From Injury to Recovery: Rehabilitation Protocols for Foot and Ankle Pain

The clinician must first do a comprehensive assessment of the extent of the injury. This includes static and dynamic measures of assessing joint range of motion. Loss of dorsiflexion and/or great toe extension has been associated with decreased function and prolonged disability of those with chronic foot and ankle pain. It would serve that if such a loss were noted in the initial assessment, this should be a marker of a functional goal to achieve by the end of the rehabilitation process. Static alignment of the injured joint should be compared to the non-injured side, as well as a pre/post weight bearing assessment. This may serve to determine if there are bony changes that occurred during the injury. Ever sprain an ankle and feel that it just isn’t the same in certain shoes? Which brings up an interesting aside: The shoe is the primary interface between the body and the ground for most activities and any consideration of foot rehabilitation must address footwear and orthotic devices that may influence the injury in a positive or negative manner. Static assessments should also include palpatory findings of bony and soft tissue structures. X-ray and/or MRI may be warranted if there is suspicion of a fracture or significant soft tissue injury. These medical imaging measures are becoming more easily accessed and common throughout both general and specialized health care providers to facilitate a more accurate diagnosis which will lead to a more successful rehabilitation.

Rehabilitation for foot and ankle injuries can be a tricky business. People use their feet in most daily activities, so getting these structures to heal may be a difficult proposition. Additionally, the relationship of the foot and ankle to the rest of the body is significantly influenced by the extensive use of ligament, tendon, and muscle connections to the lower leg. This makes the rehabilitation process one that is integrated with a fine balance of strengthening these said structures and yet not overly stressing the injured area. Since the advent of a more active society, wherein nearly everyone and not just athletes are more concerned with healthy living, the prevalence of individuals seeking greater measures to heal injuries has led to a great increase in physical therapy/rehabilitation protocols. At the same time, the spectrum of the types of health care providers offering such services is quite diverse. This article serves to outline the important considerations that must be recognized when devising a rehabilitation protocol for specific foot and/or ankle injuries.

Understanding Foot and Ankle Pain

As for the ankle, the most common cause of pain and/or injury is due to an inversion or “rolling” type sprain. This leads to damage of the lateral ligament complex and, if not rehabilitated properly, can result in chronic instability and lead to other problems in the foot and up the kinetic chain. An inversion sprain can happen to anyone at any time, not just athletes. It is more likely to happen in an unfamiliar environment where the ground is uneven, in a hurry down steps, or simply not paying attention due to some sort of distraction.

The last cause is a structural deformity. This can be either a congenital deformity such as clubfoot or something that has developed over time, such as a bunion or hammer toe.

A third cause of foot pain is an alteration of gait mechanics. This occurs in many people with low back pain. Due to the pain, they change the way they walk to decrease stress and forces through the low back. However, in doing so, they increase the force through the pelvis and the hip, and also increase the force and loading through the foot. This can cause an overuse type injury to the foot.

Research has shown that there are four common causes of foot problems. Improper footwear is one example, such as women who have worn high-heeled shoes for a great deal of their life, which can lead to a greater incidence of foot pain and bunions compared to those who have not worn high heels. A traumatic incident, such as a slip and fall or an automobile accident, can cause damage to the foot and result in the need for rehabilitation.

Understanding the cause of foot and ankle pain is important in determining the appropriate intervention and treatment protocol. As mentioned previously, the body is an interconnected chain, and the foot and ankle are the first link in that chain. If there is dysfunction at the foot or ankle, it can cause problems in the knees, hips, low back, or even the upper extremities.

Causes of Foot Pain

An injury can be the result of a single event or from accumulated repetitive trauma. Injuries are usually the result of a fracture or a dislocation. Most people will be aware if they have had a traumatic injury. A sudden onset of pain, swelling and bruising will occur at the time of injury. X-ray will usually confirm a fracture or a dislocation. In the case of a fracture or a dislocation, it is important that the bony integrity is properly rehabilitated with controlled stress to the injury, to ensure that the correct stresses are absorbed through the lower limb and to avoid compensatory injuries. Stress fractures and bone bruising can sometimes be missed in diagnosis as X-ray may not show the injury. If pain has occurred through excessive loading on a particular bone, in the absence of a major injury, it is likely that there is a stress fracture or bone bruising. This is common in people starting new exercise regimes or increasing the amount of time spent on their feet, especially when involving high impact activity such as running. Stress fractures will generally heal in 6 weeks, and a graduated return to functional activities can be commenced after this period. Systemic disease can affect the foot and ankle and cause pain. Inflammatory arthropathies such as rheumatoid arthritis or gout often result in pain in the foot and ankle joints. A person with widespread or poorly controlled diabetes may also have pain in the feet from peripheral neuropathy or from musculoskeletal pain.

