Stanbridge - T4 - TE2 - W5 - The Foot & Ankle

Therapeutic Exercise II: The Ankle and Foot

• This presentation covers the anatomy, function, and treatment of ankle and foot injuries and conditions.
• Identifying aspects of structure and function for review is one of the learning objectives.
• Implementing a therapeutic exercise program to manage soft tissue and joint issues is also a learning objective.
• The presentation further discusses the advantages and disadvantages of arthroplasty versus arthrodesis for patients with rheumatoid arthritis (RA).
• Developing and enhancing ROM are other learning objectives.
• The topic will cover various aspects, such as anatomy and arthrokinematics, ankle hypomobility, tendinopathies, shin splints, and ligamentous injuries.
• Different types of joint hypomobility conditions are rheumatoid arthritis (RA), Juvenile RA, osteoarthritis (OA)/deformative joint disease (DJD), trauma, post-dislocation joint reactions, fractures, and post-immobilization.
• It will also cover the management of conditions causing joint hypomobility.
• Common impairments during joint hypomobility include decreases in joint play, pain, swelling, restricted motion, muscle imbalance, weakness, decreased endurance, impaired balance, postural control, frequent falling, and painful weight bearing/gait deviations.
• Management of joint hypomobility will include educating patients on home exercise programs (HEP), activity modifications, gait training, range-of-motion (ROM) exercises, bracing, orthotics, assistive devices, grade 1/2 joint mobilization, and aquatic therapy/muscle setting.
•  The presentation describes the bones of the ankle and foot—posterior, medial, and lateral views including bones such as tibia, fibula, talus, navicular, cuneiform, and calcaneus.
• The hindfoot consists of the talus and calcaneus.
• The midfoot consists of navicular, cuboid, and three cuneiforms.
• The forefoot comprises five metatarsals and 14 phalanges.
• Tibio-fibular joints (superior and inferior) are included in the discussion, offering accessory motions and forming the proximal talocrural joint.
• The talocrural joint is supported laterally by the lateral collateral ligament (consisting of the anterior talofibular, posterior talofibular, and calcaneofibular ligaments).
• The joint is also supported medially by the deltoid ligament.
• Arthrokinematics are key, with dorsiflexion causing posterior glide and plantarflexion causing anterior glide of the talus.
• Functional anatomy involves tri-planar motions (supination and pronation).
• Supination consists of plantarflexion, calcaneal inversion, and forefoot adduction, maintaining stability and arch height in weight bearing.
• Pronation includes dorsiflexion, calcaneal eversion, and forefoot abduction; unlocking the midfoot for shock absorption.
• The transverse tarsal joint (talo-navicular and calcaneo-cuboid joints) participates in supination/pronation midfoot movement-abduction, adduction, inversion, eversion, and dorsal/plantar gliding.

Joint Surgery and Postoperative Management

• Total ankle replacement arthroplasty (TAA) is a surgical option.
• Indications for TAA include disabling pain during weight bearing (WB), post-traumatic arthritis (DJD), osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis (AVN) of the talus, inflexible deformity, and prior conservative care failures.
• Arthrodesis, a fusion of the ankle and foot joints, is another surgical procedure often used for late-stage arthritis, marked instability, high functional demands during weight bearing (WB), and failed TAA.

Overuse (Repetitive Trauma) Syndromes: Non-Operative Management

• Overuse syndromes encompass various pathologies, etiologies, conditions, impairments, functional limitations, and disabilities.
• The management approach for overuse syndromes focuses on distinct phases—acute, subacute, and chronic—with specific interventions for each phase.

Tendinitis vs. Tendonosis

• The distinction between tendinitis (inflammation) and tendonosis (degenerative changes) is crucial in diagnosis.
• Tendinitis typically involves sharp pain with activity, worsening with rest, and improved with activity and rest.
• Tendonosis is characterized by dull pain, worsening with activity, in the absence of significant inflammation and often shows palpable enlargement.

Plantar Fasciitis

• Plantar fascia provides arch support and assists in gait initiation.
• Corticosteroid injections are often ineffective and may cause atrophy and fascial rupture; histological studies reveal a lack of inflammation.
• Lower longitudinal arch height, high loading rates, and high arch foot (pes cavus) are potential predisposing factors.
• Symptoms often include sharp heel pain, worse in the morning or after periods of rest, and decreasing after warming up, worsening with weight-bearing.

Achilles Tendinopathy

• The Achilles tendon, the largest and strongest tendon in the body, plays a significant role during weight bearing, decelerating ankle dorsiflexion and subtalar pronation.
• Factors influencing the development of Achilles tendinopathy include overuse, training errors, faulty equipment, improper recovery, and repetitive training.
• Microscopic anatomy reveals continuous fibers with the plantar fascia.
• The hypovascular zone (approximately 5-6 cm above the insertion site on the calcaneus) is susceptible to degenerative changes.
• Conservative treatment is often effective.

Posterior Tibialis Tendinopathy

• Posterior tibialis plays a major role in controlling ankle pronation.
• Overuse from increased activity, frequent running, speed, weight, or poor footwear can lead to overload and inflammation.

Ligamentous Injuries (Nonoperative):

• Assessing and managing impairments and functional limitations in ligamentous injuries, focusing on the acute, subacute, and chronic phases of healing is important.
• Typical lateral ankle sprain occurs from plantarflexion and inversion.

Ankle Sprain:

• Radiographs to exclude fractures are important in an acute phase.
• Support (like bracing and casting) and physical therapy help address pain and swelling.

Chronic Ankle Instability (CAI):

• Occurs in 10-20% of patients following acute ankle sprains.
• Characterized by persistent and recurrent pain, swelling, and instability for over six months.
• Often involves a "giving way" sensation (neuromuscular deficit) in 17-58% of patients.

Neuromuscular Changes Following Ankle Sprain:

• Proprioception, neuromuscular control, muscle inhibition, and reaction times negatively affected.
• Reduced strength and altered muscle sequencing.
• Impaired postural control and altered lower limb movement patterns.

Goals of Neuromuscular Training:

• Optimizing lower limb postural control and stability.
• Preventing chronic ankle instability.
• Enabling safe return to sport or activity.

Phases of Rehabilitation:

• Acute phase, early subacute phase, late subacute phase, and chronic phase (including return to sport).

Acute Phase: Goals, Treatment and Considerations

• The first step in treating ankle sprains or other acute injuries involves steps to protect the joint, promote healing, and reduce inflammation/pain.
• Techniques used during the acute phase include rest, immobilization, ice application, pain relief medication (NSAIDS), compression and elevation

Early Subacute Phase:

• ROM exercises, balance training, strength training, and functional training should be implemented during the early subacute phase to facilitate a safe and effective recovery.

Late Subacute Phase:

• Strengthening and balance exercises targeted toward neuromuscular integration and promoting proper ankle joint stability and control.

Chronic Phase (Return to Sport):

• Comprehensive training programs to reintegrate the injured ankle into the specific demands of the sport are emphasized.

Ankle Sprain: Evidence

• This section covers the evidence-based diagnosis and treatment of ankle sprains, including the use of the Ottawa Ankle Rules, risk factors, and evidence-based treatment strategies.

Exercises for the Foot & Ankle:

• Various exercises, such as flexibility and strengthening exercises, are presented (e.g., gastrocnemius stretch, resisted ankle dorsiflexion, inversion and eversion exercises, calf strengthening exercises, balance exercises, and others).

Review Summaries:

• Reviews of specific conditions (shin splints, plantar fasciitis, and achilles tendinitis) are provided along with their typical presentations and treatment strategies.