Acute/Traumatic Conditions of the Foot and Ankle
- Ankle Sprains
- Inversion sprains: 80 to 85% of all ankle sprains are inversion type
injuries. The three most common mechanisms are: 1) plantar flexion with
inversion (damage to the ant. talofibular lig. and if severe
calcaneofibular lig.); 2) plantarflexion with inversion and rotational
(damage to ant. talofibular lig., calcaneofibular lig., and distal
tibiofibular lig., if severe interosseous membrane); 3) pure inversion
(very rare - primarily stresses calcaneofibular lig.).
- Eversion sprains: occur less frequently because of ankle anatomy and
strength of deltoid ligament. Often an eversion sprain results in an
avuision of the medial malleolus rather than a tearing of the deltoid
- Dorsiflexion sprains: excessive dorsiflexion force that jams the talus
into the mortise. Stress on the talus can lead to an osteochondral
fracture of the talus. Excessive and ballistic dorsiflexion can also
injure the achilles tendon.
Management Scheme for Ankle Sprains
- Acute Period (24 to 72 hours post-injury)
P - rotect
R - est
I - ce
C - ompression
E - levate
- Rehab Period
- Stage I:
a. CV fitness
b. Active and active-assistive ROM
c. Strengthening exercises to uninvolved LE and UE's
d. Electrical muscle stimulation
e. Flexability exercises
- Stage II:
a. Pain-free active, active-assistive, and active-resistive
exercise (ie: PRE, PNF)
b. Joint mobilization if indicated
c. Contrast baths, ice post-treatment
- Stage III:
Increase Joint ROM and Strength
a. Resistive exercises (including closed kinetic chain
activities and isokinetics)
b. Balance Actvites
c. Flexability exercises
- Stage IV:
Preparation for Return to Activity
a. Functional progression to stress injurned joint in specific
motion patterns required for ADL
b. Use of protective device to prevent reinjury.
- ankle taping
- commercial ankle support
Criteria For Return to Activity
1. Restoration of normal accessory and physiologic motion
2. Restoration of muscle strength
3. Balance between antagonistic muscle groups
4. Functional use of injuried part in required activities
- Stress Fractures or Reactions
Microfractures of the bone occur daily. They do not produce symptoms or
signs because the bodies reparative processes can keep pace with the
microfractures. However, if the microfractures occur at a rate too rapid for
the repair, the result can be a stress fracture or stress reaction. Stress
fractures can occur in any bone of the lower extremity or spine. The most
common sites in the foot and ankle are the 2nd an 3rd metatarsal (classic
site of a March fracture), proximal shaft of the 5th metatarsal (Jones'
fracture), and the middle and distal tibia and fibula. Stress fractures of
the tibia and fibula may also demonstrate the same symptoms as shin splints.
Differential diagnosis is difficult as roentgenograms are often negative
2 to 3 weeks post injury. Even after 2 weeks, all that is seen is a thin
callous cloud over the site of injury. Subjectively, the patient will
complain of severe pain with activity while rest causes relief. Bone
percussion techniques can be used to distinguish between bone and soft tissue
pain. One technique involves firmly tapping the fibula and tibia distally and
proximally to the site of tenderness. A sharp, stabbing sensation is often
indicative of a stress fracture. A second technique involves striking the
heel upward to elicit an identical sensation from the client. If the
therapist suspects a possible stress fracture, the patient should be referred
back to their physician for further treatment.
Anterior Compartment Syndrome is a serious condition that can mimic a
stress fracture. It often occurs after a blow or repeated blows to the shin
but can also take place after a rigorous early training session, especially if
the athlete is in poor condition. In this condition, swelling occurs within
the anterior fascial compartment compressing the anterior tibial vein and
artery as well as the deep peroneal nerve. Anterior compartment syndrome can
be differentiated from shin splints ih that improvement of symptoms does not
occur with rest and ice application. If the clinician suspects a possible
anterior compartment compression, the patient should be referred back to their
physician for re-evaluation. Untreated, anterior compartment syndrome can
result in muscle eschemia and nerve paralysis (i.e., drop foot).
- Severe Trauma
- These patients generally have extensive fractures and/or bone crushing
resulting in limitation in joint motion or ankylosis.
- Etiology in most cases are industrial or automobile accidents.
- Must evaluate ROM of subtalar joint carefully along witn midtarsal
and/or rearfoot deformities. Often patient cannot completely compensate
for boney imbalance present in the foot after the accident due to
restricted ROM at subtalar, midtarsal or talocrural joints.
- Mobilization in early stages along with exercise and modalities.
- Foot orthoses should be considered if pain present in foot is due
a a lack of ROM necessary to compensate boney deformities
imbalance. Also, if fusion has occurred in the midfoot created an
abnormal forefoot architecture, a foot orthoses may be required.
- Surgical mnagement may require a triple arthrodesis (fusion of the
subtalar, talocalcaneonavicular, and calcaneocuboid. This surgical
procedure is often done for patients with severe foot deformity
secondary to rheumatoid arthritis, poliomyelitis, or cerebral palsy.