.........................................CHAPTER 28

Principles of rehabilitation for thefoot and ankle

Erin Richard Barill and David A. Porter

CHAPTER CONTENTS

......................

Introduction

595

Cryotherapy/rest, ice, compression,and elevation (RICE)

595

Range of motion/mobilization

596

Protected weight bearing

597

Gait evaluation

598

Strengthening

598

Proprioception

598

Cardiovascular activities

599

Functional progression

599

Phases of rehabilitation

601

Rehabilitation of Achilles tendon repair

601

Rehabilitation after lateral ankle reconstruction

604

Rehabilitation of ankle fractures

607

Conclusion

609

References

609

Further reading

610

INTRODUCTION

The foot and ankle often are injured during sportingevents, recreational activities, and occupational acci-dents. Injuries to the foot and ankle may be acute orchronic in nature and often cause considerable disabilityin athletes. Garrick and Requa1 reported that foot andankle injuries represented more than 25% of the 1600athletic injuries in their series.2,3 It has been suggestedthat the sprained ankle is the single most common injuryin sports.2,4-7

The foot and ankle serve as the junction of the body tothe weight-bearing surface. This elegant collection of tis-sues, each with a variety of specialized functions, allowsefficient, upright stance and locomotion.8 Athletic popu-lations have unique and strenuous demands. Even withminor injuries, improper or incomplete rehabilitationcan lead to significant impairment. A detailed, focusedapproach to rehabilitation of the foot and ankle is cru-cial to the athlete. Fortunately, most competitive ath-letes have access to daily evaluation and monitoring ofprogress, as well as skilled assistance to help them com-ply with rehabilitation protocols. Recent technologicand procedural advances contribute greatly to thetreatment of the competitive athlete. Principles of

rehabilitation must continue to advance and keep upto date with technologic and procedural advances.A proper and advanced approach to rehabilitation canprovide an environment conducive to a complete, full,and functional recovery.

CRYOTHERAPY/REST, ICE, COMPRESSION,AND ELEVATION (RICE)

Initial treatment of acute foot and ankle injuries andpostoperative ankles still follows the RICE principle.There are several cold agents to choose from, includingthe cold pack, ice bags, cold whirlpool, ice immersion,and the Aircast Cryocuff. The primary objective of iceis to reduce swelling and help manage pain. It has beenfound that pain is inhibited by cold through a decreasein nerve conduction velocity. As the temperaturedecreases, there is a corresponding decrease in sensoryand motor nerve velocity, eventually causing synaptictransmission to be blocked.9 In our experience, we havefound the ankle and foot Cryocuffs to be effectivebecause they combine compression and cold. In addi-tion, elevation can help to reduce hydrostatic pressureand diminish edema. Physiologically, the application of

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............CHAPTER 28 � Principles of rehabilitation for the foot and ankle

cold agents also results in arteriolar vasoconstriction, adecrease in local metabolism, and an elevation in painthreshold.

The application of cold is most effective immediatelyafter injury or within the first 72 hours. Hocutt et al.10

found that patients with grade III ankle sprains thatwere treated with ice in the first day returned to func-tional activities such as running and jumping after 6 days,whereas those treated on the second day went 11 daysbefore they could run or jump. In contrast, those whoreceived heat in the first day had a recovery time of14.8 days.

A contraindication to cryotherapy is individuals withhypersensitivity to cold. Cold should be avoided inpatients with Raynaud’s syndrome or peripheral vasculardisease (see Chapter 10). Cold therapy also must bemonitored closely in postoperative patients who havewet dressings because the combination of wet dressingswith cold application can decrease the skin temperatureto a dangerous level.

RANGE OF MOTION/MOBILIZATION

There always has been an interesting rehabilitationdilemma between the need for early range of motionand the need to immobilize tissues to decrease swelling,protect injuries, and protect against pathologic motion.This section discusses the advantages of early motion.

Galileo first recognized the relationship betweenapplied load and bone morphology. In 1892, JuliusWolff, a German anatomist, was the first to link thesetwo vital concepts in his landmark thesis, ‘‘The Law ofBone Transformation.’’ Wolff explained that everychange in the function of a bone is followed by certaindefinite changes in internal architecture and externalconfirmation in accordance with mathematical laws.Stated simply, ‘‘form follows function.’’

Application of early motion on ligament healingdemonstrates that the ligament hypertrophies to com-pensate for decreased tensile strength of the individualfibers. Obviously the amount of tension and stress mustnot overcome the ultimate load to failure of the tissueand must not lead to fatigue or plastic deformation.Wolff’s law also may apply to these soft tissues, and physi-ologic stress may allow more functional and strongerhealing of soft tissues. Experimental studies of liga-ments after injury indicate that exercise and jointmotion stimulate healing and influence the strengthof ligaments after injury.11-16

Some of the early research on restoration of earlyrange of motion was performed in the hand and theknee. These historical papers revealed insight on howearly range of motion decreases complications and

actually enhances the healing process. Early mobilizationmay result in an earlier return to work and daily activity,less muscle atrophy, and better mobility compared withimmobilization by casting.14,17,18 The value and benefitof early motion was investigated in the area of rehabi-litation after flexor tendon repairs of the hand. Theobvious need for full motion in the hand promptedinvestigation into safe rehabilitation practices, whichwould eliminate postoperative adhesions and stiffnessbut allow reliable healing of the tendon. Gelbermanet al.19,20 noted an improved healing response,improved strength, and a more normal pattern of vascu-larity to the healing tendon with protective early mobili-zation. Several other studies also noted that early rangeof motion decreased adhesions around the repaired ten-don and had a positive influence to the healing tis-sue.21,22 Early motion after flexor tendon repair hasbecome standard today.

