Physical therapy department 3rd year 2013-2014

Traumatology rehabilitation

Ankle Trauma

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Table of Contents
I. 1. 2. II. 1. 2. a. b. 3. a. b. c. d. e. f. III. IV. V. VI. VII. 1. 2. 3. 4. a. b. c. VIII. Over View of ankle trauma: .................................................................................................................. 3 Ankle Anatomy .................................................................................................................................. 3 Types of ankle trauma: ...................................................................................................................... 4 Ankle Sprains:........................................................................................................................................ 6 Classification: .................................................................................................................................... 6 History and Assessment: ................................................................................................................... 7 History ........................................................................................................................................... 7 Assessment .................................................................................................................................... 8 Treatment: .......................................................................................................................................12 Goals: ............................................................................................................................................12 Acute Phase (first 2-4 days) ..........................................................................................................13 Sub-Acute stage (days 3 to 14) ......................................................................................................14 Early Rehab (week 3) ....................................................................................................................14 Late Rehab (week 4) .....................................................................................................................16 Functional Rehab (week 5+): ........................................................................................................25 High Ankle Sprain Injury ...................................................................................................................27 Lisfranc Joint Injury...........................................................................................................................27 Plantar Fasciitis ....................................................................................................................................28 Os Trigonum Syndrome ....................................................................................................................31 Ankle fracture:..................................................................................................................................32 Signs & Symptoms ............................................................................................................................32 Classification: ...................................................................................................................................32 Assessment:......................................................................................................................................36 Treatment: .......................................................................................................................................38 Phase I: 0 6 weeks ......................................................................................................................38 Phase II: 6 9 weeks .....................................................................................................................39 Phase III: 9 weeks to release .........................................................................................................40 Conclusion: .......................................................................................................................................41

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I.

Over View of ankle trauma:

Ankle injuries can happen to anyone at any age. However, men between 15 and 24 years old have higher rates of ankle sprain, compared to women older than age 30 who have higher rates than men. Half of all ankle sprains occur during an athletic activity

1. Ankle Anatomy

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2. Types of ankle trauma:

Ankle injuries are defined by the kind of tissue. The ankle is where three bones meet -- the tibia and fibula of your lower leg with the talus of your foot. These bones are held together at the ankle joint by ligaments. Tendons attach muscles to the bones to do the work of making the ankle and foot move, and help keep the joints stable. A fracture describes a break in one or more of the bones. A sprain is the term that describes damage to ligaments when they are stretched beyond their normal range of motion. A ligament sprain can range from many microscopic tears in the fibers that comprise the ligament to a complete tear or rupture. A strain refers to damage to muscles and tendons as a result of being pulled or stretched too far. Muscle and tendon strains are more common in the legs and lower back. In the ankle, there are two tendons that are often strained. These are the peroneal tendons.

fracture

bone

sprain

ligament

strain

muscle tendon

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II. Ankle Sprains:

1. Classification:
Grade I - mild stretching of the ligament without joint instability. Grade II - partial rupture (tear) of the ligament but without causing joint instability (or with mild instability of the joint). Grade III - complete rupture (tear) of the ligament with instability of the joint. Sometimes this is simply called a severe ankle sprain.

What Causes a Sprained Ankle?

Ankle sprains can occur simply by rolling your ankle on some unstable ground.

What are the Symptoms of a Sprained Ankle?

At the time of the injury you may hear a popping or cracking sound and will notice swelling, bruising and ankle pain. Lateral or medial ligament sprains are usually acutely tender over the injured ligament. Depending on the severity of your ankle sprain, you may have trouble walking or standing on your foot.

Which Ankle Ligaments are Commonly Sprained?

