LIGAMENT INJURIES OF THE ANKLE

Injuries to the lateral ligament complex (the anterior talofibular ligament, fibulocalcaneal ligament, and posterior talofibular ligament) account for approximately 14% to 25% of all sports-related injuries.34,62 Therefore inversion ankle sprains are among the most common sports and orthopedic injuries.^31,32,91 Studies report that approximately 95% of all ankle sprains occur to the lateral ligament complex.⁹² Additionally, injuries to associated structures including articular cartilage and the synovial membrane have been identified on arthroscopy in individuals who had recurrent or recalcitrant lateral ankle sprains.⁵⁹ Untreated ankle sprains may lead to chronic pain, muscular weakness, and instability.³² Ankle joint osteoarthritis has been observed in patients with chronic ankle instability.¹⁰⁸

Lateral Ligament Injuries (Inversion Ankle Sprains)

Mechanisms of Injury

Ligament sprains of the lateral aspect of the ankle usually are caused by plantar flexion, inversion, and adduction of the foot and ankle (Fig. 17-1).⁹⁷ Large forces are not needed to produce an ankle sprain. Stepping off a curb, stepping into a small hole, or stepping on a rock can produce sudden plantar flexion and inversion motions. During athletic competition, stepping on an opponent’s foot is a common occurrence that leads to lateral ligament sprains of the ankle. Most commonly ankle sprains occur with the foot is in an unloaded or non–weight-bearing (NWB) position before the injury.¹⁰⁴

Classification of Sprains

Classifying inversion ankle sprains can be difficult and confusing.⁹⁷ The standard classification of ligament injuries (e.g., first-, second-, and third-degree sprains) requires elaboration when applied to inversion ankle sprains, specifically addressing grades, degrees, and descriptive severity of the injury (mild, moderate, or severe). A classification model described by Leach⁶⁴ is contrasted with the common standard classification of ankle sprains as a means of comparison and to illustrate the potential for confusion about classification of inversion ankle sprains.

 First-degree sprain: Single ligament rupture.⁶⁴ The anterior talofibular ligament is completely torn. In the standard classification of ligament sprains a complete tear or rupture of a ligament is called a grade III, or third-degree sprain (Fig. 17-2, A).

 Second-degree sprain: Double ligament rupture.⁶⁴ Both the anterior talofibular ligaments and fibulocalcaneal ligaments are completely torn. The standard classification describes a partially torn single ligament as a grade II sprain (Fig. 17-2, B).

 Third-degree sprain: All three lateral ankle ligaments (anterior talofibular, posterior talofibular, and fibulocalcaneal) are completely torn.⁶⁴ In the standard classification, a single ligament that is completely torn is defined as a grade III ligament sprain (Fig. 17-2, C).

Consequently, it is essential that the system of classification used to describe the severity or complexity of injury be accepted and understood and not confused with another system or model of classification.

Clinical Examination

The PTA must be aware of the organization and administration of examination procedures used to inspect inversion ankle sprains. Throughout rehabilitation, the assistant must communicate changes in the patient’s status relative to initial evaluation data and make safe and appropriate modifications to the existing program based on consultation with the supervising therapist.

Testing

Ankle stability tests are used by the physician and the physical therapist (PT) to identify and quantify the integrity of the lateral ligament complex. Injury to the anterior talofibular ligament can be assessed clinically by performing the anterior drawer test (Fig. 17-3).⁹⁷ The patient must be in a relaxed seated or semirecumbent position with the involved leg flexed 90° at the knee and the involved ankle slightly plantar flexed. Stabilize the distal tibia and support it with one hand, while using the other hand to gently but firmly grasp the calcaneus and attempt to translate or pull the ankle forward. No excessive motion is seen or felt if the ligament is intact. However, the ankle demonstrates excessive forward or anterior motion if the anterior talofibular ligament is torn.

The talar tilt test or inversion stress test examines the ankle ligament’s resistance to maximal inversion stress (Fig. 17-4).⁹⁷ The patient is in the same position used for the anterior drawer test, and the ankle is gradually stressed by exertion of constant pressure over the lateral aspect of the foot and ankle while counter pressure is applied over the inner aspect of the lower leg until maximal inversion is reached.¹⁰ The severity of ligament injury should be graded according to the classification system used by the physician or the supervising PT.

Order of procedures

Table 17-1 outlines the procedure for evaluation of inversion ankle sprains. The mechanism of injury that produces an inversion ankle sprain also may cause other conditions that must be differentiated by the physician^91,97 and PT, such as fracture of the base of the fifth metatarsal, malleolar fractures, osteochondral fractures, osteochondritis dissecans, midfoot ligament sprains, and subluxing peroneal tendons.

Table 17-1

Physical Therapist Initial Evaluation Outline for the Clinical Assessment of Inversion Ankle Sprains

Order of Assessment	Procedures
History	1. How did the injury happen? 2. Where is the pain located? 3. Did you hear or feel a pop or snap? 4. Have you had a similar injury previously? If yes, explain.

Observation

1. Note any obvious deformity suggesting a fracture or dislocation.

2. Note the area and degree of swelling.

3. Evaluate complaints of pain.

4. Note any discoloration.

5. Perform a bilateral visual comparison of symmetry.

Palpation Always begin palpation by explaining the procedure, then initially performing the procedure on the uninvolved side.

1. Distal tibia-fibula

2. Lateral ligament complex

3. Medial ligaments–deltoid ligament

4. Base of the fifth metatarsal

5. Peroneal tendons

6. Achilles tendon

Intervention

The specific rehabilitation program used to treat inversion sprains depends on the severity of sprain (first-, second-, or third-degree). Generally first- and second-degree sprains can be effectively managed nonoperatively with a supervised rehabilitation program.⁹⁸

Initial management of acute inversion ankle sprains calls for rest, ice, compression, and elevation (RICE). Rest is a relative term used to define avoidance of unwanted stress; it does not necessarily require complete avoidance of all stress. The application of ice, compression, and elevation is directed at minimizing and reducing intense inflammatory response, hemorrhage, swelling, pain, and cellular metabolism to provide the most conducive environment for tissue healing.⁹¹

Clinically, the most effective means to reduce swelling are elevation and compression. Elastic compression bandages (Ace wraps) are applied while elevating the injured limb above the heart. A three-phase (phase I, maximum protection; phase II, moderate protection; phase III, minimum protection), criteria-based rehabilitation program is effective for the management of inversion ankle sprains. The maximum-protection phase calls for the RICE program to be used three to five times daily. Application of ice should be encouraged for 15 to 20 minutes, with a 1- to 2-hour rest period between applications. Protecting the torn ligaments from unwanted stress is the cornerstone of this phase. Joint protection and immobilization can be achieved through an array of commercial appliances, tape, casting, and braces; selection is left to the physician or PT. Some physicians choose to use a short-leg walking cast or posterior plaster splint. More commonly, a plastic shell brace with an inflatable air bladder or a leather semirigid ankle support is used. Tape can be used for both compression and ligament support, but it must be applied skillfully and reapplied daily to be effective. The ankle must be positioned correctly during the application and use of all support devices. It should be in a neutral position or slightly dorsiflexed and somewhat everted to closely approximate the torn ligaments. Weight-bearing status and ambulation with assistive devices are individualized to the patient’s pain tolerance. Secondary to improved stability of the ankle during weight bearing, patients are commonly instructed to “weight bear as tolerated” during this phase.

