Which is a reason for a high-arched or over-supinated foot to have restricted ankle dorsiflexion?

To make sound clinical decisions when managing patients with foot and ankle disorders, it is necessary to understand the various pathologies, surgical procedures, and associated precautions and to identify presenting impairments, activity limitations and participation restrictions (functional limitations and disabilities). In this section, common pathologies and surgeries are presented and related to corresponding preferred practice patterns (groupings of impairments) described in the Guide to Physical Therapist Practice2 (Table 22.1). Conservative and postoperative management of the conditions described in this section are based on principles of tissue healing and exercise intervention.

TABLE 22.1Foot and Ankle Pathologies/Surgical Procedures and Preferred Practice Patterns

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TABLE 22.1 Foot and Ankle Pathologies/Surgical Procedures and Preferred Practice Patterns

Joint Hypomobility: Nonoperative Management

Common Joint Pathologies and Etiology of Symptoms

Pathologies, such as rheumatoid arthritis (RA); juvenile rheumatoid arthritis (JRA); degenerative joint disease (DJD); and acute joint reactions after trauma, dislocation, or fracture, affect the foot and ankle complex. Postimmobilization contractures and adhesions develop in the joint capsules and surrounding tissues any time a joint is immobilized in a cast or splint, typically after a dislocation or fracture. The reader is referred to Chapter 11 for background information on arthritis, postimmobilization stiffness, and etiology of symptoms. The following is specific to joint conditions of the ankle and foot.

RA. Pathology of the foot and ankle as the result of RA commonly affects the forefoot early in the disease process; the hindfoot later; and least frequently, the ankle.20,54,83 Involvement may occur in the MTP, subtalar, and talocrural joints of the foot, leading to instabilities and painful deformities, such as hallux valgus and subluxation of the metatarsal heads, that increase with the stress of weight bearing. Tendon rupture of foot and ankle musculature also may occur as the result of chronic inflammation and can contribute to deformity.54

DJD and joint trauma. Degenerative symptoms occur in joints that are repetitively traumatized, and acute joint symptoms are often seen in conjunction with ankle sprains, chronic instability, or fracture. Posttraumatic arthritis leading to DJD is by far the most common type of arthritis that affects the ankle, accounting for approximately 70% to 80% of all ankle arthritis. In contrast, primary osteoarthritis, a common type of arthritis in the hip and knee, is rare in the ankle, even in the older adult population.83,139

Postimmobilization stiffness. Contractures and adhesions in the capsular tissues and the surrounding periarticular tissues may occur any time the joint is immobilized after a fracture or surgery.

Gout. Symptoms commonly affect the MTP joint of the great toe, causing pain during terminal stance, so there is a shorter stance and lack of smooth push-off.

Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities)

In RA, many of the following impairments and deformities occur with progression of the disease.54,124 With DJD and postimmobilization stiffness, only the affected joint(s) is limited.16 Activity limitations and participation restrictions occur primarily as a result of loss of weight-bearing abilities.

• Restricted motion. When symptoms are acute, the patient experiences swelling and restricted, painful motion, particularly during weight-bearing activities. When symptoms are chronic, there is restricted motion, decreased joint play, and a firm capsular end-feel in the affected joint.

  • Proximal and distal tibiofibular joints. Restricted accessory motion in these joints usually occurs with periods of immobilization and limits ankle and subtalar joint motion.71

  • Talocrural joint. Passive plantarflexion is more limited than dorsiflexion (unless the gastrocnemius-soleus muscle group also is shortened, in which case dorsiflexion is limited accordingly).22

  • Subtalar, transverse tarsal, and tarsometatarsal joints. Progressive limitation of supination develops until eventually the joint fixes in pronation with flattening of the medial longitudinal arch.22 The close-packed position of the tarsals (supination) becomes more and more difficult to assume during the terminal stance (push-off) phase of gait. Moderate to severe foot pain is experienced with midfoot arthritis, especially during weight bearing.110

  • MTP joint of the large toe. Gross limitation of extension and some limitation of flexion develop; the rest of the MTP joints are variable. Lack of extension restricts the terminal stance phase of gait with an inability to rock up onto the metatarsal heads. This exacerbates the pronation posture and inability to supinate the foot during push-off in gait.

• Common deformities. Deformities occur due to a variety of factors including but not limited to muscle imbalances, faulty footwear, trauma, and heredity. Common deformities of the forefoot are described in Box 22.2.80,124

• Muscle weakness and decreased muscular endurance. Inhibition resulting from pain and decreased use of the extremities leads to impaired muscle function.

• Impaired balance and postural control. The sensory receptors in the ankle joints and ligaments, as well as in the muscle spindles, provide important information for a balance reaction, known as the ankle strategy. The ankle strategy is used in balance control during perturbations.50,113 Faulty feedback and balance deficits occur when there is instability, muscle impairments, or arthritis.

• Increased frequency of falling. Impaired balance or a sense of instability (giving way) of the ankle may lead to frequent falling or fear of falling, thus restricting community outings.83

• Painful weight bearing. When symptoms are acute, weight-bearing activities are painful, preventing independent ambulation and causing difficulty in rising from a chair and ascending and descending stairs.

• Gait deviations. If the patient experiences pain during weight bearing, there is a short stance phase, reduced single limb support, and decreased stride length on the side of involvement. Because of the restricting motion and loss of effective plantarflexion and supination in the arthritic foot as well as pain in the forefoot area under the metatarsal heads, push-off is ineffective during terminal stance. Little or no heel rise occurs; instead, the person lifts up the involved foot.

• Decreased ambulation. Because of decreased ankle and foot mobility and resulting decreased length of stride, distance and speed of ambulation are decreased; the person may require use of assistive devices for ambulation. If pain, balance, or restricted motion is severe, the person will be unable to ambulate and will require a wheelchair for mobility.

BOX 22.2 Common Arthritis-Related Forefoot Deformities

• Hallux valgus. This deformity in the great (large) toe develops as the proximal phalanx shifts laterally toward the second toe. Eventually the flexor and extensor muscles of the great toe shift laterally and further accentuate the deformity. The bursa over the medial aspect of the metatarsal head may become inflamed and the bone may hypertrophy, causing a painful bunion.

• Hallux limitus/hallux rigidus. Narrowing and eventual obliteration of the first MTP joint space occur with progressive loss of extension. This affects terminal stance by not allowing the foot to roll over the metatarsal heads and great toe for normal push-off. Instead, the individual turns the foot outward and rolls over the medial aspect of the large toe. This faulty pattern accentuates hallux valgus and foot pronation, and usually the MTP joint is quite painful.

• Dorsal subluxation/dislocation of the proximal phalanges on the metatarsal heads. If this occurs, the fat pad, which normally is under the metatarsal heads, migrates dorsally with the phalanges, and the protective cushion during weight bearing is lost, leading to pain, callus formation, and potential ulceration.

• Claw toe (MTP hyperextension and IP flexion) and hammer toe (MTP hyperextension, PIP flexion, and DIP hyperextension). These deformities result from muscle imbalances between the intrinsic and extrinsic muscles of the toes. Friction from shoes may cause calluses to form where the toes rub.

Joint Hypomobility: Management—Protection Phase

The interventions selected for management depend on the signs and symptoms present. For acute problems, follow the general outline presented in Chapter 10 and summarized in Box 10.1. Suggested interventions for the various goals are described in this section.60,83,124

Educate the Patient and Provide Joint Protection

• Teach a home exercise program at the level of the patient's abilities.

• Teach the patient signs of systemic fatigue (especially in RA), local muscle fatigue, and joint stress and ways to modify exercises and activities to remain active within safe levels.

• Emphasize the importance of daily ROM, endurance activities, and joint protection, including avoidance of faulty foot and ankle postures and protection of the feet from deforming, weight-bearing forces and trauma imposed by improperly fitting footwear.

• If necessary, instruct the patient in safe use of assistive devices to decrease the effects of weight bearing and pain.

Decrease Pain

In addition to physician-prescribed medication, intra-articular injections of corticosteroids or nonsteroidal anti-inflammatory medications, and therapeutic use of modalities the following are used to manage painful symptoms.

• Manual therapy techniques. Gentle grade I or II distraction and oscillation techniques may inhibit pain and move synovial fluid for nutrition within the involved joints.

• Orthotic devices. Orthotic shoe inserts and well-constructed shoes help protect the joints by providing support and realigning forces.60,77,86,110 Such support has been shown to decrease pain and improve functional mobility. Splinting or bracing may also be used to stabilize an arthritic joint.

Kavlak and colleagues60 reported the effects of prescribed orthotic devices in 18 patients with RA (no control group) and a variety of bilateral foot deformities, including pes planus, hallux valgus, hammer toe, subluxation of the metatarsal heads, and others. All patients in the study were community walkers with no history of foot or ankle surgery. All patients were prescribed custom-made orthotic inserts and shoe modifications, such as a medial longitudinal arch support, metatarsal pad, or heel and forefoot wedge, to meet their individual needs. Pain, temporal-distance characteristics of gait, and energy expenditure during walking were measured before and after the patients had been wearing the custom orthoses for 3 months. There was a significant reduction in pain and energy cost during ambulation and increases in step and stride length after use of the orthotic devices for 3 months. There were no significant changes in foot angle or the width of the base of support. The authors concluded that appropriately prescribed orthoses and shoe modifications were important elements of nonoperative treatment of foot pain and impaired gait in patients with RA.

Maintain Joint and Soft Tissue Mobility and Muscle Integrity

• Passive, active-assistive, or active ROM. It is important to move the joints as tolerated. If active exercises are tolerated, the benefits of the muscle action make them preferable.

• Aquatic therapy. Aquatic therapy is an effective method of combining nonstressful buoyancy-assisted exercises with therapeutic heat.

• Muscle setting. Apply gentle, multiangle, muscle-setting techniques in pain-free positions at an intensity that does not exacerbate symptoms.

Joint Hypomobility: Management—Controlled Motion and Return to Function Phases

Examine the patient for signs of decreased muscle flexibility, joint restrictions, muscle weakness, and balance impairments. Initiate exercises and mobilization procedures at a level appropriate for the condition of the patient.

PRECAUTIONS WITH RA: Modify the intensity of joint mobilization and stretching techniques used to counter any restrictions, because the disease process and use of steroid therapy weaken the tensile quality of the connective tissue. Therefore, it is more easily torn. It may be necessary to continue joint protection with orthotics, proper fitting shoes, and assistive devices for ambulation.124 Encourage the patient to be active, but also to be aware of pain and fatigue.

Increase Joint Play and Accessory Motions

Joint mobilization techniques. Determine which articulations are restricted owing to decreased joint play, and apply grade III sustained or grade III and IV oscillation techniques to stretch the limitations. See Figures 5.55 through 5.64 and their descriptions in Chapter 5 for techniques to mobilize the leg, ankle, and foot articulations. Mobilizing the toes is the same as the fingers (see Figs. 5.42 through 5.43).

Because weight-bearing forces and joint changes with arthritis accentuate pronation, mobilizing to increase pronation usually should not be undertaken in an arthritic foot. Perform these techniques only in the stiff foot after immobilization when the foot does not pronate sufficiently during the loading response in gait.

Extension of the toes at the MTP joints is important during terminal stance for normal push-off and development of the windlass effect in gait. The great toe requires from 40° to 50° extension to function effectively during this phase of gait.105,107

Improve Joint Tracking of the Talocrural Joint

Apply mobilization with movement (MWM) techniques to increase ROM and/or decrease pain associated with movement.97 The principles of MWM are described in Chapter 5.

MWM: Plantarflexion

Patient position and procedure: Supine with hip and knee flexed and heel on the table (Fig. 22.3). Stand at the foot of the table facing the patient and contact the patient's anterior tibia with the palm of your hand (for the right foot use the left hand). Produce a pain-free graded posterior glide of the tibia on the talus. The patient should now be unable to plantarflex. While maintaining the posterior tibial glide grip the talus with your other hand (for the right foot, use the right hand) and create a passive end-range plantarflexion movement, causing the talus to roll anteriorly.

FIGURE 22.3

Mobilization with movement (MWM) to increase ankle plantarflexion. Maintain a posterior glide of the tibia while moving the talus into plantarflexion. This should not cause pain.

The sustained plantarflexion must be painless. Repeat three to four times in sets of 6 to 10 and reassess to confirm improved range.

MWM: Dorsiflexion

Patient position and procedure: Standing with the affected foot placed on a chair or stool (Fig. 22.4). Kneel on the floor facing the patient with a mobilization belt around your buttocks and the patient's Achilles tendon (padded with a towel). Place the web space of both hands around the neck of the talus with the palms on the dorsum of the foot. Hold the foot down and back and the subtalar joint in neutral pronation/supination. Use the belt to produce a pain-free graded anterior gliding force to the ankle joint. While maintaining this mobilization, have the patient lunge forward, bringing the affected ankle into dorsiflexion and causing painless end-range loading. Repeat in sets of six to ten, reassessing for effect.

FIGURE 22.4

MWM to increase ankle dorsiflexion. Maintain an anterior glide of the tibia with the mobilization belt while the patient lunges forward to move the ankle into dorsiflexion. This should not cause pain.

Increase Mobility of Soft Tissues and Muscles

Perform stretching techniques as described in Chapter 4. Self-stretching techniques are described later in this chapter.

Regain Balance in Muscle Strength and Prepare for Functional Activities

Initiate resistive exercises at a level appropriate for the weakened muscles. Begin with isometric resistance in pain-free positions, and progress to dynamic resistance exercises through pain-free ranges using open- and closed-chain exercises. Resistive exercises are described later in this chapter.

Use a pool or tank to reduce stress on the foot and ankle joints for low-load, weight-bearing exercises; ambulatory activities; and for low-impact aerobic exercises.

Improve Balance and Proprioception

Initiate protected balance exercises, and progress the intensity as tolerated. Determine the level of stability and safety during ambulation and continue use of assistive devices if necessary to help prevent falls.

Develop Cardiopulmonary Fitness

Low-impact aerobic exercises should be initiated early in the treatment program and progressed as the patient is able. Water aerobics, swimming, treadmill walking, and bicycling may be within the patient's tolerance. A person with degenerative or rheumatoid arthritis should not do high-impact (jumping, hopping, and jogging) aerobic exercises.

