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Chapter 23: Rehabilitation of Lower Leg Injuries

Chapter 23: Rehabilitation of Lower Leg Injuries. Functional Anatomy and Biomechanics. Tibia and fibula articulate with the talus Movement of leg is dictated by foot and contact with the ground Impact of pronation on lower leg mechanics Relationship of tibia and femur

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Chapter 23: Rehabilitation of Lower Leg Injuries

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  1. Chapter 23: Rehabilitation of Lower Leg Injuries

  2. Functional Anatomy and Biomechanics • Tibia and fibula articulate with the talus • Movement of leg is dictated by foot and contact with the ground • Impact of pronation on lower leg mechanics • Relationship of tibia and femur • Lower leg functions to transmit ground reaction and rotational forces to the knee

  3. Compartments of the Lower Leg • While in OKC muscle groups of lower leg function primarily in single planes • In a CKC muscle groups work to concentrically and eccentrically • Absorb ground reaction forces • Control excessive motion of the foot • Provide a stable base for propulsion • Anterior Compartment • Functionally controls plantarflexion and foot pronation following heal strike

  4. Deep Posterior Compartment • Control pronation and lower leg internal rotation with weight bearing • Tibialis posterior helps decelerate forward momentum of the tibia during midstance • Lateral Compartment • Peroneus longus plantar flexes first ray of foot at heel off • Peroneus brevis counteracts supinating forces of tibialis posterior and stabilizes subtalar joint and midtarsal regions • Superficial Posterior Compartment • Eccentrically contract controlling pronation and tibial internal rotation during midstance • Concentrically fires during push-off of gait cycle

  5. Rehabilitation Techniques for Specific Injuries • Tibial and Fibular Fractures • Pathomechanics • Generally the result of a direct blow • Present with pain, swelling and possible deformity • Injury Mechanism • Direct contact • Indirectly – rotatory / compressive force • Foot planted  proximal segments rotate with large compressive force

  6. Rehabilitation Concerns • Immobilization with restricted weight bearing • Joint stiffness, atrophy, abnormal gait patterns • Possible post-surgical considerations • Functional demands of athlete • ROM and strength • Cardiovascular endurance • Rehabilitation Progression • Communication is critical with physician when dealing with post-immobilization circumstances • Weight bearing progression • Assistive devices

  7. Range of motion • AROM, passive stretching and joint mobilization • Strengthening • Progression from isometric to isotonic exercise when ROM is normalized • Utilization of assistive devices as needed • When full, pain-free weight bearing balance and proprioceptive training can begin

  8. With improvements in ROM, strength and gait functional activities can continue • Advanced balance training – exercise sandals • Rate of rehabilitation will depend on severity of injury • Non-displaced uncomplicated tibia = 10-13 weeks • If more severe = 16-26 weeks • Fibula, uncomplicated = 4-6 weeks

  9. Criteria for Return to Play • Full ROM and strength • Normalized gait (walking, jogging, running) • Ability to hop for endurance and distance without pain or observable compensation • Successful completion of sports-specific functional testing

  10. Tibial and Fibular Stress Fractures • Pathomechanics • Occur in at a higher rate in tibia • Result of inability to adapt to repetitive loading of lower leg • Bone attempts to adapt through osteoclastic activity resulting in bone breakdown, followed by osteoblastic activity • If stresses not reduce process will result in structural irregularities • Further inability to absorb forces will result leading to stress fracture • Possible connection to ischemic reaction within bone resulting in initiation of remodeling process

  11. Pain which generally subsides with rest • Can progress to problems during performance of ADL’s • Presents with focal point tenderness • Different than medial tibial stress syndrome (MTSS) – more diffuse • Vibration testing positive • Bone scan utilized to confirm diagnosis • Often seen in athletes engaged in running and jumping events

  12. Injury Mechanism • Prevalent in running and jumping athletes • Possible tibial anterior bowing creating tension disrupting bone healing • Compression is ideal for bone healing • Excessive compensatory pronation • Structural malalignments • Forefoot varus • Tibial varum • Femoral anteversion • Each may become more of a factor with increased activity or other training variables • Muscle tension on bone due to increased muscle activity • Other factors • Training errors, poor footwear, menstrual irregularities, diet, bone density increased hip ER, tibial width, calf girth

  13. Rehabilitation Concerns • Immediate elimination of offending activity • Education of athlete • Concerns of lost fitness due to decreased activity • Footwear relative to foot biomechanics • Thorough biomechanical exam • Stretching and strengthening exercises • Modality use and bracing

  14. Rehabilitation Progression • Crutches and possible immobilization • RICE and NSAID’s for inflammation and pain • Begin water running – same training parameters • Gastroc-soleus stretching and strengthening

  15. Progress from isotonic tubing, OKC exercises to CKC exercise training • Exercise sandal progression for lower leg • Custom foot orthotic fabrication • After 3-4 weeks, with symptoms subsiding a gradual walking/jogging progression can begin • Appropriate surfaces • Gradual interval progression – providing gradual increase in stress application

