Foot and Ankle Rehabilitation

 

Trauma

 

Ankle sprain

Ankle sprains can be either mild, moderate or severe.

  • Mild ankle sprain occurs when there is injury to anterior talofibular ligament (ATFL) which remains intact and takes up to a week to recover
  • Moderate ankle sprain involves rupture of ATFL with involvement of calcaneofibular ligament, this usually takes up to 2 weeks to recover
  • Severe ankle sprain involves rupture of all the main ligaments that make up the lateral ligament complex; this injury takes 6-12 weeks to recover

For the first 48-72hrs:

R.I.C.E (Rest, Ice, Compression and Elevation)

Patients who cannot bear weight, mobilise in a removable walking boot for the first 1-2 weeks and can wean off the boot as comfort allows.

Regular ice every 2-3 hours for 15-20 minutes helps reduce pain and swelling. Compression can be achieved with ACE bandage or tubigrip. Elevation: at least two pillows under the leg in the acute phase is important to reduce the swelling.

After 72 hours:

As the pain and swelling improves, patients can start:

  • range of motion (ROM) – figure of eight exercises
  • strengthening, with a focus on eversion strengthening
  • proprioception – balancing exercises

Long term:

Patients can return to normal activities, including sports, when comfort allows; this can range from days (mild sprain) to 2-3 months with more severe ankle sprain. To prevent recurrent sprains, strengthening and proprioceptive exercises should be continued. Ankle braces can be used when patients first return to ‘high risk’ activities.

Surgery is not indicated in patients with ankle sprains, unless there is significant osteochondral defect. In patients who develop chronic ankle instability with recurrent sprains, there is a role for lateral ligament reconstruction.

1. https://www.aofas.org/footcaremd/conditions/ailments-of-the-ankle/Documents/Ankle-Sprain.pdf

2. FootEducation

 

Ankle fractures

After initial treatment, rehabilitation is the same for both operative and non-operative ankle fractures, although commencement of weight-bearing and mobilisation after ankle fixation varies from immediately post op to 6 weeks; there is no strong evidence in the current literature to suggest which is best. A multicentre trial comparing early weight-bearing and ROM to immobilisation and non weight-bearing after operative fixation supports the former, with no increase in complication rate.

Rehabilitation after immobilisation involves early range of motion and focus on strength and proprioceptive exercises. This usually requires formal physiotherapy sessions and includes the following:

  • Ankle plantarflexion and dorsiflexion – active and resisted
  • Figure-of-eight / alphabet exercises
  • Calf stretching with knee flexion and extension
  • Resisted inversion/ eversion
  • Heel raises

J Orthop Trauma. 2016 Jul;30(7):345-52. doi: 10.1097/BOT.0000000000000572. Early Weightbearing and Range of Motion Versus Non-Weightbearing and Immobilization After Open Reduction and Internal Fixation of Unstable Ankle Fractures: A Randomized Controlled Trial.

Dehghan N1, McKee MD, Jenkinson RJ, Schemitsch EH, Stas V, Nauth A, Hall JA, Stephen DJ, Kreder HJ. FootEducation. https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=zp4491

 

Lisfranc injury

Recovery and rehab are dependent on the severity of the injury and the fracture fixation stability. Usually this comprises of:

First 6 weeks post op:

  • Non-weight bearing in a below knee cast

6-12 weeks post op:

  • Protected weight-bearing in a walking boot; a firm rocker-bottom sole allows the force to be displaced from the midfoot to more proximally
  • Can start gentle ROM exercises

>12-14 weeks:

  • Change boot to rigid sole shoe, commence full weight-bearing as tolerated
  • More aggressive physio – with active and resisted ROM exercises, focusing on isometric plantar and dorsiflexion exercises, leg strength
  • Orthotics – customised insoles to raise the medial foot column plantar load can help restore a normal gait

Most patients recover by 6 months but can take up to 12-18 months for more severe Lisfranc injuries.