Joint Surgery and Postoperative Management

Advanced arthritis of the ankle or the joints of the foot can cause severe pain, limitation of motion, gross instability or deformity, and significant loss of function during activities that require weight bearing through the lower extremities (Fig. 22.5). When nonoperative management no longer alleviates symptoms, surgical options for early and advanced joint disease may be necessary (Box 22.3).* The procedure(s) selected depends on the joints involved, the extent of articular damage, the severity of joint instability or deformity, and the postoperative functional goals of the patient.

FIGURE 22.5

Late-stage arthritis of the ankle. (A) Mortise view of the ankle shows severe loss of the normal joint space and partial erosion of the lateral tibia. (B) Lateral view shows tibial erosion with mild joint space loss in the subtalar region and significant osteophyte formation in the anterior ankle. (From Hasselman, CT, Wong, YS, and Conti, SF: Total ankle replacement. In Kitaoka, HB (ed): Master Techniques in Orthopedic Surgery: The Foot and Ankle, ed 2. Philadelphia, Lippincott Williams & Wilkins, 2002, Fig. 39.1, p 583, with permission.)

BOX 22.3 Surgical Interventions for Early- and Late-Stage Ankle or Foot Arthritis and Joint Deformity Early-Stage Procedures

• Arthroscopic débridement and cheilectomy (removal of osteophytes)

• Arthroscopic subchondral drilling, mosaicplasty, or osteochondral autologous implantation for small osteochondral lesions of the talus

• Articular distraction (widening of the joint space by means of a temporarily inserted external fixation device)

• Soft tissue reconstruction

• Synovectomy

Late-Stage Procedures

• Osteotomy

• Excision arthroplasty with or without implant

• Total joint arthroplasty

• Arthrodesis

Arthroscopic repair of small osteochondral lesions, débridement of a symptomatic joint, and distraction arthroplasty are used for management of early joint changes but offer little if there is significant destruction of articular cartilage.27,83,139,145 For late-stage arthritis, arthrodesis provides pain-free weight bearing and stability of the involved joint(s) but sacrifices mobility of the operated joints, which in turn, affects functional movement. Pain-free compensatory movements must be available in adjacent joints to absorb weight-bearing forces during ambulation. Arthrodesis typically is performed in young patients with high functional demands.17,47,62,83,139 Replacement arthroplasty of the ankle37,48,66,67,68,115,116 or toes,9,141 an option less frequently selected than arthrodesis, affords pain relief while retaining some degree of ankle mobility.

The anticipated benefits of the various types of joint surgery for the ankle and foot and postoperative rehabilitation are: (1) relief of pain with weight bearing and joint motion, (2) correction of deformity, (3) restoration of stability or mobility of the involved joints, and (4) improved strength and muscular endurance of the lower extremities for ambulation and functional activities.9,20,37,66,83,139,141 Rehabilitation includes postoperative exercise; gait training with assistive devices; fabrication of foot orthoses; and patient education including information about shoe selection, fit, and modification and appropriate choices of recreational activities and activities of daily living (ADLs).

Total Ankle Arthroplasty

Total ankle arthroplasty (TAA) is an option for carefully selected patients who have disabling pain associated with advanced, symptomatic arthritis of the talocrural joint whose only surgical alternative is ankle arthrodesis. TAA provides pain relief while preserving functional motion of the ankle and therefore, reduces stresses on adjacent joints more effectively than arthrodesis. In the past, TAA was reserved for relatively sedentary individuals or those who do not expect to participate in moderate- to high-impact recreational activities or heavy labor after surgery.44,66,116,139 Although the "ideal" candidate for TAA continues to be the older (> 65 years), thinner individual with minimal foot or ankle deformity and a low-demand lifestyle,37 TAA is now being extended to younger, more active individuals (typically those with posttraumatic arthritis), who wish to continue to participate in moderately demanding activities. Improvements in implant design, instrumentation for implant alignment, and the use of cementless (bio-ingrowth) fixation are responsible for the broadening of selection criteria for TAA.37,47,48,115

Indications for Surgery

Although no consensus exists at this time, the following are frequently cited current-day indications for total ankle replacement.37,44,47,54,66,115,116,139

• Severe, persistent pain, particularly during weight bearing, and compromised functional mobility as the result of advanced degenerative or inflammatory joint disease, including posttraumatic arthritis; primary OA, RA, or JRA; or avascular necrosis of the dome of the talus

• Sufficient integrity of ligaments for ankle stability

• A flexible deformity that can be passively corrected to neutral or no more than 5° of hindfoot valgus

• Appropriate procedure for a patient with low to moderate physical demands

• An option when both ankles are involved and bilateral ankle fusions are impractical and would dramatically compromise functional mobility, such as ascending or descending stairs or rising from a chair

• Persistent pain during weight bearing and long-term, unsatisfactory functional results following ankle arthrodesis

Contraindications

There are a number of absolute and relative contraindications to current-day TAA.37,44,116 Absolute contraindications include active or chronic infection of the ankle, severe osteoporosis, avascular necrosis of a significant portion of the body of the talus, peripheral neuropathy leading to decreased sensation or paralysis, impaired lower extremity vascular supply, and long-term use of corticosteroids. As with replacement of other joints, TAA is contraindicated for the individual who has not yet reached skeletal maturity.

Relative contraindications include a remote history of infection, presence of marked ankle instability, a varus or valgus deformity of the hindfoot greater than 20°, less than a 20° total arc of dorsi- and plantarflexion, obesity, and the need to return to high-demand, high-impact physical activities.

Procedure

Implant Design, Materials, and Fixation

Introduced in the 1970s, the first total ankle replacement designs were two-component, metal-to-polyethylene implants, requiring significant bone resection and held in place with cement fixation.37 Although quite variable, short-term results of these "first generation" implants seemed to hold promise. The early designs, however, proved to have limited durability, because many had highly constrained tibial and talar components and did not replicate the complex biomechanical characteristics of the ankle's articulating surfaces.37 Functional ROM of the ankle also was difficult to achieve with the more constrained designs. Other early designs were totally unconstrained, allowing multiplanar movements but providing no ankle stability. Consequently, a high rate of complications occurred, such as loosening at the bone-cement interface and premature component wear with the constrained implants, and ankle dislocation with the unconstrained designs, leading to unsatisfactory long-term results.37,44,66,116

Since the early designs, changes in prosthetic design, based on a more thorough understanding of the biomechanics of the ankle and foot, have led to refinement of two-component, fixed-bearing designs and development of three-component, mobile-bearing designs, which incorporate sliding and rotational motions into the implant systems. Because contemporary prosthetic designs more closely mimic the characteristics of a normal ankle joint, ROM available in several of these systems now approaches that of a normal ankle.142 Advances in design and the availability of new implant materials combined with improved surgical techniques, such as better soft tissue balancing and ligament reconstruction, have led to current-day TAA (Fig. 22.6). These newer implant designs are minimally constrained or semiconstrained and completely resurface the tibial, fibular, and talar articulating surfaces. Contemporary TAA also requires far less resection of bone than early replacements and typically employs cementless (bio-ingrowth) fixation.3,7,37,44,47,48,67,116,121 A hydroxyapatite coating on the outer surfaces of the metal implants is used to increase the rate of bone ingrowth.123 However, cement fixation continues to be used for patients with poor bone stock.69

FIGURE 22.6

Total ankle arthroplasty. Lateral view of a total ankle replacement in a 78-year-old woman, one year after surgery for post-traumatic arthritis. (From Kitaoka, HB, and Claridge, RJ: Ankle replacement arthroplasty. In Morrey, BF (ed): Joint Replacement Arthroplasty, ed. 3, p. 1148, 2003, with permission from The Mayo Clinic Foundation.)

With a two-component, fixed bearing system, a porous or beaded metal-backed, high-density polyethylene tibial surface articulates with a metal talar component that also has a beaded outer surface.67,83,121 A three-component, mobile-bearing design, sometimes referred to as a meniscal-bearing design, employs a flat (table-top) tibial component made of metal and a metal talar dome distally with a mobile, polyethylene bearing interposed between the two metal components.3,7,37,47,48 All of these contemporary designs allow at least 5° to 10° of dorsiflexion and 20° to 25° of plantarflexion, sufficient for functional activities, and a small degree of rotation of the foot on the tibia to reduce stresses on the implants.

Operative Overview

Although there are numerous variations of operative techniques involved in a TAA, the following represent key components.3,7,44,47,66,123 An anterior longitudinal incision between the tibialis anterior and extensor hallucis longus tendons is the most widely used approach. The extensor retinaculum and capsule are incised to expose the joint. The joint is débrided and osteophytes are removed. An external distraction device is used to separate the joint surfaces and facilitate bone resection. Small portions of the distal tibia and talar dome are excised, followed by preparation of the joint surfaces. In some cases, the medial and lateral malleolar recesses also are resurfaced. Trial implants are inserted to evaluate their alignment and the range of dorsiflexion available. If there is less than 5° of dorsiflexion because of a contracture of the gastrocnemius-soleus muscle group, a percutaneous lengthening of the Achilles tendon is performed.

Sometimes a second incision is made along the distal fibula for fusion of the tibiofibular syndesmosis with screw fixation to provide a larger surface for fixation of the tibial prosthesis.37,66,67 If there is a significant varus or valgus hindfoot deformity, a subtalar arthrodesis may also be performed.47,123 After the permanent implants are inserted, soft tissues are balanced and repaired. Ligament reconstruction may be necessary if there is inadequate stability of the ankle and hindfoot. After the wound is closed, a bulky compression dressing and well-padded, short-leg cast or posterior splint are placed on the foot and ankle to control joint swelling and peripheral edema.

Complications

The incidence of complications after contemporary ankle replacements appears to be lower than after the early implant designs and surgical techniques. Only a limited number of long-term follow-up studies have been reported, and the full picture is not yet available. In addition, whether current-day TAA will prove to be as successful as total hip or knee arthroplasty remains unclear.65 When complications following TAA versus ankle arthrodesis are compared, the overall rate of complications is higher with TAA than with arthrodesis.115

As with all types of joint arthroplasty, postoperative infection is a potential complication. Postoperative edema in the ankle and foot also increases the risk of delayed wound healing, which in turn, often prolongs the immobilization period, delaying early ankle motion and potentially leading to poor ROM outcomes.44,65,99 Tarsal tunnel syndrome or complex regional pain syndrome occasionally develop and causes chronic foot or ankle pain.7 (Complex regional pain syndromes and interventions are described in Chapter 13.) A summary of intraoperative, early postoperative, and long-term complications unique to TAA is noted in Box 22.4.3,7,37,44,47,65,99,115 Any of these complications can adversely affect the progression of rehabilitation and short-term and long-term outcomes of ankle replacement. Persistent or severe complications may necessitate revision arthroplasty or ankle arthrodesis.

BOX 22.4 Complications of Total Ankle Arthroplasty Intraoperative Complications

• Fracture of the medial or lateral malleolus during implant insertion → the necessity for fracture stabilization with internal fixation and a longer period of ankle immobilization and restricted weight bearing

• Malpositioning of an implant → chronic ankle instability, subluxation, dislocation, early mechanical loosening, or premature implant wear

• Laceration of the posterior tibialis or flexor hallucis longus tendon during bone resection due to their proximity to the medial malleolus → necessity for tendon repair

• Nerve injury, usually the superficial or deep peroneal → impaired sensory or motor function

• Insufficient soft tissue balancing or reconstruction → chronic ankle instability or deformity

Postoperative: Early and Long-Term Complications

• Delayed wound healing → an extended period of restricted ankle motion

• Delayed union or nonunion of a tibiofibular syndesmosis fusion → an extended immobilization and restricted weight-bearing period

• Tarsal tunnel syndrome or complex regional pain syndrome

• Component migration or impaction → malalignment and premature component wear

• Mechanical (aseptic) loosening (most often the talar component) → pain and impaired functional mobility

• Hindfoot arthritis (most often the subtalar joint) → pain and impaired weight-bearing abilities.

• Heterotopic bone formation → restricted motion

Postoperative Management

There are few guidelines in the literature for postoperative management of patients who have undergone TAA. Those that are available vary considerably with regard to the duration of immobilization, weight-bearing restrictions, and the initiation and progression of exercise. There is a lack of evidence to support whether ROM exercises should be initiated a few days postoperatively or delayed several weeks until there is evidence of bone ingrowth into the implants. It also is unclear whether early protected motion has a positive impact on ROM outcomes or if it is detrimental to implant fixation or wound healing.116

Therefore, the guidelines and precautions in the following sections for postoperative management are a summary of those cited by several authors based on their experience and training.3,7,20,44,47,83,99,115,116

Immobilization and Weight-Bearing Considerations

Immobilization. The ankle is placed in a compression dressing and immobilized in a neutral position in a well-padded, short-leg cast or posterior splint, which is later replaced with a short-leg walking cast, a removable splint, or ankle-foot orthosis. The duration of continuous immobilization and initiation of ROM exercises vary depending on the type of implant fixation used, the types of concomitant surgical procedures performed during the arthroplasty and the surgeon's recommendations. For example, if a tibiofibular syndesmosis or subtalar fusion was performed, no motion is allowed for 6 weeks or until there is evidence of boney union.66,67 If a soft tissue procedure, such as an Achilles tendon lengthening or ligament repair, was required, the period of immobilization may be extended. If there was no boney fusion or soft tissue repair, as little as 2 to 3 weeks or as many as 6 weeks of immobilization after cementless fixation is recommended.3,83,115,116

Weight-bearing considerations. A patient must always wear an ankle immobilizer when initiating weight bearing after TAA. Recommendations for the initiation and extent of weight bearing after cementless fixation range from minimal weight bearing to weight bearing as tolerated immediately—or by 2 weeks—after surgery3,7,44,47 to nonweight-bearing for 3 weeks to 6 weeks.83,115,116 If a tibiofibular syndesmosis or hindfoot fusion was performed or a malleolar fracture requiring stabilization occurred during surgery, weight bearing is not permitted for at least 6 weeks.66,67 After a period of restricted weight bearing, a patient gradually progresses to full weight bearing over several weeks while still wearing the immobilizer. This is followed by a gradual return to weight bearing without the immobilizer after 6 weeks.47,83

Exercise: Maximum Protection Phase

The first phase of postoperative rehabilitation, which extends for about 6 weeks, focuses on the patient becoming functionally mobile immediately after surgery with attention to protecting the operated ankle and controlling postoperative edema. During this phase, beginning ROM exercises of the operated ankle may be permissible.