  16. Criteria for Full Return • No tenderness upon palpation of affected bone • No pain in area with repeated jumping • Plain films demonstrate good bone healing • Successful progression of graded return to running and other sports-specific activities • Flexibility WNL • Hyperpronation has been corrected with training and footwear modifications • Correction of muscle strength and length issues have been addressed

  17. Compartment Syndrome • Pathomechanics and Injury Mechanism • Increased pressure within osseofascial compartment resulting in compression of musculature and neurovascular structures • Disrupted blood flow which further compromises situation • Acute compartment syndrome • Secondary to direct trauma – medical emergency • Pain, swelling, tightness, reduction in pedal pulse, sensory changes, reproduction of pain with passive stretching of involved musculature • Increased intra-compartmental pressure • Emergency fasciotomy is definitive treatment

  18. Acute exertional compartment syndrome • No precipitating trauma • Develops with minimal to moderate activity • Increased intra-compartmental pressure with emergency fasciotomy • Chronic compartment syndrome (CCS) • Activity related – symptoms arise consistently at particular point during activity • Pain, tightness, swelling of affected compartment • Signs and symptoms relieved with decreased activity • Elevated intra-compartmental measures

  19. Rehabilitation Concerns • CCS can initially be managed conservatively • Lower quarter screening should be performed to determine structural variation – compensatory motion and stresses • Ice and stretch • Cycling to maintain fitness • Fasciotomy will be necessary if conservative treatment is unsuccessful

  20. Rehabilitation Progression • Post-surgical care • Decrease pain and swelling with RICE and assisted ambulation • Following suture removal AROM and stretching should begin • With improve ROM, weight bearing activity should be increased

  21. Incorporate gait training • Prevent abnormal patterns secondary to joint stiffness or muscle guarding • Incorporate OKC and CKC exercise progressions • Initiate balance and proprioceptive training • May have been impacted due to surgical procedure • Modify lower extremity structural variation and compensatory motion • Continue to manage athlete’s cardiovascular fitness

  22. Criteria for Return to Play • Normal ROM and strength • No gait deviations with walking, jogging or running • Athlete completes progressive jogging/running program with no CCS complaints • Athlete undergoing anterior compartment fasciotomy may require 8-12 weeks to recover from surgery • Posterior compartment fasciotomy may require 3-4 months, post-surgery

  23. Muscle Strain • Pathomechanics • Occur primarily in the medial head of the gastrocnemius at the musculotendinous junction • More common in middle-aged athletes • Result of ballistic activity • Pain with dorsiflexion in CKC position, pain with push-off • Palpable tenderness or divot • Injury Mechanism • Due to sudden ballistic movement • Generally caused by forceful contraction from elongated position (knee extended, ankle dorsiflexed)

  24. Rehabilitation Concerns • Initial treatment = RICE • Limit edema in the foot and ankle • Little stretching early in rehabilitation process • Limited weight bearing and altered gait due to difficulty with dorsiflexion in CKC position • Modified footwear (heel lift) • Gradual stretching, strengthening, functional training • Rehabilitation Progression • Initially RICE with some light towel stretching • AROM of foot and ankle in all planes of motion

  25. With mild strain, athlete will be off crutches in a few days and should begin strengthening in 7-10 days • More severe strains may require 2-4 weeks to regain ROM • Strengthening should incorporate both OKC and CKC exercises • With normalization of gait jogging progression should be initiated • Plyometrics should be incorporated • Gradual return to sports-specific activity

  26. Criteria for Full Return • Full ROM of foot and ankle • Gastrocnemius strength and endurance are bilaterally equal • Ability to walk, jog, run, jump without compensatory motion • Successful completion of sports-specific functional progression with no residual calf symptoms

  27. Medial Tibial Stress Syndrome (MTTS) • Pathomechanics • Pain along the distal 2/3 of the posterior medial aspect of the tibia • Soleus and tibialis posterior have been implicated as muscles that can stress the periosteum of the tibia during activity • Evidence of abnormal histological appearance of bone and periosteum • Diffuse pain that may have a variety of exacerbating factors • Biomechanics, footwear, training errors

  28. Injury Mechanism • Compensatory pronation is often a primary cause • Results in greater tensile stress on musculotendinous units that help to control tri-planar motion at the subtalar joint • Lower extremity structural variations • Rearfoot and forefoot varus • Overuse of plantar flexors • Training surfaces • Rehabilitation Concerns • Physician referral to rule out stress fx • Activity modification while maintaining cardiovascular fitness • Biomechanics correction • Gait, excessive pronation (orthotics) • Lower extremity strengthening • Sandal exercises

  29. Rehabilitation Progression • Eliminate running and jumping for 7-10 days • Modify workouts to maintain fitness (pool) • Work on gastrocnemius-soleus flexibility • Early pain and inflammation treatment via modalities • Initiate general lower leg strengthening (tubing, OCK, CKC, isokinetic strengthening, sandal exercises) • Foot orthotics for mechanics • With pain subsiding a gradual return to activity • Jogging progression with appropriate footwear • Criteria for Full Return • Minimal to no pain on palpation • Excessive pronation has been addressed • Adequate strength and flexibility has been established • Successful completion of running progression