An active range of motion (AROM) program must be used cautiously during the maximum-protection phase. It is imperative to avoid plantar flexion and inversion when instructing patients to perform range of motion (ROM) exercises. Excessive plantar flexion and inversion increase the load on the anterior talofibular and calcaneofibular ligaments leading to a disruption of the healing process in these ligaments.

Motion exercises are important to help reduce pain and swelling, as well as help increase function of the joint. However, if certain motions (e.g., plantar flexion or inversion) are employed too early in the rehabilitation period, these unwanted stresses can disrupt the normal healing process. Electrical galvanic stimulation also can help reduce pain and swelling.

Isometric strengthening exercises are initiated as soon as the patient’s pain tolerance allows. Isometric dorsiflexion and eversion exercises are performed for two or three sets of 10 repetitions, holding each contraction for 10 seconds. Proximal leg-strengthening exercises (leg extension, hamstring curls, hip abduction and adduction, and hip extension exercises) and general full-body conditioning should be encouraged throughout the course of rehabilitation. Clinically it is vital to view inversion ankle sprains as injuries that affect the whole person, rather than just the injured extremity. Maintaining aerobic fitness and strength during recovery is particularly important in a population involved in sports.

The moderate-protection phase can begin once the patient can bear weight on the injured limb without crutches, perform all ROM and isometric exercises without undue complaints of pain, and control the swelling. This phase encourages the use of the RICE principle, full weight bearing (FWB), and continued ligament support with the use of braces or tape. More progressive exercises are initiated, including concentric and eccentric contractions (Fig. 17-5) (with ankle weights or latex bands), heel cord stretching (Fig. 17-6) (towel stretch, wall stretch, or prostretch), and standing toe and heel raises.

Gradually and cautiously, inversion and plantar flexion motions are added as pain allows. Stationary bicycling can be initiated with the seat height lowered slightly to encourage a more neutral ankle position instead of a plantar flexion position.

Proprioception exercises are commonly initiated during the moderate-protection phase. Protection of the ligament must be encouraged during these challenging exercises. Balancing on the injured limb on a flat surface is slowly progressed to a balance board, and then to a minitrampoline—all excellent exercises that stimulate balance, coordination, and muscular endurance (Fig. 17-7).

The minimum-protection phase can begin once the patient can perform all resistive exercises, (ankle weight, Thera-Band, and manual resistance) ambulate without pain or limping, and swelling is reduced. Although proprioception training is commonly used in practice there are few articles outlining its effectiveness in rehabilitation.¹¹⁵

From 4 to 8 weeks after injury, new collagen formation allows almost-normal stresses to be applied.⁹¹ At this point, more functional activities are allowed, including straight-line jogging, large figure-of-eight running, jumping drills, and cutting activities.

The minimum-protection phase does not imply removal of all supportive devices. Maturation of the injured ligaments can take as long as 6 to 12 months.⁹¹ Therefore it is critical to encourage patient compliance with the use of either tape or a semirigid brace during all running activities.

Box 17-1 outlines a general three-phase rehabilitation program for an inversion ankle sprain. In all instances, if pain, swelling, or irritation persists, the patient is not taken to the next phase until he or she is pain free in the present phase. The ankle must be securely taped or braced when running, jumping, or otherwise performing aggressive, ballistic motions.

The treatment of grade III ankle sprains (using the standard classification) is somewhat controversial.91,98 At this time there are few, if any outcome studies that outline differences in conservative and surgical treatment for acute grade III injuries. Kerkhoffs and associates⁵⁶ concluded that “there is insufficient evidence available from randomized controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle.” Some authors^10,12,103 report that surgery is needed because “surgical exploration often reveals that the torn ends of the fibulocalcaneal ligament are so widely separated that simple immobilization alone is not sufficient to allow the ligament to heal in a stable position.”¹⁰ However, other authors have found that “early controlled mobilization (functional treatment) was the method of choice and provided the quickest recovery in ankle mobility and the earliest return to work and physical activity without compromising the late mechanical stability of the ankle.”⁹¹ Therefore depending on the physician’s choice of treatment, a grade III sprain can be treated either surgically or with early controlled motion and supervised physical therapy. A good to excellent long-term prognosis can be expected in 80% to 90% of patients with grade III ankle sprains regardless of the intervention.⁵⁴ However, if inadequate treatment is performed, chronic instability may occur leading to injuries to associated structures.³¹ Secondary to the possibility of chronic instability Ferran and Maffulli³¹ have proposed that athletes with acute grade III injuries be surgically treated.

Generally joint protection lasts longer with grade III ankle sprains than with grade I and II sprains. When these injuries are treated surgically, and postoperative immobilization is used, deleterious effects on muscle, bone, cartilage, tendons, and ligaments can be expected.¹

Deltoid Ligament Sprains (Medial Ligament)

Acute isolated sprains of the deep and superficial layers of the deltoid ligament are rare, occurring in only 3% to 5% of all ankle sprains.91,92 It is clinically important to recognize that “complete deltoid ligament ruptures occur in combination with ankle fractures.”⁹¹

However, according to Hintermann and associates,⁴³ sprains of the deltoid ligament appear to be more frequent than commonly recognized, leading to problems with posterior tibialis tendon dysfunction and chronic medial ankle instability. Fractures of the medial or lateral malleolus may cause disruption of the deltoid ligament.⁴³

High Ankle Sprain or Ankle Syndesmosis Injury

When the ankle is forced into dorsiflexion or rotation with the foot in a weight-bearing position, injury to the ankle syndesmosis commonly occurs. This mechanism of injury is prevalent in skiing, football, soccer, and other sport activities.⁶⁸ Injury to the structures supporting the ankle syndesmosis, the anterior and posterior tibiotalar ligaments, the interosseus membrane, interosseus ligament, and the deltoid ligament, can result in an unstable distal tibiofibular articulation.^68,86,89 Diagnostic testing for the high ankle sprain include the external rotation and squeeze tests, and various forms of diagnostic imaging.

Chronic Ankle Ligament Instabilities

The PTA, as an integral part of the rehabilitation team, must be aware of certain short- and long-term complications that may arise from acute or chronic ligament injuries of the ankle. Complications after surgical repair or conservative treatment of ankle sprains are common. Renstrom and Kannus⁹¹ report that 10% to 30% of patients have chronic symptoms of weakness, swelling, pain, and joint instability after inversion sprains. There are two types of instabilities associated with chronic ankle sprains: mechanical and functional.

Mechanical Instabilities

Mechanical instability is defined as laxity of the ankle ligaments. With mechanical instabilities, surgery may be necessary to stabilize the ankle joint.⁶ The Watson-Jones,¹¹⁷ Evans,³⁰ Chrisman–Snook,¹⁷ and Elmslie¹⁷ procedures are common reconstructive surgical procedures used to help stabilize the lateral ligament complex of the ankle. In general, the peroneus brevis muscle is rerouted through a surgically constructed tunnel in the distal fibula (Fig. 17-8, A). The rerouting of the peroneus brevis dynamically stabilizes the lateral aspect of the ankle. Another method used to help stabilize chronic ligament laxity is a delayed anatomic repair of the ligaments. The ligaments are surgically cut, shortened, and reattached to the bone with this method (Fig. 17-8, B). Surgical repair has been gaining popularity among foot and ankle surgeons because of the failure of most reconstruction procedures to correct preinjury ankle biomechanics.^44,70

Ankle arthroscopy has also been gaining popularity among foot and ankle surgeons secondary to the need to identify and treat intraarticular lesions at the time of surgery.21,59,70 In particular, articular cartilage lesions can be identified and treated with arthroscopy.