Goal and interventions. In addition to elevating the operated foot and ankle for edema control, maintaining mobility proximal to the operated ankle or other arthritic joints, and improving strength of the upper extremities and nonoperated lower extremity, goals and interventions include the following.3,20,83,116

• Re-establish independent ambulation and functional mobility.

  • Gait training with assistive devices and transfers, adhering to weight-bearing restrictions.

• Minimize atrophy of the ankle and foot muscles of the operated limb.

  • Low-intensity, isometric (muscle-setting) exercises of the ankle musculature while in the immobilizer.

• Prevent stiffness of the operated ankle and foot and loss of extensibility of surrounding soft tissues and regain ROM.

  • Active ROM of the toes.

  • Gentle, active ROM exercises if removal of the immobilization is allowed and wound healing is sufficient. Initially, include ankle dorsiflexion and plantarflexion, but postpone active inversion, eversion, and circumduction until after 6 weeks.

NOTE: ROM of the operated ankle may be permitted as early as 4 weeks after surgery but often is postponed until after postoperative week 6.

Exercise: Moderate and Minimum Protection Phases

Except in cases of poor soft tissue healing or delayed bone ingrowth, use of the immobilizer is gradually discontinued and weight-bearing restrictions are removed about 6 weeks after surgery. During the intermediate and advanced phases of postoperative rehabilitation after TAA, which may last as long as 6 months, emphasis is placed on increasing the range of ankle dorsiflexion and strength of the ankle plantarflexors.83 Improving standing balance and ankle proprioception also are important for a gradual return to functional activities.

The level of physical activity possible after TAA depends on many factors, including the type of arthritis (DJD versus RA), other joint involvement, the patient's overall health status, and his or her goals for recovery.

Goals and interventions. During the final phases of rehabilitation, the goals and interventions include116:

• Achieve 100% of the ROM obtained intraoperatively.

  • Active, pain-free ROM exercises first in nonweight-bearing and then in weight-bearing positions. Include dorsiflexion/plantarflexion, inversion/eversion, and circumduction.

  • Stretching of the gastrocnemius-soleus muscle group if dorsiflexion is limited. Begin with a towel stretch in a long-sitting position; progress to standing on a wedge for an extended period of time.

• Restore strength, muscular endurance, and balance in the lower extremities for functional activities.

  • Low-intensity, high-repetition, open-chain, resisted exercises against elastic resistance and closed-chain exercises, such as squats, lunges, and heel raises.

  • A progression of bilateral and unilateral balance activities on stable and unstable surfaces. (Refer to Chapters 8 and 23 for examples.)

• Improve aerobic capacity and cardiopulmonary endurance.

  • Swimming, stationary cycling, treadmill walking.

• Resume a safe level of work-related and recreational activities.

  • Integration of strength and balance training into simulated functional activities.

  • Activity modification for joint protection and patient education to help the patient return to safe and appropriate activities.

The amount of ankle dorsiflexion required while pedaling a bicycle can be adjusted by raising or lowering the seat height. A lower seat height requires greater dorsiflexion.

PRECAUTIONS: Plyometric training and other activities that involve high-impact and quick stop-and-go motions are not appropriate after TAA.143

Return to fitness and sports activities. With advances in TAA design and surgical techniques and increasing knowledge of long-term outcomes and the eventual need for revision arthroplasty, it is now possible for selected patients—typically younger patients (< 50 to 60 years of age) who were physically active prior to surgery and underwent unilateral TAA for posttraumatic arthritis—to return to low-demand (and some moderately demanding) athletic and fitness activities.143 Unlike the consensus documents describing activities that are and are not recommended by surgeons following total hip and knee replacement (see Table 20.5 and Box 21.5), a consensus of recommendations has not yet been published for physical activity after TAA. Typically, low-impact activities, such as swimming, cycling, and walking, are advocated to reduce the risk of ankle dislocation and implant loosening or wear. Participation in such activities is advisable only after completion of an individualized rehabilitation program and if the patient is free of complications.100,143 Results of two studies of patient-reported sports and fitness activities after TAA are summarized in the following section on outcomes.

Outcomes

As discussed previously, although early total ankle arthroplasty afforded pain relief for a period of time,37 there were unacceptably high rates of complications, leading to poor functional outcomes and patient dissatisfaction.37,66,115,116 Now that intermediate results of second and third generation implant systems and refined surgical techniques combined with more judiciously selected surgical candidates are becoming available, contemporary TAA is encouraging. Long-term success, however, is still in question.3,37,44,66,115,116 It is important to note that there have been no studies to date that have compared rehabilitation conditions, such as early versus delayed weight-bearing or ROM exercises following TAA.

Measurements of pain, ROM, general level of function, patient satisfaction, and postoperative complications are outcomes most often reported in follow-up studies. A variety of quantitative assessment instruments are used to measure pain relief, postoperative function, and patient satisfaction. Descriptors of outcomes, from "excellent" to "poor," are based on data from these scales. Two examples of assessment instruments are the Ankle Osteoarthritis Scale and the American Orthopedic Foot and Ankle Society Questionnaire.

Pain relief, functional improvement, and patient satisfaction in different populations. Evidence from prospective studies suggests the survival rates of implants are similar for patients with OA (primary or posttraumatic arthritis) and RA at a median follow-up of 14 years69 and for patients older or younger than 50 years of age, at a median follow-up of 6 years.67 Survival rates (the percentage of prostheses not requiring removal) in the former study were 72.7% and 75.5% respectively in the patients with OA and RA and in the latter study were 75% and 80.6% respectively in the younger and older patients.

Bai and colleagues3 conducted a prospective study to compare outcomes following mobile-bearing ankle replacement in patients with posttraumatic arthritis versus primary OA. At a mean follow-up of 38 months, no significant differences between groups were found in ankle ROM, radiographic findings, and an ankle-hindfoot assessment scale. Survival rates of the implants were comparable between the posttraumatic and primary OA groups (97% and 100% respectively) at the conclusion of the study. However, the rate of complications was significantly higher (38% versus 27%) in the group of patients with posttraumatic arthritis compared with the primary OA group.

Outcomes for a frequently used second generation, two-component system and more recently developed third generation, three-component (mobile-bearing) designs have been reported but not directly compared. Knecht67 reported positive outcomes (reduced pain and increased function) in 66 patients who had undergone a two-component ankle replacement a mean of 9 years earlier. The mean total arc of dorsi- and plantarflexion measured in 33 patients was 18°.

Buechel and colleagues7 followed 50 patients (mean age 49 years), who had received a mobile-bearing replacement with cementless fixation. They reported 48% excellent and 40% good results at a mean follow-up of 5 years (range 2 to 10 years). Of the 50 patients who participated in the study, 26% reported no pain after TAA; 60% reported slight or mild pain; and 14% reported moderate or severe pain that interfered with functional activities. The mean total arc of dorsi- and plantarflexion was 28°. In a short-term follow-up study of 116 patients who had a different mobile-bearing prosthesis implanted in 122 ankles, 84% of patients were satisfied, with 82% reporting good or excellent results at an average of 19.9 months.48 The mean total arc of ankle dorsi- and plantarflexion was 39°. Although postoperative gains in ROM reported in these studies were small (often as little as 5° to 10°), gains of even a few degrees have been reported to improve functional mobility.116

Participation in physical activities. Although most outcome studies of TAA focus on prosthetic survival rates and changes in clinical measurements, the ability to return to a physically active lifestyle is also of interest. Valderrabano and co-investigators143 studied147 patients (mean age 59.6 years, range 28 to 86 years) who participated in sports and recreational activities before and after TAA. Of these patients, 89% had a preoperative diagnosis of posttraumatic arthritis or primary OA, and only 11% had a diagnosis of RA. A combined total of 83% of all patients in the study reported excellent or good results and 69% were pain-free postoperatively. Just prior to surgery, 36% of patients were active in sports/recreational activities, and 56% were active at a mean of 2.8 years after surgery. This change reflected an increase in the activity level of the patients with posttraumatic arthritis and primary OA, not of the patients with RA. The most frequently reported preoperative activities (in descending order) were cycling, swimming, hiking, and low-impact aerobics. After surgery, hiking was most frequently reported followed by cycling, swimming, and aerobics. The only significant change in activity before and after surgery was an increase in hiking (partipation spiked from 25.5% to 52.8%). The authors recommended that before initiating any sport activity after ankle replacement, a patient should complete postoperative rehabilitation and be free of complications.

In a subsequent investigation, Naal and colleagues100 reported the results of a study comparing the preoperative and postoperative activity levels of 101 patients who had undergone ankle replacement. The diagnoses of the study participants were posttraumatic arthritis (46.5 %), primary OA (34.7%), and RA (18.8%). One year prior to surgery, 62.4% were active in sports and fitness activities, whereas 66.3% were active at an average of 3.7 years after surgery. The types of activities and the frequency of participation before and after surgery were essentially unchanged. However, 65% of those surveyed indicated that performance during their preferred activities had improved. Swimming, cycling, and weight training for fitness were the most frequently performed activities before and after surgery. Although some patients participated in high-impact sports, such as jogging, soccer, and tennis, before surgery, few or none participated in these activities at follow-up, perhaps because of postoperative patient education. Interestingly, sports participation after TAA decreased in the group of patients with posttraumatic arthritis. Consequently, of the three groups, these patients were least satisfied with their postoperative ability to participate in sports.

It is important to note that the long-term impact of sports participation following TAA has yet to be determined.

Arthrodesis of the Ankle and Foot

Arthrodesis (fusion) is the most frequently used surgery for late-stage arthritis of the ankle or one or more of the joints of the foot and toes. It typically is the procedure of choice for relatively young, active patients with posttraumatic arthritis and gross instability of the ankle and hindfoot.125,139 Arthrodesis also is an option for patients with hindfoot or forefoot involvement as the result of RA or JRA.9,20 Deformities of the forefoot, such as hallux valgus or hallux rigidus, and severe deterioration of the MTP joint of the first toe also are managed with arthrodesis.1,9,20,23

Indications for Surgery

The following are frequently cited indications for surgical fusion of selected joints of the ankle and foot.1,9,20,37,62,125,139

• Debilitating pain, particularly during weight bearing, and severe articular degeneration secondary to posttraumatic arthritis, primary OA, RA, infection, or other inflammatory arthropathies

• Marked instability of one or more joints

• Deformity of the toes, foot, or ankle associated with chronic joint malalignment as the result of congenital anomalies, neuromuscular disorders, or arthritis

• Patients with high functional demands and pain-free compensatory movements in adjacent joints

• A salvage procedure after failed TAA when revision arthroplasty is not an option

NOTE: For patients with RA or primary OA of both ankles, bilateral arthrodesis is rarely performed, because loss of dorsiflexion bilaterally makes it difficult to get up from a chair or ascend or descend stairs.

Procedures

There are many types of arthrodesis; however, all involve the use of bone grafts coupled with internal fixation devices (see Fig. 12.2) or occasionally external skeletal fixation for boney ankylosis. Internal fixation can be achieved via multiple compression screws, pins, an intramedullary nail, or a plate. The type of fixation selected depends on the joint(s) to be fused and the types of deformity. For correction of severe deformity or tendon rupture, concomitant soft tissue procedures are required.

Arthrodesis of the ankle or foot almost always is performed through an open approach. Over the past decade, however, arthroscopic or arthroscopically assisted arthrodesis of the ankle has become an option for select patients with severe pain at the tibiotalar joint but without significant fixed deformity.10,104,106,122,131 Specifically, an arthroscopic approach cannot be used if a varus or valgus deformity is greater than 5° to 10°.131 The most consistently suggested benefit of an arthroscopic approach is a reduced rate of wound healing complications because of less disruption of soft tissues during surgery.122,139

There have been reports of a more rapid rate of fusion with an arthroscopic approach compared to an open approach. However, this potential benefit is based largely on data from nonrandomized, retrospective studies and therefore, cannot be substantiated.104,106,131,139

Common Types of Arthrodesis

Arthrodesis of the ankle. When the tibiotalar joint is fused, it is positioned in 0° of dorsiflexion, 5° of hindfoot valgus, and 5° to 10° of external rotation of the foot on the tibia to match the rotation of the opposite lower extremity.17,62,115,125,139 Although ankle arthrodesis provides pain relief and ankle stability, dorsiflexion and plantarflexion are lost, thus altering the biomechanics and speed of gait and increasing energy expenditure during ambulation.139 The hindfoot and forefoot compensate to a great extent for the loss of motion at the ankle. Despite this, an asymmetrical gait pattern is detectable in most patients after ankle arthrodesis.17

When the gait of 27 patients, who had undergone tibiotalar arthrodesis at a mean duration of 44 months, was analyzed and compared with the gait of 27 age-matched normal individuals, investigators found significant differences between groups. Cadence and stride length were significantly decreased in the arthrodesis group as were motions of the hind-foot and midfoot during the swing and stance phases of gait. In addition, radiographic evaluation demonstrated evidence of severe hindfoot arthritis in 15% of the arthrodesis group.138

Arthrodesis of the hindfoot. Severe instability or chronic malalignment and deformity of the hindfoot, such as pes valgus or pes planus, and pain as the result of advanced hind-foot arthritis may require a triple arthrodesis or a single-joint fusion, such as talonavicular or talocalcaneal (subtalar) arthrodesis. A triple arthrodesis—often indicated for a rigid hindfoot deformity—involves fusion of the talocalcaneal, talonavicular, and calcaneocuboid joints.91 A single-joint fusion, such as a talonavicular arthrodesis, may be sufficient to correct a chronic but flexible hindfoot deformity.30,64,117 In most instances, the hindfoot is positioned in 5° of valgus in each of these fusions.