Over the past 2 decades, there have been significantstudies in the area of rehabilitation after knee injuryand surgery. The focus of knee rehabilitation has cen-tered on obtaining full symmetrical range of motionfollowing a knee injury or surgery. Obtaining full kneeextension was one of the most important criteria inallowing the anterior cruciate ligament to heal ana-tomically and yet still avoid a knee flexion contracture.Close observation of patients who were doing welldemonstrated that early range of motion was not detri-mental to the ligament (and in fact could be advanta-geous to proper ligament healing/strengthening) whileallowing an earlier and safe return to function.23 Earlymotion and weight bearing led to a significant decreasein muscle atrophy and decreased complications fromarthrofibrosis with an earlier return to function.

Robert Salter and associates24 investigated the effectof joint motion on cartilage nutrition. Early continuouspassive motion in synovial joints allows and promotescartilage nutrition and health. Salter et al.24 demon-strated that small cartilage defects actually could healwith continuous motion, further supporting the benefitof motion on articular cartilage nutrition and healing.

These advances in hand and knee rehabilitation gaveus reason to approach the foot and ankle with a similarapproach. Thus early mobilization of the foot and anklefollowing injury is our currently favored treatmentmethod when applicable. This method specifically avoidsor reduces immobilization. We have followed the prin-ciple that unnecessarily protracted immobilization canprolong the recovery period. Early mobilization can expe-dite the return to work and resumption of athletic activitywhile potentially decreasing the risk of complications.

Eiff et al.17 used a prospective randomized study todetermine which treatment for first-time ankle sprains,early mobilization or immobilization, is more effective.They reported that, in first-time lateral ankle sprains,

Protected weight bearing

although both immobilization and early mobilizationprevent late residual symptoms and ankle instability,early mobilization allows earlier return to work andmay be more comfortable for patients. Active and pas-sive range of motion is useful to regain motion in cardi-nal and diagonal planes. Passive range of motion allowsthe muscles to relax while working the mobility of thejoint. Active range of motion requires independentmuscle action and incorporates muscle re-education.It is important to work range of motion in the directionopposite of the mechanism of injury (i.e., we allow dor-siflexion and eversion and avoid plantarflexion andinversion initially after a grade II or III lateral anklesprain). Once the injury has healed, range of motionshould include all directions.

In addition to active and passive range of motion,joint mobilization should be incorporated in the reha-bilitation program. Accessory movements, termedjoint play, are not volitional but accompany voluntarymovements or occur passively in response to theground or other forces. The amount of joint play is afunction of ligament and soft-tissue compliance as wellas bony configuration.25 Mobilization techniquesinvolve oscillation, distraction, and gliding movementsof the joints in the planes of accessory motions. Therange of mobilization is always advanced in a gradedmanner but always stays within the physiologic limitsof the joint.25

There is much discussion with regard to immediate,short-term protection of ankle injuries. Some of the morecommon methods consist of elastic wrapping, taping/strapping, semirigid pneumatic ankle brace, nonrigidfunctional ankle brace, and a removable walking boot.A device we like is the Aircast walking boot withbuilt-in Aircast Cryocuff (Fig. 28-1). The device allows

Figure 28-1 Aircast Cryocuff and walking boot.

patients to weight bear immediately, work on range ofmotion by removing the boot, and use a continuouscold/compression device. Once the ankle has healed,a more functional brace is used for return to activity(2-4 weeks after injury). We particularly stress the useof the boot at night for the first 3 to 4 weeks to keepthe foot and ankle complex in a 90-degree dorsiflexedposition during sleep, when the relaxation of muscularcontrol and the forces on the heel passively place thecomplex in a plantarflexed and inverted position. Therigid boot counteracts this position.

PROTECTED WEIGHT BEARING

Early weight bearing has been shown to increase the sta-bility of the lateral ankle ligaments after injury whiledecreasing the amount of muscle atrophy. Protectedweight bearing provides a safe and earlier return to activitywhen appropriate by decreasing joint stiffness, muscu-lar strength deficits, and proprioception dysfunction(Fig. 28-2). We favor a postoperative protocol thatallows for early weight bearing whenever possible. Werecognize there are times when this is not possible suchas in hindfoot fusions. However, in the sports popula-tion, early weight bearing can have such a positiveimpact that we try to tailor our surgical and nonopera-tive approach to allow early protected weight bearing.

An intriguing area of research that is revealing to us isthe investigation of weightlessness. Costill et al.26 exam-ined the effect of a 17-day space flight (essentially, totalweightlessness) on muscle. They reported that therewas an 11% decrease in peak muscle power, a decreasein muscle fiber diameter, and a 21% decrease in forcewhen the muscle was contracted at peak power velocity.

Figure 28-2 Patient wearing Aircast walking boot.

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............CHAPTER 28 � Principles of rehabilitation for the foot and ankle

More specifically, Costill et al.26 examined single musclefiber changes after weightlessness. The single fiber diam-eter decreases were 20% after 17 days suspended legweightlessness (for example crutch-assisted nonweightbearing) and demonstrated similar profound muscularatrophy.

