Rehabilitation of the Foot & Ankle

Will Coggin, PT, DPT, CSCS

Andrew’s Institute

Objectives

• Review Common Foot and Ankle Pathologies

• Identify Assessment Techniques Related to the Foot & Ankle

• Recognize Key Treatment Principles to Address Identified

Impairments

• Discuss Testing Prior to Discharge

Lateral Ankle Sprain

• Most common ankle injury

• Account for 90% of ankle injuries– 20-40% will have chronic symptoms

– 67-80% of All Soccer Injuries

– 80% Reinjury Rate in Basketball

• MOI: Eversion/abducted force– Most commonly in plantarflexed position

• Structures Involved– ATFL

– CFL

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High Ankle Sprain

• 35% of Ankle Injuries in Collision Sports

– 5% of Ankle Injuries in Low Impact Sports

• MOI: Forceful External Rotation of Ankle

• Structures Involved

– Anterior/Posterior tibiofibular Lig.

– Interosseous Tibiofibular

– Posterior Transverse Inferior Tibiofibular Lig.

• Longer Healing Process

Tendinitis

• Overuse Injury

– Sudden Increase in Training

Variables

• Activity, Terrain, Volume, Intensity

– Poor Body Mechanics

• Joint Mobility

• Muscle Imbalance

• Common Types

– Peroneal

• Tendency in Higher Foot Arches

– Posterior Tibialis

• Lower Foot Arches

– Achilles

• Insertional

• Mid-substance

Plantar Fasciitis

• Overuse syndrome at origin of plantar fascia

• 1 in 10 people will experience

• Risk factors

– Lack of dorsiflexion

– 45-64 yo

– Foot posture not indicator

ROM Requirements

Motion Degrees

Dorsiflexion 15-25 (CKC 40)

Plantarflexion 50-60

Inversion 30 (2:1, 3:2)

Eversion 15

Great Toe Extension 90

Great Toe Flexion 30-50

Foot Posture Index

• 6 Factors Assessed

– Talar Head Position

– Lateral Malleolar Curve

– Calcaneal Frontal Plane Position

– Bulging Region of TNJ

– Height of Medial Longitudinal Arch

• Navicular Drop

– Abduction/Adduction of Forefoot

• Too Many Toes Sign

• Score between -12 and 12

Lateral Ankle Sprain

Anterior Drawer Test• Stabilize Distal Leg, Plantarflex 10-15 degrees.

• Provide anterior translation of calcaneus

– ATFL Emphasis

Lateral Ankle Sprain

Talar Tilt Test• Stabilize Distal Leg, Plantarflex 10-15 degrees.

• Provide anterior translation of calcaneus

– CFL Emphasis

High Ankle Sprain

Squeeze Test• Compress Proximal Fibula Against Tibia

• Possible Fracture

High Ankle Sprain

Kleiger’s Test

• Maximally Dorsiflex and Externally Rotate the Foot

• Possible Deltoid Injury

Plantar Fasciitis

Windlass Test• Stabilize Foot in Neutral, Maximally Dorsiflex Great Toe

– Weightbearing Increases Specificity (0.99)

Concerns of Fracture

Ottawa Rule• X-Rays Required If…

– Ankle

• Bone Tenderness at tip of Lateral Malleolus

• Bone Tenderness at tip of Medial Malleolus

• Inability to Bear Weight Immediately and in Emergency Department for 4 steps

– Foot

• Bone Tenderness at the Base of Fifth Metatarsal

• Bone Tenderness at the Navicular

• Inability to Bear Weight Immediately and in Emergency Department for 4 steps

Concerns of Fracture

Ottawa Rule

Regional Interdependence

• Concept that seemingly unrelated impairments in a remote

anatomical region may contribute to, or be associated with, the

patient’s primary complaint –Wainner, JOSPT 2007

• “The body is an alternating pattern of stable segments connected

by mobile joints. If this pattern is altered-dysfunction and

compensation will occur”-Gray Cook

Joint-by-Joint Approach

Global Screens

• Functional Movement Screen (FMS)

– 7 Movement Patterns

• Deep Squat

• Hurdle Step

• Inline Lunge

• Shoulder Mobility

• Straight Leg Raise

• Trunk Stability Push Up

• Rotary Stability-Quadruped

Functional Test

SL Heel Raise• 2/5=Full ROM, but no resistance, NWB

• 2+/5=Maximal Manual Resistance, NWB/Can Clear Heel in WB

• 3/5=1-9 Repetitions

• 4/5=Full ROM 10-19 Repetitions

• 5/5=20 Repetitions without fatigue– 60% Maximal Volitional Contraction

– Recommended raising to 25 repetitions• Lunsford et al.

