Injuries Summary - Ankle & Foot Ligament Injuries PDF

Injury/ History Physical examination Clinical tests Imaging Management condition ANKLE AND FOOT LIGAMENT INJURIES Acute lateral Incident of Ottawa Ankle Rules to exclude fracture Anterior drawer test C...

Injury/ History Physical examination Clinical tests Imaging Management condition ANKLE AND FOOT LIGAMENT INJURIES Acute lateral Incident of Ottawa Ankle Rules to exclude fracture Anterior drawer test CT scan indicated in Initially ankle sprain landing or Palpate medial malleolus/deltoid coalitions and POLICE (protect, trauma that ligament region (medial ankle pain and suspected bony optimally load, ice, results in ankle deltoid lesion common) avulsions compress, elevate) Inv/Inv + Pf Anterior draw test for ATFL instability Avulsion at origin educate pt on Identify painful Talar tilt test for ATFL/CFL instability of bifurcate mechanism of palpatory spot, Reduced ROM in WB lunge test (or ligament jointing injury of ankle can WB, increased) – knee to wall test the antero-superior minimal In clinical practice, only difference calcaneus to sprains + discuss oedema → between simple sprains (grade 1) and navicular and management + likely no real instability (grade 3) is relevant cuboid set expectations ligament o Grade 1 – minor swelling and RICE protocol: rupture palpatory tenderness, minimal Rest, Ice, Large oedema, functional loss, no increased had to stop instability compression + sport, o Grade 3 – severe bruising, elevation – to ecchymosis swelling and pain, significant Talar tilt test control swelling, (bruises) → loss of function, increased limit high chance of instability, unable to WB and haemorrhage ligament walk normally rupture (bruising) + Chronic Repeated Anterolateral/anteromedial ankle joint minimise lateral ankle episodes of tenderness on palpation synovial sprains LAS Reduced ROM in WB lunge test irritation Patient Positive anterior draw test and talar tilt Protect joint reported test mechanical Assessment of midtarsal ligaments is range of motion and critical – dorsal CCJ, bifurcate, dorsal (limit inversion) psychological TNJ and spring ligaments Limit activities weakness Biomechanical assessment – cavovarus that increase Presence of foot type, NWB Inv bias, rigid Pf first blood flow + pain along ray, Ff valgus swelling of the anterior ankle o Coleman block test – tests if joint with cavovarus foot is Ff or Rf joint(For swelling post driven athletes: hot activity o First ray off edge – if calc. goes showers, heat to neutral → Ff driven, if calc. rubs and remains Inv → Rf driven  Reduced reach in Star Excursion Test excessive Anterior ankle Anterior ankle Anterolateral/anteromedial ankle joint Dorsal impingement sign X-ray in lateral view weightbearing) impingement pain in Df tenderness to assess extent of Weightbearing demanding Reduced ROM in WB lunge test bony spurring activities with Pain during single or double leg squat MRI to observe guidance: cant reduced Positive dorsal impingement sign (pain marrow oedema, weightbear for mobility in last picture to the right because subchondral the first 24 hrs History of you’ve recreated the impingement like changes and by putting them recurrent LAS in WB) synovial/soft tissue in the moon Presence of thickening pain along boot (maximum anterior ankle 10 days in a joint with moon boot!) swelling post Prescribe NSAIDS activity and/or Posteromedial Persistent Palpable tenderness behind medial MRI analgesics like ankle isolated malleolus, deep to tib post tendon Coronal PD shows paracetamol to impingement posteromedial Pain with passive posteromedial digital scarring alleviate pain (POMI) ankle pain pressure with ankle Pf/Inv related to No pain during palpation with resisted 2-4 weeks activity and activation of tib post tendon Boot/brace dating back to o Tensing tib post tendon Air cast walker an Inv injury protects site of deep ASO Initial lateral posteromedial tenderness ankle from palpation 4-8 weeks symptoms Nil symptoms of TP, FHL or FDL Orthotics following Inv Lateral instability injury (ATFL/CFL)– Insidious onset Lateral Ff of wedge posteromedial Mortary pad and medial High lateral activity related heel cup pain typically Plantar EVA after 4-6 lateral arch fill weeks but can Cuboid notch be longer Lateral skive Syndesmosis Mechanism of Pain with passive ER/Df Squeeze test to correct Rf injury injury: Reproduction of pain in any positive Ev Foot in fixed Point Test, squeeze test, ER stress test, Medial instability position of ER Df test, heel thump test (deltoid/spring) – and ankle Df  while a lateral Early heel rise gait pattern to avoid High medial force at trunk painful Df range as well as push off pain heel cup/ or hip causes medial flange IR of lower Medial EVA limb (fibular in filler ER while tibia Medial heel goes into IR) skive ER stress test 1-4 Ff varus ER rotation wedge trauma with Ankle taping pain at Standard syndesmosis ankle taping that may with heel lock extend Ankle taping proximally heel lock + Inability to WB medial STJ and swelling Df test bias Pain with Low dye active/passive taping ER or Df of Medial/lateral foot/ankle variation of low dye taping Ankle brace Thump test Interpod non-custom device Custom device Richie Brace Point test 8+ weeks Orthotic/brace Deltoid Mechanism of NWB pain with palpation along Valgus tilt stress test Standard WB x-rays Consider orthopod ligament injury: anteromedial gutter – shows structural review if injury (medial Crush damage Laxity present during valgus tilt stress changes and conservative fails instability) secondary to test excludes bony after 6 months repeat LAS Positive anterior draw test with slight Pf pathologies May require brace High intensity and Abd stress o Ev stress for increased movement Valgus tilt stress test, neutral heel AP demands for 1-2 while body lateral push test radiograph years simultaneously WB asymmetrical planus or Rf valgus to Patient may rotates in o Correction of Rf evaluate benefit from opposite valgus/pronation during DL stability Adjunct therapy : direction calf raise (activation of tib Anterior draw test Coronal MRI – Acupuncture / (dancing, post) shows interstitial ultrasound / laser running, o Gradual increase in Rf tearing/contusion therapy / shock downstairs, valgus/pronation during DL through deep wave uneven squat (activation of FHL deltoid fibres Surgery may be surface) creating Ff supinatus during required if Direct Ev WB supination) treatment is trauma where Supination resistance test unsuccessful foot cannot o How much force you need to escape (pinned apply to resist pronation and to ground) product supination (two Excersises include: fingers on medial arch) – low Ankle circles , History of score = easy to supinate isometric holds, symptom weightbearing lung, onset after double and single calf above Neutral heel lateral push test raise, balance board mechanism of and walking injury Acute: injury, local pain, swelling Chronic: patient reports ‘giving way’ feeling Patient reports pain around anteromedial ankle and sometimes lateral ankle,  particularly during loaded Df Spring Mechanism of Injury is secondary to rotational ankle injury Standard WB x-rays ligament injury: (Inv/Ev sprains) or post tib tendon – shows structural (mostly all High intensity dysfunction so assessment should be in changes and similar to movement context of these other pathologies excludes bony deltoid while body NWB pain with palpation along pathologies ligament simultaneously anteromedial gutter o Ev stress injury) rotates in Possible laxity present during valgus tilt AP opposite stress test radiograph direction Possible positive anterior draw test to (dancing, with slight Pf and Abd stress evaluate running, Possible positive neutral heel lateral stability downstairs, push test Coronal MRI – uneven WB asymmetrical planus or Rf valgus shows interstitial surface) o Correction of Rf tearing/contusion Direct Ev valgus/pronation during DL through deep trauma where calf raise (activation of tib deltoid fibres foot cannot post) escape (pinned o Gradual increase in Rf to ground) valgus/pronation during DL Progressively squat worsening flat o Navicular drop/drift foot deformity o Supination resistance test o Jacks test History of o Activation of FHL creating Ff symptom supinatus during WB onset after supination mechanism of injury above Acute: injury, local pain, swelling Chronic: patient reports ‘giving way’ feeling Patient reports pain around anteromedial ankle and sometimes  lateral ankle, particularly during loaded Df Injury/ History Physical examination Clinical tests Imaging Management condition MIDFOOT & FOREFOOT INJURIES Lisfranc Mechanism of Motor examination of all tendons in midfoot Piano key test WB x-ray – ligament injury: Palpable tenderness of 1st/2nd TMTJ standard AP, injury Axial and/or Pain and/or instability with Piano key test of 1st and oblique, (tarso- rotational 2nd rays lateral metatarsa (Abd) load Pain with midfoot compression (Provocation test) + l joints) applied to a Pf dorsal and plantar flexion of the 1st met head Must be WB foot relative to 2nd met head as it creates An axial force DL heel raise, SL heel raise for pain and ability stress through results in If they can perform both these with minimal pain foot and can hyper-Pf of the and loss of function → not an unstable injury more foot, causing consistently tension failure identify of the weak presence