Chapter 19: The Ankle and Lower Leg

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Chapter 19 The Ankle and Lower Leg
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Functional Anatomy

• Ankle is a stable hinge joint
• Medial and lateral displacement is prevented by
  the malleoli
• Ligament arrangement limits inversion and
  eversion at the subtalar joint
• Square shape of talus adds to stability of the
  ankle
• Most stable during dorsiflexion, least stable in
  plantar flexion

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• Degrees of motion for the ankle range from 10
  degrees of dorsiflexion to 50 degrees of plantar
  flexion
• Normal gait requires 10 degrees of dorsiflexion
  and 20 degrees of plantar flexion with the knee
  fully extended
• Normal ankle function is dependent on action of
  the rearfoot and subtalar joint

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Preventing Injury in the Lower Leg and Ankle

• Achilles Tendon Stretching
• A tight heel cord may limit dorsiflexion and may
  predispose athlete to ankle injury
• Should routinely stretch before and after
  practice
• Stretching should be performed with knee extended
  and flexed 15-30 degrees
• Strength Training
• Static and dynamic joint stability is critical in
  preventing injury
• While maintaining normal ROM, muscles and tendons
  surrounding joint must be kept strong

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• Neuromuscular Control Training
• Can be enhanced by training in controlled
  activities on uneven surfaces or a balance board
• Footwear
• Can be an important factor in reducing injury
• Shoes should not be used in activities they were
  not made for
• Preventive Taping and Orthoses
• Tape can provide some prophylactic protection
• However, improperly applied tape can disrupt
  normal biomechanical function and cause injury
• Lace-up braces have even been found to be
  superior to taping relative to prevention

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Assessing the Lower Leg and Ankle

• History
• Past history
• Mechanism of injury
• When does it hurt?
• Type of, quality of, duration of pain?
• Sounds or feelings?
• How long were you disabled?
• Swelling?
• Previous treatments?

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• Observations
• Postural deviations?
• Genu valgum or varum?
• Is there difficulty with walking?
• Deformities, asymmetries or swelling?
• Color and texture of skin, heat, redness?
• Patient in obvious pain?
• Is range of motion normal?

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Palpation Bones and Soft Tissue

• Fibular head and shaft
• Lateral malleolus
• Tibial plateau
• Tibial shaft
• Medial malleolus
• Dome of talus
• Calcaneus

• Peroneus longus
• Peroneus brevis
• Peroneus tertius
• Flexor digitorum longus
• Flexor hallucis
• Posterior tibialis

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Palpation Soft Tissue (continued)

• Anterior tibialis
• Extensor hallucis longus
• Extensor digitorum longus
• Gastrocnemius
• Soleus
• Achilles tendon

• Anterior/posterior talofibular ligament
• Calcaneofibular ligament
• Deltoid ligament
• Anterior tibiofibular ligament
• Posterior tibiofibular ligament

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• Special Test - Lower Leg
• Lower Leg Alignment Tests
• Malalignment can reveal causes of abnormal
  stresses applied to foot, ankle, lower leg, knees
  and hips
• Anteriorly, a straight line can be drawn from
  ASIS, through patella and between 1st and 2nd
  toes
• Laterally, a straight line can go from greater
  trochanter through center of patella and just
  behind the lateral malleolus
• Posteriorly, a line can be drawn through the
  center of the lower leg, midline to the Achilles
  and calcaneus
• Internal or external tibial torsion is also a
  common malalignment

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• Percussion and compression tests
• Used when fracture is suspected
• Percussion test is a blow to the tibia, fibula or
  heel to create vibratory force that resonates
  w/in fracture causing pain
• Compression test involves compression of tibia
  and fibula either above or below site of concern
• Thompson test
• Squeeze calf muscle, while foot is extended off
  table to test the integrity of the Achilles
  tendon
• Positive tests results in no movement in the foot
• Homans test
• Test for deep vein thrombophlebitis
• With knee extended and foot off table, ankle is
  moved into dorsiflexion
• Pain in calf is a positive sign and should be
  referred

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Compression Test
Percussion Test
Homans Test
Thompson Test
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• Ankle Stability Tests
• Anterior drawer test
• Used to determine damage to anterior talofibular
  ligament primarily and other lateral ligament
  secondarily
• A positive test occurs when foot slides forward
  and/or makes a clunking sound as it reaches the
  end point
• Talar tilt test
• Performed to determine extent of inversion or
  eversion injuries
• With foot at 90 degrees calcaneus is inverted and
  excessive motion indicates injury to
  calcaneofibular ligament and possibly the
  anterior and posterior talofibular ligaments
• If the calcaneus is everted, the deltoid ligament
  is tested

