Chapter 5
Acute/Traumatic Conditions of the Foot and Ankle

  1. Ankle Sprains

    Management Scheme for Ankle Sprains

    1. Acute Period (24 to 72 hours post-injury)

      P - rotect
      R - est
      I - ce
      C - ompression
      E - levate

    2. Rehab Period

      • Stage I:
      • Immobilization Period
        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:
      • Immobilization Removed
        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

  2. 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).

  3. Severe Trauma

    1. These patients generally have extensive fractures and/or bone crushing resulting in limitation in joint motion or ankylosis.
    2. Etiology in most cases are industrial or automobile accidents.
    3. 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.
    4. Treatment:
      1. Mobilization in early stages along with exercise and modalities.
      2. Shoewear
      3. 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.
    5. 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.

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