Research suggests that early loading of damaged softtissue can enhance collagen fiber realignment and heal-ing.13,14,16,27,28 Using a removable Aircast walking bootallows the patient to progress to weight bear immedi-ately after injury. Being in a walking boot instead ofan ankle cast allows the patient to take the boot offto begin rehabilitation activities. The walking bootprovides more support than elastic wrapping, taping,and other semirigid bracing systems, and it also allowsthe patient the ability to apply cold compressionsimultaneously.

GAIT EVALUATION

The evaluation of a patient’s gait immediately afterinjury and before return to activity can provide a clini-cian with valuable information on how abnormalitiesin ambulation contribute to the rehabilitation and pre-vention of injuries. Often abnormal gait mechanics canpredispose the other joints of the lower extremity andback to overload and pain. Restoring normal gait afteracute injuries can help to prevent these abnormalmechanics and significantly reduce the amount of timerequired for return to normal function. It is importantthat a clinician evaluates the entire lower extremity andits function during gait.

Normal gait is composed of two phases, a stancephase (60%) and a swing phase (40%). The stance phaseis composed of five categories, including initial contact(heel strike), loading response (foot flat), midstance(single leg support), terminal stance (heel off), andpre-swing (toe-off). The swing phase consists of initialswing (acceleration), midswing, and terminal swing(deceleration).29-31

In acute injuries, a clinician will notice gait abnormal-ities because of pain, decreased range of motion,strength deficits, and lack of proprioception. The major-ity of the time, a patient will present antalgic witha decreased stance phase. If a patient is unable to walkwithout antalgia, a clinician should educate the patienton normal gait mechanics using assistive devices; forexample, crutches. A patient may discontinue assistivedevices when he or she can walk normally. It is extre-mely important that as clinicians we correct gait imme-diately to prevent abnormal gait habits from becomingpermanent. It is likely that some failure to return to fullstrength return after a lower-extremity injury is related

to adaptive gait changes that become permanent inunloading the injured extremity.

In chronic injuries or before return to activity, aclinician should take a closer look at lower-extremitybiomechanics and gait abnormalities to facilitate returnto function while preventing future problems. Obser-vation of gait should include lateral, anterior, andposterior view. It is important to observe and evaluatethe foot, ankle, knee, and hip/pelvis position and bio-mechanics during the gait cycle. Treatment of gaitdeviations includes flexibility, strengthening, and pro-prioception. An orthotic can be an excellent adjunctto rehabilitation if the gait deviation is a result ofabnormal biomechanics and structural problems withinthe foot.

STRENGTHENING

Muscle strengthening should be initiated once thepatient has recovered 95% to 100% of the range ofmotion of that joint. Initiating strengthening too earlycan cause an increase in joint stiffness, therefore decreas-ing the function of the joint. Working isometrically, iso-tonically, or isokinetically can achieve strengthening.Isotonic strengthening, which is most commonly per-formed, uses concentric and eccentric contractions. Con-centric contraction causes muscle shortening, whereasin an eccentric contraction the muscle lengthens whilemaintaining a load. Both phases are extremely importantand should be included in a comprehensive rehabilitationprogram.

There are several methods of strengthening, includ-ing weights, Thera-Band, and water resistance. Thera-Band is a useful tool to provide resistance in alldirections of the foot and ankle. It has different levelsof resistance to allow the athlete to progress. Once theathlete can complete 3 sets of 15 repetitions througha full range of movement, the next level of resistanceshould be started. This same concept can be used withankle weights.

PROPRIOCEPTION

Many rehabilitation programs often fail to pay attentionto proprioception deficits. Proprioception is the abilityof the body to vary the forces of muscles in responseto outside forces. Muscles, tendons, and joint receptorsprovide this information, which affects posture, muscletone, kinesthetic awareness, and coordination.29,30 Whenan individual is injured, the proprioceptive input to thatjoint is altered and diminished. Diminished proprio-ception can lead to a recurrence of injury because of thejoint’s decreased ability to respond to outside forces.

Figure 28-3 Biomechanical ankle proprioception system(BAPS) board for balance and range of motion.

Table 28-1 Increase exercise capacity program(with boot/postoperative shoe/brace on)� Exercise 10 minutes on a stationary bike 3 days a

week.� Exercise 20 minutes on a stationary bike 4 days aweek.� Exercise 30 minutes on a stationary bike 4 days aweek.

� Once you are able to ride the bike 30 minutes a day for4 days aweek, then youmay start replacing one of your days

of biking per week with 1 day of StairMaster or ellipticaltrainer. You will do the StairMaster or elliptical for the sameamount of time you normally would ride the bike.

Functional progression

Proprioception can be improved with a number oftreatment techniques. Early weight bearing can help todecrease the amount of proprioception loss. A patientcan practice standing with equal weight on both feet,progressing to single leg stance. A biomechanical ankleproprioception system (BAPS) board or kinestheticawareness trainer (KAT) can be used as a patientadvances through rehabilitation (Fig. 28-3).