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Anterior Drawer Test
Talar Tilt Test
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• Kleigers test
• Used primarily to determine extent of damage to
  the deltoid ligament and may be used to evaluate
  distal ankle syndesmosis, anterior/posterior
  tibiofibular ligaments and the interosseus
  membrane
• With lower leg stabilized, foot is rotated
  laterally to stress the deltoid
• Medial Subtalar Glide Test
• Performed to determine presence of excessive
  medial translation of the calcaneus on the talus
• Talus is stabilized in subtalar neutral, while
  other hand glides the calcaneus, medially
• A positive test presents with excessive movement,
  indicating injury to the lateral ligaments

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Kleigers Test
Medial Subtalar Glide Test
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• Functional Tests
• While weight bearing the following should be
  performed
• Walk on toes (plantar flexion)
• Walk on heels (dorsiflexion)
• Walk on lateral borders of feet (inversion)
• Walk on medial borders of feet (eversion)
• Hops on injured ankle
• Passive, active and resistive movements should be
  manually applied to determine joint integrity and
  muscle function
• If any of these are painful they should be avoided

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Specific Injuries

• Ankle Injuries Sprains
• Single most common injury in athletics caused by
  sudden inversion or eversion moments
• Inversion Sprains
• Most common and result in injury to the lateral
  ligaments
• Anterior talofibular ligament is injured with
  inversion, plantar flexion and internal rotation
• Occasionally the force is great enough for an
  avulsion fracture to occur w/ the lateral
  malleolus

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• Severity of sprains is graded (1-3)
• With inversion sprains the foot is forcefully
  inverted or occurs when the foot comes into
  contact w/ uneven surfaces

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• Grade 1 Inversion Ankle Sprain
• Etiology
• Occurs with inversion plantar flexion and
  adduction with stretching of the anterior
  talofibular ligament
• Signs and Symptoms
• Mild pain and disability weight bearing is
  minimally impaired point tenderness over
  ligaments and no laxity
• Management
• RICE for 1-2 days limited weight bearing
  initially and then aggressive rehab
• Tape may provide some additional support
• Return to activity in 7-10 days

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• Grade 2 Inversion Ankle Sprain
• Etiology
• Moderate inversion force causing great deal of
  disability with many days of lost time
• Signs and Symptoms
• Feel or hear pop or snap moderate pain w/
  difficulty bearing weight tenderness and edema
• Positive talar tilt and anterior drawer tests
• Possible tearing of the anterior talofibular and
  calcaneofibular ligaments
• Management
• RICE for at least first 72 hours X-ray exam to
  rule out fx crutches 5-10 days, progressing to
  weight bearing

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• Management (continued)
• Will require protective immobilization but begin
  ROM exercises early to aid in maintenance of
  motion and proprioception
• Taping will provide support during early stages
  of walking and running
• Long term disability will include chronic
  instability with injury recurrence potentially
  leading to joint degeneration
• Must continue to engage in rehab to prevent
  against re-injury

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• Grade 3 Inversion Ankle Sprain
• Etiology
• Relatively uncommon but is extremely disabling
• Caused by significant force (inversion) resulting
  in spontaneous subluxation and reduction
• Causes damage to the anterior/posterior
  talofibular and calcaneofibular ligaments as well
  as the capsule
• Signs and Symptoms
• Severe pain, swelling, hemarthrosis,
  discoloration
• Unable to bear weight
• Positive talar tilt and anterior drawer

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• Management
• RICE, X-ray (physician may apply dorsiflexion
  splint for 3-6 weeks)
• Crutches are provided after cast removal
• Isometrics in cast ROM, PRE and balance exercise
  once out
• Surgery may be warranted to stabilize ankle due
  to increased laxity and instability

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Eversion Ankle Sprains -(Represent 5-10 of all
ankle sprains)

• Etiology
• Bony protection and ligament strength decreases
  likelihood of injury
• Eversion force resulting to damage of deltoid and
  possibly fx of the fibula
• Deltoid can also be impinged and contused with
  inversion sprains

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• Etiology (continued)
• Due to severity of injury, it may take longer to
  heal
• Foot that is pronated, hypermobile or has a
  depressed medial longitudinal arch is more
  predisposed to eversion sprains
• Signs and Symptoms
• Pain may be severe unable to bear weight and
  pain with abduction and adduction but not direct
  pressure on bottom of foot
• Management
• RICE X-ray to rule out fx no weight bearing
  initially posterior splint tape NSAIDs
• Follows the same course of treatment as inversion
  sprains
• Grade 2 or higher will present with considerable
  instability and may cause weakness in medial
  longitudinal arch resulting in excessive
  pronation or fallen arch