of dorsal instability ligaments Pain in the midfoot after some form of trauma/injury May be able to recount the exact mechanism Some generalised swelling mostly over midfoot Plantar ecchymosis may be present depending on how acutely the patient  presents (in Provocation test chronic cases, need to ask if this was present) Patient may report inability to propel off Ff Midfoot Localised pain Passive and active examination of NWB x-ray may 0-4 weeks OA and movements – assess for asymmetry and irritability show reduced Assess irritability tenderness, Motor assessment of tendons with and without joint space, Identify tissue involved joint stiffness, resistance osteophytes, Gauge level of intervention required bony Midfoot varus/valgus stress tests, piano key test soft tissue (footwear, orthoses) enlargements WB: A more flatfoot posture, lower medial swelling, Educate patient on timeline Patient may longitudinal arch and greater midfoot loading subchondral Implement strategy report history Greater calcaneal Ev during stair ascent sclerosis Taping of previous (propulsion) Rocker bottom footwear trauma to the Increased plantar pressures + contact times in heel Carbon fibre plate joint or and midfoot – reduced Ff rocker ASO proximal ankle Functional hallux limitus test, Jacks test, supination 4-12 weeks joint resistance test Orthoses Pain localised 1st MPJ OA – consider 1st ray function: to dorsal Reduce motion → Morton’s and/or medial extension aspects of Increase motion → 1st ray cut midfoot – out worsens with Material consideration tasks requiring Moderate STJ and midtarsal greater pronation propulsive Midfoot OA – consider irritability of foot: forces to be Cushioning important  generated such Contour to midfoot important as stair ascent but consider too much pressure or propulsive Moderate STJ/midtarsal phase of gait pronation 1st MPJ Pain in 1st MPJ Get baseline measure of irritability and tolerance Shoe stiffening insert (carbon fibre plate) OA >25 months to WB or stiff shoe Patient may NWB examination: dorsal exostosis, 50% metabolic costs. 3. Education However, excessive Explain why we do or repetitive tensile activity stress can result in modification and microtrauma, gradual activity leading to a exposure breakdown of the Optimal loading tendon structure and for tendons = pain the development of 2-4/10 tendinopathy. 4. Graded exposure Tendon Grade activities Capacity vs. Load based on Demand: If the perceived Achilles tendon is apprehension and subjected to loads patient reported beyond its adaptive pain capacity, particularly Progress by after periods of increasing activity relative rest or difficulty (eg add sudden increases in external load) activity intensity, it Phase 1 – may not handle the isometric: stress effectively, o Start here if leading to injury. isotonic load unacceptably painful (loading and holding static at tolerable range) Phase 2 – isotonic: o Should be starting point if tolerable (going through full range) Phase 3 – stretch/shortening :  o Introduce stretch/shorte n cycles such as walking and running 2-3 times / week with rest days in between o Load should be guided by pace or step count Understand type of load irritating the tendon → reduce/remove the magnitude of that load Tibialis Localised pain Tendinopathy (warm up effect) 0-6 weeks posterior on medial side Pronated foot type Step 1: tendinopathy of midfoot to Rf Sore during, but able to perform, SL heel raise Assess pain intensity / and/or ankle The following may be present: and behaviour with tenosynovitis Aggravated by o Tenderness on palpation usual activities activities that o Swelling along the tendon Understand level of increase tendon o Poor Pf Inv strength tendon irritability loading (walking, Tenosynovitis (no warmup effect) Determine tissue running, Pronated foot type driving symptoms plyometrics) Sore/restricted during lunge test (tendon or sheath) Natural history Sore during, but able to perform, repeated SL heel raise Treatment goal is slow, with The following may be present: Return pain to 1-3/10 insidious onset o Tenderness on palpation during ADL of complaints o Swelling along tendon Reduce Warms up with inflammation/swelling activity only to in sheath be worse the Increase tendon next day → strength/compliance tendinopathy Treatments Worsens with Activity modification to continued remove/modify loading or provocative loads activities taking Anti-inflammatory (the the tendon night wrap for sheaths through range – diclofenac gel,  → tenosynovitis hirudoid cream, gauze, (sheath) glad wrap) Period of Mechanism of injury; support/immobilisatio Overuse and n (orthoses, ASO, Increased Load on taping) the Tibialis Posterior: Commonly due to 