Ankle & Foot Physiotherapy Management SRS

COMMON CONDITIONS
• Ankle Sprain
• Fractures
• 1st Metatarsophalangeal Joint
Sprain / Turf Toe
• Stress Fracture of the Fifth
Metatarsal
• Lisfranc Injury
• Navicular Stress Fracture
• Achilles Tendinopathy
• Extensor Tendinopathy
• Tibialis Posterior Tendinopathy
• Plantar Fasciitis
• Fat Pad Contusion (Bruised Heel)
• CTEV
2Brotzman, S. Brent, and Robert C. Manske, 2011

LIGAMENTS AROUND ANKLE
4
Anterior talofibular ligament
Posterior talofibular ligament
Calcaneofibular ligament
Anterior tibiotalar ligament
Posterior tibiotalar ligament
Tibiocalcaneal ligament
Tibionavicular ligament
Beam WJ (2012)

CLASSIFICATION OF ANKLE SPRAINS
5https://www.kintec.net/wp-content/uploads/2016/01/grade-of-sprain-

CLINICAL SIGNS AND SYMPTOMS
Grade I Grade II Grade III
Point tenderness Point and diffuse
tenderness
Point and diffuse
tenderness
Limited dysfunction Moderate dysfunction Moderate to severe
dysfunction
No laxity Slight to moderate laxity Moderate to severe laxity
Able to bear full weight Antalgic gait and pain with
FWB, may need
device to ambulate
Limited to no ability for
FWB without supportive
device
Little to no edema Mild to moderate edema Severe edema

TREATMENT
Grade I sprain :
• Ice therapy, compression bandage, ankle strap, NSAIDs, crutch
walking, etc.
Grade II sprain :
• Long leg cast, range of motion exercises, strengthening exercises, etc.
are helpful.
Grade III sprain :
• Same lines as mentioned above and may require surgical repair.
7Ebnezar, J. 2010

THE STEPS IN REHABILITATION
1. Protect the area from further injury.
2. Decrease pain, swelling, and spasm.
3. Re-establish range of motion, flexibility, and tissue mobility.
4. Re-establish neuromuscular control, muscular strength, endurance,
and power.
5. Re-establish proprioception, coordination, and agility.
6. Re-establish functional skills.

ACUTE STAGE:
GOALS AND INTERVENTIONS
1. Protect the injured tissues from further injury.
2. Encourage tissue healing.
3. Limit the pain, swelling, and spasm associated with inflammation.
4. Maintain function of the noninjured tissues.
5. Maintain overall body conditioning.

1. PROTECT THE INJURED TISSUES FROM FURTHER INJURY.
• Current practices are in favour of a functional treatment plan.
• Protect the injured tissues but absolute rest is seldom a wise choice.
• Pain-free activities that do not stress the injured ligaments.
• Protection may be necessary, especially in grade II or III sprains.

2. ENCOURAGE TISSUE HEALING.
• Rest and protection of the injured tissues are important to allow the
body to progress through its normal healing processes.
• Toward the end of the acute phase, pulsed ultrasound can be used to
promote tissue healing
•
• Avoid undesirable thermal effects obtained with continuous ultrasound.

3. LIMIT THE PAIN, SWELLING, AND SPASM
• The combination of “RICE” is one of the more commonly used approaches
to treat the acute inflammatory response.
• Electrical stimulation can be beneficial.
• Grade I joint mobilization techniques to the talus can also be beneficial for
pain relief when a “positional fault” is present.
12
For example: Applying a posterior mobilizing
force to the distal fibula may help correct the
anterior positional fault common with lateral
ankle sprain.
Brotzman, S. Brent, and Robert C. Manske, 2011

4. MAINTAIN FUNCTION OF THE NON INJURED TISSUES.
• Ankle pumps.
• Plantarflexion and dorsiflexion ROM progressing from PROM to AAROM
to AROM as tolerated.
• Posterior calf stretches.
• Drawing ABCs with foot.
• Towel curls and/or marble pick-ups with toes.
• Care must be taken to minimize extreme plantarflexion and inversion
in lateral ligaments sprains and extreme eversion in sprains of deltoid
ligament complex

5. MAINTAIN OVERALL BODY CONDITIONING.
• Patients should be encouraged to pain-free physical activities.
• Exercising on a stationary bike OR upper body ergometer and NWB
running in a therapy pool can help maintain cardiovascular endurance
and function.
• They should continue their normal strength training exercises for the
trunk and upper extremities.
• OKC knee and hip strengthening exercises for the lower extremities.
• Consider the use of compression stockinet or elastic wrap while
performing these exercises to prevent swelling if the patient’s ankle is
in a gravity-dependent position.

