16.3 Lower Extremity: Hip, Knee, Foot, and Ankle Rehabilitation
Key Takeaways
In the ACR hip OA clinical tree, internal rotation below 15° branches to ESR of 45 mm/h or less, with flexion of 115° or less substituting when ESR is unavailable. At 15° or above, check concordant pain on rotation, stiffness of 60 minutes or less and age over 50.
Femoroacetabular impingement syndrome requires compatible symptoms, signs and imaging. Cam or pincer morphology and a provocation test help frame the assessment.
Choose knee and posterolateral hip exercise for patellofemoral pain. Use the step-down to observe and reassess movement and symptoms.
The Rathleff heel-raise trial progressed from three sets at 12RM to five sets at 8RM. Its main between-group benefit appeared at three months.
Apply the ankle and foot Ottawa criteria within their respective pain zones. Check the specified bone landmarks and ability to take four steps immediately and at assessment.
Lower Extremity: Hip, Knee, Foot, and Ankle Rehabilitation
A patient with lower-limb pain may need imaging or referral, a load adjustment, or progressive exercise. The history, pain location, response to loading and examination help decide which action comes first.
Hip Osteoarthritis and Femoroacetabular Impingement Syndrome
Hip osteoarthritis
Hip osteoarthritis can involve cartilage loss, osteophytes, subchondral changes and painful restriction. The 1991 ACR clinical tree classifies patients with hip pain for research. In clinical practice, consider other causes of hip or referred pain and whether imaging would change management.
Exactly 15° enters the second branch. That branch includes stiffness lasting exactly 60 minutes. The original multicenter study reported 86% sensitivity and 75% specificity for the clinical tree in its sample. Those estimates depend on the population and how the reference diagnosis was determined.
Passive Motion in Hip Osteoarthritis
Hip osteoarthritis commonly limits passive internal rotation and flexion. Abduction and other motions can also be limited. The order and magnitude of loss vary and should be interpreted with symptoms and other examination findings.
Evidence-Based Physical Therapy Management
- Manual Therapy: The 2025 APTA hip osteoarthritis guideline includes joint and soft-tissue techniques for patients with mild-to-moderate disease and relevant mobility limitations or pain. Examples include long-axis distraction and mobilization with movement. Choose force and position from symptoms, examination and response, then reassess pain, motion and function. Exercise remains part of the plan.
- Progressive exercise: Choose hip and knee strengthening, aerobic activity and functional practice that match the patient's goals and tolerance. Cycling or water exercise can help maintain activity if walking is painful. Discuss weight management when relevant to the patient. Track changes in walking, stairs and other tasks that matter to the patient.
- Interpreting a trial: Hoeksma and colleagues compared a manual therapy program with an exercise therapy program in hip osteoarthritis. The trial did not test the extra effect of adding mobilization to an identical exercise program.
Femoroacetabular impingement (FAI) syndrome
The Warwick consensus requires compatible symptoms, clinical signs and imaging findings. Motion-related groin pain during deep flexion can fit, but a similar presentation can arise from other hip, lumbar or pelvic conditions.
Cam morphology reduces femoral head–neck clearance. With pincer morphology the acetabular rim can contact the femur earlier in the available arc. Both can affect the labrum and adjacent cartilage. Morphology can occur in people without symptoms. Interpret the alpha angle or acetabular coverage with the imaging views, clinical findings and history.
- FADIR: With the patient supine, gently combine hip flexion, adduction and internal rotation. Reproduction of the patient's familiar pain is a useful provocation finding. A positive result has limited specificity, and a negative result alone cannot exclude the syndrome or a labral lesion.
- FABER: Support the hip in flexion, abduction and external rotation and stabilize the opposite side of the pelvis as needed. Record the motion and where familiar pain occurs. Groin pain can guide further hip assessment, while posterior symptoms may warrant a lumbopelvic examination. Location alone cannot identify the source.
- Initial management: Adjust repeatedly provocative depth or volume and build hip and trunk strength and movement tolerance. Reassess the activity that prompted the referral. Persistent limitation despite appropriate rehabilitation warrants discussion with the treating team about further assessment.
Patellofemoral Pain
Diffuse pain around or behind the patella that increases with loaded knee flexion is a common presentation. Ask about stairs, squatting and running. Prolonged sitting can also provoke symptoms. Reproduce familiar pain with a functional task and consider other causes of anterior knee pain, including focal tendon symptoms and instability.