6+ weeks prolonged walking, Step 2: running, or standing, Graded exposure to particularly in load – isometric → individuals with flat isotonic → energy feet or unsupportive storage/release footwear. The tibialis Treatment goal posterior undergoes Return pain to 1-3/10 repeated strain, during ADL leading to Increase tendinopathy as it muscle/tendon fails to resist strength/capacity excessive pronation Graded intro of and support the arch stretch-shorten cycle effectively. activities based on agreed goals Treatments Footwear Orthoses Rehab Taping Standard ankle taping with heel lock Ankle taping heel lock + medial STJ bias Low dye taping Medial variation of low dye taping Orthotics High medial heel cup/medial flange Medial EVA filler Medial heel skive  1-4 Ff varus wedge Exercises Stretching isometric – ankle inversions with resistance band Isotonic – heel raises with Inv bias Walking/running depending on goals Posterior Persistent pain Stage 1 PTTD: Stages 2-3 tibial tendon on medial side Tenosynovitis symptoms 0-2 months dysfunction of midfoot to Rf Possibly sore/restricted during lunge test Step 1: and/or ankle Sore during but able to do repeated SL raise Assess pain intensity with reports of a No rigid but possible subtle/flexible flat foot deformity and behaviour with progressively Stage 2 PTTD: usual activities worsening flat The following may be present: Understand level of foot posture Tenderness on palpation tendon irritability No warm up Swelling along tendon Determine level of effect Poor Pf Inv strength tissue involvement – Age 50+ and Laxity during valgus tilt stress test tendon, sheath, obese Positive anterior drawer test with slight Pf/Abd stress ligament, bone 2a: Reduce inflammation Flexible Rf valgus, normal Ff and daily pain levels Unable to perform SL heel raise Treatment: 2b: Activity modification to Flexible Rf valgus, Ff Abd remove/modify Unable to perform SL heel raise provocative loads Sinus tarsi pain Anti-inflammatories Stage 3 PTTD: (the night wrap) Flatfoot deformity, rigid Ff Abd, rigid Rf valgus Period of Unable to perform SL heel raise support/immobilisatio Severe sinus tarsi pain (a sign of STJ involvement) n – taping, AIRCAST STJ involvement walker, ASO Stage 4 PTTD: Flatfoot deformity, rigid Ff Abd, rigid Rf valgus Step 2: Unable to perform SL heel raise Graded exposure to Severe sinus tarsi pain (a sign of STJ involvement) load STJ/ankle joint involvement Treatment goal: Return pain to 1-3/10 during ADL  Increase muscle/tendon strength/capacity but will be limited Graded intro of load Treatments: Footwear – stiff sole, rocker style Orthoses Richie brace Stages 3-4 Require surgery consultation with orthopod Peroneal Patients Palpation: recognisable tenderness over peroneal 0-2 months tendinopathy typically present tendon/insertion, crepitus, swelling Step 1: / with lateral Passive Pf + Inv / Df + Ev often exacerbate pain Assess pain intensity tenosynovitis ankle pain or Muscle weakness compared to other side and behaviour with pain along WB assessment: usual activities course of o Cavovarus foot type Understand level of peroneal o Ff or Rf driven cavus tendon irritability tendons that o RCSP Inv, Pf 1st ray, Ff valgus, laterally deviated Determine level of worsens with STJ axis tissue involvement – activity Any significant deformity worthwhile sending for imaging tendon, sheath, Acute injuries (ultrasound or MRI) ligament, bone often reported o Determine as ‘an ankle pathological sprain that presentation – never resolved’ acute, chronic, Swelling, tear tenderness, Reduce inflammation possible warm and daily pain levels up effect, feeling Treatments: of Activity modification to weakness/giving remove/modify way provocative loads Anti-inflammatories (the night wrap) Period of support/immobilisatio  n – taping, ASO, wedging or orthoses Step 2: Graded exposure to load Treatment goals: Return pain to 1-3/10 during ADL Increase muscle/tendon strength/capacity but will be limited Graded intro of load Treatments: Footwear – neutral option, or customised from cobbler who can add extrinsic lateral wedging Orthoses – reduce supination moments and create extrinsic peroneus longus moments Richie brace – lateral Orthoses Lateral Ff wedge, morarty pad High lateral heel cup, plantar EVA lateral arch filler Cuboid notch Lateral skive, cast corrected to x Ev degrees Injury/ History Physical examination Clinical tests Imaging Management condition BONE STRESS INJURIES BSI Diagnosis Low risk BSI Calcaneal squeeze test Running is poor at bone building Usually occur because NWB: Tenderness that is readily Multidirectional load vital for bone strength of a training load error palpated at subcutaneous sites (met Weekly