Causes of Ankle Pain

When the sprained ankle is first experienced, it is most likely to feel pain on the lateral side of the ankle. This is a direct result of damage to the ligaments on the lateral side. High ankle sprains, which involve damage to the syndesmotic ligaments that join the tibia and fibula, can cause chronic pain in the ankle and lower leg. The ligaments affected in a sprained ankle can also cause the surrounding muscles to atrophy due to the inhibition of movement of the ankle. This will also lead to chronic problems if not addressed properly.

The main cause of ankle pain is due to a sprain. This being an injury to the ligaments when they are stretched beyond their capacity. It is a direct result from the ligament being torn. Ligaments have poor blood supply and in the best case scenario will heal with scar tissue to form a repair. It is this that makes the ankle more susceptible to re-injury and can potentially cause the affected individual to experience chronic pain. This can affect the daily activities and quality of life for that person. Failure to address and rehabilitate a sprained ankle properly may result in chronic instability of the ankle and over time can cause development of a condition called “ankle impingement”.

Rehabilitation Protocols for Foot Pain

Another common problem with altered force generation is the development of trigger points in muscles. A trigger point is a small area of uncontrolled muscle tightness that when pressed, produces tenderness and pain. Although this is an oversimplification, it is useful to think of a trigger point as a confused and overworked muscle that needs to be reprogrammed. Visualization techniques and a massage therapy called myofascial release are helpful in the treatment of trigger points.

Physical Therapy Exercises for Foot Pain Therapeutic exercise is an important aspect of rehabilitation of foot pain. Due to the altered gait mechanics associated with foot pain, muscles that are not meant to be prime movers end up taking over as force generators and become overworked. This often results in muscle imbalances, which lead to further altered mechanics. It is important to reestablish normal muscle length-tension relationships, which will in turn lead to normal force couples about the foot and ankle. In English, this means getting the right muscles to do the right jobs! This can often be accomplished through self-administered massage and stretching techniques, and your physical therapist can guide you in the right direction.

Foot pain, and even ankle pain, is often serious and may require the use of rehabilitation techniques. If you have foot or ankle pain, ask your healthcare provider if rehabilitation may help. An evaluation of foot alignment is often crucial to a successful rehabilitation. If your foot is misaligned, the bones and soft tissue structures are not functioning correctly. This may be the actual source of pain, or it may be an associated factor that you can change to relieve your symptoms. A physical therapist is well trained to evaluate foot alignment and to provide exercises and techniques to help normalize foot and ankle function.

Physical Therapy Exercises for Foot Pain

A recent systematic review has highlighted the lack of high-quality research in this area and reinforces the fact that there is no one-size-fits-all in terms of exercise therapy for the painful foot. The review provides some general recommendations, including the importance of achieving optimal levels of muscle strength and the fact that exercises should be pain-free and functional in nature. From the literature available at this point in time and from clinical experience, we can broadly categorize exercises into the following areas for the purpose of treating foot pain: intrinsic muscle strengthening, mobilization exercises for the foot and ankle, stretching, lower limb and core strengthening (probably indicated where there are biomechanical issues), and finally, maintenance of cardiovascular fitness.

A carefully structured exercise program is an integral component of any physiotherapy treatment plan for foot pain. Whilst the benefits of exercise for any other area of the body are widely accepted, the significance of specific exercise prescription for foot problems has been largely overlooked in the past. This may reflect the fact that there is currently limited evidence pertaining to the most effective types and dosages of exercises for particular foot problems. Nevertheless, there is consensus that foot pain often leads to disuse and weakness in the intrinsic foot muscles, which can have negative implications for the dynamic support of the foot. This may perpetuate the original condition and leave the foot vulnerable to other musculoskeletal problems. We know also that proximal factors, such as hip weakness or altered mechanics at the knee and leg can have significant effects on foot function. Therefore, it is logical to rehabilitate painful feet in the broader context of strengthening other areas that may affect foot anatomy and function.

