Chapter 24: Rehabilitation of Ankle and Foot Injuries

1. Chapter 24: Rehabilitation of Ankle and Foot Injuries

2. Functional Anatomy and Biomechanics • Talocrural Joint • Articulation of tibia, fibula and trochlea of talus • Motion consisting of plantarflexion and dorsiflexion • Shape and stability of involved structures • Ligamentous support • Articular capsule • Anterior talofibular, posterior talofibular and calcaneofibular ligaments • Anterior and posterior tibiofibular ligaments • Deltoid ligament • Muscles • Extensor hallucis longus, extensor digitorum longus peroneus tertius and tibialis anterior • Gastrocnemius, soleus, plantaris, tibialis posterior, flexor digitorum longus and flexor hallucis longus

3. Subtalar Joint • Articulation between talus and calcaneus • Movements consisting of pronation and supination • Triplanar motion • Profound impact on the lower extremity • Midtarsal Joint • Calcaneocuboid and talonavicular joints • Ligamentous support and muscle tension maintain position and integrity • Stability is directly related to position of subtalar joint • Midtarsal joint position during pronation and supination • Locking and unlocking of midfoot due to motion of the subtalar joint

4. Forefoot varus Forefoot valgus

5. Tarsometatarsal Joint • Bones allow rotational force when engaged in weight-bearing activity • Dependent on midtarsal and subtalar joint position • Metatarsal Joints • Foot stabilization is dependent on relationship metatarsal joints and other joints of foot • Independent movement of first ray with respect to rest of foot • Body propulsion – reliant on peroneus longus stabilization

6. Biomechanics of Normal Gait • Two phases • Stance (support) • Heel contact to toe off • Absorb shock, transfer weight and provide propulsion • Lateral-medial-lateral movement • Movement medially – pronation – allows for shock absorption and distribution of forces during stance phase • Obligatory internal rotation of tibia with pronation • Propulsion (lateral movement) – supination – “re-locks” the foot in order to form a rigid lever • Tibial external rotation at push-off • Swing (recovery)

7. Rehabilitation Techniques for Specific Injuries Ankle Sprains • Pathomechanics and Injury Mechanism • Inversion sprain • Ankle inversion, plantarflexion and internal rotation • Injures lateral ligaments of ankle • Eversion sprain • Less common due to bony structure of ankle and strength of deltoid ligament • Syndesmotic sprain • Occur due to excessive dorsiflexion or external rotation • Will involve tibiofibular ligaments and possibly interosseous membrane

8. Rehabilitation Concerns • Swelling and pain control • Compression • Ice • Elevation • Rest • Protection • Possible immobilization depending on severity

9. Rehabilitation Progression • Adequate rest and healing time for ligaments prior to exercise initiation • Retardation of atrophy, maintenance of proprioception • Weight bearing vs. Non-weight bearing • Aquatic therapy • Enhanced ligament healing with stress application • Swelling and pain management • Range of Motion • Initially focus should be on plantar and dorsiflexion through towel exercises and joint mobilizations • With decrease in pain inversion and eversion exercises can be initiated (BAPS board)

10. Strengthening • Isometrics can begin early in the rehabilitation process • Pain will serve as a guideline • Tubing, multidirectional Elgin ankle exerciser m manual resistance and ankle weights can be utilized • Ultimately isokinetics and PNF exercises should be introduced

11. Proprioception and Neuromuscular Control • Role of proprioception and repeated ankle trauma • Progress from both feet to one, eyes open and closed • Advance to balance training on BAPS board • Other CKC exercises can also be used to enhance proprioceptive feedback

12. Cardiorespiratory Endurance • Must be maintained during the rehabilitation process • Pedaling stationary bike or UBE can be used • Pool running/aquatic therapy can be substituted as well • Functional Progression • Should begin as ambulation is resumed, without limitations or deficits in gait • Running progression • Hopping and jumping • Sports-related activity • Criteria for Full Return • Gradual completion of functional progression • Ankle support – provide stabilizing effect • Complete ROM, 80-90% of pre-injury strength • Practice tolerated without insult to injured part

13. Ankle Fractures and Dislocation • Pathomechanics and Injury Mechanism • Must be cautious (sprain vs. fracture) • Multiple mechanism of injury • Malleolar fractures, osteochondral fractures of the talus • Non-displaced or compression fractures • Dislocations rarely occur • Occurrences are generally combined with fracture • Rehabilitation Concerns • Rest, protection and immobilization • Surgical intervention

14. Rehabilitation Progression • Following surgery athlete will be non-weight bearing for 2 weeks • Work to limit swelling and pain • At 2-3 weeks a walking boot may be applied (on for 6 weeks) • ROM exercises should begin as directed by physician (2-3 times daily) • At 6 weeks weight bearing can occur • A gradual strengthening program should also be initiated • Joint mobilizations and stretching may be necessary to aid in restoration of motion • As strength and neuromuscular control are regained more functional CKC exercises can be added

15. Criteria for Full Return • Strength, flexibility and neuromuscular control must return to “normal” levels • Following completion of functional progression full activity can be resumed