running shaft, posteromedial tibia, anterior volume can be tibia) misinterpreted and Swelling, redness, heat over injured underestimate training site stress → use other NWB clinical tests variables such as time o Calcaneal squeeze test and sRPE (session rate o ‘N’ spot (navicular) of perceived exertion) o Metatarsal load test RED-S Risk o Axial compression test Stratification Tool (sesamoids) Ff BSI o Low body WB clinical tests Navicular ‘N’ spot Step 1: Pain free gait (0/10) weight due to o Hop test Create pain free status in bone – disordered footwear, carbon plate, AIRCAST, eating crutches o Low BMI Establish training history/load error or o Irregular internal risk for BSI periods Understand what you are getting the o Delayed patient back to menarche Understand foot type – o Low BMD pronated/supinated o Previous Imaging if required stress injury Step 2: Maintain fitness Aerobic fitness through cross training Low risk BSI activities Posteromedial tibia Modify loading on injured region – Distal 1-4th met shafts footwear, foot positioning Calcaneus Swimming, cycling, deep water running, Distal fibula ski erg Cuboid Combine HIIT and endurance Cuneiforms Sesamoid axial Step 3: Return to activity High risk BSI compression test Gradual return can be initiated as soon Anterior tibial cortex as patient is pain free during daily Medial malleolus activities (must remain that way) Navicular Consider “bone break” rest week at Talus each third week of loading to allow Base of 5th met osteoblasts to catch up Base of 2nd met  Sesamoids Footwear considerations Stiffness – carbon fibre inserts, History mountain hiking shoes Presence of localised Rocker soled bone tenderness that is aggravated by loading and does not warm up Normally pain free when unloaded but severe BSI can be painful at rest Pain ranges from mild diffuse ache to localised sharp pain Suspicion should be raised with following risk factors: o ‘At risk’ activities o History of previous BSI Hop test o Presence of indicators of RED-S Changes in physical activity in previous 4-6 weeks o Large change in single training feature eg duration, frequency, intensity, type o Small simultaneous changes in multiple training features  o Physical work and leisure time Injury/ History Physical examination Clinical tests Imaging Management condition MTSS & CHRONIC EXTERTIONAL COMPARTMENT OVERUSE MTSS/shin Risk factors Presence of exercise induced pain along Step 1: splints History of MTSS distal 2/3 of posteromedial tibial border Expectation management – Training load error – YES o If patient has had MTSS for sudden change in o If not → likely not MTSS, consider >3 months, 9-12 months is training other options a realistic prognosis Less running Pain provoked by (during or after) physical Education experience activity and reduced with relative rest o MTSS highly variable Reduced hip YES o Presence/severity of pain abductor strength Cramping, burning pain over posterior depends on how patient Greater contralateral compartment balances load with load pelvic drop NO capacity Prolonged Rf Ev Numbness/pins and needles in foot during o MTSS comes back, or gets Female exercise worse, if this balance is not Greater passive hip NO achieved ER measurement If all these matches up, then move on to o Nature of pain tissue (more physical examination… bony, more soft tissue etc) Recognisable pain on palpation of Load management posteromedial tibial border >5cm o Focus on what they can do o If no recognisable pain on not what they need to be palpation, or pain not >5cm → restricted from likely not MTSS o Maintain aerobic fitness o If pain very specific, more likely a through cross training BSI o Swimming, cycling, deep YES water running, ski erg Nil visible severe swelling or erythema/pain o Workloads can include high not related to loading intensity interval training NO and endurance periods If these match up → MTSS Step 2: Very specific reliable way to diagnose MTSS Graded exposure to bone loading o Combination of graded tibial loading exercises and ankle plantar flexor strengthening exercises  likely to be best option for MTSS Step 3: Loading approach o Priority is to reduce pain and ensure loading meets loading capacity o Maximum pain score of 2/10 while running o Make small changes to training workload weekly Chronic If acute → emergency Physical exam is most helpful in ruling out other Differential diagnosis exertional Compartment most potential causes of pain – popliteal artery compartment affected: anterior – MTSS and tibial BSI impingement/ overuse (CECS) lateral – deep posterior – Tinel’s sign to detect irritated nerves occlusion → pre and superficial posterior Assess for decreased pulses, swelling, post