Dynamic plantar pressure distribution, strength capacity and postural control after Lisfranc fracture-dislocation Alexander T. Mehlhorna,b, *, Markus Waltherb , Tayfun Yilmaza , Lennart Gunsta , Anja Hirschmüllera , Norbert P. Südkampa , Hagen Schmala,c aDepartment of Orthopedic and Trauma Surgery, Gait & Posture 52 (2017) 332–337  http://dx.doi.org/10.1016/j.gaitpost.2016.11.043

 

Tendoachilles rupture

Management is identical, regardless of whether or not the tendon is surgically repaired.

Although, historically, below knee, non-weight bearing cast immobilisation for the first 6-8 weeks following rupture / repair was common practice, the trend has changed to early rehabilitation to allow patients to return tovnormal activity sooner.  This is supported by a recent meta-analysis which also reports that early rehabilitation is not associated with an increase in re-rupture rate. The advantage of early functional rehab also reduces oedema, stiffness and calf muscle atrophy. 

Rehab includes:

  • Cast immobilisation in equinus for first 2 weeks
  • At 2 weeks:
    • change to ankle boot with heel wedge
    • start weight bearing
    • commence physiotherapy to focus on ankle range of motion (ROM) and low resistance strengthening exercises
  • Gradual reduction in heel wedge height every 2 weeks, until removal of heel wedge and boot by 8 weeks

Early functional rehabilitation versus traditional immobilization for surgical Achilles tendon repair after acute rupture: a systematic review of overlapping metaanalyses. Zhao et al, 2017

 

Chronic conditions - HINDFOOT 

 

Ankle / triple fusion

First 2 weeks post op:

  • Immobilisation, non-weight-bearing in a below knee cast until wound heals

2-6 (or 8) weeks:

  • Continue non-weight-bearing in a cast to promote fusion

At 6-8 weeks:

  • Once radiographs suggest signs of fusion, start protected weight-bearing for a further 6 weeks in a walking boot
  • Commence physiotherapy:
    • strengthening exercises
    • ROM exercises
    • gait education

After 12 weeks:

  • Gradual increase in physical activity when comfort allows; patients can wean off boot and transition into a rocker-soled shoe

3-6 months:

  • Transition to normal footwear
  • Physiotherapy focusing on:
    • active, active assisted, and passive ROM exercises
    • strengthening exercises
    • calf stretching
    • proprioceptive exercises
    • gait re-education

https://www.physio-pedia.com/Ankle_arthrodesis

https://www.footeducation.com/page/ankle-fusion-arthrodesis

https://www.rnoh.nhs.uk/sites/default/files/downloads/physiotherapy_rehabilitation_guidelines_subtalar_and_hindfoot_fusion.pdf

 

Ankle replacement

First 2 weeks post op:

  • Immobilisation, non-weight-bearing in a below knee cast until wound heals

2-6 weeks:

  • Change to below knee, full weight-bearing cast or aircast boot as comfort allows
  • Commence physio at 2-4 weeks (once out of cast):
    • strengthening exercises – not against resistance for first 3 months post-op (esp if concomitant tendon transfers performed)
    • ROM exercises
    • gait education

6-12 weeks:

  • Gradual increase in physical activity as comfort allows; patients can wean off aircast boot and transition into a normal shoe
  • Physiotherapy focusing on:
    • active, active assisted, and passive ROM exercises
    • strengthening exercises
    • calf stretching
    • proprioceptive exercises
    • gait re-education
    • hydrotherapy if needed

3-6 months:

  • Patients should be independently mobile without aids and with normal footwear
  • Continue physiotherapy:
    • ankle strengthening exercises
    • gait re-education
    • proprioception

After 6 months:

  • Can slowly return to low impact sports/ activities

https://www.rnoh.nhs.uk/sites/default/files/downloads/physio_guidelines_total_ankle_replacement.pdf

Zaidi et al (2013). The outcome of total ankle replacement: a systematic review and meta-analysis. The Bone & Joint Journal, 95-B (11), 1500-1507.

