Introduction
- Jason M. Jennings, MD, DPT
- Mark E. Easley, MD
Epidemiology of Tarsometatarsal Complex Injuries (Lisfranc Complex Injuries)
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Tarsometatarsal (TMT) complex injuries are rare and often subtle in athletes both clinically and radiographically. They typically occur secondary to a low-energy indirect force in contrast to the majority of nonathletic injuries, which result from high-energy direct forces (i.e., motor vehicle accident).
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Midfoot sprains in athletes represent a spectrum of injuries to the Lisfranc ligament complex from partial sprains with no diastasis (stage I) to complete tears with frank diastasis (stages II and III) ( Figure 43-1 ).
FIGURE 43-1
Nunley and Vertulla classification of ligamentous Lisfranc injuries
(Adapted from Nunley JA, Vertullo CJ: Classification, investigation, and management of midfoot sprains. Lisfranc injuries in the athlete. Am J Sports Med 30(6):871-878, 2002, with permission.)
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Twenty percent misdiagnosed at initial presentation, with 40% receiving no treatment in the first week.
Incidence
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Increased incidence in athletes secondary to greater appreciation and recognition
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Four percent of college football players per year
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29.2% of these players were offensive linemen
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Age
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Most common in third decade
Sex
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Males affected two to four times more often than females
Sport
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Most common sports: football, equestrian, windsurfing, gymnastics, basketball, baseball, other
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Women’s gymnastics is one of the highest injury-producing sports, with many of these injuries requiring surgical intervention.
Position
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Offensive lineman
Pathophysiology
Intrinsic Factors
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The midfoot is typically divided into three columns:
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Medial column: navicular, medial cuneiform, and the first metatarsal
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Middle column (most rigid): articulation between the second and third metatarsals with their respective articulation
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Lateral column (most mobile): articulation between the fourth and fifth metatarsals and the cuboid
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The Lisfranc ligament is located between the medial cuneiform and the base of the second metatarsal providing stability between the medial and middle columns.
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There is no ligamentous attachment between the first and second metatarsal joint.
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The plantar ligaments are stronger than the dorsal ligaments which may account for dorsal dislocations when they occur.
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The base of the second metatarsal is recessed between the medial and lateral cuneiforms creating the “keystone” in the shape of a Roman arch, which provides inherent osseous stability.
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In patients with injuries to the Lisfranc joint, the medial mortise depth (medial aspect of the TMT joint, between the medial cuneiform and the base of the second metatarsal) has been shown to be shallower, decreasing osseous stability and thus increasing risk to injury.
Extrinsic Factors
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Interface between the athletic shoe and playing field, particularly artificial turf
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Regular turf injuries in American football may be influenced by type of shoe or cleat worn and the forces on the foot when another athlete falls on it in a compromised position.
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Stirrup creating a fulcrum effect on the forefoot as seen in windsurfing and equestrian sports ( Figure 43-2 )
FIGURE 43-2
Mechanism of a windsurfing injury—a fall backward causing forced equines of the fixed forefoot.
(Adapted from Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete. Am J Sports Med 21:497-502, 1993, with permission.)
Traumatic Factors
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Athletic injuries of the TMT complex can be divided into three broad categories:
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Plantar flexion injury: axial force applied along the longitudinal axis ( Figure 43-3 )
FIGURE 43-3
A, Plantarflexion of the foot driven into the ground by an opposing player falling on the hindfoot or leg. B, Another mechanism demonstrates a player’s plantarflexed foot coming down on another player’s leg during a pileup .
(Adapted from Meyer SA, Callaghan JJ, Albright JP, Crowley ET, Powell JW: Midfoot sprains in collegiate football players. Am J Sports Med 22:392-401, 1994, with permission.)
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Forefoot forcefully abducted with hindfoot fixed (i.e., windsurfing and equestrian sports) (see Figure 43-2 )
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Crush to the dorsum of the foot
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These mechanisms are oversimplifications, because there are probably varying patterns of each force (e.g., rotational).
Clinical Presentation and Examination
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The presentation is often subtle, and one should have a high index of suspicion when the athlete presents with a midfoot “sprain.”
