Treatment of the Foot and Ankle Flashcards
What are the main classification systems (groups) of the foot and ankle?
- Mobilization (correction of mechanical dysfunction)
- Strengthening (stabilization)
- Postural
- Pain.
In mobilization system, what types of movement related treatments we can offer?
• Manipulation • Mobilization • Mobilization with movement • Stretching (complimentary to the postural classification).
Typically, a patient would fall into the pain classification if they are reporting pain greater than what number on the pain scale?
7/10. It suggests pain may be limiting patient function and should be treated accordingly.
Exemplify an intervention to relieve concordant sign or priority impairment ok ankle and foot.
Thrust and non-thrust manipulation.
What are the objectives of a thrust and non-thrust manipulation?
– Improve joint kinematics
– Improve capsular elasticity
– Decrease-intra-articular compression forces
– Improve ROM, pain, function.
What precautions should we have with mobilization?
– Rheumatoid arthritis – Osteoarthritis or elderly patients – Radiotherapy – Prolonged corticosteroid use – Aspirin, anti-coagulant medications – Structural instability.
Refer the absolute contraindications to a manipulation.
– VBI
– Malignancy of the spine
– No manipulation of the Cspine in patients with RA
– Spinal instability
– Fracture
– Positive neurological signs indicating compromise of spinal cord, cauda equina, or spinal nerve roots
– Total ligamentous rupture or acute repair of ligaments or tendons
– Psychological pain
– Not competent in performing the technique
– Source of symptoms cannot be determined.
How long do we perform a mobilization?
Depends on:
– Goal of mob (Treating Pain we use grade I and II; Treating Stiffness we use grade III and IV)
– Which joint?
– In general, treat until you feel change in mobility or change in patient response.
What happens with a deficient support of anterior talofibular ligament? Why manual therapy is important?
- Deficiency of the ATFL increases anterior translation, internal rotation, and superior translation of the talus.
- At 100% body weight, ATFL deficient ankles demonstrated a statistically significant increase in anterior translation of the talus compared to the intact ankle.
- These altered kinematics may contribute to the degenerative changes observed with chronic lateral ankle instability and lead to OA.
• This suggest the potential need for manual therapy to “realign” the positional faults in the ankle complex.
What can happen to fibula with inversion sprains?
Sometimes fibula will get “stuck” in an inferior and anterior direction (fibular positional fault).
• Ankles with more swelling have the most anteriorly positioned fibula.
• Fibula positioned more anteriorly (about 2.5mm) in the chronically unstable ankle.
(Potential for manual therapy).
Refer a manual therapy technique that can be helpful in patients with recurrent ankle sprain.
A study suggests that Mobilization With Movement (both the weight-bearing and non-weight-bearing) can improve posterior talar glide and dorsiflexion in individuals with chronic recurrent lateral ankle sprain.
List the main mobilization/manipulation techniques used in the ankle complex.
- Lateral glides and eversion mobilization/manipulation
- Proximal tibiofibular joint thrust mobilization/manipulation
- Distal tibiofibular joint mobilization/ manipulation
- Rearfoot distraction thrust mobilization/manipulation
- Talocrural joint anterior to posterior mobilization/manipulation
- Alternate method of talocrural joint AP mobilization/manipulation.
- Mobilization With Movement in weight-bearing and non-weight-bearing.
What cluster of findings may help to identify patients with a status of post inversion ankle sprain who would most likely benefit rapidly and dramatically from Manual Therapy + exercise?
- Symptoms worse when standing
- Symptoms worse in evening
- Navicular drop sup 5.0 mm
- Distal tibiofibular hypomobility
1 variable present – 50% prob of success
2 variables present – 78% prob of success
3 variables present – 95% prob of success
4 variables present – 56% prob of success of MT and exercice.
Even without the cluster of findings, 75% responds well.
Exemplify exercices helpful in post inversion ankle sprain.
- Achilles tendon stretch, non-weight bearing with the knee extended
- Achilles tendon stretch, weight bearing
- Alphabet exercises (draw letters with foot)
- Ankle eversion self-mobilization
- Dorsiflexion self-mobilization.
Which method looks to work better with inversion ankle sprain: Manual therapy plus exercise (2x/week x 4 weeks) OR Home exercise program (1x/week x 4 weeks)?
MTEX is superior to HEP in the treatment of inversion ankle sprains.
Is it beneficial adding myofascial therapy to a treatment of Thrust and Nonthrust Manipulation and Exercise in patients with acute inversion ankle sprain?
A small study suggests greater improvements in pain and function, so the addition of myofascial therapy to a manually based program may further improve outcomes in patients post inversion ankle sprain.
Refer the technique that can help in the suspiction of cuboid syndrome.
The cuboid whip manipulation followed by gentle massage. Patients properly diagnosed with cuboid syndrome who receive the cuboid manip may be able to return to sport within 1 or 2 visits without injury recurrence.
Attention - case series study!
Which treatment condition seems to be more effective in treating plantar heel pain?
• Calf-stretching, A/P talocrural mobs, subtalar distraction manip
• Calf-stretching, A/P talocrural mobs, subtalar distraction manip, lateral subtalar joint glides, A/P – P/A first TMT joint
• Subtalar joint distraction manip,stretching, orthosis
• Subtalar joint distraction manip, stretching, foot intrinsics
In this case series study, all 4 patients reported a decrease in NPRS from an average of 5.8±2.2 to 0/10. So, in patients with plantar heel pain, an impairment based PT
approach emphasizing manual therapy demonstrated
complete pain relief and full return to activities.
Which treatment seems better for plantar heel pain?