  30. Achilles Tendinitis • Pathomechanics • Inflammatory condition of tendon, tendon sheath or peritenon • Result of excessive tensile stress (medial aspect) • Pain and stiffness proximal to calcaneal insertion (2-6 cm) • Reduced gastrocnemius-soleus flexibility

  31. Injury Mechanism • Gradual onset • Result of repetitive weight bearing activities • Poor training progression – intensity and duration • Excessive compensatory pronation secondary to lower extremity biomechanics or decreased flexibility associated with the gastrocnemius and soleus • Inflammatory response with possible crepitace during AROM, pain with passive dorsiflexion • Rehabilitation Concerns • Often associated with slow healing (vascular supply) • Address structural and biomechanical flaws • Including flexibility and orthotics • Modality and manual therapy techniques for inflammation, scar tissue and adhesion treatment • Strengthening and activity progression for safe return

  32. Rehabilitation Progression • Activity and training modifications immediately • Proper footwear (heel lift, orthotic) must be addressed to reduce stress on tendon • Gentle stretching following modality application • OKC exercises early on and progress to CKC exercises emphasizing concentric/eccentric work • Body weight training for CKC exercises – modifying sets, repetitions, speed and intensity • Gradual running progression as ROM and strength improve • Be sure to set realistic expectations for safe return

  33. Criteria for Full Return • Full resolution with ADL’s and minimal or no symptoms with sports-related activity • ROM, strength and endurance are equal bilaterally • Contributing biomechanic faults have been corrected • Successful completion of activity progression

  34. Achilles Tendon Rupture • Pathomechanics • Injury often presents within avascular region of distal 2-6 cm section of tendon • Sudden plantarflexion moment • Severe pain, popping sensation with limited plantarflexion (palpable defect), positive Thompson test • Injury Mechanism • Sudden forceful plantarflexion • Possible degenerative changes within the tendon • Result of excessive compensatory pronation • Tendinitis symptoms that progress to tendon rupture • Fatigue, improper warm-up prior to ballistic activity

  35. Rehabilitation Concerns • Surgical care vs. immobilization • 6-8 weeks of immobilization following surgical repair • Numerous deleterious effects of immobilization • Return of full ROM is critical with appropriate strength training • Cardiovascular training • Gait normalization (walking, jogging, running) • Rehabilitation Progression • Physician should be involved in determining progression for immobilization to weight bearing and activity levels • Excellent results reported with early and controlled mobilization over 6-8 week period

  36. Controlled progressive weight bearing activity (% BW) • 6-8 weeks post-operatively • Early stages will require RICE for swelling • Gradual work with ROM in all planes • At 4-6 weeks post-operatively tubing exercises should be utilized • Gradual increase to eccentric activity (10-12 weeks) – avoid excessive loading

  37. Isokinetics can be added at submaximal speeds • By 3 months full-weight bearing heel raises can be performed • Initiate walking/jogging progression • Isokinetic testing can be done at 3-4 months to determine deficits • Single-leg heel raises can be substituted • Sports-related functional activities can be initiated at 3 months along with jogging progression • Full unrestricted return can occur after 6 months

  38. Criteria for Full Return • Full AROM • Isokinetic plantarflexion strength at 90-95% of uninvolved side • 90-95% of the number of heel raises throughout full ROM in 30 seconds as compared to uninvolved side • Ability to walk, jog, run without observable limp • Successful completion of sports-related functional progression without Achilles irritation

  39. Retrocalcaneal Bursitis • Pathomechanics • Bursa that lies between the Achilles tendon and calcaneus • Gradual onset of pain, anterior to Achilles • Pain with dorsiflexion, relieved with plantarflexion • Injury Mechanism • Loading of foot and ankle in repeated dorsiflexion resulting in mechanical compression • Uphill running • Structural abnormalities of foot resulting in compensatory motion with increased Achilles tendon friction and bursa irritation

  40. Rehabilitation Concerns • Rule out involvement of calcaneus and Achilles tendon • Rest and inflammation reduction • Period of non-weight bearing may be necessary • Gradual stretching and strengthening • Assess and correct faulty mechanics • Rehabilitation Progression • Early management will require inflammation and pain reduction via RICE, modalities, removal from offending activity, shoeware alterations and modified weight bearing • Maintain fitness through pool running • Gradual addition of gastrocnemius-soleus stretching

  41. As pain resolves and gait is normalized a progressive walking/jogging program can begin • Progress back to activity as condition allows • Heel lifts may be required initially • Shoe modification may be necessary • May be able to return 10-14 days if treated early enough • If pain persists 6-8 weeks of rest and activity modification may be required prior to return • Criteria for Return to Full Activity • No observable swelling and minimal pain with palpation (at rest or following daily activity) • Full AROM dorsiflexion and normal pain-free strength • Normal pain-free walking and running gait

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