• Considerations– Must Have Appropriate Posterior Tibialis and Peroneal Strength to Stabilize Foot

– Measuring Full ROM & Posture

Functional Test

SL Heel Raise• Considerations

– Limit Forward Trunk Lean

– Limit Hip/Knee Flexion

– Age/Gender Variances

• Male– 21-40=22.1±9.8

– 41-60=12.1±6.6

– 61-80=4.1±1.9

• Female– 21-40=16.1±6.7

– 41-60=9.3±3.6

– 61-80=2.7±1.5

Functional Test

CKC Dorsiflexion Test

• Normative Value=40 degrees

• Tape Measure vs Goniometer

– Tape Measure has Improved Rater Reliability

– Tape Measure: 10 cm, ≈4’’

Functional Tests

Static SL Balance

• Looking For Asymmetries

– Firm Surface

• Eyes Open

• Eyes Closed

– Unstable Surface

• Eyes Open

• Eyes Closed

– Cognitive Tasks

Phases of Recovery

Early Phase

Low Dye Taping

• Effective Treatment for tendinitis/fasciitis

– Reduces foot pronation

Early Phase

• ROM

– 3 planes

• Strength

– Ankle Musculature

– Foot Intrinsic

– Isometrics->Isotonic

• Neuro-Reeducation (NWB)

– Manual PNF Pattern

– BAPS board

Intermediate Phase

CKC Strength

Soleus EmphasisFoot Intrinsic/Posterior Tibialis

Intermediate Phase

– Dynamic Patterns

• Squat

– Assistive->Resistive

• Step Up/Lunge

– Multiple Directions

– Considerations

• Posturing/Footwear

• Type of Surface

Intermediate Phase

• Proprioception/Balance

– Base of Support

– Stable vs Unstable Surface

– Static vs Dynamic

– Focus Emphasis

• Internal

• External

• Multitasking

Intermediate Phase

Balance Progression

Phase III-Plyometrics

• Progression– Stepping

• Forward/Lateral � Diagonal

– Hopping• Bilat Support � Unilateral

Support

• Concentric � Eccentric

– Multi-Tasking

Discharge Testing

SEBT• Addresses dynamic postural control

• Aids in predicting risk of LE injury– Anterior Reach, 4 cm=2.5x more likely of injury

– Composite less than 94% were 6.5x more likely of injury• Varies by Sport

• Negatives– Redundancy in Number of Directions

– Fatigue

– Difficult to accurately assess distance/miscues

– Does not address Sport Specific Movements

Discharge Testing

SEBT

Discharge Testing

Hop Testing• Figure 8

– 5-m course outlined by cone. Hop on 1 limb, twice around the course, as fast as possible.

• Side Hop– Hop on 1 limb laterally over a 30-cm distance. Complete 10 as quickly as possible.

• Square Hop– 40 x 40- cm square marked on the floor with tape. Starting outside of the square,

hop in and out of the square on all four sides for 5 repetitions as quickly as possible.

• Crossover Hop– Set up 6 m long, 15 cm wide line. Hop on 1 limb diagonally over the wide line,

alternating as quickly as possible.

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Discharge Testing

Hop Testing

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References

• Caffrey E, et al. The Ability of 4 Single-Limb Hopping Test to Detect Functional Performance Deficits in Individuals With Functional Ankle Instability. J Orthop Sports Phys Ther. 2009; 39(11): 799-806.

• Chae Y., et al. Clinical and Biomechanical Effects of Low-Dye Taping and Figure-8 Modification of Low-Dye Taping in Patients with Heel Pad Atrophy. Ann Rehabil Med. 2018; 42(2): 222-28.

• Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar. 98 (2):313-29

• Gribble P, et al. Using the Star Excursion Balance Test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. J Athl Train. 2012; 47(3): 339-357.

• Houck J, et al. The Foot and Ankle: Physical Therapy Patient Management Utilizing Current Evidence, 3rd Edition. 2011. 1-87.

• Kellet J. The Clinical Features of Ankle Syndesmosis Injuries: A General Review. Clin J Sport Med. 2011; 21(6): 524-29.

• Konor M., et al. Reliability of Three Measures of Ankle Dorsiflexion Range of Motion. Int J Sports Ther. 2012; 7(3): 279-87

• Lunsford B., Perry J. The Standing heel-raise for ankle plantar flexion: criterion for normal. Phys Ther. 1995; 75(8): 694-8.

• Martin R, et al. Ankle Stability and Movement Coordination Impairments: Ankle Ligament Sprains. : Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys. 2013; 48(5): A1-A38.

• Newman JS, Newberg AH. Basketball injuries. Radiol Clin North Am. 2010 Nov. 48(6):1095-111

• Valderrabano, et al. Foot and ankle injuries in professional soccer players. Sports Orthopaedics and Traumatology. 2014; 30: 98-105.

• Walls R., et al. Football injuries of the ankle: A review of injury mechanics, diagnosis and management. World J Orthop. 2016. 18;7(1): 8-19