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The Role of Physical Therapy in Rehabilitating Foot and Ankle Injuries

by Angelina

Common Foot and Ankle Injuries

Stress fractures in the foot and lower leg are also common in both the athletic and general population. Stress fractures occur as an overuse injury and are more prevalent in people who suddenly increase their level of activity, particularly in running and jumping sports. Stress fractures cause localized pain and tenderness over the site of the fracture. They are diagnosed with the use of a bone scan or MRI as they are often missed on regular x-rays. In severe cases, patients may be placed in a boot or on crutches to offload the area. Stress fractures usually take 6 weeks to 3 months to fully heal. Failure to cease aggravating activities or premature return to activity can result in delayed union or non-union of the fracture. This is a painful condition that often requires surgery to fixate the area. High levels of successful rehabilitation for stress fractures can be achieved with a decrease in pain and return to pre-injury activity level. Optimization of bone healing is vital in the rehabilitation process. This requires a progressive increase in impact and weight-bearing activities. Any problems with healing must be referred back to the patient’s GP.

Ankle sprains are the most common of all the injuries we see. They occur when the foot inverts or rolls in, and we often see injury to one of the ligaments on the outside of the ankle. A severe sprain will also involve muscle and tendon damage. Ankle sprains are often underestimated and are not given proper medical attention – this can lead to re-injury or ongoing pain and disability. Ankle sprains, if rehabilitated properly, should not cause long-term pain or instability.

Benefits of Physical Therapy in Rehabilitating Foot and Ankle Injuries

Immobilization after a foot/ankle injury can lead to a slow, weak, and inefficient gait pattern which may not be corrected. It is this weak inefficient gait pattern that greatly increases the risk of re-injury to the same or opposite foot/ankle. This information is essential to the understanding of the importance of physical therapy in treating foot and ankle injuries. Now we will discuss the benefits of physical therapy in rehabilitating foot and ankle injuries.

When an injury to the foot and/or ankle occurs, it usually results in an antalgic (painful) gait pattern. This occurs due to the body’s natural response to pain, which is avoidance. The avoidance of pain is done by either reducing the amount of time spent on the injured limb or by altering the mechanics of the gait pattern. This altered gait pattern typically results in excessive weight bearing on the other foot, which can subsequently cause injury to that foot as a result of increased stress.

Discussing the advantages of physical therapy is unnecessary if one does not understand the injury that is being treated. Much research has been done stating that immobilization of an injured site is detrimental to the healing process. During the gait cycle (the manner in which a person walks), the human foot is the point of initial contact or heel strike and continues along the ground until it becomes the leading foot for swing phase. It is during this time that the foot and ankle are very vulnerable to traumatic forces which can result in injury.

Pain Management

A physical therapist may use different forms of pain management in order to suppress or control a painful inflammatory condition. The use of superficial heat or cold modalities can be used to affect blood flow to specific tissues in order to aid in the resolution of a painful inflammatory condition. Phonophoresis and/or Iontophoresis are techniques that can be used by the physical therapist in order to administer an anti-inflammatory agent below the skin and are indicated when using an external anti-inflammatory agent is painful or irritating and when both agents are difficult to get through the skin and into the affected area. Non-painful low-level laser or non-painful electrical stimulation can be used to control pain and muscle spasm. A TENS (transcutaneous electrical nerve stimulation) unit, when used by the patient at home, can be useful in controlling pain. Massage of soft tissue and/or joints is often very helpful in resolving muscle spasm and painful restrictions in ROM. It is important to note that while symptom (pain) relief is a priority, the patient and physical therapist will use a defined pain-free range of motion and exercise prescription in order to normalize mechanical tissue function.

Chronic and acute foot and ankle pain can develop as a result of trauma (such as a sprained ankle), an acute injury (such as an ankle fracture), or as a result of a specific medical condition (such as arthritis or gout). Foot and ankle pain and problems can be so debilitating that it limits the ability to walk or bear weight and thus affects the quality of an individual’s daily life. Pain is not normal, and it is the body’s way of sending a warning signal that something is not right.