Talonavicular, subtalar, or triple arthrodesis provides permanent medial-lateral stability and relief of pain in the hind-foot, but pronation and supination of the ankle are eliminated or substantially diminished. It is interesting to note that fusion of the talonavicular joint alone indirectly reduces motion at the subtalar and calcaneocuboid joints, providing added frontal plane stability without fusing additional joints.30,117

Arthrodesis of the first toe. Fusion of the first MTP joint for hallux rigidus and hallux valgus provides relief of pain, most notably during ambulation.1,23,54 The position of fusion is neutral rotation, 10° to 15° of valgus, and 15° to 30° of MTP extension. This allows adequate push-off during ambulation but also enables a patient to wear some types of commercially available shoes.20,23,54 If the lateral MTP joints also are involved, fusion of the great toe is performed after—not before—excision or implant arthroplasty of the lateral joints.9,20,141

Arthrodesis of the IP joints of the toes. Fusion of the IP joints of the toes in a neutral position for hammer toes, which usually occur in the second and third toes, provides relief of pain for ambulation and correction of deformities of the toes to improve shoe fit.54

Complications

The overall rate of complications associated with arthrodesis is relatively low but varies with patient population, the joints involved, and surgical techniques.139 The most common complication is nonunion, occurring in up to 10% of arthrodesis procedures and typically requiring revision arthroplasty.38,117,139

The smaller the area of the boney surfaces and the poorer their vascular supply, the higher the rate of nonunion. Factors that contribute to nonunion include postoperative infection, malalignment of the fused joint, and a patient's use of tobacco before and after surgery.64,91 Delayed wound healing is a particular problem in patients with poor vascularity of the foot and ankle. Furthermore, nerve damage can occur during surgery, or a neuroma can develop postoperatively, causing pain and limiting function. Occasionally, a postoperative stress fracture of one of the fused bones or adjacent bones occurs.

Postoperative Management

Immobilization. The method and duration of immobilization of the fused joint(s) are determined by the surgeon and are based on the site of the fusion, the type of fixation used, the quality of fixation achieved, the patient's bone quality, and the presence of factors that affect bone healing, such as systemic inflammatory disease and preoperative use of corticosteroids.

At the close of surgery, a compression dressing and splint are applied and worn for 48 to 72 hours for edema control. For an ankle or hindfoot arthrodesis, after the compression dressing has been removed, a short-leg cast is applied for an extended period of time, usually 4 to 8 weeks. During the first 6 weeks, frequent cast changes are necessary as swelling subsides. A short-leg walking cast or rigid boot is applied at about 4 to 8 weeks, and immobilization continues for an additional 6 to 8 weeks.30,64,91,106,115,117,125 After arthrodesis of the first MTP joint, a short-leg cast or surgical shoe with a flat, rigid sole is worn to protect the joint as it heals.1,23

When there is evidence of fusion, the patient is weaned from the immobilizer over several weeks. After splint use is discontinued, the patient should be advised of proper shoe selection, modification, and fit. The use of a custom-made foot orthosis may be necessary for support, relief of pressure, or shock absorption.20

Weight-bearing considerations. As with postoperative immobilization, published guidelines for the timing and extent of weight bearing permissible after arthrodesis vary considerably. The same considerations that influence decisions about immobilization also influence the progression of postoperative weight bearing on the operated extremity. The most prevalent practice is to substantially restrict weight bearing for many weeks after open or arthroscopic arthrodesis. Initially, a patient must ambulate with crutches or a walker and is not allowed to bear weight on the operated side for 4 to 8 weeks.1,64,91,106,115,117,125,131 When there is radiographic evidence of boney healing, partial weight bearing is permitted, while the patient wears a rigid short-leg boot or shoe. Full weight bearing without an immobilizer usually is permitted by 12 to 16 weeks postoperatively.

In an effort to reduce recovery time and improve a patient's quality of life during this time, the safety of early weight bearing is being investigated. To date, most studies have assessed the effects of early weight bearing only after arthroscopic ankle arthrodesis. In select patient populations, early results are encouraging. However, randomized, prospective studies have not yet been done.

Cannon and co-investigators10 conducted a nonrandomized, retrospective study of two comparable groups of patients who had undergone arthroscopic ankle arthrodesis. One group (n=16; mean age 48) wore a short-leg cast and was not permitted to bear weight on the operated limb for 8 weeks. In contrast, the other group (n=23; mean age 51) was encouraged to bear as much weight as was comfortable on the operated limb within the first few days after surgery while wearing a rigid boot that immobilized the ankle and foot.

At 8 weeks, all patients in both groups had radiographic evidence of boney union, and by 4 months, all had achieved ankle fusion. There were no significant differences between groups in the rate of postoperative complications. The investigators concluded that an early weight-bearing regimen is safe after arthroscopic ankle arthrodesis provided the ankle is protected by a rigid splint. However, the investigators cautioned that early weight bearing after arthrodesis is not appropriate for patients with reduced sensation in the foot and ankle.

Postoperative exercises. Initially, postoperative exercises focus on ROM of the nonoperated joints proximal or distal to the joints that are immobilized. If the patient is wearing a removable splint, ROM exercises of the nonoperated joints confined by the immobilizer may be permissible early in the rehabilitation program as well.10 For example, after ankle or hindfoot arthrodesis, exercises to maintain toe mobility are indicated in addition to knee ROM. For a patient with RA, active ROM is essential in all involved joints not controlled by the immobilization device.

When boney fusion has occurred and use of the immobilizer has been discontinued, there are often signs of postimmobilization muscle weakness, hypomobility of joints adjacent to the arthrodesis, and impaired balance. In such instances, exercises described previously in this chapter for nonoperative management of chronic joint hypomobility are appropriate.

Return to physical activities. Unlike TAA, no studies investigating patients' level of participation in recreational and sport activities after arthrodesis of the ankle or foot have been published to date. However, surgeons and athletic trainers have been surveyed and their opinions reported.146 In general, participation in low-impact, but not high-impact, sports is permitted. However, some low-impact activities, such as cycling, can be difficult after tibiotalar arthrodesis because of loss of dorsiflexion, which is necessary for pedaling.

Outcomes

Short-term and intermediate outcomes. Following arthrodesis, boney union is achieved in the ankle, more than 90% of the time37,38 but varies with the number and location of joint(s) fused, the extent of preoperative deformity, and the underlying pathology. When healing is complete after arthrodesis, pain relief and joint stability are predictable outcomes, resulting in improved functional mobility. However, after tibiotalar arthrodesis, in particular, patients continue to face functional challenges, such as difficulty walking on uneven surfaces and inclines and ascending and descending stairs.

Long-term outcomes. Although arthrodesis provides pain relief in the fused joint(s), it also imposes increased stresses on contiguous joints, leading to excessive compensatory motion and eventual degeneration of these joints.37 Consequently, there can be long-term adverse functional outcomes after arthrodesis. For example, Coester and colleagues17 carried out a long-term follow-up study of 23 patients who had undergone isolated ankle arthrodesis for posttraumatic arthritis a mean duration of 22 years earlier. They found a significantly higher rate of arthritis in the joints distal (sub-talar, talonavicular, naviculocuneiform, tarsometatarsal, and first MTP) but not proximal to the fused tibiotalar joint compared with the same joints of the contralateral lower limb. In addition, based on information from standardized, self-report functional assessment instruments, ipsilateral foot pain interfered with the functional mobility of almost all patients.

Leg, Heel, and Foot Pain: Nonoperative Management

The cause of pain in the leg, heel, or foot is multifactorial, but most commonly occurs from biomechanical stress or overload. It is often described as an overuse syndrome from repetitive microtrauma, but is also described as degenerative without inflammation.137 The biomechanical stress may be from obesity, work habits, faulty alignment of the lower extremity, muscle imbalances or fatigue, changes in exercise or functional routines, training errors, improper footwear for the ground, functional demands placed on the feet, or a combination of several of these factors.36, 87,137 The symptoms occur because continued demand is placed on the tissue before it has adequately healed. A common cause predisposing this region to painful syndromes is excessive pronation of the subtalar joint during weight-bearing activities. The pronation could be related to a variety of causes including excessive joint mobility, leg-length discrepancy, femoral anteversion, external tibial torsion, genu valgum, or muscle flexibility and strength imbalances in the lower extremity. Often, there is a hypomobile gastrocnemius-soleus complex related to the abnormal foot pronation.

Related Pathologies and Etiology of Symptoms

The extrinsic foot musculature may develop symptoms either at or near its proximal attachment in the leg (shin splints), or where coursing around boney prominences in the ankle, or at its distal attachment in the foot (tendonitis/tenosynovitis). Symptoms also may develop in the intrinsic muscles of the foot as well as in the plantar fascia (plantar fasciitis). Several common syndromes are described in this section.

Heel Pain

The Heel Pain Committee of the American College of Foot and Ankle Surgeons (ACFAS) published a revised clinical practice guideline (CPG)137 that categorizes mechanical heel pain as: plantar heel pain (including plantar fasciitis, plantar fasciosis, and heel spurs) and posterior heel pain (including insertional Achilles tendinopathy, and bursitis). The Orthopaedic Section of the American Physical Therapy Association has published two separate CPGs, one for heel pain (plantar fasciitis)87 and one for Achilles pain, stiffness, and muscle power deficits (Achilles tendinitis).12 Recommendations from these CPGs are included in the following information.

Plantar fasciitis. Pain is usually experienced along the plantar aspect of the heel, where the plantar fascia inserts on the medial tubercle of the calcaneus. The site is very tender to palpation. Pain occurs on initial weight bearing after periods of rest, then decreases, but returns as weight-bearing activity increases.87,137 Associated impairments include hypomobile gastrocnemius-soleus muscles and plantar fascia pain or restriction when extending the toes creating the windlass effect. A high body-mass index, inappropriate footwear, and a flexible flat foot (pes planus) may be predisposing factors. Conversely, stress forces on the fascia also may occur with an excessively high arch (cavus foot). Pressure transmitted to the irritated site with weight bearing or stretch forces to the fascia, as when extending the toes during push-off, causes pain.

A heel spur may develop at the site of irritation on the calcaneus, causing pain whenever the heel is on the ground. The individual usually avoids heel-strike during the loading response of gait.

Achilles tendinopathy (Achilles tendinitis/Achilles bursitis). Pain is experienced at the midportion of the tendon (2 to 6 cm proximal to the insertion on the calcaneus) or at the calcaneal insertion. Associated impairments include decreased ankle dorsiflexion, decreased strength in ankle plantarflexion, and increased foot pronation.36,75,112 Reported risk factors include obesity, hypertension, and diabetes.12 Pain and stiffness in the tendon occur following a period of inactivity and initially decrease with a return to activity but then increase with additional activity. Symptoms may develop when the person switches from high-heeled to low-heeled shoes followed by a lot of walking.

Tendinosis, Tendonitis, and Tenosynovitis

Any of the tendons of the extrinsic muscles of the foot may become irritated as they approach and cross behind or over the ankle or where they attach in the foot. Pain occurs during or after repetitive activity. When the foot and ankle are tested, pain is experienced at the site of the lesion as resistance is applied to the muscle action and also when the involved tendon is placed on a stretch or when palpated.13,36,98 A common site for symptoms is proximal to the calcaneus in the Achilles tendon or its sheath (Achilles tendonitis or peritendinitis) as described in the heel pain section. Tendon degeneration in the posterior tibial tendon is a common source of pain and leads to impaired walking and acquired flatfoot deformity.73 Symptoms in the anterior or posterior tibialis tendons or peroneus tendons are also associated with athletic activities, such as running, tennis, and basketball.98

Shin Splints

This term is used to describe activity-induced leg pain along the posterior medial or anterior lateral aspects of the proximal two-thirds of the tibia. It may include different pathological conditions such as musculotendinitis, stress fractures of the tibia, periosteitis, increased pressure in a muscular compartment, or irritation of the interosseous membrane.

Anterior shin splints. Overuse of the anterior tibialis muscle is the most common type of shin splint. A hypomobile gastrocnemius-soleus complex and a weak anterior tibialis muscle as well as foot pronation are associated with anterior shin splints. Pain increases with active dorsiflexion and when the muscle is stretched into plantarflexion.

Posterior shin splints. A tight gastrocnemius-soleus complex and a weak or inflamed posterior tibialis muscle, along with foot pronation, are associated with posterior medial shin splints. Pain is experienced when the foot is passively dorsiflexed with eversion and with active supination. Muscle fatigue with vigorous exercise, such as running or aerobic dancing, may precipitate the problem.

Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities)

• Pain with repetitive activity, on palpation of the involved site, when the involved musculotendinous unit is stretched, and with resistance to the involved muscle

• Pain on initial weight bearing and with repetitive weight-bearing activities and gait

• Muscle length-strength imbalances, especially tight gastrocnemius-soleus muscle group

• Abnormal foot posture (may be from faulty footwear)

• Decreased length of time the individual can stand and decreased distance or speed of ambulation, which may restrict associated community and work activities and recreational and sports activities

Leg, Heel, Foot Pain: Management—Protection Phase

If signs of inflammation are present, treat as an acute condition, with rest and appropriate modalities. (See Chapter 10 for general principles and guidelines.) Immobilization in a cast or splint with the foot slightly plantarflexed or use of a heel lift or custom orthotic inside the shoe may relieve stress.26,75,112

• Apply cross-friction massage to the site of the lesion.

• Initiate gentle muscle-setting contractions or electrical stimulation to the involved muscle in pain-free positions.

• Teach active ROM within the pain-free ranges.

• Instruct the patient to avoid activity that provokes pain.

• Use supportive taping or orthotic shoe insert to provide relief of symptoms.12,53,73,87,101,137

Leg, Heel, Foot Pain: Management—Controlled Motion and Return to Function Phases

When symptoms become subacute, the entire lower extremity as well as the foot should be examined for impaired alignment or muscle flexibility and strength imbalances. Eliminating or modifying the cause is important to improve outcomes and prevent recurrences.16,152 Orthotic devices may be necessary to correct alignment.75,77,112 Therapeutic exercises may be helpful to increase flexibility and improve general muscle performance. Detailed descriptions of stretching and strengthening exercises for the ankle and foot are in the last section of this chapter.

A multicenter, randomized study of 60 subjects with plantar heel pain compared two treatment groups, one receiving electrophysical agents and exercise, and the other treated with manual interventions (vigorous soft tissue techniques and joint mobilization directed at the hip, knee, and ankle/foot as needed) and exercise. There was a significant improvement in both groups in functional measures and pain, with those receiving the specific manual interventions and exercise showing greater differences at 4-week and 6-month follow-up.16

Educate the Patient and Provide Home Exercises

• Help the patient incorporate home exercises and soft tissue and joint mobilization into his or her daily routine.

• If the patient experiences pain when first bearing weight, especially in the morning and after prolonged sitting, teach the patient to do ROM exercises (especially dorsiflexion) or alphabet writing with the foot for several minutes before standing.

• Teach prevention, including the following principles.

  • Before intense exercise, use gentle repetitive warm-up activities followed by stretching of tight muscles.

  • Use proper foot support for the ground conditions (this cannot be overemphasized).