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• Syndesmotic Sprain
• Etiology
• Injury to the distal tibiofemoral joint
  (anterior/posterior tibiofibular ligament)
• Torn w/ increased external rotation or
  dorsiflexion
• Injured in conjunction w/ medial and lateral
  ligaments
• Signs and Symptoms
• Severe pain, loss of function passive external
  rotation and dorsiflexion cause pain
• Pain is usually anterolaterally located
• Management
• Difficult to treat and may requires months of
  treatment
• Same course of treatment as other sprains,
  however, immobilization and total rehab may be
  longer

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• Ankle Fractures/Dislocations
• Etiology
• Number of mechanisms
• Signs and Symptoms
• Swelling and pain may be extreme with possible
  deformity
• Management
• RICE to control hemorrhaging and swelling
• Once swelling is reduced, a walking cast or brace
  may be applied, w/ immobilization lasting 6-8
  weeks

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• Osteochondritis Dissecans
• Etiology
• Occur in superior medial articular surface of the
  talar dome
• One or several fragments of articular cartilage,
  w/ underlying subchondral bone partially or
  completely detached and moving within the joint
  space
• Mechanism may be single trauma or repeated
  traumas
• Signs and Symptoms
• May be a complaint of pain and effusion with
  signs of atrophy
• May also be catching, locking, or giving way

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• Osteochondritis Dissecans
• Management
• Diagnosis through X-ray or MRI
• Incomplete and non-displaced injuries can be
  immobilized with early motion and delayed weight
  bearing
• If fragments are displaced, surgery is necessary
• Surgery will minimize risk of nonunion

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• Acute Achilles Strain
• Etiology
• Common in sports and often occurs with sprains or
  excessive dorsiflexion
• Sign and Symptoms
• Pain may be mild to severe
• Most severe injury is partial or complete
  avulsion or rupturing of the Achilles
• Management
• Pressure and RICE should be applied
• After hemorrhaging has subsided an elastic wrap
  should continue to be applied
• Conservative treatment should be used as Achilles
  problems generally become chronic
• A heel lift should be used and stretching and
  strengthening should begin soon

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• Achilles Tendinitis
• Etiology
• Inflammatory condition involving tendon, sheath
  or paratenon
• Tendon is overloaded due to extensive stress
• Presents with gradual onset and worsens with
  continued use
• Decreased flexibility exacerbates condition
• Signs and Symptoms
• Generalized pain and stiffness, localized
  proximal to calcaneal insertion, warmth and
  painful with palpation, as well as thickened
• May limit strength
• May progress to morning stiffness

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• Crepitus with active plantar flexion and passive
  dorsiflexion
• Chronic inflammation may lead to thickening
• Management
• Resistant to quick resolution due to slow healing
  nature of tendon
• Must reduce stress on tendon, address structural
  faults (orthotics, mechanics, flexibility)
• Use antiinflammatory modalities and medications
• Cross friction massage may be helpful in breaking
  down adhesions
• Strengthening must progress slowly in order to
  not aggravate the tendon

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• Achilles Tendon Rupture
• Etiology
• Occurs w/ sudden stop and go forceful plantar
  flexion w/ knee moving into full extension
• Commonly seen in athletes gt 30 years old
• Generally has history of chronic inflammation
• Signs and Symptoms
• Sudden snap (kick in the leg) w/ immediate pain
  which rapidly subsides
• Point tenderness, swelling, discoloration
  decreased ROM
• Obvious indentation and positive Thompson test
• Occurs 2-6 cm proximal the calcaneal insertion

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• Achilles Tendon Rupture (continued)
• Management
• Usual management involves surgical repair for
  serious injuries (return of 75-90 of function)
• Non-operative treatment consists of RICE,
  NSAIDs, analgesics, and a non-weight bearing
  cast for 6 weeks, followed up by a walking cast
  for 2 weeks (75-80 return to normal function)
• Rehabilitation last about 6 months and consists
  of ROM, PRE and wearing a 2cm heel lift in both
  shoes

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• Peroneal Tendon Subluxation/Dislocation
• Etiology
• Occurs in sports with dynamic forces being
  applied to the ankle
• May also be caused by dramatic blow to posterior
  lateral malleolus, or moderate/severe inversion
  ankle sprain resulting in tearing of peroneal
  retinaculum
• Signs and Symptoms
• Complain of snapping in and out of groove with
  activity
• Eversion against manual resistance replicates
  subluxation
• Recurrent pain, snapping and instability
• Present with ecchymosis, edema, tenderness, and
  crepitus over the tendon