Femoral adduction and internal rotation can contribute to the observed knee position during a step-down. Joint contact stress depends on the distribution of force and contact area. The visible alignment alone cannot establish which structure hurts, quantify stress or identify why a patient moves that way. Check strength, pain, ankle motion and balance before assigning a cause.
The 2019 patellofemoral pain guideline recommends combining hip- and knee-targeted exercise. Select quadriceps and posterolateral hip exercises based on findings and tolerance. Isolated vastus medialis oblique training has no established clinical advantage over general quadriceps strengthening. Exercise can improve symptoms and function even when the measured alignment changes little.
Use a squat or step-down to document symptom reproduction and movement. Choose a repeatable step height. The Clarke grind test has limited diagnostic value. Improvement during a modified movement or with a medial patellar glide can inform a trial of taping or movement retraining. That response does not establish maltracking.
Plantar Heel Pain and the Windlass Mechanism
Plantar fasciitis commonly presents with plantar-medial heel pain during the first steps after sleep or sitting, and with prolonged standing or walking. Local tenderness near the proximal plantar fascia supports the working diagnosis. Burning, numbness, unusual rest pain or progressive pain with bony loading should prompt consideration of other causes.
During great-toe extension, the plantar fascia winds around the metatarsal head. This tensions the fascia and can raise the medial longitudinal arch. The windlass test uses gentle great-toe extension to look for familiar plantar heel pain. A negative result cannot exclude plantar fasciitis.
Rathleff trial and clinical application
In the 2015 trial, participants had ultrasound-verified plantar fasciitis. Both groups received heel inserts. One group performed plantar fascia-specific stretching and the other performed progressive heel raises every second day. The heel raise used a towel under the toes, with three seconds up, two seconds at the top and three seconds down. Participants began with three sets at 12RM, increased to four sets at 10RM after two weeks and five sets at 8RM after four weeks. A backpack added load. Participants unable to meet the repetitions on one leg could begin on both legs.
The heel-raise group had a better Foot Function Index result at the three-month primary endpoint. Between-group differences were not significant at one, six or twelve months. The 2023 plantar heel pain guideline supports plantar fascia-specific and calf stretching and foot and ankle resistance exercise. A patient's current loading tolerance can determine the starting variation and rate of progression.
Acute Ankle Inversion Sprains and the Ottawa Ankle Rules
An inversion injury can affect the lateral ligament complex. Check the mechanism, ability to bear weight, bony tenderness and neurovascular status before stressing the ankle.
- Anterior drawer: With the knee supported and the ankle in slight plantarflexion, stabilize the distal tibia and translate the hindfoot anteriorly. Compare excursion and endpoint with the other side. The maneuver mainly assesses the anterior talofibular ligament (ATFL).
- Inversion talar tilt: Support the leg, stabilize the distal tibia and gently apply hindfoot inversion. Testing nearer neutral places more emphasis on the calcaneofibular ligament (CFL). Record symptoms, excursion and endpoint. Manual testing cannot assign an exact tear grade.
- Timing: Pain and guarding can limit the early ligament examination. In van Dijk's study the delayed examination, which combined several findings, had 96% sensitivity and 84% specificity for ligament injury. Reassessment after several days can improve interpretation. Triage suspected fracture or other serious injury at presentation.
The Ottawa Ankle and Foot Rules (OAR)
Apply these rules after eligible acute blunt trauma to guide ankle and foot radiography. First screen for injuries requiring immediate escalation, such as an open injury, deformity or neurovascular compromise. Apply each relevant zone separately.
The two times for weight bearing are immediately after injury and at assessment. Four steps may be taken with a limp. Palpate the specified bone landmarks directly. Tenderness confined to the ATFL does not satisfy the bone tenderness criterion. In a patient who meets the rule's applicability criteria, a negative rule substantially lowers the probability of fracture. Reassess persistent or worsening symptoms and consider injuries outside the rule.
Early lateral ankle rehabilitation
For an uncomplicated lateral sprain, use an appropriate brace or taping, progressive weight bearing and exercises matched to symptoms and severity. Begin with protected motion and walking practice, then add strength and balance and progress to the demands of the patient's activity. A more severe injury may need a short period of immobilization. Disproportionate pain, persistent instability or findings that suggest a syndesmotic or other associated injury warrant further assessment.