1. anterior talo-fibular ligament (ATFL) 2. calcaneofibular ligament (CFL) 3. posterior talo-fibular ligament (PTFL)

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2. History and Assessment:

a. History
i. ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii. xiii. xiv. xv. xvi. xvii. xviii. xix. Last name: First name: Age: Gender : Marital state : Number of children : Job: Telephone number, address : Risk factors : Diagnosis: Surgical intervention: Allergy : Referent doctor: Admission date : Date of surgery : Date of accident Past medical history: past surgical history Radiologic report

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b. Assessment
Pain:
Location Type Degree Stimulators Relieving agents

Observation:
Standing alignment Shoe wear Swelling or effusion Skin color, texture, temperature, moisture, and scars

ROM:
test active dorsiflexion Plantar flexion Supination pronation Inversion eversion right passive active Left passive Active # passive

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Accessory ROM tests:

Talocrural joint:
Anterior gliding Posterior gliding

1st metatarsophalangeal test:

Superior glide Inferior glide

Muscle Assessment:
muscle Gastrocnemius Peroneals Anterior tibialis Posterior tibialis Extensor hllucis longus Extensor degetorom longus Flexor hllucis longus Flexor degetorom longus right Left notes

Special tests:
a) Anterior drawer test b) Thompson test c) Homan`s test d) Tinel`s test e) Leg lengths

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a- Anterior drawer test:

Purpose: To test for ligamentous laxity or instability in the ankle. This test primarily assesses the strength of the Anterior Talofibular Ligament. Test Position: Supine or Sitting. Performing the Test: The examiner stabilizes the anterior distal leg with one hand & grasps the patient's calcaneus and rear foot with their second hand. The examiner then places the patient's foot into 10-15 degrees of plantar flexion and translates the rear foot anteriorly. A positive test results if the talus translates forward. Positive test results are often graded on a "0 to 3 scale", with 0 indicating no laxity & 3 indicating gross laxity.

b-

Thompson test

Purpose: to examine the integrity of the Achilles' tendon Position: With the patient lying prone on the table with his or her foot extended beyond the end of the table the examiner squeezes the calf. Results: A normal non-injured response to this maneuver is slight plantar flexion of the ankle. Lack of ankle movement can indicate a rupture of the Achilles' tendon.

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c- Homan`s test: Purpose: to determine the presence of a deep vein thrombophlebitis Position: the patients knee is in an extended position and the examiner forcefully dorsiflexes the patients ankle. However, some individuals seem to have a different opinion on how this test should be applied,they believe to assess properly Homans sign, the patients knee must be in a flexed position instead of an extended position.

Results: A positive sign is indicated when pain in the popliteal region and the calf is elicited as the foot is dorsiflexed. A positive sign doesnt automatically conclude a DVT. In fact, a positive Homans sign can be elicited due to factors such as superficial phlebitits, Achilles tendonitis, and injury to the gastroc and plantar muscles. Further conditions such as herniated intervertebral discs and shortened heel cords can also result in a false positive. A negative Homans sign, on the other hand, doesnt automatically conclude an absence of DVT. d- Tinel`s test: Purpose: to detect irritated nerves Position: It is performed by lightly tapping (percussing) over the nerve Result: a positive test is when a sensation of tingling or "pins and needles" in the distribution of the nerve

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3. Treatment:
a. Goals:

Short term :
o o o Injury Protection Pain Relief Control Inflammation

Long term:

o Regain Full Range of Motion

NWB - Non-Weight Bear PWB - Partial Weight Bear FWB - Full Weight Bear

o Strengthen your Ankle and Calf Muscles o Restore Joint Proprioception & Balance o Restore Normal Function
Walking Running Jumping & Landing Speed & Agility Sport-Specific Skills

o Resume Sport

Graduated Training Return to Competition

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b. Acute Phase (first 2-4 days)

the initial treatment is RICE Rest: In the early phase you`ll most likely be unable to walk on your sprained ankle. Our first aim is to provide you with some active rest from pain-provoking postures and movements. In most cases, you will need to be non-weight bear. You may need to be placed in an ankle walking boot, a supportive ankle brace or utilize crutches. Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.