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• Peroneal Subluxation (continued)
• Management
• Conservative approach should be used first,
  including compression with felt horseshoe
• Reinforce compression pad with rigid plastic or
  plaster until acute signs have subsided
• RICE, NSAIDs and analgesics
• Conservative treatment time 5-6 weeks followed by
  gradual rehab program
• Surgery if conservative plan fails

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• Anterior Tibialis Tendinitis
• Etiology
• Commonly occurs after extensive down hill running
• Signs and Symptoms
• Point tenderness over anterior tibialis tendon
• Management
• Rest or at least decrease running time and
  distance, avoid hills
• In more serious cases, ice stretch before and
  after running to reduce symptoms
• Daily strengthening should be conducted
• Oral antiinflammatory medication may be required

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• Posterior Tibial Tendinitis
• Etiology
• Common overuse condition in runners with
  hypermobility or over pronation
• Repetitive microtrauma
• Signs and Symptoms
• Pain and swelling in area of medial malleolus
• Edema, point tenderness and increased pain during
  resistive inversion and plantar flexion
• Management
• Initially, RICE, NSAIDs and analgesics
• Non-weight bearing cast w/ foot in inversion may
  be used
• Correct problem of over pronation with taping or
  orthotic

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• Peroneal Tendinitis
• Etiology
• Not common, but can be found with athletes that
  have pes cavus due to excessive supination
  placing stress on peroneal tendon
• Signs and Symptoms
• Pain behind lateral malleolus during push-off or
  rising on ball of foot
• Pain along distolateral aspect of calcaneus and
  beneath the cuboid
• Management
• RICE, NSAIDs, elastic taping, appropriate
  warm-up and flexibility exercises
• LowDye taping or orthotics to help support foot

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• Shin Contusion
• Etiology
• Direct blow to lower leg (impacting periosteum
  anteriorly)
• Signs and Symptoms
• Intense pain, rapidly forming hematoma w/ jelly
  like consistency
• Management
• RICE, NSAIDs and analgesics as needed
• Maintaining compression for hematoma (which may
  need to aspirated)
• Fit with doughnut pad and orthoplast shell for
  protection
• If not managed appropriately may develop into
  osteomyelitis (deterioration of bone)

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• Muscle Contusions
• Etiology
• Contusion of leg, particularly in the region of
  the gastrocnemius
• Signs and Symptoms
• Bruise may develop, pain, weakness and partial
  loss of limb function
• Palpation will reveal hard, rigid, inflexible
  area due to internal hemorrhaging and muscle
  guarding
• Management
• Stretch to prevent spasm apply cold compression
  and ice
• If superficial therapy and massage do not return
  athlete to normal in 2-3 days, ultrasound would
  be indicated
• Wrap or tape will help to stabilize the area

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• Leg Cramps and Spasms
• (sudden, violent, involuntary contraction, either
  clonic (intermittent) or tonic (sustained)
• Etiology
• Difficult to determine fatigue, loss of fluids,
  electrolyte imbalance, inadequate reciprocal
  muscle coordination
• Signs and Symptoms
• Cramping with pain and contraction of calf muscle
• Management
• Try to help athlete relax to relieve cramp
• Firm grasp of cramping muscle with gentle
  stretching will relieve acute spasm
• Ice will also aid in reducing spasm
• If recurrent may be fatigue or water/electrolyte
  imbalance

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• Gastrocnemius Strain
• Etiology
• Susceptible to strain near musculotendinous
  attachment
• Caused by quick start or stop, jumping
• Signs and Symptoms
• Depending on grade, variable amount of swelling,
  pain, muscle disability
• May feel like being hit in leg with a stick
• Edema, point tenderness and functional loss of
  strength
• Management
• RICE, NSAIDs and analgesics as needed
• Grade 1 should apply gentle stretch after cooling
• Weight bearing as tolerated heel wedge to reduce
  calf stretching while walking
• Gradual rehab program should be instituted

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• Acute Leg Fractures
• Etiology
• Fibula has highest incidence of fracture,
  occurring primarily in the middle third
• Tibial fractures occur predominantly in the lower
  third
• Result of direct blow or indirect trauma
• Signs and Symptoms
• Pain, swelling, soft tissue insult
• Leg will appear hard and swollen (Volkmans
  contracture)
• Management
• X-ray, reduction, casting up to 6 weeks depending
  on the extent of injury