CARDIOVASCULAR ACTIVITIES

During the rehabilitation program it is extremely impor-tant to keep the patient active. If the patient becomessedentary, the cellular metabolism levels will decreaseand the individual will lack energy, and may experienceboth diminished desire and blunted motivation becauseof a form of depression seen after injury in athletes. Thisconsequently can then present a challenge for recoveryand rehabilitation. Early in the rehabilitation, we feelthat it is vital to start a sensible regimen of low-resistance exercise bike or pool therapy training 3 to 4days a week for 10 to 15 minutes with a progression by5 to 10 minutes of training per session per week. If thebike is used, then a walking boot or protective brace isused. Pool therapy is not initiated until the sutures areremoved and the wound is fully healed. By initiating earlyactivity during the rehabilitation program, the cellularmetabolism will be maintained. The early exercise alsoprovides psychological benefits for the athlete. Physicallyit allows an active blood flow to the involved extremity,and psychologically it helps to keep the patient motivatedand counteracts the potential for depression.

Our experience with and observation of clinical heal-ing and postoperative wound healing have proven that it

is important to progress the patient’s activity gradually.Increasing the time increments of 10 minutes a weekon a bike will allow the patient to be working approxi-mately 30 minutes per session in a 3-week span(Table 28-1). Typically, low-impact, weight-bearingexercise will be introduced when the athlete is able towalk normally in a protective device and regular shoe.The rehabilitation program will begin replacing oneday of bike with a StairMaster/elliptical machine( Fig. 28-4 , A and B) . We allow an additional day ofStairMaster or elliptical each successive week until theathlete has been converted to StairMaster or elliptical4 to 6 days per week. The athlete will continue toincrease low-impact, weight-bearing exercise as toler-ated. We have found that when an athlete can workout on the StairMaster or elliptical machine 4 to 5 daysa week for 30-plus minutes, it is safe to initiate running.Running should gradually replace StairMaster/ellipticaleach week. It is important to give the athlete a set ofrunning guidelines that allows for a gradual progressionof activity (Table 28-2).

FUNCTIONAL PROGRESSION

A functional progression is a series of sport-specific skillsthat increase in the level of difficulty that an athlete mustcomplete before he or she can safely return to com-petition. Yamamoto and Fragi described a functionalprogression in the rehabilitation of injured West Pointcadets.32,33 The emphasis in this program was placedon restoring agility through dynamic exercise after kneeinjury. Kegerreis et al.34 added specific movement pat-terns and skills to the program and introduced theimportance of addressing the psychological needs of

599

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Table 28-2 Running progression

Day

Week no. 1 2 3 4 5 6 7 Total minutes

1 10 0 10 0 12 0 14 36

2 0 16 0 18 0 20 0 54

3 25 20 0 25 25 0 30 125

4 30 0 30 35 0 35 40 170

Previously running 30-45 minutes per day.

Subtract times from time spent on low-impact aerobic training.

Figure 28-4 (A) Patient performing StairMaster with Aircast walking boot. (B) Patient performing StairMasterwith ankle stabilizing orthosis (ASO) brace.

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............CHAPTER 28 � Principles of rehabilitation for the foot and ankle

the injured athlete. They also addressed the scientificprinciples that play an important role in the functionalprogression and the need to break down sport-specificfunctions to be addressed in the order of difficulty.

The functional progression is vital to a complete sport-specific rehabilitation program. It serves as the key ele-ment in advancing the athlete from clinical rehabilitationto athletics. Each sport has certain demands and skills thatstress the foot and ankle differently. It is extremely impor-tant that the athlete advance one step at a time withoutpain or apprehension. Once the athlete has completedthe list of activities in order without pain or apprehension,he or she may return to full sport activity.

There are several physical and psychological benefitsthat the functional progression will address. The

functional progression promotes healing through theapplication of Davis’ law and Wolfe’s law, which werediscussed earlier. It is important that the healing tissuebe stressed in the way required of it before injury so thatthe tissue will be ready to fully accept preinjury activityrequirements. As described in Davis’ law and Wolfe’slaw, injured tissue and bone stressed in this controlledmanner will lead to further tissue and bone healingand strength. In addition, the functional progressionbreaks up the monotony of traditional rehabilitationand allows the athlete to begin performing activitiesrelated to function. Psychologically it allows the athleteto increase self-confidence and mentally prepares himor her to return to sport. As the athlete completes eachstep, confidence will increase and apprehension will

Table 28-3 Functional progression—court sports

Begin with step one. If you can do this exercise withoutpain or limping, you may proceed to the next step. It isvery important that you perform each exercise correctly,

without apprehension. When you have successfullycompleted each step of the functional progression, youmay then attempt to return to your sport. You should wearthe Aircast, Swedo, knee brace, or tape as instructed.

Heel raises injured leg—10 times

Walk at fast pace—full court

Jumping on both legs—10 times

Jumping on the injured leg—10 times

Jog straight—full court

Jog straight and curves—2 laps

Spring: 12,

34, full speed—baseline to court

Run figure eights: 12,

34, full speed-baseline to 1

4 court

Triangle drills: sprint baseline to 12 court, backward run to 1

2

court, defensive slides along baseline, both directions

Cariocas (cross-over drill) 12,

34, full speed—

12 court

Cutting 12,

34, full speed—full court

Rehabilitation of Achilles tendon repair

decrease, allowing the athlete to enter the competitiveenvironment at the level of function needed for playingstandards (Table 28-3).