Pain Management Techniques for Foot Pain

Although not a form of medication, gait re-education using walking aids in patients with lower limb injuries is greatly underused as a method of pain relief. By altering the type and level of weight bearing through the use of aids, abnormal stress can be removed from an affected area and transferred to a less affected or pain-free area, thereby limiting the extent of exacerbation of the injury. This method, in conjunction with the use of taping and/or orthoses for biomechanical correction, was discussed recently by Bell and seems a more valid use of physiotherapy time in patients with acute injuries who may be seeking surgical intervention as a quick fix solution to their pain.

Another mode of pain relief is through ice therapy (cryotherapy). This has been shown to have a vasoconstrictive effect on the blood vessels and therefore limits the extent of secondary tissue damage caused by the injury. It also has an analgesic effect similar to that of medication. The PRICE principle (Protection, Rest, Ice, Compression, Elevation) is a simple self-care technique that can be taught to patients to effectively manage their pain and symptoms.

As already noted, the cornerstone of physical therapy practice is the rehabilitation of orthopaedic injuries. A crucial aspect of the therapy, though, relies on the patient’s management of symptoms in order to facilitate their participation in the prescribed exercises and activities. The appropriate medication would involve the taking of non-steroidal anti-inflammatory drugs or corticosteroid injection therapy for a short-term analgesic effect in painful acute conditions. It needs to be appreciated by both the patient and therapist that although it may provide some relief, medication does not promote healing and therefore is not the primary management of musculoskeletal injuries.

Supportive Devices for Foot Pain

Foot supports and orthoses can help reduce stress on the foot. When the foot of an individual with foot and ankle pain comes into contact with the ground, the body weight causes compression and shear forces on the joints of the foot and ankle. These forces can cause deformation of the joints and exacerbation of pain in some cases. Compression and shear forces can be reduced by altering joint alignment and distributing load away from high pressure areas. This can be achieved with a well-molded and designed orthosis. A simple and effective way to reduce pain and stress on the foot is by taping. Low Dye taping is an effective way to control excessive pronation, which can be a causative factor for many foot and ankle injuries. The use of a heel cup can also reduce the forces experienced by the foot. Bracing can also be an effective way to reduce movement of the foot and ankle that will cause increased pain or damage to a specific area. Many forms of foot and ankle pain are the result of ligament sprains or muscle/tendon strain. These injuries can take a number of weeks to heal because of the relative poor blood supply to the area. During the recovery period, it is important to prevent excessive stretching or loading of these tissues. This can be difficult to achieve as the foot is required for mobility during daily activities. A brace can effectively restrict movement of the injured area and prevent further damage, but it is important to find the middle ground between immobilization and allowing too much movement. A health professional such as a podiatrist, physiotherapist, or chiropractor can give advice on what support would be best and how it should be applied.

Rehabilitation Protocols for Ankle Pain

An ankle injury that is not dealt with proper care can cause a lifetime of chronic ankle sprains. The best way to treat an ankle sprain is to never have it in the first place. This indicates extra conditioning of the muscles, increases flexibility, and sport or game-specific training. It is important that the athlete fully rehabilitates the ankle before returning to activities which require full and pain-free ankle motion. The patient should begin with a simple walking program. This should be pain-free and without a limp. Ensure the patient wears shoes that provide good support. Brisk walking will help prevent blood clots and help to restore strength and flexibility. Range of motion exercises are typically prescribed next. This is done with a towel or band, and is held on the ball of the foot pulling the foot toward their body. They may do this with knees bent and straight. With knees bent, they are now isolating motion to the ankle and are ensuring they do not have inversion of the ankle, which would indicate re-injury. Writing the alphabet with the big toe in the air is another good exercise. This helps to restore motion and strength. These exercises should be done for 10 minutes.

Physical Therapy Exercises for Ankle Pain

When there is significant pain and swelling, it is normally not recommended to do strengthening exercises. These are better done once the pain and swelling have subsided. At this point, one good exercise is to do heel raises. This involves going up on your toes as high as possible, keeping your knees straight. Do this 3 sets of 10-15 repetitions. Another good exercise is resistance band inversion and eversion. This can start with the band tied to a stationary object and doing 3 sets of 15 each way, eventually progressing to tying the band to a table leg and doing the same.

