMAS), is an ordinal rating scale from 0 points (totally impaired function) to 100 points (completely unimpaired function) It is related to 9 different items given different points: pain, stiffness, swelling, stair climbing, running, jumping, squatting, supports and work/activity level. Commonly used to assess patients with ankle fractures

48. LOWER EXTREMITY FUNCTIONAL SCALE(LEFS) The LEFS is a self-report questionnaire. Patients answer the question "Today, do you or would you have any difficulty at all with:" in regards to twenty different everyday activities. Patients select an answer from the following scale for each activity listed: Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty The patient's score is tallied at the bottom of the page. The maximum possible score is 80 points, indicating very high function. The minimum possible score is 0 points, indicating very low function.

49. INDICATIONS OF DELORME BOOT

50. PROGRESSIVE RESISTANCE EXERCISE A system of dynamic resistance training in which a constant external load is applied to the contracting muscle by some mechanical means. The concept of PRE was introduced over 60 years ago by Delorme . Delorme studied and proposed the use of 3 sets of a percentage of 10-RM with progressive load during each set. Other investigators developed a regimen, the oxford technique, with regressive loading in each set.

51. DELORME BOOT Delorme boot is a weighted device used for progressive resisted exercise training. It is made of aluminium casting with rods for holding weights. The boot is used for quadriceps strengthening and strengthening of ankle dorsiflexors through progressive resistance exercise.

52. PARTS OF BOOT It has an aluminium cast base for ankle support. The boot consist of a collor and a rod to hold weight to give progressive graded exercise. The boot has two straps to secure the foot firmly in place.

53. METHOD OF APPLICATION Patient position: sitting position with knee 90* flexed Ask the patient to pull his foot up ( dorsiflex ) and bring down (plantar flex) simultaneously. The weights are added according to the repetition maximum of the patient. Repetition maximum indicates the heaviest weight a person can lift with maximum effort in a single repetition.

54. Training using delorme boot induces contraction of dorsiflexors . It also increases the size and volume of muscle fiber . When the ankle goes into plantarflexion , the weight of the boot along with the pull of gravity causes lengthening of dorsiflexors giving an effect of stretching. For strengtehing of quadrieps , ask the patient to lift his leg up and down with knee in full extension.

55. USES OF BOOT For giving progressive graded resistance exercise Strengthening of dorsi flexors Lengthening of plantar flexors Strengthening of quadriceps To reduce tightness of antagonistic muscle Hypertrophy(increase in size) of muscle caused by increase in myofibrillar volume.

56. INDICATIONS OF BOOT COMMON PERONEAL NERVE INJURY The nerve supplies the anterior and lateral aspect of leg and dorsum of foot. Injury to common peroneal nerve causes weakness of dorsiflexors resulting in foot drop. Delorme boot can be used to give strengthening exercise to the dorsiflexors thus recovering normal gait pattern

57. LEPROSY Leprosy, also called Hansen's disease, is a chronic infectious disease that primarily affects the skin, the peripheral nerves, the mucosa of the upper respiratory tract, and the eyes. Leprosy can lead to progressive permanent damage of these structures, and the resulting devastating disfigurement and disability . When the disease affects the lateral popliteal nerve,the person will have weakness of dorsiflexors . Delorme boot can be used in strengthening of dorsiflexors .

58. Transfering of tibialis posterior tendon to the dorsum of the foot can restore dorsi flexion and prevent chances of ulcers. The insertion of tibialis posterior tendon into naviculum is detatched and is attached to tibialis anterior tendon. Delorme boot can be used to strengten tibialis anterior and lengethen the tibialis posterior muscles. It can be also used in training new action.

59. POST POLIO SYNDROME Post-polio syndrome (PPS) is a condition that affects polio survivors years after recovery from an initial acute attack of the poliomyelitis virus. Post-polio syndrome is mainly characterized by new weakening in muscles that were previously affected by the polio infection and in muscles that seemingly were unaffected. Ankle dorsiflexors are commonly affected in post polio syndrome. High intensity resistance training has proved to be effective in restoring muscle strength. Delorme boot can be used to give strengthening exercise to ankle muscles.

60. ACUTE ANKLE SPRAIN OR CHRONIC INSTABILITY Ankle sprain and ankle instability are common conditions of ankle complex. First line of rehabilitation focuses on cryotherapy and resting of ankle. Strength training is given in the later stages of rehabilitation. Strength training via delorme boot improves strength and stability of ankle. Increased stability also results improvements in gait and joint position sense.

61. TIBIAL STRESS SYNDROME(SHIN SPLINT) Shin splints is a common term for pain or inflammation in the front or inside section of the tibia. The patient will complain of tightness or tenderness and sometimes throbbing pain along the border of the tibia.  Anterior tibial stress is often experienced by new runners or walkers when pain occurs in the anterior muscles of the shin during exercise. Posterior shin splints (medial tibial pain) is a more chronic condition occurring along the inside edge of the tibia. It generally occurs with overuse during sports.