Restoring Range of Motion

The final technique is the use of manipulation. Although not recommended for patients with chronic ankle issues, manipulation was found to result in clinically important changes and increased range of motion of the ankle in the long term, so it can be considered for the high ankle sprain patient because of a faster recovery time.

The second technique is using a combination of manual therapy and stretching. This was deemed to be effective for improving passive ankle motion to help reach the prescribed levels for exercise and functional activities. Static stretching, using straps to apply a constant moderate force/low load prolonged duration stretch, can help improve active ankle dorsiflexion and has been associated with no adverse effects on muscle strength or athletic performance.

Passive range of motion is motion that occurs at the joint when the foot is relaxed, using muscles other than those controlling the joint to move the ankle (for example, using your hand to move your foot). Active range of motion is motion that occurs at the joint when the ankle musculature is used to move the foot. Studies have shown manual therapy to be superior in improving passive range of motion in the ankle compared to exercises. The most commonly applied technique is the use of joint mobilizations. Joint mobilizations are a set of techniques which involve therapist-applied movements of the joint surfaces in order to restore motion, improve function, and reduce pain. Joint mobilizations have been shown to be effective in increasing both active and passive range of motion in all directions of the ankle.

Ankle range of motion is nearly always impaired following injury. Problems with ankle dorsiflexion have been linked to decreased balance, as this motion helps position the body’s centre of mass over the stance limb. A physical therapist will prescribe specific treatment to help increase your passive and active ankle range of motion.

Strengthening and Stability Exercises

Strengthening of the entire lower extremity is also important because some muscle weakness may alter gait patterns that can interfere with full return to normal activities. Isotonic or closed kinetic chain exercises are effective ways to strengthen the entire lower extremity. An example of a closed kinetic chain exercise is a partial squat. This exercise strengthens the quads, hamstrings, and gluteal muscles simultaneously. These exercises are important for those who have suffered from an ACL tear or reconstruction. Error on this page?

Theraband exercises are a common way to increase the strength in ankle musculature. For peroneal strength, the patient can perform eversion isometric exercises with the band secured to a fixed object and placed around the ankle.

Clients with foot and/or ankle injuries often demonstrate decreased strength and stability. Inversion ankle injuries have been linked to decreased balance and ankle strength. Studies have shown a 40-70% recurrence of sprains in those who have suffered from an ankle sprain. The decreased strength contributes to the high percentage of re-injury. By increasing the strength in the muscles, it will allow the client to gain stability which will prevent against future injuries. It is important to closely monitor the client during the exercises. Resistance should be started at a minimal level and progressed to a maximum level to increase muscle strength. The client should not feel pain during the exercise and there should be no additional pain following the exercise.

The main focus of physical therapy is to perform therapy that can restore and mobilize the foot to its normal function. This is best carried out by initially applying the PIER principle: Protect, Immobilize, Elevate, and Reduce activity. It is important to minimize the use of crutches and special shoes as this can slow down the recovery process and can continue to cause the patient to walk abnormally. By weight-bearing, patients can increase the efficiency of the healing process while minimizing muscle and tissue wastage and also preventing joint stiffness. Active mobilization is also significantly important in ensuring that the ankle achieves its normal functional range. This can often be disrupted by pain inhibition and muscle/tissue guarding reflexes. If these are left unresolved, studies have shown that there is a higher chance of re-injury to the ankle. To ensure a full recovery and minimize the chance of re-injury to the ankle, it is essential that the foot and ankle be fully rehabilitated to regain the full strength, flexibility, and functional abilities. This can often take a period of a few weeks to a few months depending on the severity of the injury. With professional rehab and diligent attention to the specific needs of the individual, a standard or a higher level of function can be achieved in the previously injured ankle. This provides a better long-term outcome and helps in preventing unwanted after-effects from the recent injury. Competitive athletes often acquire lateral ankle sprains more frequently than most of the general population. With the help of a physical therapist, an individual can improve the stability of the injured ankle beyond that of which it was before the injury occurred. High-level function of the foot and ankle is often necessary in the line of competing in high-level sports. It is therefore important that the therapy provided fully rehabilitates the injury and also provides the patient with the necessary knowledge and self-administered therapy to ensure that a similar type of injury does not occur in the future.

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