  • Allow time for recovery from microtrauma after high-intensity workouts

Stretch Range-Limiting Structures

• The gastrocnemius-soleus muscle complex is frequently hypomobile in cases of foot problems and should be stretched if limiting dorsiflexion. Restricted mobility causes the foot to pronate when the ankle dorsiflexes.

• With heel pain (fasciitis, heel spurs), apply joint and soft tissue mobilization techniques.16

  • Deep massage to the insertion of the plantar fascia at the medial calcaneal tubercle and the gastrocnemius-soleus tendon.

  • Joint mobilization directed to specific limitations such as lateral glide to the subtalar joint to improve rearfoot inversion and posterior glide to the talus to improve ankle dorsiflexion.

  • Stretching exercises to the plantar fascia

• Stretching exercises to any lower extremity region that may affect alignment and function of the foot and ankle.

Instruct patients with pes planus to wear supportive shoes with medial arch support when performing standing gastrocnemius-soleus stretches to protect the foot.56

Improve Muscle Performance

• Begin with resistive isometric and progress to resistive dynamic exercises to the foot and ankle in open- and closed-chain activities.

• For medial and lateral support, develop a balance in strength between the muscle groups, especially the invertors and evertors.

• Emphasize muscular endurance, and train the muscles to respond to eccentric loading.12,73

• With plantar fasciitis, the intrinsic muscles need to be strengthened. Include exercises that require toe control, such as scrunching tissue paper or a towel and picking up marbles and other small objects with the toes.

Ligamentous Injuries: Nonoperative Management

After trauma, the ligaments of the ankle may be stressed or torn. First- and second-degree (grades I and II) sprains are usually treated conservatively. The most common type of ankle sprain is caused by an inversion stress and can result in a partial or complete tear of the anterior talofibular (ATF) ligament and often the calcaneofibular (CF) ligament (see Fig. 22.2).51,114 The posterior talofibular (PTF) ligament, the strongest of the lateral ligaments, is torn only with massive inversion stresses. If the inferior tibiofibular ligaments are torn after stress to the ankle, the mortise becomes unstable. Rarely do the components of the deltoid ligament become stressed; there is greater likelihood of an avulsion from or fracture of the medial malleolus with an eversion stress. Depending on the severity of injury, the joint capsule also may be involved, and intra-articular pathology, including articular cartilage lesions, may occur,70 resulting in symptoms of acute (traumatic) arthritis.

Common Structural and Functional Impairments, Activity Limitations, and Participation Restrictions (Functional Limitations/Disabilities)

• Pain when the injured tissue is stressed in mild to moderate injuries.

• Excessive motion or instability of the related joint in the case of complete tears.

• Proprioceptive deficit manifested as decreased ability to perceive passive motion and development of balance impairments.32

• Related joint symptoms and reflex muscle inhibition.

• Possible decreased ROM of the talocrural joint in recurrent lateral ankle sprains due to anterior subluxation and impaired tracking of the talus in the mortise.147

• Postural control deficits following an acute lateral ankle sprain in both the injured and uninjured limb.84

• Restricted ambulation (requiring an assistive device) during the acute and subacute phases. With chronic instability, the individual may have difficulty walking or running on uneven surfaces or making quick changes in direction. He or she may be unable to land safely when jumping or hopping or may fall more frequently.

A study of recreational athletes with chronic ankle instability (n=15) and matched healthy athletes without instability (n=15) tested single limb postural stability on a moving surface while simultaneously performing a cognitive activity. Results showed when the cognitive activity was performed, there was significantly poorer postural stability in those with chronic instability than in those without instability. The authors suggest that this demonstrated decreased automaticity of postural control in the group with ankle instability.109

Acute Ankle Sprain: Management—Protection Phase

See Chapter 10 for principles of treatment during stages of inflammation and repair.

• If possible, examine the ankle before joint effusion occurs. To minimize the swelling, use compression, elevation, and ice. The ankle should be immobilized in neutral or in slight dorsiflexion and eversion.

• Use gentle joint mobilization techniques to maintain mobility and inhibit pain.

• Educate the patient.

  • Teach the patient the importance of RICE (rest, ice, compression, and elevation), and instruct the patient to apply ice every 2 hours during the first 24 to 48 hours.

  • Teach partial weight bearing with crutches to decrease the stress of ambulation.34

  • Teach muscle-setting techniques and active toe curls to help maintain muscle integrity and assist with circulation.

Green and associates35 studied 38 individuals following acute ankle sprain (within 72 hours of injury and requiring partial weight bearing). All subjects received RICE intervention. Those randomly assigned to the experimental group (n=19) also received gentle anterior-posterior (AP) joint mobilization techniques to the talocrural joint with the foot positioned in dorsiflexion. Range of pain-free ankle dorsiflexion, gait speed, step length, and single support time were measured. The majority of those in the experimental group were discharged after fewer treatments (13 of 19 subjects by the fourth treatment), having gained full range of dorsiflexion, whereas only three subjects in the control group met this criterion and required additional treatment. Also, subjects in the experimental group demonstrated improved stride speed compared to the control group.

Ankle Sprain: Management—Controlled Motion Phase

• As the acute symptoms subside, continue to provide protection for the involved ligament with a splint during weight bearing. Fabricating a stirrup out of thermoplastic material and holding it in place with an elastic wrap or Velcro straps provides stability to the joint structures while allowing for the stimulus of weight bearing for proprioceptive feedback and proper healing. Commercial splints, such as an air splint, are also available to provide medial-lateral stability while allowing dorsiflexion and plantarflexion.40,63

• Apply cross-fiber massage to the ligaments as tolerated.

• Use grade II joint mobilization techniques to maintain mobility of the joint.

• Teach the patient exercises to be done within tissue tolerance at least three times per day. Suggestions include:

  • Nonweight-bearing AROM into dorsiflexion and plantarflexion, inversion and eversion, toe curls, and writing the alphabet in the air with the foot.

  • Sitting with the heel on floor and scrunching paper or a towel and picking up marbles with the toes.

  • If adhesions are developing in the healing ligament, have the patient actively move the foot in the direction opposite the line of pull of the ligament. For the anterior talofibular ligament, the motion is plantarflexion and inversion. Also, stretch the gastrocnemius-soleus muscle group for adequate dorsiflexion. Progress to weight-bearing stretches when the patient's recovery allows.

  • As swelling decreases and weight-bearing tolerance increases, progress to strengthening, endurance, and stabilization exercises; include isometric resistance to the peroneals, bicycle ergometry, and partial to full weight-bearing balance board exercises. Have the patient wear a brace or splint that restricts end-range motion to control the range and prevent excessive stress on the healing ligament.34

Ankle Sprain: Management—Return to Function Phase

• Progress strengthening exercises by adding elastic resistance to foot movements in long-sitting (open-chain) and sitting with the heel on the floor for partial weight bearing. Use isokinetic resistance if a unit is available.

• Progress postural/stabilization and proprioceptive/balance training for ankle stability, coordination, and neuromuscular response with full weight-bearing activities.

  • Incorporate movement patterns, such as forward/backward walking and cross-over side stepping with elastic resistance secured around the unaffected lower extremity.43

  • Utilize an unstable surface, such as a BOSU® or BAPS® board.33,113,150

  • Depending on the final goals of rehabilitation, train the ankle with weight-bearing activities, such as walking, jogging, jumping, hopping, and running, and with agility activities, such as controlled twisting, turning, and lateral weight shifting.

• When the patient is involved in sports activities, the ankle should be splinted, taped, or wrapped, and proper shoes should be worn to protect the ligament from reinjury.23

Twenty-five individuals with postacute (3 to 4 weeks) lateral ankle sprain (unilateral grade I or II), who exhibited postural sway instability in the sprained ankle (modified Romberg Test), were tested under two conditions (with a commercial air splint and nonbraced control) with two dependent variables (shuttle-run and vertical-jump). The tests were repeated after 5 to 7 days of wearing the splint during ADLs to determine if acclimation to the brace affected performance. Results demonstrated immediate performance enhancement, while wearing the air splint for the shuttle-run test (mean 9.43 ± 0.72 seconds) compared with the nonbraced condition (mean 9.57 ±pm 0.75 seconds) in sessions 1 and 2, demonstrating that an acclimation period was not necessary for the stabilizing benefit. The vertical jump did not show improvement when the splint was worn.40

A systematic review of the literature was carried out to determine the effectiveness of balance and coordination training for lateral ankle instability and revealed the following.85 Prophylactic balance and coordination training is effective in reducing the risk of ankle sprains; the effect is greater in those with a history of sprains (strong evidence) than for those without prior injury. There was inadequate evidence to show that training prevented ankle sprains in those without prior injury. The review also demonstrated that balance and coordination training substantially improved treatment outcomes after acute ankle sprains, but the evidence is inconclusive regarding improved postural control. The authors suggested that self-reported function is improved (limited, but promising evidence) in those with chronic ankle instability who complete balance and coordination training.85

Traumatic Soft Tissue Injuries: Surgical and Postoperative Management

Repair of Complete Lateral Ankle Ligament Tears

A third-degree (grade 3) sprain of the lateral ankle, which usually occurs as the result of a severe inversion injury, causes a complete tear or rupture of the anterior talofibular (ATF) ligament, often the calcaneofibular (CF) ligament, and only occasionally, the posterior tibiofibular (PTF) ligament (Fig. 22.7).31,128 Tearing of both the ATF and CF ligaments leads to combined instability of the tibiotalar and subtalar joints. The ATF ligament is most likely to tear when forceful inversion occurs while the ankle is plantarflexed.130 Associated injuries that occur include articular cartilage lesions, a transverse fracture of the lateral malleolus, or an avulsion fracture of the base of the fifth metatarsal.29,31,114,145

FIGURE 22.7

A complete tear of the lateral collateral ligament complex as the result of a severe (grade 3) inversion injury of the ankle. (From McKinnis, LN: Fundamentals of Musculoskeletal Imaging, ed. 3. FA Davis, Philadelphia, 2010, p. 432, with permission.)

In addition to significant swelling, tenderness, and often times pain, a complete tear of one or more lateral ligaments causes marked mechanical instability and functional instability of the ankle during weight-bearing activities. Mechanical instability is defined as ankle mobility beyond the physiological ROM, increased talar tilt, and an anterior drawer sign indicative of joint laxity, whereas functional instability is characterized by the patient's sensation of the ankle "giving way."49,132 The severity of functional ankle instability does not appear to be directly related to the magnitude of anterior joint displacement or talar tilt.49 This may be why as many as 20% of patients without evidence of mechanical instability complain of the ankle "giving way" after a severe lateral ankle sprain, thus significantly impairing functional activities.18

After an acute, grade 3 inversion injury, nonoperative treatment is successful for most patients. However, some patients continue to have pain and a "giving way" sensation and sustain recurrent inversion injuries after the acute injury has healed, leading to chronic, symptomatic instability. For patients with demonstrated mechanical instability who do not respond to nonoperative management and for select patients with acute lateral ankle injuries who regularly engage in high-impact activities, surgical repair or reconstruction may be required to manage the instability and return the patient to a desired level of function.18,31 The overall goal of surgery and postoperative management is to restore joint stability while retaining pain-free, functional ROM of the ankle and subtalar joints.18,31,41,42,128

Indications for Surgery

The following are frequently cited indications for surgical repair or reconstruction of the soft tissues of the lateral aspect of the ankle.29,31,41,128,136

• Chronic mechanical and functional instability of the ankle during activity, which remains unresolved after conservative management.

• Acute, third-degree lateral ankle sprain resulting in a complete tear of the ATF and/or CF ligaments.

Procedures

Types of Stabilization Procedures

There are numerous surgical procedures that may be used for repair and reconstruction of the lateral ligaments and associated structures of the ankle (Fig. 22.8).11,19,29,31,52,128,136 Arthroscopy, for the most part, is reserved for perioperative examination to assist the surgeon in identifying pathologies associated with ankle instability that may not be readily evident through physical examination or during the ligament surgery.11,29 The various procedures for ligament repair, however, are performed almost exclusively through an open approach, although arthroscopic repair of ATF ligament tears by means of staples or bone anchors has been reported.127

FIGURE 22.8

Lateral view of the ankle depicting reconstruction of torn ATF and CF ligaments using a tendon graft to augment stability. Proximal advancement and suturing of the extensor retinaculum (not shown) over the reconstructed ligaments to the distal fibula provide additional stability.

Open procedures are classified into two broad categories: those that primarily involve a direct (anatomic) repair of the torn or attenuated (overstretched) ligaments and those that involve tenodesis (tendon graft and transposition) to reconstruct the lateral ankle complex and augment joint stability.72 During the last decade an arthroscopic, thermally assisted capsular shift was introduced as an alternative to open repair for select patients.52

The type of procedure selected depends on the severity and chronicity of the instability, the presence of co-morbidities, the age of the patient, and the patient's anticipated postoperative activity level. Some procedures are used predominantly for a primary repair, whereas others are reserved for revision surgery.

Direct repair. The surgery used most commonly for a primary repair is an open procedure called the modified Broström procedure, also known as the Broström-Gould procedure.29,41,42,46 This procedure involves an anatomic repair with direct suturing of the torn ATF and/or CF ligament ends, imbrication (reefing) of lax ligaments in a pants-and-vest manner to tighten the ligament and provide a double layer of reinforcement or reinsertion of an avulsed ligament to bone. The lateral aspect of the ankle is reinforced by advancing the lateral portion of the extensor retinaculum proximally over the repaired structures and suturing it to the anterior aspect of the distal fibula.

The advantages of the modified Broström procedure are that it provides stability (without the need to harvest a soft tissue graft) while retaining full ROM of the tibiotalar and subtalar joints, an outcome particularly important to individuals who wish to return to activities that require full ankle mobility, such as gymnastics and ballet.