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“Pop” felt over the dorsal aspect of the foot
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Inability to weight-bear
Abnormal Findings
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Physical examination findings are often subtle.
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Inability to weight-bear
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Variable amount of edema
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Variable deformity
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Plantar arch ecchymosis
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Diastasis between the first and second toes
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Tender to palpation over the TMT complex
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Pain with pronation and abduction of the forefoot
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Pain with passive plantar flexion, dorsiflexion, abduction, and adduction of the first and second metatarsal complex
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Coronal plane stress across the forefoot
Imaging
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Despite being associated with relatively minor radiographic changes, subtle TMT complex injuries can be a source of considerable morbidity in athletes.
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Twenty to fifty percent of tarsometatarsal injuries are missed on initial non–weight-bearing radiographs.
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False negative findings are associated with inability to weight-bear secondary to pain. If weight bearing is limited by pain, ankle block anesthesia may be used.
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Standard weight-bearing radiographs
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Anteroposterior: The medial border of the second metatarsal should be in alignment with the medial border of the middle cuneiform. With significant Lisfranc joint disruption this alignment will be compromised.
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30° internal oblique: The medial border of the fourth metatarsal should be aligned with the medial border of the cuboid. Disruption is indicative of a lateral column injury.
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Lateral view: Note the continuity of the dorsal cortex of the first and second metatarsal to the medial and middle cuneiform. Flattening of the longitudinal arch, which is correlated with a worse functional outcome, is noted by measuring the distance from the plantar aspect of the fifth metatarsal and the plantar aspect of the medial cuneiform.
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Fleck sign: a small avulsion fragment noted over the lateral edge of the medial cuneiform or the medial aspect of the second metatarsal, which is indicative of a Lisfranc injury ( Figure 43-4 )
FIGURE 43-4
Radiograph of the foot demonstrating the fleck sign.
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Associated injuries: base of second metatarsal, navicular, cuneiform, cuboid, or other
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Stress radiographs (pronation and abduction) may be used to assist with diagnosis if weight-bearing and non–weight-bearing radiographs are normal or equivocal. Adequate anesthesia must be utilized secondary to pain when performing this maneuver. Many physicians will opt for MRI prior to performing stress radiographs.
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MRI: sensitive study for the diagnosis of subtle (stage I) midfoot ligamentous injuries when compared with intraoperative findings
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Bone scintigraphy: diagnosis of subtle (stage I) midfoot injuries or those with delayed diagnosis
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CT: Sensitive for fracture but remains limited in the athletic low-energy TMT complex injury for assessment of instability, and without weight-bearing stress or clear diastasis, the status of the joint stability remains unclear.
Differential Diagnosis
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Midfoot sprain is a tarsometatarsal complex injury until proved otherwise.
Treatment
Nonoperative Management
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Non–weight-bearing immobilization
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Weight-bearing immobilization
Guidelines for Choosing Among the Nonsurgical Treatment Options
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Stage I (no diastasis) Lisfranc ligament sprain
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It is the authors’ preference to allow the patient to weight bear as tolerated in a cam walker for the first 6 weeks. Serial weight-bearing radiographs are obtained at 2 and 6 weeks to assure there is no diastasis or instability.
Surgical Indications
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Absolute: Stage II and III Lisfranc ligament sprains, displaced fractures, subluxation/dislocation
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Relative: continued pain and failed conservative treatment for stage I injuries
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Table 43-1 lists five steps that can be used to determine the need for surgical intervention based on imaging studies
Table 43-1
Stepwise Evaluation of a Patient with Lisfranc Injury to Determine Whether to Perform Nonsurgical or Surgical Treatment
Step
Study
Result
Recommendation
Rationale
1
Physical examination
Plantar bruising, painful piano key test, midfoot swelling
Obtain weight-bearing radiographs unless injury is obvious with non–weight-bearing images
Weight-bearing radiographs are always useful, but oblique views may be helpful for the tentative patient.
2
Radiography
Loss of arch on comparative weight-bearing lateral radiograph, widening between the first and second metatarsal vases or comparative AP views, fleck sign
ORIF is indicated with positive results. External rotation views are necessary when there is uncertainty based on plain radiographs or the patient cannot bear weight. When uncertainty remains, MRI is useful.