Intervention

Perhaps secondary to the large number of surgical procedures the postoperative course of treatment after surgical correction of chronic ankle instability is variable. Commonly rehabilitation involves some form of ankle immobilization for approximately 2 to 6 weeks depending on the surgeon. Passive dorsiflexion and plantar flexion exercises are begun after immobilization has ended. When reconstructive procedures involving the rerouting of the peroneus brevis tendon are utilized active motion is not permitted initially. Restriction of AROM allows for the reconstruction to stabilize. When tolerated, AROM exercises begin with careful avoidance of excessive plantar flexion and inversion motions. A general body fitness program is encouraged throughout the period of immobilization. The use of aerobic exercises (stationary bicycle), leg strengthening exercises (leg extensions and hamstring curls), and proprioception exercises is vital throughout rehabilitation.

In primary delayed repair or anatomic reconstruction, the ligament is surgically shortened and reinserted (imbricated). The healing time for ligaments is slightly longer and more tenuous than that for muscle and tendon reconstructions (tenodesis); therefore the period of immobilization may be prolonged. The progression of rehabilitation is the same as with a tenodesis. Active and passive ROM, control of swelling and pain, isometric and manual resistive exercises (being careful to avoid unwanted excessive plantar flexion and inversion motions), Thera-Band and isotonic exercises, and isokinetics are used.

Dynamic muscular support is the foundation of various surgical procedures to correct chronic ankle instabilities. Therefore careful and thorough consideration is given to isometric stabilization exercises, Thera-Band resistive exercises in all directions, manual resistance, isotonic resistance (with ankle weights), and isokinetic strengthening during the minimal-protective phase. In all cases, full ROM exercises with an emphasis on the eccentric contraction phase of each repetition should be encouraged.

Generally, proprioceptive exercises are used extensively. Single-leg standing exercises, balance board activities, minitrampoline exercises, and heel walking exercises are part of the moderate- and minimum-protection phases of rehabilitation. In all cases, joint protection with tape, braces, or a hinged orthosis is a rudimentary but critical principle throughout rehabilitation.

Functional Instabilities

Functional instability refers to a subjective feeling of giving way without affecting ligament laxity. Unlike mechanical instability, functional instability involves a host of factors, including strength, proprioception, and ligament stability. McVey and colleagues⁷⁷ report that up to 40% of patients with lateral ankle instability have functional instability.

Intervention

The primary components of rehabilitation for chronic functional instabilities are closed-chain resistance exercises, proprioception maneuvers, dynamic muscular exercises (concentric and eccentric loads), and bracing for support. Single-leg support proprioception exercises with external resistance (Fig. 17-9) provide dynamic support and balance training. Balance board activities, heel-toe walking, and minitrampoline activities are the cornerstones of proprioception exercises for the ankle throughout all phases of rehabilitation for functional ankle instabilities.

SUBLUXING PERONEAL TENDONS

The PTA must recognize that certain anatomic variations and acute injuries can result in instability of the peroneal tendons and ultimate disability. This injury is classified as acute or chronic. The mechanism of injury involves passive dorsiflexion with the foot slightly everted.27,73 Acute subluxation of the peroneal tendons can be misdiagnosed as a lateral ankle sprain because of the close anatomic proximity of the tendons to the lateral ligament complex (Fig. 17-10). Patients suffering with peroneal tendon subluxation commonly describe posterior ankle pain and may complain of a popping sensation in the lateral ankle. Active dorsiflexion with eversion of the ankle may reproduce the symptoms.⁴¹

Some patients who suffer dislocation of the peroneal tendons have a loose retinaculum (which supports the tendon within the peroneal groove) and also may have a very shallow peroneal groove.³³ Acute injuries to the ankle ligaments (grades I, II, and III, using the traditional classification of sprains) may also result in injury to the peroneal retinaculum. Misdiagnosis of an ankle sprain is quite common.³³ When subluxation occurs the peroneal tendons normally dislocate anteriorly over the lateral malleolus with ankle dorsiflexion.^27,33,73

ACHILLES TENDINOPATHY

Achilles tendinopathy is an overuse injury resulting from repetitive microtrauma and accumulative overloading of the tendon (Fig. 17-11).⁵⁵ The primary feature of Achilles tendinopathy is localized pain at the midportion, distal third, and insertion on the calcaneus. It should be distinguished from other similar posterior foot and ankle disorders such as retrocalcaneal bursitis and Haglund disease.¹⁰¹

Many intrinsic and extrinsic factors can lead to Achilles tendinopathy. Decreased vascularity, malalignment of the hindfoot or forefoot, and issues with gastrocnemius–soleus flexibility are common intrinsic factors.55,101 Extrinsic factors include variations in training, running surface changes, and poor or inappropriate footwear. The general features of Achilles tendinopathy include soft-tissue swelling, pain, and crepitus.

Intervention

Most cases of Achilles tendinopathy are managed conservatively with various physical agents, oral medications, relative rest, and progressive exercises. Initial management includes the use of ice massage or ice packs for 15 to 20 minutes, three to five times daily. The treating physician may prescribe a nonsteroidal antiinflammatory drug (NSAID) to help reduce swelling and pain. All aggravating motions must be stopped. For example, an athletic patient who runs must stop running temporarily until symptoms subside. A program of aerobic exercise using a stationary bicycle or a swimming program can take the place of the running program. Sometimes a small felt heel-lift can be placed in everyday shoes to help reduce the stress on the tendon. Use of the heel-lift is gradually diminished as symptoms are reduced. It is not advisable to suddenly remove the heel-lift support when symptoms improve because pain and swelling return occasionally.

Ultrasound also can be used to help reduce pain and assist with collagen synthesis.⁵⁰ Generally, ultrasound can be used immediately before an exercise program to improve circulation, enhance relaxation of the soft tissues, and reduce pain. Occasionally phonophoresis (ultrasound used with a topical hydrocortisone cream) is used in cases of severe pain.

Flexibility exercises are used to increase dorsiflexion motion and reduce the effects of scarring in prolonged cases of Achilles tendinopathy. Researchers have pointed out that a lack of dorsiflexion is a common denominator for patients suffering from Achilles tendinopathy.⁶³

Initially, active dorsiflexion exercises are used. Towel stretches are gradually added as pain allows. In many cases it may be helpful to apply ice packs or ice massage to the tendon before stretching and strengthening exercises. Standing heel cord stretches can be added to the flexibility program as soon as towel stretches do not cause pain or swelling. In all cases of stretching, it is advisable to avoid any ballistic motions, stretch gently and firmly, and hold each stretch for 10 to 30 seconds.

Standing heel cord stretches can be performed on a small block or with a commercial appliance to produce greater dorsiflexion motion. A soleus stretch is also used for Achilles tendinopathy. The patient faces a wall with his or her knees touching the wall while keeping the heels on the floor (Fig. 17-12).

Strengthening exercises often prove very beneficial for patients with Achilles tendinopathy. However, most full ROM strengthening and stretching exercises also cause complaints of pain. A safe and effective exercise program focuses initially on limited ROM and submaximal exercises. When the patient can perform all exercises without pain, the next phase of more vigorous exercise can begin.