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• Medial Tibial Stress Syndrome (Shin Splints)
• Etiology
• Pain in anterior portion of shin
• Stress fractures, muscle strains, chronic
  anterior compartment syndrome
• Accounts for 10-15 of all running injuries, 60
  of leg pain in athletes
• Caused by repetitive microtrauma
• Weak muscles, improper footwear, training errors,
  varus foot, tight heel cord, hypermobile or
  pronated feet and even forefoot supination can
  contribute to MTSS
• May also involve, stress fractures or exertional
  compartment syndrome

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• Shin Splints (continued)
• Signs and Symptoms
• Four grades of pain
• Pain after activity
• Pain before and after activity and not affecting
  performance
• Pain before, during and after activity, affecting
  performance
• Pain so severe, performance is impossible
• Management
• Physician referral for X-rays and bone scan
• Activity modification
• Correction of abnormal biomechanics
• Ice massage to reduce pain and inflammation
• Flexibility program for gastroc-soleus complex
• Arch taping and or orthotics

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• Compartment Syndrome
• Etiology
• Rare acute traumatic syndrome due to direct blow
  or excessive exercise
• Signs and Symptoms
• Excessive swelling compresses muscles, blood
  supply and nerves
• Increase in fluid accumulation could lead to
  permanent disability
• Chronic cases appear as gradual build-up that
  dissipates following activity generally
  bilateral and becomes predictable can remain
  elevated producing ischemia and pain or ache w/
  rare neurological increased pressure involvement
  
• Weakness with foot and toe extension and
  occasionally numbness in dorsal region of foot

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• Compartment Syndrome (continued)
• Management
• If severe acute or chronic case, may present as
  medical emergency that requires surgery to reduce
  pressure or release fascia
• RICE, NSAIDs and analgesics as needed
• Surgical release is generally used in recurrent
  conditions
• Return to activity after surgery - light
  activity- 10 days later

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• Stress Fracture of Tibia or Fibula
• Etiology
• Common overuse condition, particularly in those
  with structural and biomechanical insufficiencies
• Runners tends to develop in lower third of leg,
  dancers middle third
• Often occur in unconditioned, non-experienced
  individuals
• Often training errors are involved
• Component of female athlete triad
• Signs and Symptoms
• Pain more intense after exercise than before
• Point tenderness difficult to discern bone and
  soft tissue pain
• Bone scan results (stress fracture vs.
  periostitis)

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• Management
• Discontinue stress inducing activity 14 days
• Use crutch for walking
• Weight bearing may return when pain subsides
• Cycling before running
• After pain free for 2 weeks athlete can gradually
  return to running
• Biomechanics must be addressed

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Rehabilitation Techniques

• General Body Conditioning
• Must be maintained with non-weight bearing
  activities
• Weight Bearing
• Non-weight bearing vs. partial weight bearing
• Protection and faster healing
• Partial weight bearing helps to limit muscle
  atrophy, proprioceptive loss, circulatory stasis
  and tendinitis
• Protected motion facilitates collagen alignment
  and stronger healing

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• Joint Mobilizations
• Movement of an injured joint can be improved with
  manual mobilization techniques
• Flexibility
• During early stages inversion and eversion should
  be limited
• Plantar flexion and dorsiflexion should be
  encouraged
• With decreased discomfort inversion and eversion
  exercises should be initiated
• BAPS board progression

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• Strengthening
• Isometrics (4 directions) early during rehab
  phase
• With increased healing, aggressive nature of
  strengthening should increase (isotonic exercises
• Pain should serve as the guideline for
  progression
• Tubing exercises allows for concentric and
  eccentric exercises
• PNF allows for isolation of specific motions
• Proprioception Neuromuscular Control
• Deficits can predispose individuals to injury
• Athletes should engage in proprioception
  progression including double and single leg
  stances, eye open and closed, single leg kicks
  and alternating apparatuses and surfaces

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• Taping and Bracing
• Ideal to have athlete return w/out taping and
  bracing
• Common practice to use tape and brace initially
  to enhance stabilization
• Must be sure it does not interfere with overall
  motor performance
• Functional Progressions
• Severe injuries require more detailed plan
• Typical progression initiated w/ partial weight
  bearing until full weight bearing occurs w/out a
  limp
• Running can begin when ambulation is pain free
  (transition from pool - even surface - changes of
  speed and direction)

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• Return to Activity
• Must have complete range of motion and at least
  80-90 of pre-injury strength before return to
  sport
• If full practice is tolerated w/out insult,
  athlete can return to competition
• Must involve gradual progression of functional
  activities, slowly increasing stress on injured
  structure
• Specific sports dictate specific drills