Reconstruction with augmentation. The other broad grouping of procedures are those that use a tenodesis, usually a tendon autograft and transposition of the peroneus brevis tendon, to reinforce the lateral ankle complex with or without ligament repair. Examples of early procedures, classified as nonanatomic, include various modifications of the Evans, Chrisman-Snook, and Watson-Jones procedures.18,31,46 These early procedures, all of which provided additional reinforcement to the joint to augment stability but sacrificed a portion of the ankle evertors and often limited the range of inversion available after surgery, also were associated with increased risk of osteoarthritis of the subtalar and talocrural joints.72

To preserve the integrity of the peroneal tendons, anatomic reconstruction procedures using a gracilis tendon autograft19,136 or a bone-patellar tendon allograft134 have been developed as alternatives to a peroneal tendon autograft. Reconstruction procedures, in general, are employed when primary repair is not an option because of deterioration of the torn ligament(s) or as a revision procedure when previous direct repair has failed to prevent recurrence of lateral instability. Reconstruction with augmentation also is used occasionally during a primary repair for large patients, specifically those weighing more than 200 to 250 pounds.41

Arthroscopic thermally assisted capsular shift. Similar to its use for glenohumeral joint instability, arthroscopic, thermally assisted capsular shift (capsulorrhaphy) is a relatively new type of procedure for the chronically unstable ankle. The procedure shrinks and tightens attenuated lateral ligaments and the joint capsule by means of radiofrequency or laser energy for the purpose of improving joint stability. The long-term success of this procedure at the ankle has not yet been determined. (Refer to Chapters 12 and 17 for additional discussions of thermally assisted capsular shift.)

Operative Overview

Prior to an open repair or reconstruction for lateral ankle instability, arthroscopy is performed to assess the extent of intra-articular pathology, because a high percentage (reported as 77%135 in one study and 93%70 and 95%29 in two other studies) of chronically unstable ankles exhibit associated intra-articular pathology, specifically small articular cartilage lesions, which are thought to be a precursor to osteoarthritis of the ankle. If a chondral lesion is identified, arthroscopic subchondral drilling typically is carried out to manage the lesion.

After arthroscopy, an oblique or vertical incision is made beginning at the anterior aspect of the distal fibula and extending distally along the lateral aspect of the ankle and foot. If a direct repair is used, torn or ruptured structures are identified and sutured in a pants-and-vest manner. If a peroneus brevis tendon graft is to be used to provide additional reinforcement of the lateral ankle, the tendon is split longitudinally. One-half of the tendon is harvested by detaching it proximally at its musculotendinous junction and weaving it through prepared drill holes in the fibula, talus, and/or calcaneus. Then it is doubled back and sutured to itself. The extensor retinaculum is advanced proximally and sutured over the ligament repair to the distal fibula for additional reinforcement.

Prior to wound closure, the stability and ROM of the ankle are checked. The foot and ankle are placed in a compression dressing and well-padded, short-leg, bivalved cast or posterior splint with the ankle in 0° of dorsiflexion and slight eversion. The leg is elevated for control of joint swelling and peripheral edema.

Postoperative Management

In the past decade, there has been a trend to allow early postoperative weight bearing while the ankle is immobilized and in select patients, early but protected ROM after lateral ligament reconstruction. The exercise progression after surgery is similar to that used for nonoperative management of lateral ankle sprains. Postoperative management is geared toward not only returning a patient to a pre-injury level of function, but also toward preventing re-injury.

NOTE: After an arthroscopic thermally assisted capsular shift, the period of continuous immobilization and nonweight-bearing is longer than after an open repair or reconstruction, because the thermally treated ligaments are vulnerable to excessive stress.52

Immobilization and Weight-Bearing Considerations

Immobilization. After some degree of swelling has subsided, usually within 3 to 5 postoperative days or as late as a week to 10 days, the compression dressing and protective cast is removed and reapplied or replaced with a short-leg walking cast that continues to immobilize the ankle in a neutral position. If a short-leg cast is used initially, it may be removed at 4 to 6 weeks and replaced with an air-stirrup-type splint,41 a removable cast-boot, or a controlled active motion (CAM) walking brace, which is worn for several additional weeks.19,29,31,98,130,132,136

By 8 to 12 weeks, the patient gradually discontinues use of the immobilizer during ambulation. However, patients returning to athletic activities that involve jumping, running, and quick changes of direction are advised to wear a protective orthotic device or to tape the ankle for at least 3 to 6 months or even indefinitely to prevent re-injury.

Weight-bearing considerations. Immediately after surgery the patient must remain nonweight-bearing on the operated extremity while the ankle is in the compression dressing and protective cast or posterior splint. When the compression dressing is removed and the short-leg walking cast applied, protected weight bearing is initiated as early as 3 to 4 weeks. Weight bearing is gradually progressed to full weight bearing by 6 weeks.19,29,31,41,130,132,136 Full weight bearing without the immobilizer during ambulation usually is postponed until about 3 months after surgery.

Exercise: Maximum Protection Phase

The focus of the first phase of rehabilitation, which lasts from 4 to 6 weeks, is to regain independent mobility for functional activities while protecting the repaired or reconstructed lateral ankle structures. Ambulation with crutches, nonweight-bearing on the operated extremity, is initiated directly after surgery. Elevation of the operated foot is essential when the patient is resting to control peripheral edema and reduce pain. ROM of the operated ankle is not permitted during this period.

Goals and interventions. The following exercise-related goals and interventions are appropriate during the first postoperative phase.31,41,130,132

• Maintain strength of nonimmobilized muscle groups. Perform active or gentle resisted exercises of the hip and knee of the operated lower extremity and resistance exercises of the upper extremities and sound lower extremity. When partial weight bearing is permissible and if the immobilizer, such as a boot or posterior splint, allows a small degree of dorsi- and plantarflexion, perform mini-squats in bilateral stance while using a walker for support.

• Prevent reflex inhibition of immobilized muscle groups. While the ankle is immobilized, begin gentle, pain-free muscle-setting exercises of the ankle musculature including isometric contractions of the peroneal muscles.

Exercise: Moderate and Minimum Protection Phases

By the intermediate phase of rehabilitation, which begins at approximately 4 to 6 weeks and continues to about 12 weeks postoperatively, healing structures are able to sustain progressive but controlled levels of stress. Ankle ROM typically is limited and painful with end-range overpressure. Lower extremity strength and balance are impaired from weeks of restricted weight bearing as well.

This phase is characterized by a gradual weaning from the immobilizer and restoring pain-free ankle mobility and neuromuscular control during weight bearing without jeopardizing stability of the ankle joint. Because most patients are allowed to bear full weight on the operated extremity by 6 weeks after surgery while wearing the immobilizer, improvement of lower extremity strength and balance is now possible.

The focus of the final phase of rehabilitation is to restore strength and muscular endurance of the operated lower extremity equal to that of the sound side, re-establish a normal, pain-free gait pattern, and prepare the patient to safely return to necessary and desired work-related and recreational activities while preventing reinjury of the ankle.31,98,130,132

With proper precautions, a return to functional activities, including select sports, may be possible by 16 weeks postoperatively41,132 or when peroneal muscle strength is normal (compared to the contralateral ankle) and when multiple, pain-free single-leg hops on the operated lower extremity are possible.130

Goals and interventions. The following exercise-related goals and interventions are appropriate during the intermediate and final phases of rehabilitation.

• Restore pain-free ROM of the operated ankle. It is not unusual for a patient to have just a few degrees of ankle dorsiflexion beyond neutral after weeks of immobilization. To increase ankle ROM:

  • Begin assisted or active dorsiflexion and plantarflexion within the limits of pain as soon as the immobilizer may be removed for exercise as determined by the surgeon.

  • Postpone inversion and supination movements until 6 to 8 weeks postoperatively.

  • Progress to multiplanar active motions, such as figure-of-eight movements.

  • Perform grade II or III joint mobilization techniques to the tibiotalar and tibiofibular joint if joint restriction limits dorsi- or plantarflexion. Avoid stretch mobilization of the subtalar joint.

  • Add gentle self-stretching exercises to improve flexibility of specific muscle groups, most frequently the gastrocnemius-soleus complex.

PRECAUTION: It is advisable to begin with stretching in a nonweight-bearing position, such as a towel stretch or closed-chain stretching in a seated position with the foot resting on the floor, because stretching in a standing position imposes significant ground reaction forces on the repaired ligaments.

Functional ankle instability has been shown to be associated with decreased strength (peak torque) of the ankle evertors of the involved ankle when compared with the contralateral ankle in individuals who have not undergone a surgical stabilization procedure.119 In addition, the extent of strength loss in the ankle musculature has been shown to be associated with the chronicity of the instability.57 Therefore, after surgical repair or reconstruction of the lateral ligaments, improving strength of the evertors is particularly important for developing dynamic stability of the ankle.

• Increase isometric and dynamic strength of ankle and foot musculature and throughout both lower extremities.

  • Perform low-intensity, pain-free resistance exercises of all ankle muscles, first in nonweight-bearing and then in weight-bearing positions.

PRECAUTION: Postpone unilateral heel raises in standing to strengthen the plantarflexors on the operated side until late in the rehabilitation process. The risk of reinjury by overstressing the repaired ligament(s) is high if loss of balance and excessive inversion occur during plantarflexion.

• • Emphasize strengthening of the ankle evertors. For isometric strengthening, have the patient cross the ankles and press the lateral borders of the feet together. For dynamic strengthening, perform eversion against elastic resistance (see Fig. 22.13).

  • Include bilateral hip and knee strengthening in nonweight-bearing and weight-bearing positions for proximal control (see Chapters 20 and 21).

  • Progress to plyometric training if weight bearing is pain free. Include jumping, then hopping forward, diagonally, backward, and side-to-side on the floor or a mini-trampoline. (Refer to Chapter 23 for descriptions and illustrations of advanced balance activities and plyometric training.)

• Improve muscular endurance and cardiopulmonary fitness. Begin with pool walking, swimming, stationary bicycling, treadmill walking, or using a cross-country ski machine. Progress to deep-water running and outdoor walking, jogging, or running, being certain the ankle is appropriately supported for land-based activities.

• Improve neuromuscular control, balance reactions, dynamic stability, and agility.

  • Initiate proprioceptive/balance training at about 6 weeks postoperatively or when weight bearing on the operated lower extremity without ankle pain is possible.

  • Include a progression of bilateral to unilateral balance activities first on a level, firm surface, then on a soft surface, such as dense foam, and then on a balance board or BOSU®.

  • Progress to activities to improve agility, such as grapevine walking (carioca), lateral shuffles, use of a slide board, and pivoting and cutting activities.

  • Refer to Chapter 23 for a sequence of balance and agility activities.

For patients with a functionally unstable ankle, proprioceptive/balance training, using rocker or wobble boards has been shown to be an effective method of improving joint proprioception (joint position sense) and single-leg standing ability and reducing postural sway and muscle reaction times during balance activities.28,33,43,113,150

In a prospective study by Verhagen and co-investigators,144 1,127 male and female professional volleyball players from 116 teams were randomly assigned by team to a training group or a control group. Throughout the 36-week volleyball season, the training groups participated in a proprioceptive training program consisting of a variety of balance activities, some on balance boards. The control groups were not given any training program. The training and control groups kept track of injuries sustained during the season. Among players who had a history of lateral ankle sprains prior to the beginning of the study, those who participated in the balance training program had a significantly lower incidence of acute lateral ankle sprains during the season than those in the control group. Among training and control group players who did not have a history of lateral ankle sprains, there was no significant difference in the incidence of ankle injury during the season. The authors concluded that proprioceptive training was effective in preventing recurrence of lateral ankle injury in adult volleyball players.

Although this and other studies have not involved patients undergoing rehabilitation after repair or reconstruction of the lateral ankle ligaments, proprioceptive training programs such as these may be beneficial for the postoperative patient.

• Re-establish pain-free, symmetrical weight bearing during gait and related activities.

  • Begin gait training in a pool or land-based training on level surfaces as soon as ambulation in a controlled ankle motion brace (which allows dorsi- and plantarflexion) is permitted.

  • Emphasize symmetrical weight bearing during sit-to stand movements and eventually ascending and descending stairs.

  • Progress to ambulation and functional activities without the brace.

• Safely return to functional activities and prevent re-injury. Sport-specific training, beginning with low-intensity, simulated movements, usually is permissible by 8 to 12 weeks postoperatively.41,130,132 Precautions to reduce the risk of re-injury when returning to sports or high-demand activities after repair or reconstruction of lateral ankle ligaments are summarized in Box 22.5.

Outcomes

An optimal postoperative outcome after lateral ankle repair or reconstruction is an ankle that has full mobility but remains stable and pain-free during functional activities. At this time, an open approach for primary repair or reconstruction provides more predictable long-term results than an arthroscopic stabilization procedure.18,29 Although not an optimal result, a slight loss of ankle motion, possibly 5° to 10° of eversion, occurs most often after nonanatomic reconstruction (tenodesis) procedures.136

Current and past reviews of studies involving patients with chronic lateral ankle instability indicated that 87% to 95% of patients report excellent or good results after surgery.29,108,136 (Based on a variety of clinical and functional assessment instruments, an "excellent" result is the absence of symptoms with full activity, and a "good" result is the ability to participate in full activity with some symptoms.29) Similar results were reported in a postoperative follow-up study of ballet dancers who had undergone a modified Broström procedure a mean of 64.3 months earlier.42 Results of a subsequent retrospective study29 revealed that 100% of 21 patients who underwent the same surgical procedure for chronic ankle instability demonstrated excellent and good results 60 months after surgery.

Several studies have compared the results of a direct anatomic repair with reconstruction with a tendon graft (tenodesis). Hennrikus and associates46 compared two types of lateral ankle reconstruction, one using anatomic repair (modified Broström procedure) and the other involving augmentation with a peroneus brevis tendon graft (Chrisman-Snook procedure). Both procedures yielded good to excellent results in 80% of patients, but the latter was associated with a higher rate of complications.

In a multicenter, retrospective, nonrandomized study, Krips and colleagues72 evaluated two groups of athletes (n=77) who had undergone either direct anatomic repair or a reconstruction with a tenodesis procedure for chronic lateral ankle instability 2 to 10 (mean 5.4) years earlier. There were no significant differences in preoperative characteristics of the athletes in the two groups. All had participated in a nonoperative treatment program for at least 6 months before surgery. Physical examination at follow-up revealed significantly more patients (15 of 36) in the tenodesis group had limited ankle ROM than patients (3 of 41) in the anatomic repair group. Functional abilities reported by patients on a quantitative questionnaire were rated as excellent and good by 21 of 36 subjects in the tenodesis group and by 36 of 41 in the anatomic repair group. Those in the tenodesis group reported a noticeably diminished push-off power on the operated side during running. They also reported a lower activity level and a perception of less ankle stability than those in the anatomic repair group. The authors concluded that an anatomic repair was a better choice than tenodesis for primary repair of chronic ankle instability in an athletic population.72 However, current-day anatomic reconstruction methods, which more closely restore normal ankle kinematics, do not appear to be associated with restricted postoperative ROM or increased incidence of arthritis.120

In summary, primary anatomic repair or reconstruction of the lateral ligaments effectively stabilizes the ankle joint and enables patients to return to functional activities. That said, successful outcomes may be compromised for some patients due to continued or late onset of ankle or foot pain if intra-articular pathology associated with the acute injury or chronic instability, such as a bone spur or chondral lesion, is not identified and treated in conjunction with the stabilization procedure.136

BOX 22.5 Activity-Related Precautions to Reduce the Risk of Re-injury After Lateral Ligament Reconstruction of the Ankle

• Modify activities, if possible, by participating in low-impact sports, such as swimming, cycling, low-impact aerobics, or cross country skiing.