Compression: A compression bandage, tubigrip compression stocking or kinesiology supportive taping will help to both support the injured soft tissue and reduce excessive swelling. Elevation: Elevating your injured ankle above your heart will assist gravity to reduce excessive swelling around your ankle. Other treatments may include: TENS Joint mobilization Light massage Acupuncture

The patient also mustn`t do any HARM: Heat Alcohol Running Massage

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c. Sub-Acute stage (days 3 to 14)

The sub-acute stage begins by bearing weight on the ankle to pain tolerance. This is graduated from partial weight-bearing with a Plastic Cast Walker and crutches to full weight-bearing without crutches. A normal walking pattern should be encouraged and there should be no limping. Ice therapy can be continued so long as there is pain. When possible the ankle should be elevated. Electrotherapy treatment should be continued and augmented with gentle massage to encourage the dispersal of swelling towards the back of the knee. Ankle pumping exercises can be started and progressed to being done in water. Exercises in water are effective because they involve only partial weight-bearing and because the hydrostatic pressure provided by the water has the effect of encouraging the swelling to disperse.

d. Early Rehab (week 3)

After two weeks most of the rehabilitation is achieved through active exercise, although the physiotherapist may help regain range of movement by carrying out passive mobilising techniques. This involves the physio gently moving the bones of the ankle to help restore range of movement and relieve stiffness.
Exercise 1 The first exercise is to help restore the ankle's range of movement. Sitting on the floor, the ankle is pumped forward and back. 20 repetitions, 5 times daily. The patient progresses to doing the same exercise while sitting on a high bench or chair, letting the feet hang down.

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Exercise 2: This exercise uses a Resistance Band to strengthen the dorsi

flexor muscles that pull the toes back towards the knee. Sitting on the floor, a resistance band is tied around the foot, with the other end attached to a fixed object in front of the foot; slowly the foot is pulled back towards the knee.

Exercise 3: This exercise is designed to strengthen

the plantar flexor muscles that push the foot down, sitting on the floor, with the legs out straight, a Resistance Band is tied around the foot, and the other end held in the hand. Slowly, the foot is pushed forward and then relaxed.

Exercise 4: This exercise is a progression of the

previous plantar flexor strengthening exercises. The patient stands with their hands resting against a wall so that it is taking some of their body weight. With both feet, the patient pushes up on the toes so the heels rise up off the floor. This position is held for 2 seconds and then the heels are slowly lowered.20 repetitions, 5 times daily. Once this becomes easier, the same exercise is done but without any hands against the wall. Once this has been mastered, the patient progresses to doing the exercise with the toes positioned on a block, so that the heels have to come down lower before pushing up. The final progression to this exercise is to do it on the affected ankle alone.

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Exercise 5: This exercise is designed to strengthen the evertor muscles that enable the foot to turn outwards.
Standing up, the base of the foot is turned outwards, held for 2 seconds and then relaxed. 20 repetitions, 5 times daily.

Proprioception exercises: can be done while partial weight-bearing

first, then progressed to full weight-bearing, such as using a Wobble Board. The Wobble Board together with Ankle Brace are commonly used in the rehabilitation of ankle instability. Wobble boards are designed to assist the re-education of the proprioceptive system by improving sensory nerve function. Research has shown that wobble board training improves single leg stance ability and balance, while other studies have suggested that patients with ankle instability who underwent wobble board training experienced significantly fewer recurrent sprains during a follow-up period than those who did not follow the training program.

e. Late Rehab (week 4)

Progressive strengthening of the muscles around the ankle should be continued, as should the proprioception exercises. To prepare for a return to functional activities the intensity of exercise should be increased. The use of an Ankle Brace or Ankle Taping can provide essential support at this stage. Taping and Bracing the ankle can help to reduce recurrent ankle injury. A research study has shown the injury incidence in students with taped ankles was 4.9 ankle sprains per 1000 participant games, compared with 2.6 ankle sprains per 1000 participant games in students wearing ankle braces. This compared with 32.8 ankle sprains per 1000 participant games in subjects that had no taping or bracing. Basic plyometric exercises should be commenced. Plyometric drills decrease the reaction time of the nervous system in response to external stimuli. This allows the muscles to contract faster to prevent falling or twisting an ankle. The technique was first used during the 1960's and 70's by eastern European athletes, who organized hopping and jumping techniques into specific plyometric drills. As the athlete plants their foot before jumping, the muscle that will produce the jump is stretched. As the muscle contracts, the pre-stretched energy is released, producing kinetic energy (movement) which enhances muscle power. By doing plyometric drills the time taken for the stretch to be converted into kinetic energy is decreased. Before initiating plyometric activities there must be a sound strength base, otherwise the risk of injury is increased. As a general rule the athlete should be comfortable in squatting 60% of their body weight, at a

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rate of 5 repetitions in 5 seconds, before these exercises are commenced. The athlete should be able to stand on one leg, with eyes both open and shut, for 30 seconds and should be able to long jump the distance of their own height. Ideally, plyometric training should be done under the supervision of a trainer or chartered physiotherapist.