Curwin and Stanish²³ advocate eccentric strength training exercises for treatment of many types of tendinopathy. When strengthening the gastrocnemius–soleus muscle group, standing heel raises are a preferred form of exercise. The patient is instructed to rise up on the balls of the feet using the uninvolved limb, then before the descent phase, body weight is transferred to the involved limb and slowly lowered using the ipsilateral gastrocnemius–soleus muscle. Several authors have strongly advocated the use of an eccentric only strength training program for Achilles tendinopathy.^3,58 Alfredson and associates³ describes excellent clinical outcomes following a 12-week eccentric strength training program for Achilles tendinopathy. In their study subjects who performed the eccentric program were able to resume running in 12 weeks, whereas those who performed a more standard concentric rehabilitation program were not able to return to running during this same time frame.³ Knobloch⁵⁸ reports that “daily eccentric training for Achilles tendinopathy is a safe activity without any evidence of adverse effects in either mid-portion and insertional Achilles tendinopathy.”

In some severe cases of Achilles tendinopathy, physicians may prescribe rigid cast immobilization of the ankle for 10 days.⁶³ The entire program of rehabilitation after cast immobilization progresses at a slightly slower rate because of the ROM and strength loss associated with immobilization. In all cases of Achilles tendinopathy, the patient is instructed in a general body fitness program. Aerobic exercise can be achieved with an upper body ergometer (UBE), seated bicycle ergometer with the seat height corrected to prevent plantar flexion, or a swimming program. Upper- and lower-body stretching and strengthening exercises are encouraged as long as the tendon suffers no undue stress or pain.

RUPTURES OF THE ACHILLES TENDON

Complete ruptures of the Achilles tendon can occur with sudden eccentric-concentric contraction of the gastrocnemius–soleus (Fig. 17-13).¹⁰¹ These ruptures usually involve the area “3 to 4 cm proximal to its insertion on the calcaneus, within the area of decreased vascularity” and occur mostly in men 20 to 50 years old.^55,101 Racquet sports and other activities requiring a deceleration to acceleration mechanism are often the mechanism of injury. Approximately 50% of Achilles tendon ruptures are secondary to degenerative changes in the tendon.¹⁰¹ Corticosteroid injections or fluoroquinolone antibiotics are also responsible to weakening the tendon and predisposing an individual to rupture.¹⁰¹

In acute Achilles tendon rupture, palpation reveals a defect or gap in the continuity of the distal third of the tendon. The Thompson test clinically assesses the integrity of the Achilles tendon. To perform this simple test, the patient lies prone on an examining table with the feet extending off the end. The entire lower leg is exposed, from knee to toes. The belly of the calf of the uninvolved limb is grasped and squeezed so that the foot plantar flexes. If the tendon is ruptured on the involved limb when the calf is squeezed, no plantar flexion motion results (Fig. 17-14).

Intervention

A ruptured Achilles tendon can be treated surgically or with cast immobilization.57,101 Nonoperative treatment of Achilles tendon ruptures requires the patient to be immobilized for as long as 8 weeks.^55,57,101 However, with nonoperative treatment, researchers have documented rerupture rates of 8% to 39%.^9,30,52,57 In addition, there is a greater loss of strength, power, and endurance compared with surgically repaired tendons.^9,49,52,55 Surgically repaired Achilles tendons have a much lower rate of rerupture (0% to 5%), and there is a significant increase in the ultimate recovery of muscular strength, power, and endurance.⁵⁷ However, Nistor⁸⁵ reports only minor differences between surgical and nonsurgical management. Some surgeons⁸⁵ prefer nonoperative management because there are fewer complications related to surgery, reduced complaints, no hospitalization, and no significant differences in function compared with surgically treated patients. There are numerous surgical techniques used to repair acute Achilles tendon ruptures, including end-to-end primary repair and direct repair and augmentation with tendon or synthetic grafts.^∗

The rehabilitation program used after nonoperative immobilization of an Achilles tendon rupture requires the PTA to appreciate the time-dependent nature of tendon healing and plastic and elastic deformation principles. Throughout the course of immobilization, the patient should be instructed in a general body conditioning program that does not stress the involved tissues. The muscles of the noninvolved limb (i.e., quadriceps, hamstrings, gastrocnemius–soleus) should be vigorously strengthened along with the thigh and hamstring muscles of the involved limb. Aerobic exercise is also encouraged. Stationary bike ergometers using only the uninvolved limb (a toe clip is necessary for single-limb cycling) and UBEs are appropriate and safe cardiovascular fitness tools. When the cast is removed and after the initial evaluation by the PT, the PTA proceeds with thermal agents as indicated. Moist heat can be used before ROM and flexibility exercises. If pain and swelling are present, a cold whirlpool or ice packs with compression can be applied.

Regaining full dorsiflexion and plantar flexion motion is an exceedingly slow process after cast removal. Gentle active dorsiflexion and plantar flexion exercises are initiated immediately. Typically, a small heel-lift is used in everyday shoes to minimize stress on the healing tendon. Because the tendon was not surgically repaired, the process of regaining tensile strength and collagen alignment must be approached cautiously. Progressive active motion is an essential component for full return to function. However, if the tendon is stressed too soon or vigorously, it may rerupture. The heel-lift is commonly worn for 3 to 4 weeks and gradually reduced in size to prevent sudden excessive stress on the tendon.⁵⁵

Progressive plantar flexion and dorsiflexion exercises using a latex band are encouraged as pain and motion allow. Proprioception exercises can be employed early, depending on the patient’s tolerance. Generally, proprioception exercises begin with the patient in a seated position (Fig. 17-15) and progress as tolerated. If rerupture occurs, it is usually within 4 weeks after immobilization.⁵⁵ During this maximum-protection phase, the patient is encouraged to avoid sudden forceful plantar flexion or dorsiflexion motions.

As motion increases gradually, closed-chain resistive exercises can be initiated, based on the patient’s ROM, pain tolerance, swelling, and the length of time after cast removal. Seated stationary cycling can be used for aerobic fitness, ROM, and local muscular endurance. The seat must be adjusted to avoid excessive plantar flexion or dorsiflexion, however. Step-ups can be used (with heel-lift) to encourage weight bearing eccentric loading.

Weight-bearing plantar flexion can begin gradually once the patient has successfully completed the prescribed program of ROM and strengthening exercises without complications. Standing plantar flexion is initiated without a block to stand on. The patient is instructed to gradually rise up on the toes using primarily the uninvolved limb, then lowers himself or herself using both feet. As strength improves, the patient gradually uses more of the involved limb to rise up on the balls of the feet. Adding a small block of wood on which to rise adds greater dorsiflexion stress and motion. Seated calf raises can be performed by modifying a leg extension machine (Fig. 17-16). The seated position may be more comfortable initially.

The PTA reassesses the patient’s ROM, strength, pain, and swelling on a daily basis. Modifications are necessary if the patient is having undue pain with any phase of the program. Daily communication with the PT allows continuous restructuring of the rehabilitation plan based on the patient’s needs as assessed by the PTA. Isokinetic testing for plantar flexion, dorsiflexion, ROM, strength, power, and local muscular endurance generally is reserved for the minimal-protection phase. However, isokinetic strengthening exercises can be employed early if done at higher speeds and performed submaximally under limited ROM conditions.