• Minimize or avoid participation in activities that involve high-impact (basketball, volleyball), rapid stopping and starting and changes of direction (tennis, soccer), or traversing uneven surfaces.

• If involved in activities associated with high risk of ankle injury:

  • Participate in a pre-season injury prevention program that includes progressive proprioceptive and plyometric training and continue the program throughout a sport season.144

  • Wear a prescribed orthotic device, such as a functional stirrup brace or splint, to provide medial-lateral stability of the ankle.130

  • Tape the ankle or insert a slight lateral lift in the shoe.86,98

Repair of a Ruptured Achilles Tendon

Acute rupture of the Achilles tendon is a common soft tissue injury, occurring more frequently in men than in women, 30 to 50 years old, who intermittently participate in exercise or athletic activities.4,61,151 The rupture usually is associated with a forceful concentric or eccentric contraction of the gastrocnemius-soleus muscles (triceps surae) during sudden acceleration or abrupt deceleration, such as jumping or landing.8 Degenerative and mechanical factors appear to increase the risk of acute rupture, including decreased strength or flexibility of the plantarflexors, excessive body weight, preexisting tendinosis, corticosteroid injections into the tendon, and decreased vascularity of the tendon.8

The tendon often ruptures proximal to the distal insertion of the tendon on the calcaneus.45 At the time of injury, a complete rupture leads to pain, swelling, a palpable defect, and significant weakness in plantarflexion. It also is associated with a positive Thompson test (absence of reflexive plantarflexion when the patient is prone-lying with the knee flexed or the knee extended and the foot over the edge of a table and the calf squeezed).90,140

Historically, an acute rupture of the Achilles tendon has been managed nonoperatively or surgically with an extended period of cast immobilization or functional bracing combined with restricted weight bearing with both approaches to treatment. There is general agreement in the literature and in clinical practice that surgical intervention is recommended for the elite athlete wishing to return to a high-demand sport as quickly as possible78 and for the young, regularly active individual, but nonoperative management is the better option for the relatively sedentary individual, older than 50 to 60 years of age.4,61,151 Furthermore, surgery is considered the only option for the symptomatic patient with a chronic rupture in which the diagnosis or treatment was delayed 4 weeks or more.90,96,148

Several systematic reviews and meta-analyses of the literature that included only prospective, randomized, and quasi-randomized studies have revealed there is insufficient evidence to indicate whether the nonoperative or operative option is the better treatment strategy or yields better outcomes.4,61,151 Both options have their advantages and disadvantages. With surgical repair followed by postoperative rehabilitation, there is a lower rate of rerupture of the tendon than with nonoperative management, but there also is a risk of wound closure problems, infection, and nerve injury with surgery. Nonoperative management typically requires a longer immobilization and recuperative time and is associated with a higher rate of deep vein thrombosis (DVT).4,15,61,62,151 There is a trend, however, to minimize the duration of immobilization and restricted weight bearing with surgical as well as nonoperative management. Consequently, evidence is emerging to suggest that when either approach to management includes accelerated rehabilitation, outcomes, including rerupture rates, are similar.89,149 Both patient and surgeon, therefore, must weigh the different advantages and disadvantages of surgery and nonoperative treatment in the decision-making process.

Indications for Surgery

The following are frequently cited indications for surgical repair or reconstruction of an acute or chronic rupture of the Achilles tendon.

• Acute, complete rupture of the Achilles tendon8,14,15

• Typically indicated for the elite athlete or active individual who wishes to return to high-demand functional activities4,15,78,151

• Chronic, previously undiagnosed or untreated complete rupture in which end-to-end apposition cannot be achieved by conservative means96,148

Procedures

Primary versus Delayed Repair

There are a considerable number of surgical procedures and techniques for repair or reconstruction of a ruptured Achilles tendon.8,14,15,94,95,148,151 An open, minimally invasive, or percutaneous surgical approach can be used for a primary repair.5,21,76,78,129 However, only an open approach is used for a delayed repair requiring reconstruction of the torn tendon.

Primary repair of an acute rupture is performed within the first few days after the injury and usually is carried out with a direct, end-to-end repair in which the ends of the torn tendon are re-opposed and sutured together.8 The repair site may or may not be reinforced by some method of tissue augmentation. Delayed repair of a chronic rupture requires reconstruction and augmentation of the tendon most often by an autograft, or tendon transfer, or possibly an allograft.96,148 Structures that may serve as a donor graft are the flexor hallucis longus, plantaris, or peroneus brevis tendons or a flap of fascia from the gastrocnemius muscle.

Operative Overview

Primary repair. With a percutaneous repair, the tendon ends are located and sutured together through several small puncture wounds that are made along the medial and lateral aspects of the Achilles tendon or through several small transverse incisions made directly over the tendon.39,78 In an open primary repair, a posterior incision is made at the distal leg just medial to the Achilles tendon. Placing the incision medial of the tendon avoids possible damage to the sural nerve. The tendon ends are identified; frayed fibers are removed; and the ends re-opposed and sutured together.8 A minimally invasive approach uses a less lengthy skin incision but provides the surgeon with a smaller visual field than with a fully open approach. The tendon end is identified and sutured and then guided subcutaneously to a boney drill hole for the repair.5,88 In each of these approaches, the tendon is repaired while the ankle is maintained in a slightly plantarflexed or neutral position.

Delayed repair/reconstruction. With a tendon reconstruction, a second incision is made to harvest the donor graft. If, for example, the flexor hallucis longus (FHL) tendon is selected, an incision is made along the medial aspect of the sole of the foot at the midmetatarsal level. A sufficient portion of the FHL tendon is left distally, so the remaining portion can be sutured to the flexor digitorum longus tendon to retain active flexion of the first toe.148 The harvested portion of the FHL tendon then is woven into and sutured to bridge the gap of the Achilles tendon ends.

Before closure, the ankle is moved through the ROM to assess the stability of the repair or reconstruction. A compression dressing and below-knee posterior splint are applied after closure with the ankle usually positioned in 15° to 20° of plantarflexion.8,148 If immediate or very early postoperative weight bearing is to be allowed by the surgeon, the ankle is placed in a neutral position (0° of dorsiflexion), if possible, and stabilized with a rigid anterior splint.58

NOTE: An above-knee cast is applied (and later replaced with a below-knee cast) if the rupture occurred at the myotendinous junction or the quality of the repair is tenuous.8

Complications

Complications associated with surgical repair or reconstruction of a ruptured Achilles tendon that may negatively affect postoperative outcomes are summarized in Box 22.6.15,61,88, 92,93,149,151 A meta-analysis of randomized controlled trials revealed that one-third of patients experience some type of complication following open repair of a ruptured Achilles tendon.61 The risk of complications associated with operative management decreases with minimally invasive and percutaneous approaches compared with an open approach for repair.88

Of the complications noted in Box 22.6, rerupture and severe wound infection have the greatest negative impact on long-term postoperative outcomes. For example, patients who experience reruptures after repair are most likely to discontinue or change postrehabilitation sports activities.88 It is important to note that some complications, including tendon rerupture, DVT, decreased ankle ROM, and impaired strength or endurance of the plantarflexors, also occur with nonoperative treatment of Achilles tendon ruptures, particularly when the injury is managed with an extended period of cast or brace immobilization in plantarflexion and restricted weight bearing.15,61,92,93,151

BOX 22.6 Complications Following Primary Repair of a Ruptured Achilles Tendon

• Tendon rerupture or failure of the tendon to heal (palpable gap)

• Wound complications: infection, delayed healing of the incision

• Sural nerve injury leading to altered sensitivity of the lateral border of the foot

• Adherent or hypertrophic scarring

• Deep vein thrombosis or pulmonary embolism

• Restricted ankle ROM as the result of joint hypomobility or soft tissue adhesions or contractures, leading to impaired function, such as difficulty ascending or descending stairs due to limited dorsiflexion

• Strength and muscular endurance deficits, typically of the plantarflexors

• Pain at the site of a suture knot

• Complex regional pain syndrome (rare)

Postoperative Management

Guidelines for postoperative rehabilitation after a primary open repair of an acute Achilles tendon rupture vary considerably in the literature and clinical practice. These guidelines tend to fall within two categories: (1) use of a traditional (conventional) management strategy or an early remobilization and/or (2) weight-bearing approach, sometimes referred to as accelerated functional rehabilitation.149 The duration of continuous immobilization and the initiation of weight bearing distinguish one approach from the other.

Guidelines for management after percutaneous repair vary as well and are often quite similar to postoperative guidelines following open repair or reconstruction. Therefore, specific guidelines for percutaneous repair are not addressed in the following sections but can be found in other resources.21,39,76,78,129

Immobilization and Weight-Bearing Considerations: Conventional versus Early Remobilization Approaches

Conventional approach. After an open primary repair of an acute Achilles tendon rupture, conventional postoperative management, a widely used practice for many years, involves approximately 6 weeks of continuous immobilization with the ankle held in plantarflexion at least a portion of that time.4,8,15,39,90,92 The patient remains nonweight-bearing on the operated extremity during most or all of this time. After a delayed tendon reconstruction with graft augmentation for a chronic rupture, the duration of time before motion and weight bearing are initiated is longer, usually an additional 2 weeks or more.148

Table 22.2 summarizes immobilization and weight-bearing guidelines associated with conventional management after primary Achilles tendon repair.4,8,15,92,133 Although this approach is safe and associated with a low risk of rerupture, extended immobilization, traditionally thought to be necessary to protect the healing tendon, has been shown in some studies to lead to deficits in strength, particularly in the plantarflexors, and loss of ROM of the ankle.13,90, 94,129

TABLE 22.2Conventional Postoperative Management After Achilles Tendon Repair or Reconstruction with Graft*

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TABLE 22.2 Conventional Postoperative Management After Achilles Tendon Repair or Reconstruction with Graft*

Early remobilization and weight-bearing approach. For the past two decades or more, there has been a trend to decrease the period of continuous postoperative immobilization and to initiate early ankle ROM in a protected range and early weight bearing in a functional orthosis.13,45,58,79,81,89, 94,95,111,126, 133,149 An accelerated rehabilitation approach is an option after primary repair of an acute rupture—but not after a delayed reconstruction. Early motion and weight bearing are possible because of advances in surgical procedures, such as stronger suturing techniques and materials and sometimes the use of soft tissue augmentation to reinforce the primary repair.14,58,79,81,89,94,95,126,133,149

Although published recommendations for accelerated functional rehabilitation following open repair vary widely, hallmarks of this approach include a very brief period (1 to 2 weeks) of continuous immobilization in a cast or splint followed by early ankle and weight bearing in a below-knee (boot-like) functional brace or dorsal or posterior splint. If bracing is prescribed, it often is a hinged, controlled ankle motion (CAM) orthosis that can be locked in various positions.111 The orthosis is adjusted to allow movement but only in a protected range, typically limiting dorsiflexion beyond neutral.13,45,92 If a rigid dorsal splint is used, its configuration limits dorsiflexion to 0° but allows plantarflexion.58,79

Initially, the brace or splint holds the ankle in plantarflexion but is adjusted (or refabricated in the case of a splint) to neutral or less plantarflexion by 2 weeks postoperatively.45,79,89,133,149 During the first 6 weeks of rehabilitation, the protective orthosis is worn during ambulation with progressive weight bearing and at all other times except when removed for wound care and select exercises.

When the patient is able to ambulate on level surfaces without pain while bearing full weight on the operated extremity, the protective boot or splint is gradually discontinued (usually by 8 to 10 weeks postoperatively). As with a conventional approach, after discontinuing the functional brace or splint, many surgeons prescribe a 1.0- or 1.5-cm heel lift for both shoes. The lifts are worn for several weeks to decrease ground reaction forces during functional activities.94

The guidelines for initiating and progressing weight bearing and ankle ROM recommended in published programs differ from study to study. A summary of these guidelines is presented in Box 22.7.58,79,89,111,133,149 Common to all early remobilization programs is the use of safe levels of applied stress while protecting the healing tendon. Close communication among the surgeon, therapist, and patient is essential for success with this approach to postoperative management.

BOX 22.7 Features of Early Weight-bearing and Remobilization Programs After Repair of Acute Achilles Tendon Rupture* Weight-bearing Guidelines

• Initiated as tolerated while using crutches immediately after surgery58,79 or after 1 or 2 weeks89, 92,111,133,149 in a below-knee orthosis with the ankle immobilized most often in plantarflexion or possibly neutral

• Progress gradually to full weight-bearing status between 3 to 6 weeks postoperatively58,111,133,149

• Orthosis worn during all weight-bearing activities for 6 to 8 weeks after surgery111,133

• Full weight bearing without the functional orthosis but wearing regular shoes with bilateral heel lifts when orthosis discontinued beginning at about 6 to 8 weeks postoperatively58,130,133

ROM Exercises

• Immediately58,79,81,126 or by 1 to 2 weeks92,111,130,133,149 after surgery, active plantarflexion and dorsiflexion of the operated ankle initiated while wearing a functional brace or splint to prevent dorsiflexion beyond 15° to 20° of equinus or to no more than a neutral position

• During the first 4 to 6 weeks and with the orthosis removed, ankle inversion and eversion while maintaining the ankle in plantarflexion149

• By 6 to 8 weeks, dorsiflexion to 10° beyond neutral permitted in the orthosis and inversion/eversion out of the orthosis58,92

Although there have been few randomized studies directly comparing a functional bracing or splinting and early motion and weight-bearing program after acute Achilles tendon repair with a program of extended cast immobilization (usually 6 weeks) followed by ROM exercises, a recent meta-analysis of these studies demonstrated that patients managed with an early motion/functional bracing program had a significantly lower rate of adhesion formation and limited ankle ROM. However, the investigators noted that the pooled data from the available studies must be interpreted with caution because of the variety of postoperative regimens used.61

After that review was published, Suchak and colleagues133 reported results of a randomized controlled trial in which 110 patients were assigned to one of two groups following open primary repair for acute Achilles tendon rupture. All patients wore a posterior splint set in plantarflexion and ambulated nonweight-bearing with crutches for 2 weeks after surgery. Then, all patients wore a fixed-angle, hinged ankle-foot orthosis until 6 weeks after surgery. One group was allowed to begin weight bearing (as tolerated) in the orthosis at 2 weeks after surgery; the other group remained nonweight-bearing through the sixth postoperative week and then was permitted to begin weight bearing as tolerated in the orthosis. Both groups gradually discontinued use of the orthosis after 6 weeks and then began a progressive home exercise program.