Quick feet drills:

Quick feet drills using a rope ladder are a form of plyometric activity. Lateral (sideways)

The progression is to multi-directional patterns using the rope ladder, moving from left to right

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Then back, from ri

Continuing the sideways pattern. Note the muscle work in the quads to control the movement. This lateral exercise puts a controlled load through the collateral ligaments of the knees and ankles.

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Forward jump drills: Double footed forward jumps over a 30cm barrier.

The progression of this exercise is to do it using one leg...

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Cross jump drills: Cross jumps help to train power. The starting position is with one leg in front and the other behind.

with the front leg moved back and the back leg moved forward to land.

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Box jump drills : Double footed box jumps encourage explosive power. Note the use of the arms to help generate force.

The knees are tucked in as the box is cleared...

and the landing is controlled by eccentric muscle work.

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Consecutive box jumps can be undertaken using a sequence of boxes.

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then off.

The same exercise can be done on one leg.

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Multi-directional jump drills; The progression from straight line jumps is multi-directional jumps and, as an advanced exercise, multi-

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then off, moving round the trampette.

f. Functional Rehab (week 5+):

The progression to functional activities can begin once the patient can jog without pain and is comfortable doing plyometric drills. The idea of this stage is to progress from gentle exercise to the high intensity at which games are played. All exercises are preceded by a warm up. As each exercise is a progression they should be completed at least one day apart, under the supervision of a chartered physiotherapist.

Exercise 1

Variable pace running with the gradual introduction of turns. This involves running round a 20m diameter figure-of-eight course. The figure-of-eight course puts very gentle stress on the ankle and prepares the player for later turning drills. The pace is limited to walk, jog or half pace running and is determined by the physiotherapist who shouts out the desired pace. The physiotherapist also shouts the commands stop and start. This re-introduces the player to the variable demands of a game of football. The session should last about 25 minutes.

Exercise 2

Variable pace running with gradual turns and various starting positions. The player starts at one end of the course and makes a 30m run up to a 20m diameter semicircle, around which they gently turn before completing another straight 30m run back to the finish. The pace of the run is dictated by the physiotherapist and is either a jog or half pace. The starting position should be different for each run (standing, lying on back, lying on front, sprint start position, squatting, right side lying, left side lying, jumping, hopping, facing backwards).

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The patient should aim to complete 20 runs.

Exercise 3

A progression of exercise 1 - variable pace running with slightly tighter turns. Run round a 10m diameter figure-of-eight course. The figure-of-eight course puts stress on the ankle and prepares the player for later turning drills. The paces used are walking, jogging, half pace running, and three-quarter pace running, as determined by the physiotherapist who shouts out the desired pace. The physiotherapist also shouts the commands stop and start. The session should last about 25 minutes.

Exercise 4

A progression of exercise 2 - variable pace running with gradual turns and various starting positions. The player starts at one end of the course and makes a 30m run up to a 20m diameter semicircle, around which they gently turn before completing another straight 30m run back to the finish. The pace of the run is either three-quarter or full pace, as dictated by the physiotherapist. The starting position should be different for each run (standing, lying on back, lying on front, sprint start position, squatting, right side lying, left side lying, jumping, hopping, facing backwards). The player should aim to complete 20 runs.

Exercise 5

Two 5m diameter circles are placed 30m apart. Travelling at full pace the player makes a run, with a football at the feet, goes around the far circle and then back to the finish. This should be repeated 20 times.

Exercise 6

As exercise 5, but single cones are used instead of 5m diameter circles.

Exercise 7

Six cones are placed 5m apart in a straight line. The player completes a shuttle run, at full pace, turning alternately to the left and right. This should be repeated 10 times.

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III.