Rehabilitation following surgical repair or reconstruction of the Achilles tendon is quite variable. Secondary to the large number of procedures available, the timing of the surgery (acute vs. chronic), stability of the repair/reconstruction, and intrinsic patient variables the rehabilitation progression may be different from surgeon to surgeon, and patient to patient. In particular the surgical variations are numerous with each having differing needs for immobilization and restriction of weight bearing during the immediate postoperative period. Variables such as ROM, weight bearing, and initiation of strength training are determined by the surgeon. Therefore each individual should be rehabilitated independently.^∗

Generally, rehabilitation following Achilles tendon repair or reconstruction follows a criteria-based rehabilitation program as described previously. Following a period of immobilization a gradual progression of weight bearing and ROM is pursued. Normally plantar flexion is less restricted than dorsiflexion during the early postoperative period. Strength training can begin as early as 2 to 4 weeks postimmobilization.⁵⁵

Secondary to the large differences in Achilles tendon surgery and rehabilitation programs the return to full activity is also variable. At least one author believes that successful outcomes are dependent on tendon elongation. Kannas and Renstrom⁵⁴ report that improved outcomes occur when less elongation of the Achilles tendon occurs. Therefore symmetric ankle dorsiflexion ROM is a goal of treatment, and increased dorsiflexion beyond the contralateral side is discouraged. Generally most patients are able to return to full activity within 6 to 9 months. Surgical complications following Achilles tendon repair or reconstruction include sural nerve dysfunction, infection, skin sensitivity, adhesions, rerupture, and tendon necrosis.^57,61 The vast majority of patients appear to be satisfied with their results.^{2,29,48,57,88}

COMPARTMENT SYNDROMES

Compartment syndromes of the lower leg are defined as either acute or chronic elevated tissue pressure within a closed fascial space, resulting in occlusion of vessels and compromised neuromuscular function.4,35,93

Acute compartment syndromes of the leg are most commonly associated with tibial fractures, direct trauma to the area, muscle rupture, muscle hypertrophy, and circumferential burns.62,91 Acute elevated intracompartmental pressure within the lower leg is considered a medical emergency.³⁵

Chronic compartment syndromes also are referred to as exertional compartment syndrome or exercise-induced compartment syndrome. Muscular contractions and exertion have been shown to cause increases in muscle size, leading to increased intracompartmental pressure.62,91 This results in ischemia and reduced neuromuscular function. To understand this series of events, it is necessary to review pertinent anatomy of the lower leg.

There are four well-defined compartments of the leg, divided by nonyielding fascia.4,93 The anterior compartment of the lower leg contains the tibialis anterior muscle, anterior tibial artery and vein, and foot and toe extensor muscles. The lateral compartment contains the superficial peroneal nerve and short and long peroneal muscles. The superficial posterior compartment contains the soleus muscle and plantaris and gastrocnemius tendons. The deep posterior compartment contains the posterior tibialis muscle, the peroneal artery and vein, tibial nerve, and posterior tibial artery and vein. If swelling occurs in one or more of these compartments, reduced capillary blood perfusion results in neurovascular and muscular dysfunction.

Clinical symptoms of acute compartment syndrome include pain, palpable swelling or tenseness, and paresthesias.4,93 The skin may be warm, shiny, and tense. Passive stretching of the muscles of the lower leg may produce severe pain.

Symptoms of chronic or exertional compartment syndromes include a dull aching pain within the muscle during and after long-term exercise. Paresthesias also may develop as the syndrome progresses. The sections most commonly affected with chronic exercise-induced compartment syndromes are the anterior and deep posterior compartments of the lower leg.

ANKLE FRACTURES

The most widely accepted classification of ankle fractures is called the Lauge–Hansen classification.⁷⁶ Another type of classification, called AO, is based on principles, which are similar to, though slightly different from, the Lauge-Hansen (Fig. 17-7). The organization and classification of ankle fractures frequently involve the direction of force, which results in specific patterns of injury. For example, a Lauge–Hansen pronation-abduction or pronation–lateral rotation injury may result in a malleolar or bimalleolar fracture of the ankle (Fig. 17-18).

Ankle fractures include lateral malleolar fractures, medial malleolar fractures, bimalleolar fractures (combined medial and lateral malleolar fractures), and trimalleolar fractures (bimalleolar fractures plus the posterior margin of the tibia). Though simple malleolar fractures are managed initially with immobilization, many fractures are managed with an open reduction with internal fixation (ORIF) procedures. Typically, these fractures are fixed with various screws and plates to hold the fragments in place (Fig. 17-19).

In many cases of ankle fractures repaired with an ORIF procedure, the patient is in a semirigid postoperative removable splint for 2 weeks. This splint can be removed to allow for active dorsiflexion and plantar flexion ROM exercises. However, this is patient-specific and should be confirmed with the surgeon. Because of the mechanism of injury that caused the malleolar fracture and the position of the internal fixation devices, no inversion or eversion exercises are performed.

A walking cast is applied once the patient achieves full plantar flexion and dorsiflexion ROM. Before casting, the surgical wound must be fully closed, sutures removed, infection absent, and no drainage present. A general full-body conditioning program is prescribed throughout immobilization. Both aerobic fitness and strengthening exercises are advocated also. Further, strengthening of the uninjured limb has shown beneficial crossover results in strength of the injured limb.¹¹⁴

ROM exercises, isometric strengthening, stationary cycling, and weight-bearing exercises are begun once the cast is removed. Progressive exercises employ latex rubber tubing or bands, manual resistive exercises, isoinertial/isotonic strengthening, and proprioception exercises. Return to function exercises should be incorporated as soon as the patient is able. Single limb activities, landing activities, and out of plane activities are important examples used for proprioceptive training and return to activity.

The PTA must be acutely aware of the signs and symptoms of possible hardware loosening (increased pain, swelling, crepitus, and motion) so as to swiftly inform the PT and make all necessary modifications in the present program. If, for example, after cast removal following an ORIF procedure for a medial malleolar fracture the PTA recognized increased swelling and complaints of crepitus when strengthening exercises were increased, stressing inversion of the ankle, the PTA should halt those particular exercises and inform the PT. Weight-bearing status; active, passive, and resisted ROM; and functional progression should be determined by the physician throughout rehabilitation.

Calcaneal Fractures

Calcaneal fractures are intraarticular depression fractures usually caused by falls from a height and resulting in compression of the calcaneus from the talus (Fig. 17-20). McRae⁷⁶ describes seven common patterns of calcaneal fractures:

1. Vertical fractures of the calcaneal tuberosity

2. Horizontal fractures

3. Fractures of the sustentaculum tali

4. Anterior calcaneal fractures

5. Fracture of the body of the calcaneus without involvement of the subtalar joint

6. Calcaneal fractures with lateral displacement and involvement of the subtalar joint

7. Central calcaneus crushing fractures

Each calcaneal fracture type has individual characteristics that allow the physician to determine the treatment options and the rehabilitation progression. Both conservative (casting) and surgical (ORIF) procedures are used with calcaneus fractures.⁷⁶ As with all fractures, specific rehabilitation procedures should be cleared by the physician before initiation. When possible early ROM activity is used in rehabilitation to reduce stiffness and prevent long-term ROM loss. Weight-bearing status; active, passive and resisted ROM; and functional progression should be determined by the physician throughout rehabilitation. Supportive measures to control pain and swelling are used as necessary.

In the long term, the cornerstone in recovering from a calcaneal fracture lies in regaining motion and strengthening the plantar flexors. Multiangle isometric plantar flexion can be initiated and progressed to full ROM manual resistance dorsiflexion and plantar flexion. The use of latex rubber tubing and bands for plantar flexion in a long-seated position is an appropriate and challenging calf-strengthening exercise during the moderate-protection phase of rehabilitation. Strengthening of the soleus can be achieved by having the patient lie prone with the affected leg flexed 90° at the knee and placing ankle weights around the foot of the affected leg (Fig. 17-21).

Gait examination and retraining will be necessary in this population, because initial contact during gait will be compromised. Patients are more likely to load on the midfoot or forefoot at initial contact. Training of a normal heel strike pattern on soft surfaces may be necessary to avoid long-term gait deviations.