Any measurable subluxation is an indication for ORIF. When in doubt, proceed with further tests. On MIR, edema indicates midfoot injury, and subluxation confirms Lisfranc injury.
3
MRI
Edema at the tarsometatarsal joint, bone bruise, subluxation, or ligament tear
If edema but no ligament tear or subluxation, then CT is recommended. Perform ORIF in the presence of subluxation or a clear ligament tear.
MRI is more sensitive to edema in subtle injuries. CT may better illustrate subluxation, but MRI may show both.
4
CT
1 mm of subluxation
Strong evidence for Lisfranc injury when edema is noted on MRI and subluxation on CT. ORIF is indicated.
MRI with edema and no ligament tear combined with normal CT requires stress examination under anesthesia, with possible ORIF.
5
Stress examination
Subluxation
ORIF
When negative, treat as a sprain
From Watson TS, Shurnas PS, Denker J: Treatment of Lisfranc joint injury: Current concepts. JAAOS 18(12):718–728, 2010.
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
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Low-energy (athletes) versus high-energy injury
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Associated injuries
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Operative treatment is generally indicated for all obvious displaced injuries (stage II and III injuries).
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The patient with minimal ambulatory ability, an insensate foot, or preexisting inflammatory arthritis may be best treated nonoperatively.
Aspects of Clinical Decision Making When Surgery Is Indicated
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Open versus closed injury
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Vascular status
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Compartment syndrome
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Timing of surgery
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Delay in diagnosis
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ORIF versus arthrodesis versus percutaneous screw fixation
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Postoperative management and the patient’s ability to comply with the strict non–weight-bearing status and rehabilitation protocol
Evidence
Multiple Choice Questions
- QUESTION 1.
Which statement is false regarding the tarsometatarsal complex?
- A.
The Lisfranc ligament is located between the medial cuneiform and the base of the second metatarsal.
- B.
The plantar ligaments are stronger than the dorsal ligaments.
- C.
The ligamentous attachment between the first and second metatarsal provides most of the structural support.
- D.
The base of the second metatarsal is recessed between the medial and lateral cuneiforms.
- A.
- QUESTION 2.
Which imaging modality has limited use in the diagnosis of pure ligamentous tarsometatarsal complex injuries?
- A.
Weight-bearing radiographs
- B.
Stress radiographs
- C.
MRI
- D.
Bone scintigraphy
- E.
CT scan
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Intrinsic Factors that Predispose to Injury)
- QUESTION 2.
Correct answer: E (see Imaging Studies)
Nonoperative Rehabilitation of Midfoot Sprains (Stage I Ligamentous Lisfranc Injuries)
- Eric R. Schweitzer, DPT, OCS, MTC
- Lacy D. Jennings, DPT, SCS, MTC
- Mark E. Easley, MD
- Jason M. Jennings, MD, DPT
- Lacy D. Jennings, DPT, SCS, MTC
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Understand:
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Stage I ligamentous Lisfranc injuries in athletes (see Introduction )
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Importance of serial radiographs throughout rehabilitation progression
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Specific intrinsic rehabilitation strengthening exercises for the Lisfranc injury
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Proper selection of exercise and sport-specific progressions
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Provide thorough rehabilitation and treatment so to restore normal foot and lower extremity function
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Patient education regarding injury prevention and footwear modification
Phase I (weeks 0 to 6)
Protection
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Controlled ankle motion (CAM) boot immobilization at all times except for physical therapy–specific exercises
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Weight-bearing as tolerated with crutches. Pain to dictate how much weight.
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Heel lift in the opposite shoe to avoid pelvic asymmetries
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Weight-bearing radiographs at the 2- and 6-week marks. Any diastasis indicates failed nonoperative management.
| PHASE I (weeks 0 to 6) | PHASE II (weeks 6 to 10) | PHASE III (weeks 10 to 12) | PHASE IV (weeks 12+) |
|---|---|---|---|
|
|
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Management of Pain and Swelling
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Elevate lower leg above heart level
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Nonsteroidal anti-inflammatory drugs (NSAIDs)
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Ice
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Ace wrap/compression
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Ankle pumps, circles, ABCs
Therapeutic Exercises
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Core exercises, upper extremity and contralateral lower extremity strengthening
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Upper body ergometer is utilized for cardiovascular fitness
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Aquatic therapy: initiated at week 2. Basic progressions as follows:
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Shoulder → waist deep water
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Double leg → single leg exercises
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Sensorimotor Exercises
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Contralateral limb proprioceptive training including single leg balance
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Early pain-free protected weight-bearing (CAM walker), for proprioceptive input
Milestones/Criterion-Based Rehabilitation Guidelines to Progress to the Next Stage
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Stable radiographic alignment with no evidence of diastasis at 2 and 6 weeks.