16. Subluxation and Dislocation of the Peroneal Tendons • Pathomechanics • Peroneal tendons run beneath the peroneal retinaculum within the peroneal groove • May be the result of retinaculum rupture • No correlation between groove size and instability of tendons • Injury Mechanism • Can occur as a result of forceful contraction of peroneal muscles • Results in retinaculum rupture • Must distinguish between lateral ligament sprain and tendon disruption

17. Rehabilitation Concerns and Progression • Reduce and place in compression wrap with felt focal compression • Following symptom reduction a short leg cast should be utilized (5-6 weeks) • After cast removal treatment should follow aggressive ankle rehabilitation • Surgery may be necessary if avulsion fx is involved • Criteria for Full Return • Return in 10-12 weeks as tolerated • Should have normal ROM , strength, and neuromuscular control

18. Tendinitis • Pathomechanics and Injury Mechanism • Generally seen in tibialis anterior and posterior tendons as well as peroneals • May be the result of a specific cause or repetitive stress (collection of mechanisms) • Mechanics • Acute trauma • Reduced flexibility • Training errors • Pain with active motion, passive stretching, swelling, stiffness following periods of inactivity

19. Rehabilitation Concerns and Progression • Early stages should focus on pain and swelling reduction • RICE, modalities, NSAID’s • Determine cause – mechanics and/or mechanism of injury • Treat the cause • Re-establish ROM, strength and neuromuscular control • Criteria for Full Return • Provide sufficient rest for tendon healing • Slow and controlled  must be pain free

20. Excessive Pronation and Supination • Pathomechanics and Injury Mechanism • Normal movements of the foot that are often not pathologically related • When excessive = overuse injuries • Result of structural or functional deformity • Causes compensatory motion • Forefoot varus and rearfoot varus • Generally associated with excessive pronation • Forefoot valgus • Associated with excessive supination

21. Common Foot Deformities

22. Prolonged pronation (during stance phase) is one of the major causes of stress injuries • Compensatory subtalar motion = midtarsal joints remain unlocked, increased tibial internal rotation • Ability of foot to return to “rigid lever” is reduced = decreased push-off • Can ultimately result in callus formation, 2nd metatarsal stress fx, bunions due to hypermobility, plantar fasciitis, posterior tibialis tendinitis • External indicators of pronation • Excessive calcaneal eversion in stance • Excessive tibial internal rotation • Lowering of medial longitudinal arch • Increased talar bulge

23. Excessive supination • Does not allow midtarsal joint to unlock = foot remains rigid lever and prevents the foot from effectively absorbing ground reaction force • Limits internal rotation • Potential injuries = inversion ankle sprains, tibial stress syndrome, peroneal tendinitis, IT-band friction syndrome and trochanteric bursitis

24. Other Structural Deformities • Tibia varum (bowleg deformity) – causes increased pronation • Ankle equinus • Adequate ROM • 10 degrees of dorsiflexion • If lacking appropriate amount of ankle ROM, compensatory motions will develop

25. Rehabilitation Concerns • Goal of treatment is to correct faulty biomechanics • Must perform an accurate biomechanical analysis • Orthotic fabrication • Examination • Determine subtalar neutral

26. Common Foot Deformities

27. Constructing orthotics • Used to control foot deformity and compensatory motion • Provide support that places subtalar joint in neutral position during stance • Types of orthotics • Pads and soft flexible supports • Semi-rigid orthotics composed of flexible thermoplastics, rubbers or leather • Functional or rigid orthotics – provide most control for overuse symptoms

28. Fabrication of Orthotic • Cast and ship to manufacturer • Fabricate a neutral mold to determine appropriate subtalar positioning (plaster) • Create a positive mold • Utilize Aliplast and Plastazote for orthotic fabrication relative to positive mold

29. Utilize convection oven and grinder to heat, mold, and shape orthotic • Orthotic should be trimmed and shaped to bisect metatarsal heads • Additional layers of Plastazote can be glued on in order to post the arch of calcaneal region

30. Selective grinding occurs to adequately post different points throughout the foot • Additional appliances can be applied (Spenco) to completely cover the orthotic for comfort and prevent foot drop-off • Gradual wearing of orthotic should occur over the course of 3-4 days  use in athletic participation should occur after several days of wearing insert

31. Shoe Selection • For pronator – less flexible with good rearfoot control • Increased cushioning and flexibility is recommended for the supinated foot • Last • Board • Split (board and slip) • Slip • Midsole (EVA) • Heel counter • Outsole contour • Lacing system • Forefoot wedges

32. Shoe wear patterns • Excessive pronators often wear out the front of the shoe under the 2nd metatarsal • Should actually wear out the back outside edge of the shoe • Observe the heel counter and forefoot wear patterns

33. Stress Fractures in the Foot • Pathomechanics and Injury Mechanism • Most commonly seen in 2nd metatarsal (March fracture), navicular and diaphysis of 5th metatarsal (Jones fracture) • Navicular stress fracture • Excessive pronator during running gait • Second metatarsal fracture • Occur most often due to running and jumping • Causes include rearfoot varus, forefoot varus, training errors, inappropriate shoe wear • Greater bone stress if longer than 1st metatarsal • Fifth metatarsal fracture • Occurs from overuse (pes cavus foot), inversion or high velocity rotational force • Poor blood supply and may result in non-union requiring extensive rehabilitation and possible surgery

