Chapter 23: Rehabilitation of Lower Leg Injuries

1. Chapter 23: Rehabilitation of Lower Leg Injuries

2. Functional Anatomy and Biomechanics • Tibia and fibula articulate with the talus • Movement of leg is dictated by foot and contact with the ground • Impact of pronation on lower leg mechanics • Relationship of tibia and femur • Lower leg functions to transmit ground reaction and rotational forces to the knee

3. Compartments of the Lower Leg • While in OKC muscle groups of lower leg function primarily in single planes • In a CKC muscle groups work to concentrically and eccentrically • Absorb ground reaction forces • Control excessive motion of the foot • Provide a stable base for propulsion • Anterior Compartment • Functionally controls plantarflexion and foot pronation following heal strike

4. Deep Posterior Compartment • Control pronation and lower leg internal rotation with weight bearing • Tibialis posterior helps decelerate forward momentum of the tibia during midstance • Lateral Compartment • Peroneus longus plantar flexes first ray of foot at heel off • Peroneus brevis counteracts supinating forces of tibialis posterior and stabilizes subtalar joint and midtarsal regions • Superficial Posterior Compartment • Eccentrically contract controlling pronation and tibial internal rotation during midstance • Concentrically fires during push-off of gait cycle

5. Rehabilitation Techniques for Specific Injuries • Tibial and Fibular Fractures • Pathomechanics • Generally the result of a direct blow • Present with pain, swelling and possible deformity • Injury Mechanism • Direct contact • Indirectly – rotatory / compressive force • Foot planted  proximal segments rotate with large compressive force

6. Rehabilitation Concerns • Immobilization with restricted weight bearing • Joint stiffness, atrophy, abnormal gait patterns • Possible post-surgical considerations • Functional demands of athlete • ROM and strength • Cardiovascular endurance • Rehabilitation Progression • Communication is critical with physician when dealing with post-immobilization circumstances • Weight bearing progression • Assistive devices

7. Range of motion • AROM, passive stretching and joint mobilization • Strengthening • Progression from isometric to isotonic exercise when ROM is normalized • Utilization of assistive devices as needed • When full, pain-free weight bearing balance and proprioceptive training can begin

8. With improvements in ROM, strength and gait functional activities can continue • Advanced balance training – exercise sandals • Rate of rehabilitation will depend on severity of injury • Non-displaced uncomplicated tibia = 10-13 weeks • If more severe = 16-26 weeks • Fibula, uncomplicated = 4-6 weeks

9. Criteria for Return to Play • Full ROM and strength • Normalized gait (walking, jogging, running) • Ability to hop for endurance and distance without pain or observable compensation • Successful completion of sports-specific functional testing

10. Tibial and Fibular Stress Fractures • Pathomechanics • Occur in at a higher rate in tibia • Result of inability to adapt to repetitive loading of lower leg • Bone attempts to adapt through osteoclastic activity resulting in bone breakdown, followed by osteoblastic activity • If stresses not reduce process will result in structural irregularities • Further inability to absorb forces will result leading to stress fracture • Possible connection to ischemic reaction within bone resulting in initiation of remodeling process

11. Pain which generally subsides with rest • Can progress to problems during performance of ADL’s • Presents with focal point tenderness • Different than medial tibial stress syndrome (MTSS) – more diffuse • Vibration testing positive • Bone scan utilized to confirm diagnosis • Often seen in athletes engaged in running and jumping events

12. Injury Mechanism • Prevalent in running and jumping athletes • Possible tibial anterior bowing creating tension disrupting bone healing • Compression is ideal for bone healing • Excessive compensatory pronation • Structural malalignments • Forefoot varus • Tibial varum • Femoral anteversion • Each may become more of a factor with increased activity or other training variables • Muscle tension on bone due to increased muscle activity • Other factors • Training errors, poor footwear, menstrual irregularities, diet, bone density increased hip ER, tibial width, calf girth

13. Rehabilitation Concerns • Immediate elimination of offending activity • Education of athlete • Concerns of lost fitness due to decreased activity • Footwear relative to foot biomechanics • Thorough biomechanical exam • Stretching and strengthening exercises • Modality use and bracing

14. Rehabilitation Progression • Crutches and possible immobilization • RICE and NSAID’s for inflammation and pain • Begin water running – same training parameters • Gastroc-soleus stretching and strengthening

15. Progress from isotonic tubing, OKC exercises to CKC exercise training • Exercise sandal progression for lower leg • Custom foot orthotic fabrication • After 3-4 weeks, with symptoms subsiding a gradual walking/jogging progression can begin • Appropriate surfaces • Gradual interval progression – providing gradual increase in stress application

16. Criteria for Full Return • No tenderness upon palpation of affected bone • No pain in area with repeated jumping • Plain films demonstrate good bone healing • Successful progression of graded return to running and other sports-specific activities • Flexibility WNL • Hyperpronation has been corrected with training and footwear modifications • Correction of muscle strength and length issues have been addressed

