Lower Leg Interventions

Question 1

Interventions that have strong evidence (A) for Lateral Ankle Sprains

Answer 1

1. recommending the use of prophylactic bracing to reduce risk of a first-time sprain
2. prophylactic bracing + proprioceptive and balance-focused TherEx
3. TherEx including:
   
   • AROM, stretching, Neuro re-edu, postural re-edu, and balance training
4. DO NOT use ultrasound
5. Manual therapy

Question 2

T/F: in more severe injuries, immobilization ranging from semi-rigid bracing to below-knee casting may be indicated for up to 10 days post injury (for ankle sprains)

Answer 2

TRUE

Question 3

Interventions for Ankle Impingement Syndromes

Answer 3

1. address acute impairments
   
   • acute management
   • balance/coordination training and other muscle performance exercises as appropriate
2. NSAIDs
3. surgery

Question 4

when is surgery applicable for ankle impingement syndrome

Answer 4

1. failure of positive response to conservative interventions x6 months following injury
2. arthroscopic debridement common
   
   • worse prognosis with articular lesion
3. Post-operative management
   
   • monitor/address entry site
   • acute management
   • address impairments as appropriate

Question 5

heavy slow resistance vs eccentric exercise for Tendinopathies

Answer 5

Beyer et al

found 12 week eccentric exercise and heavy load slow resistance exercise program yielded improvements in tissue quality, pain, and function

Question 6

what does evidence suggest pertaining to the use of modalities for treating Achilles Tendinopathies?

Answer 6

• B → iontophoresis
• C → night splints, stretching
• D → heel lifts, low-level laser, orthoses
• F → manual therapy, dry needling, taping

Question 7

Achilles Tendon ruptures repairs

Answer 7

1. commonly NWB with crutches x4 weeks
   
   • with boot, passively PF and active DF (limitations 20º)
     
     • ~20º PF with heel lift
     • ROM as above once incision healed
     • wean from heel lift and progress to ankle neutral at 4 weeks (gradually by 6-8 weeks)
     • cycling w/o resistance at ~week 6
     • walking boot until ~week 8
2. Cast vs boot
   
   • if casted, commonly 6-8 weeks
     
     • boot with heel lift ~subesquent month
     • NWB resistance ~week 8-10
     • cycling w/o resistance at ~week8

Question 8

Tibialis Posterior Tendinopathy interventions

Answer 8

1. Eccentrics
2. Shoe insert (medial arch support) to diminish mechanical loading on TP tendon
3. Address contributors to excessive pronation/LE IR
4. Coordination training (other deep posterior compartment supporters of medial arch)

Question 9

Interventions that have strong evidence (A) for plantar fascitis

Answer 9

1. manual therapy
2. plantar fascia-specific and gastroc/soleus stretching to provide short term pain relief
3. anti-pronation taping
4. use of foot orthoses
5. night splint program of 1-3 months

Question 10

Interventions that have weak-moderate evidence for plantar fascitis (C-D)

Answer 10

1. low-level laser
2. phonophoresis
3. ultrasound
4. rocker-bottom shoe

Question 11

interventions for metatarsalgia

Answer 11

1. metatarsal pads
2. avoid high heels
3. orthotics to address pes cavus
4. address triceps surae length

Question 12

CPR for manual therapy and exercise in Lower Leg

Answer 12

1. symptoms worse when standing
2. symptoms worse in evening
3. navicular drop 5.0 mm
4. distal tibiofibular joint hypomobility

Question 13

interpretation of the CPR for manual therapy and exercise

Answer 13

3/4 variables

• sensitivity = 0.28
• specificity = 0.95
• +LR = 5.9
• dramatic short-term effect

Question 14

effect of MWM for subjects with recurrent inversion sprains

Answer 14

1. MWM with posterior talocrural mobs resulted in greater posterior talar translation and DF ROM

Question 15

Oscillations and Sustained Hold Mobilizations for the Lower Leg

Answer 15

1. Tibiofibular Joint
   
   • proximal and distal joints
     
     • A/P glides
2. Talocrural Joint
   
   • A/P glides
   • distraction
3. Subtalar Joint
   
   • M/L glides
4. MTP/IP Joint
   
   • dorsal and plantar glides
   • distraction glide

Question 16

Joint Manipulations for Lower Leg

Answer 16

1. Talocrural distraction manipulation
2. Cuboid whip

Question 17

Other Manual Therapy Interventions for the Lower Leg

Answer 17

1. Posterior Talocrural Mobilization with movement (MWM)
2. “Muscle Flow” soft tissue mobilization triceps surae

Question 18

Pt position for cuboid whip

Answer 18

prone, knee flexed 70º, ankle near neutral