SUBACUTE STAGE:
1. Prevent further injury.
2. Minimize pain and inflammation.
3. Promote tissue healing.
4. Restore ROM and flexibility.
5. Re-establish neuromuscular control and restore muscular strength
and endurance.
6. Re-establish proprioception, agility, and coordination.

1. PREVENT FURTHER INJURY.
• Crutches or a cane should be weaned as FWB becomes tolerated.
• Other protective devices (such as brace or tape) should still be used,
especially with grade II or III sprains.
• Extremes of plantarflexion and inversion in lateral ligaments sprains
and extreme eversion in sprains of deltoid ligament complex should
still be minimized to prevent damage to the newly formed scar tissue.

2. MINIMIZE PAIN AND INFLAMMATION.
• Thermotherapy techniques such as warm whirlpools and hot packs
should be introduced.
• Therapeutic ultrasound may also be used at this time, progressing
from pulsed to continuous duty cycles.
• The continued use of electrical stimulation can assist with minimizing
pain and inflammation.
• It is still wise to continue cryotherapy, especially after activity, to
reduce pain and limit inflammation.
• Grades I and II joint mobilizations are also indicated at this time to
assist with pain control

• Posterior mobilization to the talus.
Grade I and II joint mobilization
techniques are effective in reducing
pain.
Brotzman, S. Brent, and Robert C. Manske, 2011 18

3. PROMOTE TISSUE HEALING.
• Continuing to protect the injured ligaments to allow its normal healing
process.
• Use of therapeutic ultrasound and thermotherapy help promote tissue
healing.
• Controlled ROM and strengthening exercises will also promote proper
alignment and strength of the scar tissue.
• Therapeutic massage techniques;
• Start with petrissage to promote blood flow and circulation and
• progressing to cross-friction massage to promote tissue alignment.

4. RESTORE ROM AND FLEXIBILITY.
• As the subacute stage progresses, so should the sets and reps of the
exercises, the degree of motion performed, and the intensity of the
stretches.
• Perform ROM exercises and stretches several times throughout the day.
• Progressing from grade II to grade III joint mobilizations for decreased
ROM.
• Biomechanical Ankle Platform System (BAPS) or wobble board can be
introduced.
• Massage, myofascial release, and other manual therapy techniques to treat
soft tissue restrictions may also help restore ROM, flexibility, and tissue
mobility.

Joint mobilization techniques to
restore range of motion and
arthrokinematics.
A. Anterior mobilization to increase
plantarflexion.
B. Medial mobilization to increase
eversion.
C. Lateral mobilization to increase
inversion.
D. Distraction of the talocrural joint
for pain control and general
mobility.

Using a BAPS board to
maintain range of motion.
• The patient seen
progressing from NWB
to PWB to FWB.
• Start with uniplanar
motions in
plantarflexion,
dorsiflexion, inversion,
and eversion and later
to multiplanar motions
by performing “circles”Brotzman, S. Brent, and Robert C. Manske, 2011 22

• Begin with dorsiflexion, plantarflexion, and eversion before starting inversion
in lateral ligament complex sprain and vice versa in Deltoid ligament
complex sprain.
• Dorsiflexion and limited plantar flexion should be emphasized in lateral
ligament complex sprain
• Caution must be taken, when performing an anterior mobilization technique
of the talus in a patient with a grade II or III lateral ligament sprain to avoid
stressing the anterior talofibular ligament
• Because the talus subluxes anteriorly in a sprain caused by plantarflexion
and inversion, a posterior mobilization to the talus may be more
appropriate.