Valderrabano et al (2006) “Sports and recreation activity of ankle arthritis patients before and after Total Ankle Replacement” The American Journal of Sports Medicine 34, (6): 993-999

Coetzee J & Castro M (2004) “Accurate measurement of ankle range of motion after Total Ankle Arthroplasty” Clinical Orthopaedics and Related Research 424, 27-31

Ali et al (2007) “Intermediate results of Buechel Pappas unconstrained uncemented Total Ankle Replacement for osteoarthritis” The Journal of Foot and Ankle Surgery 46, (1): 16- 20

 

Calcaneal osteotomy and tendon transfers

Usually performed for deformity correction and combined with tendon transfers or tendoachilles lengthening. Therefore, rehabilitation following surgery will depend on which concomitant procedures were performed.

First 6 weeks post op:

  • Non-weight-bearing or toe-touch weight-bearing in a below knee cast
  • If concomitant tendon transfer, then:
    • Cobb procedure – non-weight-bearing cast (in plantarflexion and inversion for 6 weeks, with cast change fortnightly to gradually transition to neutral foot position)
    • FDL transfer – non-weight-bearing cast for 4-6 weeks

6-12 weeks post op:

  • If radiographs satisfactory, patients can start protected weight-bearing in a walking boot; a firm, rocker-bottom sole allows the force to be transferred from the midfoot to more proximally.
  • Physiotherapy - to start:
    • gentle ROM exercises – active, active assisted and passive ROM
    • isolate tendon transfer activation without overuse of other muscle groups
    • proprioceptive and strengthening exercises
    • if tight calf, ensure calf stretching exercises are started
    • gait education

3-6 months post op:

  • Continue physio – focusing on:
    • active, active assisted, and passive ROM
    • progressive isolation transfer activation without lengthening
    • gait re-education
    • consider hydrotherapy if required

6-12months:

  • Progress with physio:
    • tendon transfer activation – aim for grade 4/5 inversion strength
    • heel raise exercises
    • return to low impact activities

https://www.footeducation.com/page/calcaneal-osteotomy

Myerson & Corrigan (1996) “Treatment of posterior tibial tendon dysfunction with Flexor Digitorum Longus tendon transfer and calcaneal osteotomy”

https://www.rnoh.nhs.uk/sites/default/files/downloads/physiotherapy_rehabilitation_gudelines_tibialis_posterior_reconstruction.pdf

 

Ankle lateral ligament reconstruction

First 2 weeks post op:

  • Non-weight-bearing in a boot or below knee cast; foot in neutral position.

4-6 weeks:

  • Start fully weight bearing in boot
  • Commence physio at 4-6 weeks (once out of cast):
    • avoid active eversion for first 6 weeks

6-12 weeks:

  • Gradual increase in physical activity and, when comfort allows, patients can wean off aircast boot and transition into normal footwear
  • Physiotherapy – focusing on:
    • active, active assisted, and passive ROM exercises
    • isolate evertors without overusing other muscle groups
    • strengthening exercises – aim for eversion strength grade 4/5
    • resisted inversion / eversion exercises
    • consider starting proprioceptive exercises
    • no impact sport e.g. running

3-6 months:

  • Patients should be independently mobile without aids and with normal footwear.
  • Continue physiotherapy:
    • eversion strengthening exercises
    • continue proprioceptive exercises
    • gait education

After 6 months:

  • Physiotherapy:
    • aim for grade 5 strength of evertors
    • heel raise exercises
    • return to normal and sporting activities as able

https://www.rnoh.nhs.uk/sites/default/files/downloads/physiotherapy_rehabilitation_guidelines_lateral_ligament_reconstruction_of_the_ankle.pdf

 