17. Compartment Syndrome • Pathomechanics and Injury Mechanism • Increased pressure within osseofascial compartment resulting in compression of musculature and neurovascular structures • Disrupted blood flow which further compromises situation • Acute compartment syndrome • Secondary to direct trauma – medical emergency • Pain, swelling, tightness, reduction in pedal pulse, sensory changes, reproduction of pain with passive stretching of involved musculature • Increased intra-compartmental pressure • Emergency fasciotomy is definitive treatment

18. Acute exertional compartment syndrome • No precipitating trauma • Develops with minimal to moderate activity • Increased intra-compartmental pressure with emergency fasciotomy • Chronic compartment syndrome (CCS) • Activity related – symptoms arise consistently at particular point during activity • Pain, tightness, swelling of affected compartment • Signs and symptoms relieved with decreased activity • Elevated intra-compartmental measures

19. Rehabilitation Concerns • CCS can initially be managed conservatively • Lower quarter screening should be performed to determine structural variation – compensatory motion and stresses • Ice and stretch • Cycling to maintain fitness • Fasciotomy will be necessary if conservative treatment is unsuccessful

20. Rehabilitation Progression • Post-surgical care • Decrease pain and swelling with RICE and assisted ambulation • Following suture removal AROM and stretching should begin • With improve ROM, weight bearing activity should be increased

21. Incorporate gait training • Prevent abnormal patterns secondary to joint stiffness or muscle guarding • Incorporate OKC and CKC exercise progressions • Initiate balance and proprioceptive training • May have been impacted due to surgical procedure • Modify lower extremity structural variation and compensatory motion • Continue to manage athlete’s cardiovascular fitness

22. Criteria for Return to Play • Normal ROM and strength • No gait deviations with walking, jogging or running • Athlete completes progressive jogging/running program with no CCS complaints • Athlete undergoing anterior compartment fasciotomy may require 8-12 weeks to recover from surgery • Posterior compartment fasciotomy may require 3-4 months, post-surgery

23. Muscle Strain • Pathomechanics • Occur primarily in the medial head of the gastrocnemius at the musculotendinous junction • More common in middle-aged athletes • Result of ballistic activity • Pain with dorsiflexion in CKC position, pain with push-off • Palpable tenderness or divot • Injury Mechanism • Due to sudden ballistic movement • Generally caused by forceful contraction from elongated position (knee extended, ankle dorsiflexed)

24. Rehabilitation Concerns • Initial treatment = RICE • Limit edema in the foot and ankle • Little stretching early in rehabilitation process • Limited weight bearing and altered gait due to difficulty with dorsiflexion in CKC position • Modified footwear (heel lift) • Gradual stretching, strengthening, functional training • Rehabilitation Progression • Initially RICE with some light towel stretching • AROM of foot and ankle in all planes of motion

25. With mild strain, athlete will be off crutches in a few days and should begin strengthening in 7-10 days • More severe strains may require 2-4 weeks to regain ROM • Strengthening should incorporate both OKC and CKC exercises • With normalization of gait jogging progression should be initiated • Plyometrics should be incorporated • Gradual return to sports-specific activity

26. Criteria for Full Return • Full ROM of foot and ankle • Gastrocnemius strength and endurance are bilaterally equal • Ability to walk, jog, run, jump without compensatory motion • Successful completion of sports-specific functional progression with no residual calf symptoms

27. Medial Tibial Stress Syndrome (MTTS) • Pathomechanics • Pain along the distal 2/3 of the posterior medial aspect of the tibia • Soleus and tibialis posterior have been implicated as muscles that can stress the periosteum of the tibia during activity • Evidence of abnormal histological appearance of bone and periosteum • Diffuse pain that may have a variety of exacerbating factors • Biomechanics, footwear, training errors

28. Injury Mechanism • Compensatory pronation is often a primary cause • Results in greater tensile stress on musculotendinous units that help to control tri-planar motion at the subtalar joint • Lower extremity structural variations • Rearfoot and forefoot varus • Overuse of plantar flexors • Training surfaces • Rehabilitation Concerns • Physician referral to rule out stress fx • Activity modification while maintaining cardiovascular fitness • Biomechanics correction • Gait, excessive pronation (orthotics) • Lower extremity strengthening • Sandal exercises

29. Rehabilitation Progression • Eliminate running and jumping for 7-10 days • Modify workouts to maintain fitness (pool) • Work on gastrocnemius-soleus flexibility • Early pain and inflammation treatment via modalities • Initiate general lower leg strengthening (tubing, OCK, CKC, isokinetic strengthening, sandal exercises) • Foot orthotics for mechanics • With pain subsiding a gradual return to activity • Jogging progression with appropriate footwear • Criteria for Full Return • Minimal to no pain on palpation • Excessive pronation has been addressed • Adequate strength and flexibility has been established • Successful completion of running progression