PHASES OF REHABILITATION

The cornerstone to appropriate rehabilitation is an accu-rate diagnosis, so that an appropriate rehabilitation pro-gram can be established efficiently and safely. For anyinjury or condition, the rehabilitation can be divided intothree general phases. Each phase has specific goals, and,although there is a time frame assigned to each phase,advancement from one phase to another should be basedon the patient’s achieving the prescribed goals ratherthan on time. A clinician must be willing to adapt andmodify the exercise program for each patient. There area variety of rehabilitative techniques to choose from; eachcan have benefit to the patient. As a clinician, it is impor-tant to stay up to date with current rehabilitative trends.

Phase I

Phase one emphasizes pain modulation and inflamma-tory control of the soft tissues. Controlling pain andinflammation will allow patients to be better able to per-form their rehabilitation exercises. Restoration of nor-mal range of motion and joint accessory motions,including glide, roll, and spin, are stressed in this phase.Early return of pain-free range of motion will enhancethe rehabilitative process and allow the patient to beginis olated and functi onal rehabi litati on exercises in phaseII with greate r effectiv eness. Once a patient has min imalpain and has normal to near normal range of motion, heo r she may be advanc ed to phase II .

Phase II

Once inflammation is decreased, pain has subsided, andra nge of motion is near nor mal, phas e II may begin.Foot and ankle flexibility with functional strengtheningare initiated and are the focus of this phase. In addition,cardiovascular conditioning and proprioceptive trainingalso are started at this time. The goals of this particularphase are to improve flexibility, restore strength, andbegin light, sport-specific functional training. A patientmay be progre ssed to pha se III when he or she is readyfor a gradual return to activity and participation insports.

Phase III

Em phasis in phase III is on functio nal return to activitie sof daily living (ADLs) and previous activity/sport parti-cipation. Advanced activity-specific exercise should beimplemented with special attention to mechanics of theactivity. Proper mechanics, as well as maintenance offlexibility and strength, can prevent further chance ofreinjury. To ensure safe return to sport, athletes shouldperform a functional progression. External supportssuch as braces, straps, taping, and orthotics may be usedat this time to allow the patient to participate in his orher activity pain free.

REHABILITATION OF ACHILLESTENDON REPAIR

The rehabilitation after an Achilles repair is an exampleof progression toward a more functional recovery.Recently, rehabilitation after an Achilles repair has pro-gressed from long-leg casting to short-leg casting tothe use of intermittent immobilization and early weightbearing. Mandelbaum et al.35 have established anaccelerated rehabilitation protocol for the Achillesrepair. Their protocol involves early range of motion at72 hours and early weight bearing at 2 weeks postrepair.This functional approach allows the competitive athlete

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Figure 28-5 (A) Towel toe curls. (B) Resisted plantarflexionusing Thera tubing. (C) Single-leg balance for proprioception.

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to return to sports more quickly without a reportedincrease in complications.

At Methodist Sports Medicine, more than 75 acuteAchilles repairs have been performed over the past8 years using an ankle-block anesthetic, no casting,intermittent immobilization with a removable boot,and cryotherapy. Patients have been full weight bearingby 2 weeks, and range of motion is started at the firstpostoperative visit, along with a bike program and sit-ting toe raises. We use the concept that early-protectedrange of motion and weight bearing encourage strongtendon healing and protect against disuse atrophy. There-rupture rate has been consistent with that of lessaccelerated protocols (<2%). This is an example of ourrehabilitation program.

Immediately postoperatively the patient is placed inan Aircast walking boot with a built-in Cryocuff. Thewalking boot also has one 9

�16-inch felt heel lifts placed

inside to put the foot/ankle in a slight equines positionfor healing. (We will use two heel lifts if the repair is3-8 weeks after the tear.) The patient is instructed tobe nonweight bearing for the first 5 to 7 days and isappropriately trained in axillary crutch use for walkingand negotiating stairs. This decreases the risk of earlypostoperative swelling and allows appropriate initialwound healing.

The immediate postoperative protocol consists of rest,elevation, and continuous daytime Cryocuff use. Thepatient also is instructed to wiggle toes and perform leglifts every 3 to 4 hours in the first postoperative week.

Dressing changes and rehabilitation will begin1-week postoperatively. Physical therapy will consist ofa home exercise program, gradual progression of weightbearing, and a light bike program to maintain cellularmetabolism. Biking is performed with the ankle immo-bilized in the boot. The home exercise program includestoe curls (Fig. 28-5 A), active plantarflexion, resistive-band plantarflexion (Fig. 28-5, B), and sitting calf raises(Fig. 28-5 C). We use the concept of early-protectedmotion and resistance training, which encourages stron-ger tendon healing and protects against disuse atrophy.Exercises are performed at a higher frequency with alow load (see phase I exercise prescription) to continu-ously stimulate the tendon to heal. It is extremelyimportant to avoid ankle dorsiflexion activity or a heelcord stretch to protect the tendon from overstretching.

Partial weight bearing is started at 1 week with agradual progression to full weight bearing at 2 to3 weeks postoperatively. The first week of rehabilitationallows partial weight bearing in the walking boot withaxillary crutches and the amount of weight bearing isincreased as tolerated by pain and swelling. After thefirst week, the patient may begin using one crutch underthe opposite arm and then progress to full weight bear-ing when the athlete is able to walk normally.