STRESS FRACTURES OF THE FOOT AND ANKLE

A stress fracture is a partial or complete fracture of bone caused by unrelenting stress and force that do not allow for osteoblastic repair of bone and in turn cause accelerated bone resorption. Common sites for stress fractures in the foot and ankle are the metatarsals, lateral malleolus, os calcis, navicular, and sesamoid.

Clinically, pain is the predominant feature of a stress fracture. The pain usually increases with activity and subsides with rest. The incidence of stress fractures in the foot and ankle is related in part to participation in demanding physical activity. If stress and forces are applied to bone and are not removed to allow the bone to repair, osteoclast activity overtakes the rate of osteoblast activity and stress fractures occur.

The development of stress fractures can be viewed in part as resulting from a linear progression or continuum of excessive external forces that lead to intrinsic reactions of muscle, bone, and periosteum. For example, with increased muscular forces resulting from continued and excessive use (marathon running, recreational jogging, aerobic dance, or occupations that require standing or walking all day) there is an associated increased rate of bone remodeling around the area of increased stress.¹⁰² If the stress is not removed, this increase in bone remodeling is followed by a greater rate of bone resorption. If the stress continues, the bone eventually responds by developing microfractures, periosteal inflammation, and resultant stress fractures.¹⁰² If stressed further, and the bone and soft tissues are not allowed to recover fully and heal properly, the development of linear fractures and ultimately displaced fractures can occur.¹⁰²

There are certain stress fractures that pose a greater risk of delayed union, nonunion, and displacement than others.⁷⁴ The base or proximal diaphysis of the fifth metatarsal is described as “no-man’s-land” and is “at risk” for delayed union or nonunion after a stress fracture.^74,91 Usually, complete rigid-cast immobilization is indicated for 6 to 8 weeks when conservative, relative rest has failed to arrest symptoms of pain.^74,91,92 Other stress fractures termed at risk²² are tarsal navicular fracture, sesamoid fractures, and all intraarticular fractures.

The management of not-at-risk⁷⁴ stress fractures of the foot and ankle can be effectively rehabilitated with activity modification; relative rest; therapeutic agents to relieve pain and swelling; and specific leg, ankle, and foot stretching and strengthening exercises. Low-impact aerobic exercise is useful in athletic patients who are extremely active. For example, instead of running, the patient can use a stationary cycle, recumbent cycle, elliptical trainer or run in a NWB manner under water.

For stress fractures of the foot and ankle that are at risk⁷⁴ (fifth metatarsal, navicular, sesamoids, and intraarticular fractures), more caution is necessary during the advancement of closed-chain activities to protect the healing bone from unwanted forces. With at-risk stress fractures, some form of external support can be used to brace the area. Usually some type of bracing, padding, casting, or orthosis is applied to control stress and forces to the healing bone.⁷⁴ The application of therapeutic exercises must be approached cautiously. Submaximal isometric exercises are encouraged initially. AROM and light concentric and eccentric loads are added as pain allows. Obviously, vertical compressive loads and shearing forces (i.e., jumping, running, cutting) are strictly prohibited to allow proper healing. Modifications in aerobic activity and general physical conditioning can allow the patient to continue to participate in strenuous physical conditioning, provided no stress is applied to the healing tissues. The initiation of closed-chain functional activities must be deferred until radiographic confirmation by the physician documents stable bone healing.

MEDIAL TIBIAL STRESS SYNDROME

Musculoskeletal overuse injuries of the lower leg involving the distal third of the posterior medial border of the tibia have historically been referred to as shin splints. This term has no place in orthopedic management and should be discarded as a nonspecific term used to describe any pain occurring in the lower leg.⁴ A more precise and descriptive term is medial tibial stress syndrome (MTSS), which describes pain over the distal and middle thirds of the tibia along the posterior medial border.¹⁰ Differential assessment by the physician and PT includes stress fractures of the tibia and fibula, ischemic disorders, and deep compartment syndromes of the lower leg.

The predominant feature of MTSS is tenderness over the distal, posteromedial tibia.⁸⁰ Traditionally a number of different structures are thought to cause these symptoms. Musculotendinous inflammation, periosteal inflammation of the muscle–tendon–bone interface at the posterior medial border of the tibia, injury to the tibia bone, the posterior tibialis muscle, and the medial origin of the soleus muscle have been identified as a primary source of pain in patients with MTSS.^4,7,25,78 More recent work has noted that a primary source of symptoms with MTSS is the tibial bone.^72,80

Several studies have attempted to determine the etiology of MTSS.8,28,46,80,112,121 Intrinsic factors for MTSS include overpronation of the foot, female sex, high body mass index, hip ROM (internal and external rotation), and ankle ROM loss (dorsiflexion). Hubbard and colleagues⁴⁶ report that a previous history of MTSS, previous history of stress fracture, and less than 5 years of experience in a sport predispose an athlete to MTSS. Runners, basketball and volleyball players, tennis players, and military recruits have a greater incidence of MTSS.^28,80 Diagnosis of MTSS is primarily made on physical exam, but diagnostic imaging including plain film radiographs, bone scans, dual energy x-ray absorptiometry (DEXA) scans, and magnetic resonance imaging (MRI) are also used.^72,80

Because pain is the predominant feature of MTSS, it is helpful to classify and describe the severity of pain related to the patient’s ability to perform activities.⁵¹ Grade I describes pain that is experienced after activities. Grade II defines pain felt both during and after activities that does not affect the actual performance of activities. Grade III pain is felt before, during, and after activities and affects the patient’s ability to perform activities. Grade IV pain is so significant that no activities can even be attempted.

In general, grade I pain refers to muscle soreness and minor soft-tissue inflammation. Grade II pain is viewed as a mild or moderate soft-tissue inflammation. Grade III pain involves significant soft-tissue inflammation and bone microfractures. Grade IV pain defines an actual stress fracture.

A patient experiencing minor pain (grade I) typically describes transient muscle soreness and general tenderness after activities.

Treatment generally consists of ice packs or ice massage, physician-prescribed NSAIDs, rest, and gradual stretching and strengthening exercises for the entire lower leg. However, treatment of MTSS is highly individualized and specifically related to the comprehensive evaluation performed by the PT. If the PT determines that the patient demonstrates excessive foot pronation, custom molded orthotics may be prescribed to relieve stress. Cryokinetics (ice packs or ice massage in conjunction with stretching and strengthening exercises) usually are advocated as a means to control pain and swelling and encourage motion and function. Relative rest is prescribed in most cases of MTSS. That is, instead of complete rest and immobilization, the patient’s activity level is modified to accommodate the patient’s complaints of pain and dysfunction. For example, a patient who is an avid jogger may be encouraged to jog in a pool instead. If a UBE is available, the patient can still actively perform aerobic conditioning activities without the associated stress on the lower leg.

Currently there is evidence to support the use of relative rest, foot orthotic devices, and stretching to improve symptoms in patients with MTSS.80,112 However, a multimodal approach utilizing mechanical and therapeutic approaches appears to be most beneficial with this disorder.²⁸

PLANTAR FASCIITIS (HEEL SPUR SYNDROME)

Chronic inflammation of the plantar aponeurosis, with or without an associated calcaneal heel spur, is called plantar fasciitis (Fig. 17-22). Leach and co-workers⁶⁵ describe plantar fasciitis as repetitive microtrauma leading to injury, attempted repair, and chronic inflammation. Brody¹³ describes plantar fasciitis as an “inflammatory reaction due to chronic traction on the plantar aponeurosis (fascia) at its insertion into the calcaneus.”