High Ankle Sprain Injury

A sprained ankle is the most common ankle injury in sport. A High Ankle Sprain refers to soft tissue damage to the ligaments of the ankle Syndesmosis, which is the joint between the Tibia (shin bone) and Fibula (splint bone). This ankle ligament damage is characterised by ankle pain and a swollen ankle. Severe High Ankle Sprains may need surgery although physiotherapy treatment is effective for moderate injuries. In the early stages it is important the follow the PRICE protocol for treatment of a sprained ankle protection, rest, ice, compression and elevation.

Common High Ankle Sprain signs & symptoms:

A history of ankle trauma. Pain just above the ankle. Swollen ankle.

Assessment and treatment are similar to any ankle sprains.

IV. Lisfranc Joint Injury

A Lisfranc injury is a cause of foot pain that may be difficult to diagnose. This infrequent foot injury occurs when there is high energy trauma to the top of the foot. This trauma may occur in road traffic accidents or during sports such as soccer when a player kicks the sole of an opponents boot. Because of the history of direct trauma to the top of the foot it is difficult to differentiate from a Tarsal bone fracture or bone bruising. There may or may not be a swollen foot. Treatment is dependent on the severity of the injury. If there is a sprain of the Tarso Metatarsal ligament, with no widening of the Metatarsals evident onx-ray , then conservative management should suffice. Where there is more severe Tarso-Metatarsal ligament damage, the prognosis is not so good. This ligament damage causes instability at the Lisfranc joint complex, which is evident on x-ray as widening between the Tarso-Metatarsal joints. Many orthopaedic consultants advocate surgical fixation to reduce the likelihood of developing arthritis of the foot.

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Common Lisfranc Joint Injury signs & symptoms: A history of trauma to the top of the foot. Foot pain on separating the Metatarsals. Foot pain when walking, running and turning.

Assessment and treatment are similar to any ankle sprains.

V. Plantar Fasciitis
Explanation :
Plantar Fasciitis is a common foot condition that causes heel pain and pain in the sole of the foot. Plantar Fasciitis is inflammation of the Plantar Fascia. During walking and running, as you 'toe-off', the Plantar Fascia becomes taut and helps the foot act as a lever to pus h off with force. It is one of the primary stabilizing structures of the arch on the inner side of the foot.. Inflammation of the Plantar Fascia usually occurs at the point where it attaches to the heel bone. Plantar Fasciitis is reasonably common in older individuals, where the movement in the joints of the foot has become restricted and strain on the Plantar Fascia is increased. It may also occur in individuals who do a lot of standing, walking or sporting activities, usually as a result of overuse. It tends to be more common in females and in people who are overweight.

Plantar Fasciitis Signs & Symptoms:

Plantar Fasciitis produces foot pain over the inside of the heel and this usually radiates down the inside of the sole of the foot. This foot pain usually occurs with activity and is also typically present in the morning when taking the first steps of the day. Plantar Fasciitis can be diagnosed by a doctor or physiotherapist, if pain is present on touching the affected area, and/or on stretching the Plantar Fascia (by pulling the toes up). The diagnosis of Plantar Fasciitis can be confirmed on an Ultrasound scan, when the fascia has a thickened appearance

Plantar Fasciitis Treatment:

Plantar Fasciitis is inflammatory in nature and the key to successful treatment is to determine what is causing the inflammation and address this problem. In most sporting individuals the cause is overuse and the most important advice is to allow adequate rest, to take the strain off the Plantar Fascia and allow the affected tissues time to heal.

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In some cases of Plantar Fasciitis there may be a problem with the biomechanics of the foot, contributing to the problem. The usual findings are a foot that 'over pronates', where the inner arch of the foot rolls over too much during walking an d running. This can lead to tightness in the Achilles tendon and recent research has suggested that a tight Achilles tendon can increase strain on the Plantar Fascia. Conservative treatment, such as physiotherapy, aims to reduce local inflammation and address any biomechanical problems. While the Plantar Fascia is still painful it may be treated with Ice Packs and antiinflammatory drugs prescribed by a doctor. Once the pain has subsided, stretching the Plantar Fascia is effective in encouraging the tissue to regain its normal alignment. This helps the healing process and can relieve the symptoms of Plantar Fasciitis. Prolonged stretching of the Plantar Fascia can be achieved using a Night Splint which is worn during sleep. Research indicates that night splinting can significantly reduce Plantar Fasciitis symptoms in over 80% of cases - particularly pain on the first few steps after waking up each morning. Stiff joints around the foot and ankle can be treated using mobilisation, where the physiotherapist gently moves the joints manually to remove the stiffness and restore the normal range of movement.