Rehabilitation of Achilles tendon repair

A bike program is initiated in the first week using thewalking boot. The program consists of 10 minutes threetimes the first week and increases by 10 minutes perweek and to 4 days over the first month. We progressthis slowly to give the incision/wound time to healwithout increasing the moisture or swelling to the ankle.Once clinical wound healing has occurred, a patient canbe more aggressive with cardiovascular activity.

The second phase of rehabilitation begins approxi-mately 6 weeks after repair. At this time, an increase inweight-bearing exercise is allowed, and proprioceptionretraining with an emphasis on normal gait is initiated.Athletes at this time are instructed in a program to weanout of the boot into an athletic shoe with one 9

�16-inch

felt heel lift. Our goal is to wean the patient out ofthe boot over 2 weeks with normal pain-free gait(Table 28-4).

Exercises in the second phase consist of balance,standing calf raises, and elliptical/StairMaster progres-sion. Single-leg balance (Fig. 28-6) is first initiatedbarefoot on a hard surface with a goal of approximately60 seconds. Once that is achieved, balance is pro-gressed to a soft surface with other possible variations(i.e., ball toss). Patients will begin bilateral calf raises(Fig. 28-7) with a progression to single calf raises.Thera-Band exercise is performed in all directions toincorporate the entire ankle. However, dorsiflexionpast neutral is not allowed. Once completely out ofthe boot, 1 day of elliptical/StairMaster may be substi-tuted for the bike each week, so that over a 4-weekperiod the athlete transitions into full cardiovascularworkouts with a StairMaster/elliptical 4 to 5 days aweek. It is important to avoid passive dorsiflexion or

Table 28-4 Wean out of boot/postoperative shoe

Week 1: Wear your boot/postoperative shoe from 8 AM to

4 PM.

Wear the brace/shoe insert/steel shank after 4 PM.

Week 2: Wear your boot/postoperative shoe everyMonday, Wednesday, and Friday from 8 AM to 4 PM.After 4 PM, wear the brace/shoe insert or steel shank.

Wear your brace/shoe insert/steel shank all day Tuesday,Thursday, Saturday, and Sunday.

Week 3 and beyond: Wear your brace/shoe insert/steelshank every day of the week.

You should wear the boot if you are doing excessive

walking.

Achilles tendon stretching to protect the Achilles repairfrom stretching out. We have found that normal dorsi-flexion will return naturally without being aggressivewith dorsiflexion motion.

The final phase of rehabilitation starts approximatelyat the 3-month mark. Patients will continue to workon balance, ankle strength, and unilateral calf raises. Atthis time, full lower-extremity strengthening will beinitiated. Exercise will include stepdowns (Fig. 28-8, A)leg press (Fig. 28-8, B), knee extensions (Fig. 28-8, C),

Figure 28-6 Single-leg balance for proprioception.

Figure 28-7 Bilateral calf raise.

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Figure 28-8 (A) Stepdown for balance and strengthening.(B) Leg press using single leg. (C) Knee extension machine forquadriceps strengthening.

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............CHAPTER 28 � Principles of rehabilitation for the foot and ankle

and hamstring curls that can be advanced per patienttolerance. Weighted calf raises typically are initiatedaround 4 months.

Once an athlete is capable of using a StairMaster/elliptical machine for 30 minutes 5 days a week, he orshe may begin light jogging (usually at 3-4 monthsafter the repair). It also is important to begin sport-specific skills, such as shooting a basketball or hittinga tennis ball. Agility drills should be advanced graduallyper patient tolerance. Before return to sport, thepatient should successfully complete a functional pro-gression to ensure a safe return to competition. Returnto sports normally occurs at 5 to 8 months aftersurgery.

REHABILITATION AFTER LATERAL ANKLERECONSTRUCTION

The treatment and rehabilitation after acute anklesprains begins by positioning the ankle in a position thatreapproximates the torn ligament ends (neutral dorsi-flexion with weight bearing). The application of aremovable walking boot with an Aircast Cryocuff andimmediate weight bearing place the ankle mortise in itsmost stable position. Early range of motion, Achillesstretching, and peroneal strengthening is started imme-diately after injury. However, plantarflexion and inver-sion will result in separation and possible elongation of

Figure 28-9 (A) Resisted eversion using Thera tubing. (B) Resisted dorsiflexion using Thera tubing.

Figure 28-10 Achilles/calf stretch with towel.

Rehabilitation after lateral ankle reconstruction

the injured ligaments and therefore should be avoided.Once the ligaments have healed, then advancing therehabilitation is safe.

A similar approach can be used following a lateralankle reconstruction. For the reliable athlete with closemedical monitoring and sturdy tissue at the time ofreconstruction, there may be a place for intermittentimmobilization with early weight bearing and specificrange-of-motion exercise. Overall the objective is toobtain as ‘‘normal’’ an ankle as possible. This is anexample of our rehabilitation program.

Immediately after surgical reconstruction, the athleteis placed in an Aircast walking boot with a Cryocuffplaced inside the boot. Dressing changes and rehabilita-tion will begin 3 days postoperatively. The clinical goalsin the first phase of rehabilitation (4 weeks) consist ofrestoring full eversion and dorsiflexion, normalizing gait,increasing calf flexibility, and beginning light strengthen-ing. Physical therapy will consist of a home exerciseprogram, progression to full weight bearing, a lightbike program, Cryocuff, and desensitization massage.Competitive athletes with training room availability useon-site athletic trainers’ and physical therapists’ expertise.