Although most authors and clinicians believe this pathology is an inflammation of the plantar fascia there are several authors who describe this disorder as a plantar fasciopathy or plantar fasciosis.67,94 These authors believe that the pathology can be degenerative as well as inflammatory in nature, depending on the chronicity of the pathology. The same issue has been discussed with other overuse tendon injuries.

Patients with plantar fasciitis frequently complain of pain along the medial border of the calcaneus on the plantar surface. Many patients report that pain is worse in the morning when the foot contacts the floor in getting out of bed. Palpation of the plantar fascia usually reveals tenderness at the medial tuberosity of the os calcis or throughout the entire course of the fascia.⁴ Palpation is performed with the toes flexed, which reduces tension on the fascia, or with the toes extended, which increases tension on the fascia.¹¹ Dorsiflexion of the ankle may also provoke symptoms.¹⁶

Intervention

Many patients respond well to conservative physical therapy procedures.83,94 Relative rest, stretching, manual therapy, exercise, iontophoresis, arch taping, and foot orthotic devices have been shown to improve symptoms and function in patients with plantar fasciitis.^∗ A specific physical therapy approach where the clinician treats impairments, functional limitations, and disabilities with interventions designed to improve each item observed in the examination appears to have the greatest impact on patients with plantar fasciitis.⁷⁵

Specifically addressing ROM deficits at the ankle joint (dorsiflexion) with manual therapy and stretching exercises appears to be helpful in these patients. If indicated, both the gastrocnemius and soleus muscles should be stretched. However, if stretching of the gastrocnemius or soleus is painful in the area of the plantar fascia the clinician may want to decrease this activity.¹⁶ In the author’s experience if arch taping is helpful in reducing symptoms use of an over-the-counter foot orthotic device may be helpful. Custom-made foot orthotic devices may also be used in selected patients. In particular those patients who have a large arch deformity and did not respond favorably to an over the counter device may be good candidates for a custom-made foot orthoses.

Strength training for the musculature in the foot and lower leg may be indicated if specific weaknesses are observed during the examination. Inversion, eversion, dorsiflexion, and/or plantar flexion strength training is necessary when weakness occurs. Strength training for the intrinsic musculature in the foot may also be necessary. Activities such as toe curls, picking up marbles with the toes, or gripping a towel can be used to strengthen the foot intrinsic musculature (Fig. 17-23).

The physician may inject a local steroid to help decrease pain and swelling in more severe cases. Because many patients complain that the most severe pain is in the morning, some physicians and PTs prescribe night splints to stretch the Achilles tendon and the plantar fascia. In an athletic population, plantar fasciitis occurs from running and competitive sports participation. During recovery from plantar fasciitis, it is imperative to maintain aerobic fitness and general body strength. Aerobic exercises can be performed without weight bearing in a pool or with a UBE to decrease repetitive loading on the plantar fascia. Stationary cycling is an excellent alternative.

Extracorporeal shockwave therapy has been used for several years to assist in the healing process in patient with plantar fasciitis. This modality attempts to break up adhesions and improve soft tissue extensibility of the plantar fascia. Several authors have shown good results with this form of treatment.94,110,116

With some patients who do not respond to conservative therapy, the physician may decide to correct the problem surgically. Surgical options include plantar fascia release (fasciotomy) and partial plantar fascia release. Rompe⁹⁴ states that conservative management is the first and best option, and should last approximately 6 months before other forms of treatment. If conservative management fails, then surgery is the next option.

ARCH DEFORMITIES (PES PLANUS AND PES CAVUS)

Pes planus (flatfoot) is a congenital or acquired deformity of the foot where the medial longitudinal arch of the foot is reduced, causing the medial border of the foot to contact the ground when a person is standing.⁷¹ The usual cause of acquired pes planus is muscular weakness, laxity of ligaments that support the medial longitudinal arch, paralysis, or a pronated foot.⁷¹ Pes planus deformity can be classified as mild, moderate, or severe.⁸¹

During the initial evaluation, the PT measures the degree of hindfoot and forefoot alignment in NWB. The hindfoot alignment is defined as the longitudinal bisection of the calcaneus relative to the long axis of the lower leg, and the forefoot alignment is defined as the metatarsal alignment relative to the perpendicular of the longitudinal bisection of the calcaneus. If the plantar surface of the distal segment is medial relative to the proximal segment, this is defined as a varus alignment. If the plantar surface of the distal segment is lateral relative to the proximal segment, this is defined as a valgus alignment. In addition, the PT assesses the deformity in a weight-bearing position.⁹² With a rigid pes planus deformity, the foot appears to have an abnormally low arch in both weight-bearing and NWB positions.⁹² With a flexible pes planus deformity, the foot appears to have a normal arch in a NWB position, but an abnormally low or flat arch in weight bearing.

No specific therapeutic interventions are necessary if there is no associated pain or dysfunction. However, because the area is a terminal component of the closed kinetic chain during weight bearing (the arch can affect the knee, hip, and spine in a closed kinetic chain), treatment that is specific to the arch may be indicated if associated pain and dysfunction are experienced in other joints along the kinetic chain. For example, pes planus can affect the normal neutral-to-pronation sequence of the foot during the gait cycle. Because the foot is already pronated (with pes planus), the reduced normalized motion from neutral to pronation is affected during gait. Therefore the knee and other joints along the kinetic chain must compensate for this reduced motion. If pain and resultant dysfunction occur in one or more of these associated joints, then corrective action is necessary to place the foot in a more neutral position to enhance the normal physiologic motion of the entire kinetic chain. Injuries common to those with pes planus occur more often to medial soft tissue structures of the knee.¹¹⁹

Usually the use of a custom-fabricated foot orthotic device is indicated to create a more normal mechanical arch. Materials used to fabricate foot orthotic devices include cork, leather, rubber, foam, felt, and plastic.¹⁸ The rationale for the use of a custom-molded foot orthotic device to correct a symptomatic pes planus is supported in the literature.²⁴ Further, successful treatment of other lower extremity injuries commonly attributed to pes planus have been documented.³⁷ However, individual consideration should be given to each patient for prescription foot orthoses as lower extremity overuse injuries are always multifactorial.⁸⁴

Pes cavus, on the other hand, describes an abnormally high arch.71,91 Pes cavus usually is a result of neurogenic pathologic processes, muscle imbalances, and congenital abnormalities; both medial and lateral longitudinal arches can be affected. Clinically, patients may complain of painful calluses beneath the metatarsal heads because of the mechanical friction and pressure that occur with metatarsal heads. Osteoarthritic changes are not uncommon in the tarsal area because of the altered biomechanics of the foot. Mechanical compensation at proximal joints in the lower extremity is also common with injuries being more common to lateral bony structure of the foot and lower leg.¹¹⁹

Treatment for pes cavus is much more challenging than for pes planus and should be focused on pain and shock attenuation. Recent evidence supports the effectiveness of custom-made foot orthoses for treatment of pain related to pes cavus. ⁴⁰ No treatment is indicated if no symptoms exist, although the PT may document this deformity during a lower-quarter evaluation.