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Taping has been shown to be an effective treatment for Plantar Fasciitis. The tape supports the Plantar Fascia and removes some of the strain that can aggravate the condition. Plantar Fasciitis settles with conservative treatment in 95% of cases.

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VI. Os Trigonum Syndrome

Os Trigonum Syndrome Explained:
Os Trigonum Syndrome refers to pain in the back of the ankle that is caused by impingement of soft tissues on a bony prominence at the back of the Talus bone. This prominence is present in 1 in 20 of the population but, in professional footballers, it is reported to be present in 1 in 5. This is thought to be due to repeated hyper plantar flexion (pushing the ankle forwards) during footballing activities. Due to the impingement, the soft tissues at the back of the ankle become inflamed and painful.

Os Trigonum Syndrome Signs & Symptoms:

Pain in the back of the ankle is the first indicator of Os Trigonum Syndrome. On examination by a doctor or chartered physiotherapist the area in front of the Achilles tendon can be painful to touch, and the bony prominence may even be palpable. The diagnosis of Os Trigonum Syndrome can usually be confirmed by xray views of the ankle from the side.

Os Trigonum Syndrome Treatment:

Rest from the activities that aggravate the condition is required for 4 to 6 weeks, to allow the soft tissues to settle down and heal. Physiotherapy treatment consists largely of ice therapy. Ice Packs applied for twenty minutes every couple of hours may help with the pain. The Aircast Ankle Cryo/Cuff is the most effective method of providing ice therapy as it can provide continuous ice cold water and compression for 6 hours and significantly reduce ankle pain and swelling. A doctor may prescribes anti-inflammatory medication, or administer acorticosteroid injection to reduce the soft tissue inflammation. If there are persistent symptoms of ankle pain and swelling from Os Trigonum Syndrome, an orthopaedic consultant may operate to remove the offending bony prominence. Rehabilitation with a physiotherapist following this procedure usually takes between 4 and 8 weeks before full sports activities can be resumed.

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Os Trigonum Syndrome Prevention

In individuals who have a bony prominence at the back of the Talus bone, then success in preventing Os Trigonum Syndrome may be limited. However, using an Ankle Brace that prevents excessive ankle plantar flexion (pushing the foot down, like pressing the pedals of a car) may help to prevent soft tissue impingement and the development of Os Trigonum Syndrome.

VII. Ankle fracture:

1. Signs & Symptoms
There is typically a history of twisting or trauma accompanied by a great deal of ankle pain and an inability to use the affected ankle. Any suspected broken ankle needs to be urgently transferred to hospital for assessment by a specialist trauma doctor. 'Open' fractures, where the bone fragments push through the skin, are patently obvious but all serious ankle injuries require a full assessment and an x-ray evaluation.

2. Classification:
According to Weber and Lauge-Hansen Classification Basically there are three main types of ankle fractures. Weber classified them as:

type A - infrasyndesmotic type B - transsyndesmotic type C suprasyndesmotic

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type A

infrasyndesmotic

Occurs below the syndesmosis, which is intact. According to Lauge-Hansen, it is the result of an adduction force on the supinated foot.

Stage 1 - Tension on the lateral collateral ligaments results in rupture of the ligaments

or avulsion of the lateral malleolus below the syndesmosis.

Stage 2 - Oblique fracture of the medial malleolus.

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type B

transsyndesmotic

This is a transsyndesmotic fracture with usually partial - and less commonly, total - rupture of the syndesmosis. According to Lauge-Hansen, it is the result of an exorotation force on the supinated foot. Stage 1 - Rupture of the anterior syndesmosis Stage 2 - Oblique fracture of the fibula (this is the true Weber B fracture) Stage 3 - Rupture of the posterior syndesmosis

or - fracture of the malleolus tertius

Stage 4 - Avulsion of the medial malleolus

or - rupture of the medial collateral bands

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type C

suprasyndesmotic

This is a fracture above the level of the syndesmosis. Usually there is a total rupture of the syndesmosis with instability of the ankle. According to Lauge-Hansen, it is the result of an exorotation force on the pronated foot. Stage 1 - Avulsion of the medial malleolus

or - ligamentous rupture
Stage 2 - Rupture of the anterior syndesmosis Stage 3 - Fibula fracture above the level of the syndesmosis (this is the true Weber C fracture) Stage 4 - Avulsion of the malleolus tertius

or - rupture of the posterior syndesmosis

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3. Assessment:

Observation:
o o o o o Gait Posture heel walking(L4-S1) toe walking((s1-S2) Heel raise

Pain assessment:
o o o o o Location Scale Type Aggravators Relievers

ROM: Right active passive active Left passive active # Passive

Dorsi flexion Plantar flexion inversion eversion

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Skin Trophic assessment:

Observation: Skin color Scars Edema Atrophy

Measurements: Measure edema between lateral and medial malleolus

Muscle assessment:

muscle Gastrocnemius Peroneals Anterior tibialis Posterior tibialis Extensor hllucis longus Extensor degetorom longus Flexor hllucis longus Flexor degetorom longus

right

Left

notes

Neurologic assessment:

right Light touch Pin brick tactile Thermal pain

left

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Reflexes :
right patellar Ankle jerk Babinski left

Palpation:
Dorsal pedal Posterior tibial artery pulses Soft tissue Bony landmarks

4. Treatment:
a. Phase I: 0
Goals for Phase I: 1. Pain and swelling control
2. Normal ROM of non-involved joints 3. Safe/functional gait with or without assistive gait device

6 weeks

A. Orthotics: Patient is immobilized in insert, cast or walking boot as directed by the physician. May remove walking boot for bathing and AROM B. Gait training: Weight-bearing to be determined by the physician. If WBAT, patient should be progressed from WBAT with crutches to FWB without crutches C. ROM: Work to restore normal ROM of non-involved joints. If in walking boot, may remove boot for gentle AROM of involved ankle/foot. Ankle Fx ORIF: AROM started during 1st post op visit (DF,PF, INV, EV), Achilles towel stretching as tolerated. Ankle Fx w/out ORIF: Pain free AROM (do not exceed 10 degrees of Dorsiflexion), PROM Dorsiflexion to neutral during 1st 2 wks, progress to 5 degrees of pain free PROM by 4 weeks, then 10 degrees by 6 wks. Avoid inversion/eversion ROM until 4 weeks post accident. Begin

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active Inv/Ev ROM at start of 5th wk. PROM Inv/Ev and joint mobs after 6th wk. Metatarsal /Foot Fx: Ankle AROM as tolerated, If passive Dorsiflexion is necessary, perform w/ foot supported on floor unweighted during gastroc/soleus stretch. Avoid towel roll stretching to prevent undistributed forces/torque throughout the metatarsals. D. Soft tissue management: wound monitoring (avoid getting stitches wet), swelling control, scar massage, desensitization E. Modalities: Utilize for pain, inflammation, swelling control, and muscle re-education as necessary

b. Phase II: 6
Goals for Phase II: 1. Functional ROM
2. Functional strength 3. Normal gait

9 weeks

(transfers, housecleaning etc.) 5. Begin work/sports activities

A. Orthotics: Gradually discontinues use of walking boot when directed by physician, use air-cast, rocket-soc etc as ordered by physician B. Gait-training: If patient has been NWB, begin progressive weight-bearing, patient should be progressed from WBAT with crutches to FWB without crutches C. ROM: Work to restore full P/AROM of ankle and foot, including sub-taler joint mobility/mobs ics, thera-band, heel lifts etc), weightbearing activities, conditioning activities (bike, treadmill). If ankle ORIF, t-band strengthening may begin at beginning of 3rd week if ROM is progressing. E. Balance/Proprioception: Single leg stance activities, balance beam, BAPs board etc.

jump, zig-zags etc.)

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G. Modalities: Utilize for pain, inflammation, swelling control, and muscle re-education as necessary

c. Phase III: 9 weeks to release

Goals for Phase III: 1. Good strength
2. Return to sports activities

A. Orthotics: Continue strengthening/conditioning/functional activities as needed

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VIII. Conclusion:

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