62. Initial treatment includes ice therapy and resting of the muscles. Later phase of rehabilitation includes stretching of the tight muscles and strengthening. Delorme boot can be used for stretching the plantar flexors in medial tibial syndrome. In lateral tibial syndrome, delorme boot can be used for strengthening the dorsi flexors. Inclusion of delorme boot as a strengthening measure in the fitness regimen of athelets can reduce the risk of developing shin splints.

63. PRONATION DISTORSION SYNDROME Pronation distortion syndrome is characterized by excessive foot pronation (flat feet) with concomitant knee internal rotation and adduction (“knock-kneed”).  Functionally tightened muscles that have been associated with pronation distortion syndrome include the peroneals , gastrocnemius , soleus , IT-band, hamstring, adductor complex, and tensor fascia latae (TFL). Functionally weakened or inhibited areas include the posterior tibialis , anterior tibialis , gluteus medius and gluteus maximus . 

64. First, inhibit the muscles that may be tight/overactive via self- myofascial release. The next step is to lengthen the tight muscles via static stretching. Key muscles to stretch include the gastrocnemius / soleus , TFL, bicep femoris and adductor complex.  Once the overactive muscles have been addressed, activate the underactive muscles. Key areas to target with isolated strengthening are the anterior tibialis via resisted dorsiflexion , posterior tibialis via a single-leg calf raise, gluteus medius via wall slides and gluteus maximus via floor bridges.  Delorme boot can be used in lengthening of tibialis posterior and strengthening of tibialis anterior.

65. EXTENSOR HALLUCIS LONGUS Weakness of extensor hallucis longus occurs in peroneal nerve injury or palsy. During normal locomotion, an individual contacts the ground with the heel of the foot first. The ground reaction force applies a plantarflexion moment to the whole foot, which is resisted by all of the dorsiflexors . Weakness of the EHL diminishes an individual’s ability to control the descent of the medial portion of the foot, particularly the great toe. Patients with weakness of the extensor hallucis longus also report that the toe tends to fold under the foot when they are pulling on socks or shoes and can cause tripping. Delorme boot improves strength of EHL

66. Tightness of the EHL pulls the metatarsophalangeal joint of the great toe into extension, which, as in the fingers and thumb, tends to produce flexion at the interphalangeal joint as the flexor hallucis longus is stretched, and a claw toe deformity emerges. Hyperextension of the great toe pulls the plantar plate distally, exposing the metatarsal head to excessive loads and producing pain. Delorme boot can be used in lengthening and stretching of EHL.

67. SPRINT RUNNERS In sprint runners, the muscle group to be aware of in the lower extremity is tibialis anterior. Tibialis anterior is a dorsiflexor of the ankle meaning it pulls your toes towards your knees (along with the extensor group). Increased speed and force of dorsiflexion will shorten the lever arm of the recovering leg during sprinting. This means that the quicker the ankle can go into dorsiflexion , the quicker the leg can get through into the next stride. This will obviously increase stride frequency.  Delorme boot can be an effective in fitness training to strengthen the dorsi flexors.

68. FRACTURE Fractures around ankle joint results in immobilization of the ankle joint. inhibition of movement due to pain and decreased use of extremities can lead to weakness of muscles. Initial rehabilitation phase includes isometrics of ankle muscles. In later phase of rehabilitation, progressive resisted exercise can be given using delorme boot.

69. STROKE The gait pattern of stroke patients is characterized by a slow gait cycle and velocity, a difference in stride lengths between the affected and unaffected sides, and short stance and relatively long swing phases on the affected side. In particular, when the stiffening of the flexor on the bottom of the ankle joint is severe, it hinders the advance of the lower limbs during gait, resulting in problems such as asymmetric postures and balance disorders

70. Improvement in the ability of the ankle joint had a major effect on gait velocity and stride length. Undesirable gait exhibited by stroke patients is the result of weakening of the ankle muscles and the lack of their activation Exercises that can increase the ROM of the ankle joint and strengthen the flexor in the back of the ankle joint are necessary which can be given using delorme boot.

71. REVIEW OF LITERATURE

72. Analysis of the psychometric properties of the American Orthopaedic Foot and Ankle Society Score (AOFAS) in Rheumatoid Arthritis patients: application of the Rasch model Cristiano Sena et.al ABSTRACT Objective : To tested the reliability and validity of Aofas in a sample of rheumatoid arthritis patients. Methods : The scale was applicable to rheumatoid arthritis patients, twice by the interviewer 1 and once by the interviewer 2. The Aofas was subjected to test–retest reliability analysis (with 20 Rheumatoid arthritis subjects). The psychometric properties were investigated using Rasch analysis on 33 Rheumatoid arthritis patients.