Postoperative hip and knee rehabilitation in Saudi practice
The Saudi MOH 2025 total hip arthroplasty protocol describes early assisted walking with the permitted weight-bearing status. Check the surgeon's orders for the surgical approach, fixation and additional procedures. For example, a trochanteric osteotomy can require restricted weight bearing during bone healing. Motion precautions and their duration can differ by approach and procedure.
The Saudi MOH 2025 total knee arthroplasty protocol calls for rehabilitation within 24 hours and before discharge. For a medically ready patient, early care addresses pain and swelling, knee motion, quadriceps activation and safe transfers and gait. Progress the assistive device and strengthening as the patient demonstrates safe function and tolerates loading. Use the operative orders and clinical findings for individual progression.
Clinical Case Scenario: Lower Extremity
A 26-year-old female recreational runner presents to the physical therapy clinic 5 days after stepping in a hole while trail running and sustaining an acute inversion injury to her right ankle. She also complains of bilateral anterior retropatellar knee pain that has plagued her for the past 6 months whenever she runs down hills or sits for longer than 30 minutes at her office desk.
The runner walked several steps immediately after injury. On day five she walks six steps in clinic with a limp. There is swelling and lateral ligament tenderness. The distal posterior edges and tips of both malleoli, navicular and base of the fifth metatarsal are nontender. There is no deformity or neurovascular deficit. The anterior drawer shows more excursion than on the left. Step-down testing reproduces her familiar anterior knee pain and shows femoral adduction and internal rotation. Hip abductor and external rotator testing also shows weakness.
- Ankle decision: The history and direct bone palpation give a negative ankle rule. Assess the foot rule separately if she has midfoot-zone pain. The drawer finding and mechanism support a lateral sprain. Begin protected weight bearing with a brace as needed, gentle active motion and later strength and balance work. Reassess if recovery deviates from the expected course.
- Knee decision: The pain pattern and response to the step-down support patellofemoral pain. Use tolerable quadriceps and posterolateral hip exercises, adjust downhill running and reassess stairs and step-down symptoms before increasing running volume. Treat the ankle and knee findings on their own merits and adapt the combined training load.
A 58-year-old with persistent hip pain has no ESR result. Which finding satisfies the low-internal-rotation branch of the original ACR hip osteoarthritis clinical classification tree?
Internal rotation of 15° and flexion of 110°
Internal rotation of 12° and flexion of 125°
Internal rotation of 12° and flexion of 110°
Internal rotation of 20° and flexion of 125°
A 22-year-old female collegiate cross-country runner presents with diffuse retropatellar knee pain that worsens during descent on stairs and prolonged sitting. Physical examination reveals pronounced dynamic knee valgus during single-leg squats, with hip abductor and external rotator strength graded at 3+/5. Based on current clinical practice guidelines, what is the most evidence-based physical therapy approach?
Use patellar taping alone and postpone exercise until stairs are pain-free.
Use quadriceps exercise alone and leave the provoking activity unchanged.
Use hip strengthening alone and avoid loading the knee during rehabilitation.
Combine posterolateral hip and quadriceps strengthening and adjust the provoking activity load.
A nurse with plantar heel pain starts the heel-raise program used in the 2015 Rathleff trial, with a towel under the toes. Which schedule matches the trial?
Every second day, 3 seconds up, 2 at the top and 3 down, progressing from three sets at 12RM to five at 8RM.
Every second day, 3 seconds up, 2 at the top and 3 down, progressing from three sets at 12RM to four at 8RM.
Daily, 3 seconds up, 2 at the top and 3 down, keeping all sets at the initial 12RM load.
Daily, 2 seconds up, no pause and 2 seconds down, progressing from three sets at 12RM to five at 8RM.
A soccer player presents after an acute ankle inversion injury. Which finding meets the original Ottawa Ankle Rule for ankle radiographs in an eligible patient?
Point tenderness directly over the anterior talofibular ligament with full ability to bear weight for 10 steps
Malleolar-zone pain and either tenderness along the posterior distal 6 cm or tip of either malleolus, or inability to take four steps both immediately and at assessment.
Pain localized strictly to the calf muscle belly without any malleolar, midfoot, or ligamentous tenderness
Mild soft tissue swelling over the dorsal foot with painless palpation of all malleolar and midfoot bony landmarks
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