The home exercise program consists of range ofmotion exercises and strengthening with Thera-tubing(Fig. 28-9, A and B) in the directions of eversion anddorsiflexion. Over the first 4 weeks, the patient isinstructed to avoid inversion and plantarflexion to pro-tect the integrity of the newly reconstructed ligaments.It also is important to begin Achilles tendon stretchingusing a towel (Fig. 28-10) with progression to a stairstretch. Exercises are performed at a high frequencywith a low load to stimulate the ligament to heal with-out creating swelling or reinjury. The Cryocuff will beused to help control swelling and inflammation and ismost helpful in the first week after surgery.

Partial weight bearing is started immediately aftersurgery with progression to full weight bearing in the

next 7 to 10 days in the walking boot. A bike programis initiated the first week postreconstruction with thewalking boot. The program will advance each week asthe incision/wound has had time to heal. Once clinicalwound healing has occurred, a patient can be moreaggressive with cardiovascular activity.

Desensitization massage is an important part of theearly rehabilitation program. Because of the highlyinnervated foot and ankle, the patient often will experi-ence some surface hypersensitivity after surgery. It isimportant to stimulate this nerve tissue with light mas-sage and tactile stimulation to reeducate and desensitizethe tissue to normal pressure and touch. This can beaccomplished with a light massage 3 to 5 minutes severaltimes a day.

The second phase of rehabilitation begins 1-monthpostoperatively. At this time patients are instructed towean out of the boot into a stirrup ankle brace(Fig. 28-11). Our goal is to wean the athlete out ofthe boot within 2 weeks and obtain a normal, pain-freegait (see Table 28-4).

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Figure 28-11 Patient using active ankle brace.

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Exercises in the second phase include range ofmotion/strengthening in all four directions, aggressiveheel-cord stretching (Fig. 28-12), calf raises, and pro-prioception exercise. Dorsiflexion and inversionstrengthening still are performed with Thera-tubing.Aggressive peroneal strength (Fig. 28-13) is accom-plished by having the athlete lie in a lateral positionwith ankle weights hung over the end of the foot and

Figure 28-12 Aggressive Achilles/calf stretch on step.

the toes pointed to isolate the peroneal tendons. Theathlete then everts the foot and ankle to strengthenthe tendons. We have found this to be a very effectivemeans of maximizing peroneal strength. Bilateral calfraises are initiated with progression to single calf raise.We like to have the patient work on eccentric phase ofcalf raise by going up on both and lowering slowly onthe injured side. Once the patient has no difficulty withthe eccentric phase of the exercise, he or she may addthe concentric phase of the exercise. Proprioceptionexercise (Fig. 28-14) should begin with one-foot bal-ance, with progression of balance with opposite hip/leg exercise. Cardiovascular exercise should beadvanced from the bike to StairMaster/ellipticalmachine (4-6 weeks after surgery) and eventually tolight jogging (6-10 weeks after surgery).

Figure 28-13 Aggressive peroneal strengthening with cuffweight.

Figure 28-14 Single-leg balance for proprioception usingopposite hip strengthening with Thera tubing.

Figure 28-15 Cybex isokinetic strengthening for inversion/eversion.

Rehabilitation of ankle fractures

There are several other ways to strengthen the anklepostoperatively, including Cybex/Biodex (Fig. 28-15)and the multiaxial machine. As long as the emphasis ison pain-free strengthening involving dorsiflexion, ever-sion and plantarflexion these exercise follow the sameclinical guideline set in this phase. The final phase ofrehabilitation (2 months) should focus on advancestrengthening of the entire lower extremity and sport-specific agility drills. The final goal of this phase is returnto sport after finishing a sport-specific functionalprogression.

Exercises in the final phase will continue to focus onankle strengthening, flexibility, and proprioception acti-vity. Advanced lower-extremity exercise can include legpress, knee extension, and hamstring curls as tolerated.Sport-specific skills, such as kicking a soccer ball, ballhandling drills, or catching a football should be imple-mented at this time. The intensity of these activitiescan be increased as tolerated. Before return to sport,the patient should successfully complete a sport-specificfunctional progression program to ensure safe returnto competition. Return to sports participation is 10 to12 weeks.

REHABILITATION OF ANKLE FRACTURES

Figure 28-16 Stationary bike using Aircast walking boot.

The treatment and rehabilitation after acute displacedankle fractures in the athlete can be particularly excitingwith the ability to anatomically and rigidly fix bony frac-tures and anatomically repair torn ligaments. Displacedfractures should be treated with anatomic open reduc-tion and internal fixation. We have progressed fromshort-leg casting and nonweight bearing to the use ofintermittent immobilization, early range of motion,

and protected weight bearing. The goal of rigid, stable,internal fixation is to allow a more functional recovery.This is an example of our rehabilitation program.

Immediately after surgery, the patient is placed inan Aircast walking boot with a Cryocuff for cold andcompression. Early immobilization consists of rest, ele-vation, and continuous daytime Cryocuff use. Patientsare instructed to stay down as much as possible to helpdecrease swelling. Nonweight bearing with axillarycrutches is initiated initially after surgery to reduce therisk of immediate postoperative swelling. The patientshould also wiggle the toes and perform leg lifts every3 to 4 hours while awake.