Chronic conditions - FOREFOOT

 

Hallux valgus

First 6 weeks:

  • Darco shoe (heel wedge shoe) – heel weight-bearing
  • Elevate and ice to reduce swelling and aid analgesia
  • Physiotherapy:
    • from 2-4 weeks – passive ROM of MTPJ and IPJ

6-12 weeks:

  • Can transition into normal footwear
  • Start fully weight bearing as able, through hallux and focus on toe-off during gait
  • Physiotherapy:
    • gait education
    • commence active ROM and continue passive ROM exercises of MTPJ
    • strengthening and proprioceptive exercises

3-6 months:

  • Continue physiotherapy – improving on ROM, gait and proprioceptive exercises (using aids such as wobble boards)
  • Address tight Achilles tendon with stretching exercises
  • Return to normal activities, including sports, as able

https://www.rnoh.nhs.uk/sites/default/files/downloads/rehabilitation_guidelines_for_patients_undergoing_hallux_valgus_deformity-_scarf_osteotomy.pdf

 

 

1st MTPJ replaement

First 6 weeks:

  • Darco shoe (heel wedge shoe) – heel weight-bearing
  • Elevate and ice to reduce swelling and aid analgesia
  • Physiotherapy:
    • from 0-2 weeks: start gentle MTPJ ROM exercises (active and passive) – within the bandage
    • from 2-6 weeks: focused physio to increase ROM (active, passive and resisted) at MTPJ
    • further physio to work on swelling reduction, gait education and addressing any muscle tightness

6-12 weeks:

  • Can transition into normal footwear
  • Start fully weight bearing as able, through hallux and focus on toe-off during gait
  • Physiotherapy:
    • gait re-education
    • strengthening and proprioceptive exercises

3-6 months:

  • Continue physiotherapy – improving on gait training and proprioceptive exercises (using aids such as wobble boards)
  • Address tight Achilles tendon if present with stretching exercises
  • Return to normal activities including sports, as able, by 6 months. Can take up to 12-18 months for full recovery.

 

1st MTPJ fusion

First 6 weeks:

  • Darco shoe (heel wedge shoe) – heel weight-bearing to allow 1st MTPJ to fuse
  • Elevate and ice to reduce swelling and aid analgesia
  • Physiotherapy:
    • from 2-4 weeks – focusing on swelling reduction, gait education and addressing any muscle tightness

6-12 weeks:

  • Can transition into normal footwear
  • Start fully weight bearing as able, through hallux and focus on toe-off during gait
  • Physiotherapy:
    • gait re-education
    • commence active ROM and continue passive ROM exercises of IPJ
    • strengthening and proprioceptive exercises

3-6 months:

  • Continue physiotherapy – improving on gait training and proprioceptive exercises (using aids such as wobble boards)
  • Address tight Achilles tendon if present with stretching exercises
  • Return to normal activities including sports, as able by 6 months. Can take up to 12-18 months for full recovery.

 

PIPJ/ IPJ fusion

First 6 weeks:

  • Darco shoe (heel wedge shoe) – heel weight-bearing to allow IPJ / PIPJ to fuse
  • Elevate and ice to reduce swelling and aid analgesia
  • At 4-6 weeks – removal of K wire(s)
  • Physiotherapy at 4-6 weeks:
    • start digit exercises (active and passive ROM)
    • focus on swelling reduction, gait education and addressing any muscle tightness

6-12 weeks:

  • Can transition into normal footwear
  • Start fully weight bearing as able, through forefoot and focus on toe-off during gait
  • Physiotherapy:
    • gait re-education
    • strengthening and proprioceptive exercises

3-6 months:

  • Continue physiotherapy – improving on gait training and proprioceptive exercises (using aids such as wobble boards)
  • Address tight Achilles tendon if present with stretching exercises
  • Return to normal activities including sports, as able by 6 months. Can take up to 12-18 months for full recovery.