30. Achilles Tendinitis • Pathomechanics • Inflammatory condition of tendon, tendon sheath or peritenon • Result of excessive tensile stress (medial aspect) • Pain and stiffness proximal to calcaneal insertion (2-6 cm) • Reduced gastrocnemius-soleus flexibility

31. Injury Mechanism • Gradual onset • Result of repetitive weight bearing activities • Poor training progression – intensity and duration • Excessive compensatory pronation secondary to lower extremity biomechanics or decreased flexibility associated with the gastrocnemius and soleus • Inflammatory response with possible crepitace during AROM, pain with passive dorsiflexion • Rehabilitation Concerns • Often associated with slow healing (vascular supply) • Address structural and biomechanical flaws • Including flexibility and orthotics • Modality and manual therapy techniques for inflammation, scar tissue and adhesion treatment • Strengthening and activity progression for safe return

32. Rehabilitation Progression • Activity and training modifications immediately • Proper footwear (heel lift, orthotic) must be addressed to reduce stress on tendon • Gentle stretching following modality application • OKC exercises early on and progress to CKC exercises emphasizing concentric/eccentric work • Body weight training for CKC exercises – modifying sets, repetitions, speed and intensity • Gradual running progression as ROM and strength improve • Be sure to set realistic expectations for safe return

33. Criteria for Full Return • Full resolution with ADL’s and minimal or no symptoms with sports-related activity • ROM, strength and endurance are equal bilaterally • Contributing biomechanic faults have been corrected • Successful completion of activity progression

34. Achilles Tendon Rupture • Pathomechanics • Injury often presents within avascular region of distal 2-6 cm section of tendon • Sudden plantarflexion moment • Severe pain, popping sensation with limited plantarflexion (palpable defect), positive Thompson test • Injury Mechanism • Sudden forceful plantarflexion • Possible degenerative changes within the tendon • Result of excessive compensatory pronation • Tendinitis symptoms that progress to tendon rupture • Fatigue, improper warm-up prior to ballistic activity

35. Rehabilitation Concerns • Surgical care vs. immobilization • 6-8 weeks of immobilization following surgical repair • Numerous deleterious effects of immobilization • Return of full ROM is critical with appropriate strength training • Cardiovascular training • Gait normalization (walking, jogging, running) • Rehabilitation Progression • Physician should be involved in determining progression for immobilization to weight bearing and activity levels • Excellent results reported with early and controlled mobilization over 6-8 week period

36. Controlled progressive weight bearing activity (% BW) • 6-8 weeks post-operatively • Early stages will require RICE for swelling • Gradual work with ROM in all planes • At 4-6 weeks post-operatively tubing exercises should be utilized • Gradual increase to eccentric activity (10-12 weeks) – avoid excessive loading

37. Isokinetics can be added at submaximal speeds • By 3 months full-weight bearing heel raises can be performed • Initiate walking/jogging progression • Isokinetic testing can be done at 3-4 months to determine deficits • Single-leg heel raises can be substituted • Sports-related functional activities can be initiated at 3 months along with jogging progression • Full unrestricted return can occur after 6 months

38. Criteria for Full Return • Full AROM • Isokinetic plantarflexion strength at 90-95% of uninvolved side • 90-95% of the number of heel raises throughout full ROM in 30 seconds as compared to uninvolved side • Ability to walk, jog, run without observable limp • Successful completion of sports-related functional progression without Achilles irritation

39. Retrocalcaneal Bursitis • Pathomechanics • Bursa that lies between the Achilles tendon and calcaneus • Gradual onset of pain, anterior to Achilles • Pain with dorsiflexion, relieved with plantarflexion • Injury Mechanism • Loading of foot and ankle in repeated dorsiflexion resulting in mechanical compression • Uphill running • Structural abnormalities of foot resulting in compensatory motion with increased Achilles tendon friction and bursa irritation

40. Rehabilitation Concerns • Rule out involvement of calcaneus and Achilles tendon • Rest and inflammation reduction • Period of non-weight bearing may be necessary • Gradual stretching and strengthening • Assess and correct faulty mechanics • Rehabilitation Progression • Early management will require inflammation and pain reduction via RICE, modalities, removal from offending activity, shoeware alterations and modified weight bearing • Maintain fitness through pool running • Gradual addition of gastrocnemius-soleus stretching

41. As pain resolves and gait is normalized a progressive walking/jogging program can begin • Progress back to activity as condition allows • Heel lifts may be required initially • Shoe modification may be necessary • May be able to return 10-14 days if treated early enough • If pain persists 6-8 weeks of rest and activity modification may be required prior to return • Criteria for Return to Full Activity • No observable swelling and minimal pain with palpation (at rest or following daily activity) • Full AROM dorsiflexion and normal pain-free strength • Normal pain-free walking and running gait