running cramping, spasming ultrasound or MRI to Similar to MTSS To appropriately diagnose CECS, it is of utmost diagnose If cramping/burning pain importance to exercise the patient and attempt over posterior to reproduce the symptoms they experience compartment, or during exercise numbness/pins and The running leg pain profile test needles in feet during o Treadmill test where speed/incline exercise → consider CECS is gradually increased and patients Complain of pain, give pain scores of 1-10 for six leg tightness, weakness, regions cramping, sensory loss in affected extremity Usually pain free at rest but often describe dull ache or burning sensation that comes on shortly after onset of exercise Pain slowly progresses over course of constant exertion and does not resolve until cessation of physical  activity, usually within 15 mins Injury/ History Physical examination Clinica Imaging Management conditio l tests n PLANTAR HEEL PAIN Plantar fascia (aponeurosis) Origin – plantar calcaneal tubercle Insertion – plantar plate, deep transverse met ligament, further subcutaneous slips into skin Function – o Windlass effect – hallux Df, Pf of met heads, raising of medial longitudinal arch, Inv of STF, ER of lower leg o Reverse windlass effect – GRF to met heads, lengthens PF, allowing purchase of digits on ground in standing o Plantar Risk factors Physical examination X-ray Stage 1 – reduce pain/symptoms (reduce stressors) → calm tissue down heel pain Increased BMI Swelling and bruising Rule out Stage 2 – load management and exercise rehab → build tissue up Foot posture are rare tumour or Decrease AJ Df Palpation fracture Decreased 1st MPJ ROM Central/medial PF Ultrasound Prolonged standing origin, lateral PF band, >4mm plantar calc surface, PH thickness band midportion, Baxter’s insertion nerve Negative calc squeeze Fat pad test / Slump testing MRI o If positive → Bone calc fracture, marrow Clinical presentation/history medial oedema Pain insidious onset calcaneal Baxter’s o If sudden onset, nerve, systemic nerve consider PF tear, condition baxters nerve causing Consider Education entrapment, medial hypersensitivit imaging/ Footwear – drop, rocker, cushioning, fit and comfort, support calcaneal nerve, y eg testing/referral fracture, tumour fibromyalgia when… Treatment First step pain – warms up 1st MPJ ROM and pain Night pain Taping Orthoses  o No warm up effect → Ankle joint DF ROM Sudden o Medial arch support PF tear, fat pad (non-WB and WB) onset o Stiff shell atrophy/ contusion, Foot posture Trauma o High heel cup fracture, Abd hallucis Windlass test (non-WB Morning o Ff valgus wedging compartment and WB) stiffness >30 o PF accommodation syndrome, tumour Gait mins o Heel post Nil neural symptoms and night Calf raise variations Multi joint o Heel raise pain DL and SL hop stiffness o Heel aperture o If present → tarsal Footwear Unable to o Medial heel skive tunnel (Tinel’s), Still need to consider WB Gel heel raise baxters nerve forces, if the symptoms Posterior Night splints entrapment, medial are created from tensile heel pain Compression socks calcaneal nerve, sural or compressive forces. Neurological Shockwave therapy nerve o If unable to WB symptoms Corticosteroid injections Localised pain – single finger → trauma Strengthening point history, Dry needling o If not localised → PF/muscle Heel pain trigger point therapy consider referred tear, fracture, Plate rick plasma injection pain/multiple calc periostitis, Management of other conditions pathologies, and fat pad Psychological support question duration of contusion Massage/ foam roller/ rolling ball under foot morning stiffness and o No trauma Surgery other joints in body history → Load change?/ unable to more systemic recover from unusual load? conditions Exercises Occupation – standing Activity – runner/surface Isometric: Weight gain Toe Stretch with Towel: Sit with foot extended, wrap a Sleep/stress towel around the toes, and pull toward the body; hold for Emotional pain factors 30 seconds, repeat 3 times. Plantar Fascia Stretch: Cross affected leg over the other, Mechanism of injury: grasp toes, and pull back toward the shin; hold for 20-30 Repetitive stress / loads seconds, 3-5 reps. considered to be a primary Calf Stretch: Wall stretch with knee straight and bent to driver of pathological target gastrocnemius and soleus; hold for 30 seconds, development (+/- the repeat 3-4 times daily. interplay of individual risk Isotonic: factors). Strengthening Exercise: Towel scrunches or marble pick- ups to improve intrinsic foot muscle strength. slow calf raises, gradually build pace, load and range (add height under toes to increase stretch on PF),  step movement rocking back and forwards