In addition to a baseline assessment, follow-up evaluations were carried out at 6 weeks, 3 months, and 6 months postoperatively. Outcomes assessed were physical activity level and health-related quality of life (by means of a self-report assessment tool), ankle ROM, calf muscle strength and endurance, return to work, and complications. At 6 weeks, the early weight-bearing group reported significantly better levels of physical and social functioning and patient satisfaction than the nonweight-bearing group based on the quality of life questionnaire. At 6 months, there were no significant differences between groups for any of the outcomes measured. Rerupture did not occur in either group. However, at 6 months, both groups continued to exhibit decreased calf muscle endurance compared with the contralateral side. This study demonstrated that weight bearing initiated during the early postoperative period after tendon repair contributes to a better quality of life and daily activity level without adverse consequences.

Exercise Progression

After open, primary repair of an acute Achilles tendon rupture, the types of exercise included in a postoperative program are similar regardless of whether an early motion/early weight-bearing approach or a conventional (extended immobilization/delayed motion and weight bearing) approach is employed. What is different is the timing and progression of the exercises based on when ROM and weight bearing are permissible.

In the phases of rehabilitation that follow, a progression of exercises designed to help a patient achieve a number of treatment goals and ultimately function at the pre-injury level is presented. The time frame for the initiation of weight bearing on the operated extremity and ankle ROM and the resumption of pre-injury work-related and sports activities must be determined by the surgeon.

Exercise: Maximum Protection Phase

Achilles tendon repair frequently is performed on an outpatient basis. Therefore, patient education is essential before surgery or prior to discharge. It focuses on wound care (if the immobilizer is removable), controlling peripheral edema by elevating the operated leg, gait training, and a home exercise program.

Goals and interventions. The following treatment goals and exercise interventions are appropriate during the first 4 to 6 weeks after surgery.

• Maintain ROM of nonimmobilized joints. In a seated, supine, or prone position, perform active ROM of the hip, knee, and toes of the operated side while wearing the immobilizer.

• Prevent reflex inhibition of immobilized muscle groups. If early ROM is not permitted, begin submaximal, pain-free, muscle-setting exercises of the ankle in the immobilizer within the first few days after surgery. Start with setting exercises of the dorsiflexors, invertors, and evertors. At 2 weeks, add setting exercises of the plantarflexors.

• Prevent joint stiffness and soft tissue adhesions in the operated ankle and foot. If an early motion and weight-bearing approach was planned, begin the ROM exercises within a few days to 2 weeks after surgery as determined by the surgeon (see Box 22.7).

• Begin to restore balance reactions in standing. If partial weight bearing on the operated limb is permitted, perform weight-shifting activities in bilateral stance while wearing the orthosis. Use the parallel bars or another stable surface (countertop, table) for upper extremity support as needed.

• Maintain cardiopulmonary fitness. Use an upper extremity ergometry for endurance training, if available.

Exercise: Moderate Protection Phase

At the end of 4 weeks or more often after 6 weeks postoperatively, the patient typically is permitted to bear weight as tolerated on the operated extremity regardless of whether an early weight-bearing program or conventional program was implemented. However, a functional CAM orthosis or another type of ankle-foot orthosis is worn during progressive weight-bearing activities. Weaning from the orthosis begins at about 6 to 8 weeks and is discontinued by 12 weeks after surgery.133,149 As the patient is weaned from the orthosis, it may be necessary to resume using a cane or crutches for a period of time even if the patient had been ambulating without an assistive device while wearing the orthosis.

During this phase of rehabilitation, which begins at about 4 to 6 weeks and extends to 12 weeks after surgery, the stress placed on the operated tendon and surrounding structures is gradually increased. Patients typically begin a supervised exercise program at this time. Precautions for progressing exercises and functional activities are noted in Box 22.8.133,149

BOX 22.8 Precautions and Guidelines for Exercise and Functional Activities Following Achilles Tendon Repair* General Precautions

• Progress all exercises very cautiously that place resistance or a stretch on the gastrocnemius-soleus muscle group.

• Postpone all unilateral weight-bearing exercises on the operated side until full weight bearing without pain is possible.

Stretching to Increase Ankle Dorsiflexion

• Begin with nonweight-bearing stretches, such as a towel stretch

• Limit dorsiflexion to no more than 10° beyond neutral until 8–12 weeks after surgery

• Initiate weight-bearing stretches in sitting with feet on the floor or a rocker board

• Begin standing stretches in bilateral stance, such as standing on a wedge, only if pain-free

• Postpone unilateral standing stretches or bilateral standing stretches with heels over the edge of a step until advanced activities are permitted (after 12 to 16 weeks) postoperatively.

Resistance Exercises

• Begin strengthening exercises for ankle and foot musculature in nonweight-bearing positions against low-loads (light-grade elastic resistance) before progressing to closed-chain exercises against body weight.

• Cautiously progress heel raising/lowering exercises for closed-chain calf muscle strengthening. (See suggested sequence in Box 22.9.)

• Postpone unilateral heel raising/lowering against full body weight until about 12 weeks postoperatively.

Advanced Training (Plyometric, Agility, Sport-Specific Training)

• Begin plyometric training in a pool (chest-deep progressing to waist-deep immersion).

• Postpone land-based plyometric training and activities that involve high-impact and quick acceleration/deceleration and changes of direction until about 16 weeks postoperatively.

• Teach the patient correct landing technique for proper alignment during jumping and hopping exercises.

• Wear a prescribed functional ankle-foot orthosis or tape the ankle during high-impact, high-velocity activities to minimize the risk of rerupture of the repaired tendon.

Goals and interventions. The following goals and exercises are implemented during the intermediate phase of rehabilitation.

• Increase ROM of the operated ankle with joint mobilization and stretching techniques.

  • Grade III joint mobilization techniques if ankle or foot joints are restricted.

  • Gentle self-stretching exercises, such as a towel stretch in a sitting position, to increase ankle dorsiflexion with the knee extended and slightly flexed.

  • Gentle manual self-stretching to increase inversion/eversion and dorsiflexion/plantarflexion and toe extension.

  • Gentle active ankle ROM with patient seated and foot on a wobble or rocker board.

  • Self-stretching to increase dorsiflexion by standing on a wedge in bilateral stance with knees flexed and extended.

  • Postpone unilateral standing stretches of plantarflexors until the end of this phase of rehabilitation (about 10 to 12 weeks postoperatively).

• Improve strength and muscular endurance of the operated lower extremity. Initiate a progression of open- and closed-chain, low-load, high repetition resistance exercises at 6 to 8 weeks. Emphasize controlled, eccentric loading of the plantarflexors. Perform closed-chain exercises without the orthosis as its use is gradually discontinued. Examples of resistance exercises include:

  • Open-chain resistance exercises for the hip, knee, and ankle musculature against a light grade of elastic resistance.

  • Closed-chain exercises, such as bilateral progressing to unilateral heel raising and lowering while seated.

  • Standing heel raising/lowering in bilateral stance against the resistance of body weight. (See Box 22.9 for a suggested sequence of heel raising/lowering exercises.) Postpone heel raises in unilateral stance until about 12 weeks after surgery.133

  • Partial lunges with the involved leg forward, bilateral mini-squats, and toe raises.

  • Using handheld weights, a weighted backpack, or a weight belt to add resistance to standing exercises.

A resistance training program should focus on improving muscular endurance as well as strength. Substantial deficits in muscular endurance of the calf muscles of the operated limb compared with the contralateral limb (as determined by the number of unilateral heel raises performed in standing) have been identified in men more than women and have been shown to persist for at least a year after surgical repair of Achilles tendon ruptures. It has been suggested that the presence of resting pain in the Achilles tendon at 3 months postoperatively may be an early indicator of delayed muscular endurance at one year.6

• Improve balance reactions. While wearing the functional orthosis, initiate or continue proprioceptive/balance training in bilateral stance on a firm surface. Progress to soft surfaces and narrow the base of support.

  • While continuing to wear the orthosis, progress to balance training in unilateral stance when full weight bearing is tolerated on the operated side.

  • Transition to a sequence of more advanced balance exercises in supportive shoes (usually with a heel lift inserted) after use of the functional bracing has been discontinued.

• Reestablish a symmetrical gait pattern. When full weight bearing is comfortable and as the patient is weaned from the orthosis, begin gait training, emphasizing symmetrical alignment and weight shifting as well as equal step lengths and timing, paying particular attention to push-off on the operated side.

• Improve cardiopulmonary endurance. Begin and gradually progress level-surface treadmill walking or stationary cycling (recumbent or upright) while wearing the functional, hinged orthosis, if required, or regular shoes with a heel lift. Raise the seat height of the upright bicycle to accommodate for limited dorsiflexion. Progress to treadmill walking on an incline.

Exercise: Minimum Protection/Return to Function Phase

The final phase of rehabilitation, which begins around 12 to 16 weeks postoperatively, is directed toward returning a patient to a pre-injury level of function for expected work-related demands and desired recreational/athletic activities. Stretching exercises continue until full ROM is achieved, and then the patient transitions to a maintenance program.

Strength and muscular endurance training is continued, emphasizing eccentric loading of the gastrocnemius-soleus muscle group with heel-lowering exercises in unilateral stance (see Fig. 22.17) or with resistance equipment. Descending stairs step over step also imposes eccentric loading. Depending on the patient's pre-injury activity level, plyometric training can be initiated in a pool, if available, at the beginning of this phase (see Chapter 23). A variety of activities on a level surface can now be used for cardiopulmonary conditioning as well.

After 16 weeks postoperatively,89,149 begin land-based plyometric training and treadmill walking on an incline. Advance to jogging, running, agility drills (cutting, pivoting), and sport-specific training. Patient education is a priority and focuses on ways to reduce the risk of rerupture of the repaired tendon, such as warming up before strenuous activity and daily stretching. If the strength of the operated extremity is relatively comparable to that of the contralateral extremity, most patients are permitted to resume athletic activities gradually by 5 to 6 months.8,79,92

Outcomes

The ideal outcome is for a patient to return to a pre-injury level of physical activity without pain or rerupture of the repaired Achilles tendon. Patients undergoing primary repair of an acute rupture have consistently better outcomes than those who undergo a delayed repair for a chronic rupture. The longer the delay between injury and repair, the poorer the results.148 The patient population with the highest risk of rerupture after primary repair of an acute rupture is active individuals 30 years of age or younger.111

The results of numerous studies comparing methods of management of acute tendon ruptures have been reported. Methods compared include operative and nonoperative management, open and percutaneous procedures, and conventional (traditional) and "accelerated rehabilitation" (early motion/early weight bearing) approaches to postoperative treatment. Outcomes typically reported are rate of rerupture, ROM, strength, functional or sport-related activity level, and patient satisfaction. Some generalizations can be drawn from systematic reviews of the literature and individual studies.

Nonoperative versus operative management. When comparing outcomes of nonoperative (cast immobilization) with operative management of acute ruptures, three systematic reviews and meta-analyses of the literature have revealed that there is a significantly higher rate of rerupture associated with nonoperative management than with surgical repair.4,61,151 The authors of one of these reviews of randomized trials concluded that there is a three times higher risk of rerupture after nonoperative treatment than after surgery. However, excluding rerupture, operative management is associated with a substantially higher rate of complications than nonoperative treatment, including infection, adhesions, and nerve injury.61 The authors of another one of the reviews noted that when patients who sustain a rerupture are excluded from an analysis of outcomes of nonoperative and operative management, long-term results, including activity level, ROM, and strength, are similar.4

Two recent randomized, controlled trials89,149 directly compared outcomes of surgical and nonoperative approaches to treatment of acute Achilles tendon ruptures with all groups participating in accelerated functional rehabilitation programs postoperatively. Results of these two studies demonstrated no significant differences in outcomes (rerupture rates, ankle ROM, calf muscle strength, or overall functional assessment) between treatment groups in either study. Moreover, there were significantly fewer complications in the nonoperative groups in both studies.

Open versus percutaneous repair. A systematic review of the literature demonstrated that, overall, fewer complications occur with percutaneous versus open repairs.More specifically, complications develop in 10% of patients following percutaneous repair compared with approximately one-third of patients after open repair.61 However, there is no significant difference in the rate of rerupture between the two techniques. A higher rate of wound complications occurs with open repair.39,76 The cosmetic result, not surprisingly, is better with a percutaneous approach, but a higher rate of sural nerve damage occurs when compared with an open approach.151 Postoperative ankle ROM and calf muscle strength are comparable between the two approaches, but return to work typically occurs more quickly when a percutaneous approach is used.

Traditional versus accelerated rehabilitation. Post-injury management that includes "accelerated rehabilitation" (early but protected motion and/or weight bearing) appears to be as safe as management with prolonged cast or fixed-hinge brace immobilization and delayed weight bearing. Follow-up studies have demonstrated that accelerated rehabilitation does not increase the incidence of tendon rerupture.13,59,79,81,89,94,149 In addition, the complications associated with prolonged immobilization, such as DVT and decreased ankle ROM and calf muscle strength, occur less often with accelerated rehabilitation. It remains unclear, however, whether early motion and weight bearing enable a patient to return to a full, pre-injury level of functional activity sooner than if managed with a conventional postoperative approach.59,81,94

In summary, there continues to be controversy as to whether surgical or nonoperative treatment is the better option for management of acute Achilles tendon ruptures. Regardless of which treatment option is selected, it is apparent from the literature that early but protected ankle motion and weight bearing are becoming the standard of care for rehabilitation.90

Which is a common cause of limited ankle dorsiflexion?

Which is a common compensation observed in the overhead squat associated with limited ankle dorsiflexion?

What activities require ankle dorsiflexion?

During which phase of gait is ankle mobility assessed?