73. Results : Intra-Class Correlation Coefficient (ICC) were (0.90 < ICC < 0.95; p < 0.001) for intraobserver reliability and (0.75 < ICC < 0.91; p < 0.001) for inter-observer reliability. Subjects separation rates were 1.9 and 4.75 for the items, showing that patients fell into three ability levels, and the items were divided into six difficulties levels. The Rasch analysis showed that eight items was satisfactory. One erroneous item have been identified, showing percentages above the 5% allowed by the statistical model. Further Rasch modeling suggested revising the original item 8. Conclusions : The results suggest that the Brazilian versions of Aofas exhibit adequate reliability, construct validity, response stability. These findings indicate that Aofas Ankle- Hindfoot scale presents a significant potential for clinical applicability in individuals with rheumatoid arthritis. Other studies in populations with other characteristics are now underway.

74. Evidence of Validity for the Foot and Ankle Ability Measure (FAAM) RobRoy L. Martin et.al ABSTRACT Background : There is no universally accepted instrument that can be used to evaluate changes in self reported physical function for individuals with leg, ankle and foot muscular disorders. The objective of this study was to develop an instrument to meet this need: the Foot and Ankle Ability Measure (FAAM). Additionally, this study was designed to provide validity evidence for interpretation of FAAM scores. Methods : Final item reduction was completed using item response theory with 1027 subjects. Validity evidence was provided by 164 subjects that were expected to change and 79 subjects that were expected to remain stable. These subjects were given the FAAM and SF-36 to complete on two occasions 4 weeks apart.

75. Results : The final version of the FAAM consists of the 21-item activities of daily living (ADL) and 8-item Sports subscales, which together produced information across the spectrum ability. Validity evidence was provided for test content, internal structure, score stability, and responsiveness. Test retest reliability was 0.89 and 0.87 for the ADL and Sports subscales, respectively. The minimal detectable change based on a 95% confidence interval was ±5.7 and ±−12 .3 points for the ADL and Sports subscales, respectively. Two-way repeated measures ANOVA and ROC analysis found both the ADL and Sports subscales were responsive to changes in status (p < 0.05). The minimal clinically important differences were 8 and 9 points for the ADL and Sports subscales, respectively. Guyatt responsive index and ROC analysis found the ADL subscale was more responsive than general measures of physical function while the Sports subscale was not.

76. The ADL and Sport subscales demonstrated strong relationships with the SF-36 physical function subscale (r = 0.84, 0.78) and physical component summary score (r = 0.78, 0.80) and weak relationships with the SF-36 mental function subscale (r = 0.18, 0.11) and mental component summary score (r = 0.05, −0.02). Conclusions : The FAAM is a reliable, responsive, and valid measure of physical function for individuals with a broad range of musculoskeletal disorders of the lower leg, foot, and ankle.

77. Psychometric Properties of the Foot and Ankle Outcome Score in a Community-Based Study of Adults With and Without Osteoarthritis Yvonne M. Golightly et.al Objective. Foot and ankle problems are common in adults, and large observational studies are needed to advance our understanding of the etiology and impact of these conditions. Valid and reliable measures of foot and ankle symptoms and physical function are necessary for this research. This study examined psychometric properties of the Foot and Ankle Outcome Score (FAOS) subscales (pain, other symptoms, activities of daily living [ADL], sport and recreational function [sport/recreation], and foot- and ankle-related quality of life [QOL]) in a large, community-based sample of African American and white men and women ages >50 years.

78. Methods. Johnston County Osteoarthritis Project participants (n 1,670) completed the 42-item FAOS (mean age 69 years, 68% women, 31% African American, mean body mass index [BMI] 31.5 kg/m2). Internal consistency, test–retest reliability, convergent validity, and structural validity of each subscale were examined for the sample and for subgroups according to race, sex, age, BMI, presence of knee or hip osteoarthritis, and presence of knee, hip, or low back symptoms. Results. For the sample and each subgroup, Cronbach’s alpha coefficients ranged from 0.95–0.97 (pain), 0.97–0.98 (ADL), 0.94–0.96 (sport/recreation), 0.89–0.92 (QOL), and 0.72–0.82 (symptoms).

79. Correlation coefficients ranged from 0.24–0.52 for pain and symptoms subscales with foot and ankle symptoms and from 0.30–0.55 for ADL and sport/recreation subscales with the Western Ontario and McMaster Universities Osteoarthritis Index function subscale. Intraclass correlation coefficients for test–retest reliability ranged from 0.63–0.81. Items loaded on a single factor for each subscale except symptoms (2 factors). Conclusion. The FAOS exhibited sufficient reliability and validity in this large cohort study.

80. CONCLUSION There are many outcome measures available for ankle foot complex which are either patient reported or clinician reported. Using a valid and reliable outcome measure is important to assess the condition and progress of treatment.