MORTON NEUROMA (PLANTAR INTERDIGITAL NEUROMA)

Patients with a neuroma may complain of diffuse, occasionally radiating pain into the toes and proximally to the dorsal or plantar surface of the foot.²² A neuroma usually occurs at the 3-4 interspace and less frequently at the 2-3 interspace (Fig. 17-24).⁷⁹ Morton neuroma occurs bilaterally only 15% of the time, with the patient complaining of a burning, cramping, or catching sensation.^22,79 A painful mass can be palpated in approximately one third of the cases.⁷⁹

HALLUX VALGUS

Hallux valgus is a lateral or valgus deviation of the great toe with both soft tissue and bony deformity (Fig. 17-25). This condition can be exacerbated by improper footwear (narrow toe box), and often the associated pain can be relieved by modifying or changing poor footwear. Examination should include assessment of the deformity in a standing position, which often accentuates the deformity,^22,79 and measurement of the hallux valgus angle (normal is <15 degrees) to determine the degree of deformity and angle of deviation. Hallux valgus is often associated with hallux rigidus. Therefore, first metatarsal phalangeal joint extension ROM should also be assessed. Further, it has been suggested that abnormal pronation is associated with the development of hallux valgus.⁹⁶

Management options include both conservative care and operative procedures. Initial care is supportive, with a change in footwear to include a wider toe box (this alone can significantly reduce symptoms), over-the-counter or custom foot orthotic devices, or pads to dissipate stress and relieve pain. Modifications in activity may reduce symptoms profoundly. In an athletic population, changing from running activities to swimming or bicycling can reduce pain caused by the repetitive pounding of running. Ultimately, activity modification alone will not be enough to eliminate pain related to hallux valgus.

Many surgical options are available, depending on the severity of the deformity. General physical therapy management of postoperative bunionectomy is designed to reduce pain and swelling, improve first metatarsal phalangeal joint ROM, and increase strength to enable a return to normal daily activities. Initially after surgery, the patient wears a hard-soled shoe, progressing to walking boot, and then to shoes with a wide or open toe box. Gauze padding and toe spacers may be used to maintain proper alignment after the surgical procedure. Once the sutures are removed and the wounds closed, AROM exercises for both flexion and extension of the great toe can begin. Manual resistive toe extension and toe flexion exercises can begin as pain allows. Gait mechanics must be reviewed carefully and correct walking encouraged after bunionectomy. Usually weight-bearing patterns and restrictions of movement affect proper gait mechanics, especially the strength, power, and motion needed for toe-off. Restoration of joint motion and stability, and toe flexion and extension strength, form the foundation of the rehabilitation program.

LESSER TOE DEFORMITIES (HAMMER TOES, MALLET TOES, AND CLAW TOES)

Three distinct types of lesser toe deformities are hammer toes, mallet toes, and claw toes (Fig 17-26). All three deformities are worsened by wearing improper shoes (narrow toe box).

Hammer toe (see Fig. 17-26, A) is characterized by deformity of the metatarsophalangeal (MTP) joint, proximal interphalangeal (PIP) joint, and distal interphalangeal (DIP) joint. The MTP joint is either in neutral position or extension. The PIP joint is held in flexion with the DIP joint in either flexion or extension.

Mallet toe (see Fig. 17-26, B) is characterized by a neutral MTP joint, a neutral PIP joint, and a flexed DIP joint.

Claw toes (see Fig. 17-26, C) often are associated with neuromuscular disease and are similar in appearance to hammer toes. Claw toes are distinguished by MTP hyperextension, PIP flexion, and DIP flexion. This deformity usually results from “simultaneous contraction of the extensors and flexors.”⁷⁹

The physician or PT determines if the lesser toe deformity is either rigid (fixed) or flexible. Flexible deformities usually are correctable with conservative, passive measures, whereas fixed deformities may require surgery.

COMMON MOBILIZATION TECHNIQUES FOR THE ANKLE, FOOT, AND TOES

Limitations of movement resulting from fibrosis after trauma, surgery, or disease of the foot, ankle, or toes frequently require specific mobilization procedures to regain normal joint function. Mobilization techniques typically are used in conjunction with thermal modalities to control pain and swelling and aid in relaxation; these modalities include hot packs, ultrasound, whirlpool baths, and ice packs. Active and passive exercises, specific stretching exercises, strengthening exercises (open progressing to closed chain), and proprioception tasks help the patient regain balance, coordination, and function. The choice of mobilization technique, direction of application, grades, amplitude of force, velocity, oscillations, and distractions is made by the PT based on the specific pathologic condition involved, tissue-healing constraints, and overall appropriateness with regard to the short- and long-term goals of the rehabilitation program.

The following techniques are general procedures used for a wide variety of specific joint limitations. These techniques can be modified by the PT depending on the specific nature of the limitations involved. This list is not intended to be a comprehensive review of all techniques for each joint of the ankle, foot, and toes. These methods are commonly used, easily practiced, effective procedures for treating a host of joint limitations. It is clinically relevant to restate that the delegation of selected mobilization techniques to be used by the PTA is entirely at the discretion of the PT, and peripheral joint mobilization is not universally accepted as a routine domain of practice of the PTA. Information concerning peripheral joint mobilization has been provided as a means to stimulate the PTA’s awareness of the rationale for improving motion and for the reduction of pain as identified and prescribed by the PT.

Ankle Mobilization

Anterior and posterior glides are best performed with the patient in a supine or long-sitting position with the lower leg firmly and comfortably supported. For anterior glide of the calcaneus, the hand position, stabilization, and direction of force are similar to those for the anterior drawer test for ligament stability testing of the anterior talofibular ligament. One hand should be placed firmly on the distal anterior surface of the tibia and fibula. The application hand should be used to firmly cup the calcaneus and provide an anterior-directed force (Fig. 17-27).

The posterior glide technique is performed with the patient in the same position as the anterior glide. The distal tibia and fibula should be stabilized with the palm of one hand. The application hand should be placed on the dorsal surface of the talus to provide a posterior-directed force (Fig. 17-28).

Traction is achieved through long-axis distraction of the talus caudally from the tibia and fibula. The patient can be supine or prone with the lower leg firmly and comfortably supported. The dorsal surface of the talus should be firmly grasped with the open palm of one hand, while the other hand is used to firmly grasp and cup the calcaneus. The force should be applied simultaneously with both hands along the long axis of the tibia and fibula (Fig. 17-29), effectively distracting the talus from the mortise.

Metatarsal Mobilization

Distal metatarsal glides are performed while the patient is supine with the lower leg supported. The hand, thumb, and fingers of one hand should be used to stabilize the ray of the second metatarsal while the hand, thumb, and fingers of the application hand firmly grasp the first ray at the metatarsal head. Force should be applied in a plantar and dorsal direction (Fig. 17-30).

Proximal Interphalangeal Joint Mobilization

Long-axis distraction of the PIP joint is achieved by stabilizing the affected metatarsal ray with one hand while using the application hand to firmly grasp the affected phalanx. The thumb and fingers apply long-axis traction (distraction) (Fig. 17-31).

Plantar and dorsal PIP glides are performed with the patient supine and the lower leg supported. One hand should be used to firmly grasp the first metatarsal ray at the metatarsal head. The thumb of the stabilizing hand must be placed on the dorsal surface of the metatarsal head. The application hand should be used to grasp the proximal phalanx and apply a plantar and dorsal force while stabilizing the metatarsal head (Fig. 17-32).

GLOSSARY

Calcaneus fracture A calcaneus fracture that heals in a varus position locks the subtalar joint in inversion, creating a rigid transverse tarsal joint.

Posterior tibialis tendon Rupture results in planovalgus, or flatfoot.

Syndesmosis Ligaments responsible for maintaining stability of the distal tibiofibular articulation.

Talar tilt test Tests integrity of both anterior talofibular ligament and calcaneofibular ligament. Both must be disrupted for a positive tilt.

Talus No muscle attachment origin or insertion. Has a tenuous blood supply.

Tibial nerve Passes behind the medial malleolus.