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Rehabilitation of the Foot & Ankle
Will Coggin, PT, DPT, CSCS
Andrew’s Institute
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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
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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
wc8
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Slide 3
wc8 https://emedicine.medscape.com/article/85224-overview#a6william coggin, 2/2/2019
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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
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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
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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
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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
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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
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Lateral Ankle Sprain
Anterior Drawer Test• Stabilize Distal Leg, Plantarflex 10-15 degrees.
• Provide anterior translation of calcaneus
– ATFL Emphasis
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Lateral Ankle Sprain
Talar Tilt Test• Stabilize Distal Leg, Plantarflex 10-15 degrees.
• Provide anterior translation of calcaneus
– CFL Emphasis
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High Ankle Sprain
Squeeze Test• Compress Proximal Fibula Against Tibia
• Possible Fracture
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High Ankle Sprain
Kleiger’s Test
• Maximally Dorsiflex and Externally Rotate the Foot
• Possible Deltoid Injury
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Plantar Fasciitis
Windlass Test• Stabilize Foot in Neutral, Maximally Dorsiflex Great Toe
– Weightbearing Increases Specificity (0.99)
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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
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Concerns of Fracture
Ottawa Rule
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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
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Joint-by-Joint Approach
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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
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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
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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
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Functional Test
CKC Dorsiflexion Test
• Normative Value=40 degrees
• Tape Measure vs Goniometer
– Tape Measure has Improved Rater Reliability
– Tape Measure: 10 cm, ≈4’’
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Functional Tests
Static SL Balance
• Looking For Asymmetries
– Firm Surface
• Eyes Open
• Eyes Closed
– Unstable Surface
• Eyes Open
• Eyes Closed
– Cognitive Tasks
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Phases of Recovery
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Early Phase
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Low Dye Taping
• Effective Treatment for tendinitis/fasciitis
– Reduces foot pronation
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Early Phase
• ROM
– 3 planes
• Strength
– Ankle Musculature
– Foot Intrinsic
– Isometrics->Isotonic
• Neuro-Reeducation (NWB)
– Manual PNF Pattern
– BAPS board
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Intermediate Phase
CKC Strength
Soleus EmphasisFoot Intrinsic/Posterior Tibialis
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Intermediate Phase
– Dynamic Patterns
• Squat
– Assistive->Resistive
• Step Up/Lunge
– Multiple Directions
– Considerations
• Posturing/Footwear
• Type of Surface
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Intermediate Phase
• Proprioception/Balance
– Base of Support
– Stable vs Unstable Surface
– Static vs Dynamic
– Focus Emphasis
• Internal
• External
• Multitasking
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Intermediate Phase
Balance Progression
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Phase III-Plyometrics
• Progression– Stepping
• Forward/Lateral � Diagonal
– Hopping• Bilat Support � Unilateral
Support
• Concentric � Eccentric
– Multi-Tasking
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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
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Discharge Testing
SEBT
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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.
wc3
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Slide 34
wc3 https://www.jospt.org/doi/pdf/10.2519/jospt.2009.3042william coggin, 1/1/2019
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Discharge Testing
Hop Testing
wc4
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Slide 35
wc4 https://www.jospt.org/doi/pdf/10.2519/jospt.2009.3042william coggin, 1/1/2019
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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