5. RE-ESTABLISH NEUROMUSCULAR CONTROL AND
STRENGTH.
• Towel curls and marble pick-ups also can be used to strengthen the
intrinsic muscles of the foot.
• Patients can begin isometric exercises in a variety of degrees within a
ROM, but painful ROM should be avoided.
• Progress to isotonic exercises as tolerated.
• Both isometric and isotonic exercises should begin with a limited ROM
and progress to full ROM as tolerated and should progress from
submaximal resistance to maximal efforts.
• As weightbearing becomes tolerated, heel and toe raises can be
incorporated as can walking on the heels or toes

Sample Isotonic exercises.
A. Eversion against manual
resistance.
B. Eversion using a cuff
weight for resistance.
C. Using an elastic band to
resist eversion.

• Closed kinetic chain
exercises.
• should be incorporated
once the patient is able
to fully bear weight.
• The patient can also
walk on the toes or
heels as a more
functional strength
training exercise.

6. RE-ESTABLISH
PROPRIOCEPTION, AGILITY, AND COORDINATION
• Encourage loading of the ankle by “weight shifts” in various directions.
• Start with weight shifted to the non-injured leg, then progressively
shifts the weight onto the injured leg before returning to the NWB
position.
• Continue until equal weight is distributed on both legs.
• Progress to a staggered stance requiring the patient to shift forward,
backward, and laterally.

Proprioception exercises without
perturbations.
• Anteroposterior and Lateral Stepping up
and down develops proprioception.
• Provide assistive device initially to gain
confidence.
• The patient should perform these in
various directions

Brotzman, S. Brent, and Robert C. Manske, 2011
Proprioception exercises
with perturbations.
A. Single-legged stance
with movement.
B. On an unstable surface.
29

Proprioception
exercises with
perturbations.
C. Single-legged
stance with lower
extremity motion.
D. On an unstable
platform.

Proprioception exercises with
perturbations.
• Dynamic squats on an unstable
platform.

Proprioception
exercises with
perturbations.
A. Lunges on an
unstable surface.
B. Lateral movements
on a slide board while
playing catch.

Proprioception exercises
with perturbations.
A. Single-legged stance while
playing catch.
B. “Stick fighting” drills.

7. MAINTAIN OVERALL BODY CONDITIONING.
• Continue upper body and trunk exercises that were used during the
acute phase.
• CKC lower extremity strength training exercises such as lunges,
squats, leg presses, and calf raises can be added to the program.
• Cardiovascular exercises such as walking, light jogging, climbing stairs
(i.e., Stairmaster), and swimming can also be added.

MATURATION STAGE:
1. Prevent reinjury.
2. Restore ROM and flexibility.
3. Improve muscular strength, endurance, and power.
4. Improve proprioception, agility, and coordination.
5. Improve functional (sport-specific) skills.

RETURN TO ACTIVITY CRITERIA
1. The patient should be pain free
2. The ankle should not be swollen.
3. The ankle should have full, functional range of motion.
4. The ankle should have full, functional muscle strength, endurance,
and power.
5. The patient should have adequate proprioception, balance, agility,
and coordination.
6. The patient should be psychologically ready to return to activity.

WARNINGS
• Although the goal is to minimize pain and inflammation, it should be
noted that an increase in pain or inflammation, especially after the
acute stage, often is a sign that the injured structures are not ready
for the activity being performed.
• If the patient experiences an increase in pain, inflammation, or both,
he or she should be re-evaluated to ensure there is no worsening of
the injury and the rehabilitation protocol should be slowed until the
pain and inflammation are under control.

REFERENCES
1. Brotzman, S. B, and Robert C. M. Clinical Orthopaedic Rehabilitation:
An Evidence-Based Approach. Elsevier Health Sciences, 2011.
Chapter 5: Foot and Ankle Injuries: pp. 315-369
2. Ebnezar, J. Clinical examination methods in orthopedics. 4th ed. New
Delhi: Jaypee Bros. Medical Publishers, 2010. Chapter 21: Injuries of
the Ankle: pp. 274-282.
3. Beam WJ. Orthopedic Taping, Wrapping, Bracing, & Padding. 2nd ed.
F. A. Davis Company, Philadelphia, 2012. Chapter 4: Ankle
38

Ankle & Foot Physiotherapy Management SRS

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