34. Rehabilitation Concerns • Determine and alleviate cause or causes • 2nd metatarsal fractures respond well to rest and non-weight-bearing exercise (pool) • Maintain cardiovascular endurance (2-4 weeks) • Implement progressive return to running and jumping over 2-3 week period • Navicular and 5th metatarsal fractures • Aggressive treatment • Non-weight bearing with casting 6-8 weeks • Surgical intervention may be necessary • If highly competitive athlete = internal fixation should be recommended

35. Plantar Fasciitis • Pathomechanics • Attributed to heel spurs, plantar fascia irritation, bursitis • Tension increases in fascia with weight bearing and extension of toes • Pes cavus feet are subject to fascial strain • Changes in footwear • Lordosis  increasing anterior pelvic tilt and altering foot-strike angle

36. Injury Mechanism • Anatomical and biomechanical considerations • Leg length discrepancy • Excessive pronation • Inflexibility of longitudinal arch • Tightness of gastrocnemius-soleus complex • Improper footwear • Pain in anterior-medial heel, arch tightness • Pain in morning and increased pain with toe and foot dorsiflexion • Rehabilitation Concerns • Orthotic use (with extra deep heel cup) • Heel cup for additional cushioning • Taping for symptom relief • Night splints to maintain static stretch • Flexibility – vigorous heel cord stretching

37. NSAID’s are also recommended • Steroidal injections may be warranted if symptoms fail to resolve • Criteria for Full Return • Will require extensive treatment • Symptoms may persist for 8-12 weeks • Must remain persistent with rehabilitation • In some instances the athlete is able to continue if symptoms and pain are not prohibitive

38. Cuboid Subluxation • Pathomechanics • Mimics plantar fasciitis • Pronation and trauma are prominent causes of this condition • Results in pain along the 4th and 5th metatarsals • Pain is result of stress placed on the long peroneal muscle when foot is pronated • Pain increases after long periods of non-weight bearing and attempting to bear weight

39. Rehabilitation Considerations • Dramatic results may be obtained through manipulation • Orthotic is often useful following manipulation to provide support • Criteria for Return • In cases where manipulation is used athlete is often ready to return relatively pain free, immediately • Wear appropriate shoes and orthotics to reduce chances of recurrence

40. Hallux Valgus Deformity (Bunions) • Pathomechanics and Injury Mechanism • Deformity of 1st metatarsal head • Toe assumes a valgus position • Associated with forefoot varus (1st ray tends to splay) • Inflammation and thickening of bursa over 1st metatarsophalangeal joint • Results in malalignment of 1st toe • Also associated with flattening of medial longitudinal arch • Tight fitting shoes (in the toes) and high heels can also present problems • Present with tenderness, swelling, and calcification

41. Rehabilitation Concerns • Orthotic device may be helped to normalize foot mechanics • Assists in increasing first ray stability • Shoe selection is critical to treatment • Local modality use for symptom treatment • Protective devices – wedges, pads, and tape • Surgical intervention • Criteria for Full Return • Athlete can generally continue to play with appropriate footwear, support and protection

42. Morton’s Neuroma • Pathomechanics • Mass occurring about a nerve sheath of the common plantar nerve • Occurs between metatarsal heads • Severe intermittent pain which is often relived with non-weight bearing • Discomfort increases with collapse of transverse arch, excessive foot pronation, hyperextension of toes, narrow toe box of shoes, high heels • May be necessary to rule out stress fracture

43. Rehabilitation Concerns • Orthotic intervention with metatarsal block • Modalities for inflammation • Phonphoresis with hydrocortisone • Shoe selection • Criteria for Full Return • Appropriate orthotic padding will often allow a return to activity

44. Turf Toe • Pathomechanics and Injury Mechanism • Hyperextension injury resulting in sprain of metatarsophalangeal joint of great toe • Repetitive overuse or traumatic condition • Shoe support and flexibility • Rehabilitation Concerns • Addition of steel plating or additional supports in shoes to limit motion • Toe taping can also provide some support and relief • Modality use for pain control

45. Criteria for Full Return • Return to activity when swelling has resolved and is pain-free • Full ROM • In less severe cases athlete can continue participation with addition of rigid insole • With more severe sprains 3-4 weeks may be required for pain relief

46. Tarsal Tunnel Syndrome • Pathomechanics and Injury Mechanism • Area around medial malleolus that is bordered by retinaculum binding tibial nerve • Pronation and overuse problems (tendinitis) can cause neurovascular problems • Symptoms may vary - pain, numbness and paresthesia along medial ankle and sole of foot • Tenderness over tibial nerve • Rehabilitation Concerns • Neutral foot control may alleviate symptoms • Surgery may be required it symptoms do not resolve following conservative treatment or if toe flexor weakness results