Dressing changes and rehabilitation will begin 1 weekpostoperatively. If stable bone alignment is demon-strated on radiographs, range-of-motion exercises arestarted. Range of motion should be initiated in a man-ner that does not put tension on an injured or repairedligament. For an isolated lateral fibula or stablebimalleolar fracture, range of motion can include alldirections. If the patient has a medial ligament injury,dorsiflexion with eversion should be avoided until theligament is healed. Range of motion and light tubingexercises are guided by pain and should be performedseveral times a day in high repetitions (15-20); towelstretch for the Achilles and manual plantarflexion stretchcan be started (20 seconds, 5 repetitions) if there is nocontraindicating ligament injury. The home exerciseprogram will consist of toe curls (see Fig. 28-5, A),range of motion in appropriate directions, resistive bandin appropriate directions, desensitization massage, and alight bike program wearing the boot (Fig. 28-16).

Partial weight bearing is started at 1 week, with pro-gression to full weight bearing in the walking boot in2 weeks (if the fracture is stable and does not involve aweight-bearing surface). Patients are instructed to use

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Figure 28-17 Patient using Aircast stirrup brace.

Figure 28-18 Single-leg balance for proprioception on Theradisk.

Figure 28-19 Unilateral calf raise.

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axillary crutches and increase weight bearing as toler-ated. After the first week of partial weight bearing, thepatient may begin using one crutch under the oppositearm and eventually progress to full weight bearing overthe next week. Once a patient can walk normally withthe walking book (typically within 3 weeks), we beginweaning the patient out of the boot and into a stirrupbrace (Fig. 28-17) and regular shoe over the next2 weeks. Patients with highly comminuted fracturesand those with weight-bearing joint injury or significantcartilage injury do not follow this same protocol.

The second phase of rehabilitation begins approxi-mately 1 month after surgery. At this time, an increasein weight-bearing exercise, proprioception, and gaittraining with an athletic shoe is initiated. Exercises con-sist of progression of Thera-Band activities to includedirections originally avoided because of ligament com-plications. Standing calf stretching, balancing exercises,double to single leg calf raises, and elliptical/StairMasterprogression are included during this phase. Thera-Bandexercise should continue to be high repetitions (15-20)in all directions. Single leg balance is first initiated in aregular shoe and then progressed to bare foot on a hardsurface. Our goal is approximately 60 seconds. Balancecan be advanced by use of a soft surface and balanceboard (Fig. 28-18). The patient should work aggres-sively with calf stretching using a stair or an inclineboard for 3 minutes three times a day. Bilateral standingcalf raises should be initiated with progression to single-leg calf raises (Fig. 28-19). Once completely out ofthe boot, elliptical or StairMaster progression should

be substituted for the bike with use of the brace andathletic shoes (see Fig. 28-4, B). Patients typically aregiven a home exercise program to be performed twoto three times a day. Athletes who have athletic trainingresources should work under the guidance of the athletictraining staff.

The final phase of rehabilitation (2 months) shouldfocus on advance strengthening of the entire lowerextremity and sport-specific agility drills. The final goalof this phase is the return to sport after finishing asport-specific functional progression program.

References

Exercises in the final phase will continue to focus onankle strengthening; flexibility; and proprioception acti-vity; and advanced lower-extremity exercise, includingleg press, knee extension, and hamstring curls as toler-ated and indicated. Sport-specific skills, such as kickinga soccer ball, ball handling drills, or catching a footballshould be implemented at this time, increasing theintensity of these activities as tolerated. Return to sportscan be as early as 4 weeks after rigid fixation of anisolated fibula fracture to 8 to 10 weeks after a bimalleo-lar and equivalent repair. Fractures that require fixationof the syndesmosis can take 4 to 6 months beforereturn.

CONCLUSION

The athlete will desire and in most instances demand100% strength, 100% motion, and 100% function. Thisis a challenge for the surgeon, therapist, and trainer.The understanding of muscle function and its need formotion with controlled resistance to return to func-tional ability has shown us that our rehabilitation musttake this into account. We have discussed our principlesof rehabilitation and some specific approaches for ath-letes and their injuries. We also have tried to relate thebasics of science understanding that underlie our princi-ples and specific approaches. The area of rehabilitationof the foot and ankle will continue to progress as weunderstand more clearly the appropriate use of weightbearing, early motion, and function resistance. Also, asour understanding of proper anatomic repair and recon-struction advance, our rehabilitation must and willadvance also. This is an exciting time in the treatmentof athletes with foot and ankle injuries. We hope thatthis chapter both encourages you and challenges youin your treatment of your athletes.

44 P E AR L

Rehabilitation PearlsEvery injury has a position that must be protected and anopposite motion that must be rehabilitated.

Every week of immobilization will add 2 weeks to therehabilitation.

Once an athlete can use the StairMaster or ellipticalmachine 30 minutes 4 to 5 days a week without problems,he or she may start running.

A good surgery that is poorly rehabilitated will equal apoor result.

The athlete’s goal is always 100% full function.

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FURTHER READING

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Pugia ML, et al: Comparison of acute swelling and function in subjects

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Rozzi SL, et al: Balance training for persons with functionally unstableankles, J Orthop Sport Phys Ther 29:478, 1999.

Smith LS, et al: The effects of soft and semi-rigid orthoses upon

rearfoot movement in running, J Am Podiatr Med Assoc 76:227,1986.