Initially, restoring the range of motion to the ankle is the first priority. This can be done with mobility exercises such as the alphabet exercise. As the name suggests, this involves pretending that you are writing each letter of the alphabet with your big toe. This should be done 2-3 times per day. Another common exercise is to write the alphabet with your foot, trying to write as clearly and accurately as possible.

The aim of physical therapy for ankle pain is to restore function, lessen pain, decrease swelling, and prevent further injury. Before beginning any exercise program, it is always recommended to see a qualified health professional who can give you a correct diagnosis. Once you know the reason for the pain, a program can be specifically tailored to return the injured ankle to full function. Ankle sprains that keep recurring are often not rehabilitated completely and thus lead to chronic pain and instability.

Pain Management Techniques for Ankle Pain

If an injury results in chronic pain or instability, a corticosteroid injection may be considered. Corticosteroid injections are used to treat chronic synovitis or to reduce the pain from an ankle arthritis. While the short-term relief from a corticosteroid injection can be significant, it is not recommended as a long-term treatment for ankle arthritis and there is a risk of acceleration of the joint degeneration. The last option to consider in controlling pain from a chronic ankle injury is surgery. There are many surgical procedures that can be done depending on the injury. Whether it is a ligament repair, a fusion, or a total joint replacement, the ultimate goal is to reduce pain and increase the function of the ankle. The decision for surgery is based on the extent of pain and how it is affecting the quality of life of the individual.

Physical agents and modalities are often used to control pain and inflammation associated with ankle injuries. One of the most common modalities is ice. Ice is effective in the first 48 hours post-injury to reduce pain and swelling. It is recommended to apply ice two to three times daily for 15-20 minutes. Another modality commonly used is electrical stimulation. Research indicates that electrical stimulation is effective immediately post-injury in reducing pain and swelling. Ultrasound is another modality that is commonly used in the rehabilitation of ankle injuries. Ultrasound works by a thermal effect to increase blood flow. This can be useful in the later stages of the healing process to increase the rate of tissue repair. A newer modality that is starting to gain popularity is the use of low level laser therapy. It is thought that laser therapy has an analgesic and anti-inflammatory effect, however there is no compelling evidence as to the effectiveness of this modality to treat ankle injuries.

When the pain associated with an ankle injury is substantial or if the pain persists for more than a month, other measures can be taken to reduce pain. The first line of defense against ankle pain is to use non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs work to reduce pain and swelling associated with the injury. It is not recommended to use NSAIDs for more than a week without consulting a healthcare provider. If the injury is significant, NSAIDs may not effectively control the pain.

Supportive Devices for Ankle Pain

An Ankle Foot Orthosis (AFO) is a full coverage brace extending from just below the knee to the base of the toes. It is most commonly used in cases of severe foot drop which is an inability to dorsiflex the foot secondary to nerve deficits. The goal of the AFO is to hold the foot in an anatomically neutral position to improve walking and prevent tripping, while offering the foot/ankle complex both sagittal and frontal plane support. Static AFO’s may be constructed from a plaster mold of the patient’s leg and are custom made from various materials including: thermoplastics, carbon composites and metals. They do not allow for joint movement and thus restrict ankle motion. Dynamic AFO’s allow for joint movement with the use of leather and custom plastic molds to provide medial/lateral and heel cup stability for more mobile patients. The AFO historically has been covered under durable medical equipment and has relatively strong evidence for coverage under certain conditions through insurance plans. As rehabilitation concepts continue to evolve with evidence based practice, the AFO will remain a valuable tool in the stepwise progression from the bed ridden patient to the return of full functional activities.

Ankle braces follow taping in the continuum of offering external support to the injured ankle. They provide the necessary restriction of ankle motion, while being able to be worn for extended time periods, making them an ideal form of mechanical support. They offer an advantage over taping in their relative cost effectiveness because of the potential for re-use, and the reduced readiness for application that does not require the assistance of a trained professional. Recent systematic reviews on the use of bracing in preventing ankle sprains in individuals with a history of ankle sprains have found moderate evidence to support the use of bracing as an effective means of reducing the recurrence of ankle sprains. Although this recommendation targets individuals with a previous ankle sprain, it speaks to the ability of bracing to improve the mechanical stability of the ankle joint in preventing further injury during the functional recovery phase.

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