Background

The ankle joint is made up of three bones: the tibia, fibula, and talus. The ankle plays an important role in balance and strength when walking, running, and ascending/descending stairs. Changes or restrictions in the ankle can greatly affect daily mobility. The foot is composed of twenty six (26) bones and many small joints. Having so many small joints is the reason the posture of the foot is variable from one person to the next. For example, some people have high arches (pes cavus) and some have low arches (pes planus). The unique structure and flexibility of the foot dictates the amount of shock absorption and the amount of effort required for pushing off during walking, running, or jumping.

Diagnoses

Ankle or Foot Fracture 

A broken or fractured ankle is a common injury for people of all ages. A fracture can come from a traumatic injury like a fall or severe twisting motion. A fracture can also be caused by an overuse injury, commonly called a stress fracture. A fracture often requires immobilization for a period of time in either a cast or a brace depending on the extent of the fracture. Sometimes an ankle or foot fracture requires surgery whereby the surgeon uses screws and plates to secure the fracture site (ORIF or open reduction, internal fixation), followed by immobility and therapy. Once cleared by the physician for physical therapy, the goals will be to increase range of motion and strength. Achieving a normal walking pattern is key to recovery and to achieving optimal range of motion. Another important aspect of rehab is proprioception, which is defined as the body’s automatic ability to sense movement, make adjustments, and maintain upright postures. One’s proprioceptive ability is impaired with a sprained ankle or after a fracture. However, completing a balance program and getting stronger will improve proprioception. 

Ankle Sprain

Although ankle sprains are one of the most common injuries that we experience, a physical therapist is rarely consulted for this injury. Ankle sprain is an over stretch of a ligament when the ankle is forced into an extreme range of motion. The most common ligament involved is the anterior talofibular ligament (ATFL) which is located on the outside of the ankle (1). Immediately after an ankle sprain, it is important to reduce the swelling with elevation, compression, and ice. Physical therapists may use modalities such as ultrasound or electrical stimulation to reduce swelling and expedite the recovery process. Once the acute phase of the ankle sprain is complete, the physical therapist will progress for a safe return to activities. Risk factors for an ankle sprain include previous ankle sprains, weakness in hip muscles, and poor balance. It is important to complete a systematic therapy program to reduce risk of reinjuring the ligament. Physical therapy focuses on proprioception, which is vital in balance during high level activities like running, jumping, and all sports activities. Balance, ankle strength, and proprioception are all components of a physical therapy program after an ankle sprain. 

Tendonitis/Tendonopathy

Plantar Fasciitis

Pain at the bottom of the foot, very near the heel, is often indicative of plantar fasciitis. Other symptoms are pain with the first 10-15 steps in the morning, pain walking barefoot, and/or pain with walking long distances. The plantar fascia is a structure that runs from the heel to the base of the toes at the bottom of the foot. The job of the plantar fascia is to provide support to the arch of the foot. It is not clear the exact etiology of plantar fasciitis, however risk factors include having a high arch or a low arch, decreased ability to flex the foot up towards the shin (dorsiflexion range of motion), and tightness in the calf muscles. Despite its name, it is often not an inflammatory process, but rather a biomechanical issue resulting in stress to the plantar fascia (3). The approach of physical therapy is to calm down the plantar fascia as well as correct the mechanical issues. This is often done with stretching the calf muscles, deep tissue massage into the plantar fascia, as well as correcting weakness into the hip muscles. Strengthening the small intrinsic muscles of the foot with balance training may also be used in therapy.

Shin Splints or Medial Tibial Stress Syndrome (MTSS)

The term shin splints is a common term used for pain below the knee either in the shin or the inside of calf muscle. There are multiple theories why MTSS occurs including irritation of the periosteum (the outer most layer of the bone), small tears of muscles pulling from the bone, or inflammation of the muscles at the attachment to the bone. Although the exact reason for shin splints has not been identified, a common theory is poor training habits. Additionally, having low arches or a planus foot requires the muscles in the shin to work harder and places people at an increased risk for shin splints (3). Over training or increasing exercise too quickly can overload the muscles and bones resulting in pain. Once this pain starts it is important to immediately reduce or even stop the painful activity. Pushing through the pain and continuing with the training can result in a stress fracture (breakdown of the bone from repeated stress over time). If pain continues despite rest, a walking boot may be prescribed by a physician. Physical therapy will focus on education on proper training as well as strengthening of the bigger, stronger muscles in the hips and knees. When pain has begun to subside, the physical therapist will systematically introduce harder exercise to re-train the muscles and bones for a safe return to activities. 

Turf Toe/1st MTP Arthritis

Turf toe is the sprain of the 1st metatarsophalangeal joint, or the knuckle of the big toe. This can result from repetitive strain while playing sports or a traumatic injury when landing on the foot and/or toe. Pain in this area can also be due to arthritic changes. When walking, the big toe is the last part of the foot to touch the ground and absorbs significant amount of stress each and every step. When the joint is sprained or arthritis limits the range of motion at the joint, it becomes painful with walking and more so with running. If the joint is very inflamed and irritated, a cortisone injection may be suggested by a physician to regain range of motion and reduce pain. The physical therapist will likely use joint mobilization to the 1st toe or ankle to increase range of motion as well as reduce pain. There are also several taping techniques that help reduce pain and assist in a quicker return to walking and exercise.