• Therapeutic ultrasound, ionto with dexamethasone, gastroc/soleus/plantar fascia stretch, intrinsic foot strengthening; 3x/day x 4 weeks
• STM, rearfoot eversion mobilization, ankle eversion self mobs, manual STM of plantar fascia, + gastroc/soleus stretches ; impairment based mobs at the hip, knee, ankle, foot.
- Manual physical therapy and exercise is superior to a combination of ultrasound, iontophoresis, and exercise for the management of patients with plantar heel pain.
- Both approaches demonstrated benefits; however, the magnitude of the benefit was more substantial with manual physical therapy and exercise.
Does grade III sesamoid mobilisation helps in individuals with hallux limitus (turf toe)?
Sesamoid mobilization, flexor hallucis strengthening, and gait training should be included in the plan of care when treating an individual with hallux limitis.
Describe a total intervention that can work in management of peroneal tendinopathy.
- Visit 1-2: rearfoot/forefoot posts, talocrural A/P, calf stretches, peroneal strengthening (At 1 month, pain had worsened)
- Visit 3: Lateral calcaneal glide. Immediate ability to perform 10 heel raises pain free
- Visit 4-7: Repeat lateral calcaneal glide, progress peroneal strengthening
- Visit 8: 0/10 pain with return to all previous activities pain free.
A lateral calcaneal glide, in combination with other manual techniques, and a structured HEP may be a useful treatment approach for a patient with peroneal tendinopathy.
How to apply a rearfoot distraction thrust manipulation?
- Grasp the dorsum of the patient’s foot with interlaced fingers
- Provide firm pressure with both thumbs in the middle of the plantar surface of the forefoot
- Engage the restrictive barrier by dorsiflexing the ankle and applying a long axis distraction
- Pronate and dorsiflex the foot to engage the barrier
- Apply a high velocity, low amplitude thrust in a caudal direction. The clinician applies a distraction forces at the talocrural joint by shifting his or her weight away from the patient. The thrust is targeted purely into distraction.
Describe the lying talocrural joint anterior to posterior mobilization.
- Use your left hand to firmly stabilize the lower leg at the malleoli
- Grasp the anterior, medial, and lateral talus with your right hand
- Apply an anterior to posterior oscillatory mobilization force to the talus.
Explain the talocrural joint anterior to posterior mobilization with movement standing.
- The clinician grasps and supports the arch of the foot and applies a stabilizing force over the anterior talus
- A padded belt is placed over the patient’s distal posterior tibia and fibular and around the therapist’s buttock region
- The patient is guided into dorsiflexion of the involved ankle while the therapist produces a posterior to anterior force to the distal leg by pushing/moving backwards and pulling on the belt.
How to do lateral glides and eversion mobilization?
- Grasp the malleoli just proximal to talocrural joint with your left index finger, thumb, and web space, and use your forearm to stabilize the patient’s leg agains the table
- Place your right thenar eminence on the talus just distal to malleoli and grasp the rearfoot
- Use your body to impart a mobilizing force through your right arm and thenar eminence to the medial talus.
We also can do medial and subtalar glides.
Describe distal tibiofibular joint mobilization.
- Place the distal leg at the edge of the table. Use your leg to stabilize the foot and move the ankle into progressive dorsiflexion
- Grasp and stabilize the distal tibia with one hand
- Place your thenar eminence over the lateral malleolus and use your body to impart an anterior to posterior directed mobilizing force.
How to perform cuboid whip manipulation?
The patient assumes a prone position. The clinician grasps the foot by stabilizing the medial and lateral sides of the foot within his or her webspaces. The thumbs of the clinician are placed on the cuboid on the plantar aspect of the foot. The knee is flexed to approximately 70 degrees and the ankle is dorsiflexed to end range. In a quick movement, the clinician moves the knee into extension, the ankle into plantarflexion and supination. Concurrently with the physiological movements, the clinician also applies a plantar to dorsal thrust with his or her thumbs.
How should we manipulate proximal tibiofibular joint?
- Place your 2nd MCP joint in the popliteal fossa, then pull the soft tissue laterally until your MCP is firmly stabilized behind the fibular head
- Use your right hand to grasp the foot and ankle
- Externally rotate the leg and flex the knee to the restrictive barrier
- Once at the restrictive barrier, apply a high-velocity, low amplitude thrust through the tibia (direct the patient’s heel towards the ipsilateral buttock).
What are the main purposes of exercise therapy to the foot and ankle?
– Improve muscle strength – Decrease muscle stiffness – Decrease ground reaction forces – Improve cardiorespiratory fitness – Improve ROM, pain, function.
Refer the types of treatment to manage a posterior tibial tendinopathy.
- PRICEMM
- Foot orthosis to decrease pronation
- Posterior tibial tendon strengthening
- Consider immobilization in short leg cast for two to three weeks.
How to treat a peroneal tendinopathy?
- PRICEMM
- Foot orthotic
- Lateral heel wedge
- Eversion stengthening.
What are the treatment points to Achilles tendinopathy?
- PRICEMM
- Gastrocnemius and soleus stretching
- Eccentric strengthening program.
Summarise 2 differents protocols of exercise to an achilles tendinopathy.
• Protocol 1: – 3 sets of 10 reps – Increased load weekly – Speed of movement changed daily – 95% of patients reported symptom resolution in 6-8 weeks
• Protocol 2:
– Unilateral heel raises with no concentric component
– 3 sets of 15 reps, 2x/day, 12 weeks
There is strong evidence in support of eccentric loading to decrease pain and stiffness, and improve function in patients with Achilles tendinopathy.
A patient arrives to you with a med-tendon achilles pain. What should you evaluate and exclude?
Exclude rupture, evaluate peritendeinous structures.