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Minimal tenderness with palpation over the Lisfranc complex—progress to Phase II.
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Diastasis indicates failure of nonoperative management.
Phase II (weeks 6 to 10)
Protection
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At 6 weeks, a custom-molded orthosis is prescribed and the athlete is allowed to ambulate in a stiff-soled shoe.
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As weight-bearing is introduced, initially reduce forefoot loading during push off.
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Midfoot taping may assist in plantarflexion of the first ray, which helps to stabilize forefoot and support longitudinal arch in beginning stages of functional training ( Figure 43-5 ).
FIGURE 43-5
Lisfranc taping technique. Tape begins and ends on dorsomedial aspect of the first metatarsal and loops around the heel as pictured. The tape aims to improve plantarflexion of the first ray, as can be seen in the positional relationship versus the second ray in the picture. A horizontal anchor across the midfoot is also shown.
(From Wadsworth DJ, Eadie NT: Conservative management of subtle Lisfranc injury: A case report. J Orthop Sports Phys Ther 35:154–164, 2005, with permission.)
Management of Pain and Swelling
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Gradual increase in pain-free weight-bearing therapeutic exercise will help to further reduce pain and edema. Continue with elevation as in Phase I. Begin with selective modalities as needed (i.e., ice and electrical stimulation).
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
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No joint mobilizations because of emphasis on stabilization of the midfoot
Stretching/Flexibility Techniques for the Musculotendinous Unit
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Gastrocnemius/soleus complex stretching with care not to fulcrum across the midfoot region (i.e., standing wall stretch recommended over long sit towel stretching) ( Figure 43-6 ).
FIGURE 43-6
Ankle dorsiflexion measurement and treatment in weight bearing. Measure how far the athlete can slide foot away, keeping the heel planted, and touch the knee to the wall. Hold the subtalar joint in neutral throughout the test. Measure from tip of the hallux to the wall.
(From Hudson Z: Rehabilitation and return to play after foot and ankle injuries in athletes. Sports Med Arthrosc Rev 17:203–207, 2009.)
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Continue stretching proximal musculature as needed.
Other Therapeutic Exercises
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Continue core, hip, and knee therapeutic exercise. Treatment adjusted based on residual deficits found in ongoing reevaluations.
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Progression of aquatic therapy regimen—basic progressions as the athlete tolerates:
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Shoulder → waist-deep water
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Double leg → single-leg exercises
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Hop → jump
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Fast walk → jog → run
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Activation of Primary Muscles Involved
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Intrinsic foot muscle strengthening ( Figures 43-7 and 43-8 ):
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Towel scrunches and marble grabs
FIGURE 43-7
Short foot exercise contracts the plantar intrinsic muscles. Ask the patient to “cup” the arch upward as a palm of a hand might cup water. Emphasis should be placed on minimizing extrinsic muscle activity.
(From Chin L, Hertel J: Rehabilitation of ankle and foot injuries in athletes. Clin Sports Med 29:157–167, 2010, with permission.)
FIGURE 43-8
Intrinsic toe flexors isolation by contracting the extensor hallicus longus to inhibit the ability of the long toe flexors to contract.
(Redrawn from Mulligan E: Leg, ankle and foot rehabilitation. In: Andrews JR, Harrelson GH, Wilk KE, editors. Physical rehabilitation of the injured athlete , 3rd ed. Philadelphia, 2004, Saunders, pp. 329-376, with permission.)
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Gastrocnemius and soleus:
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Concentric progressed to eccentric
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Retrain at heel strike to decelerate tibial internal rotation and control the lower limb moving over the foot.
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Controlled pronation by gastrocnemius and soleus allows forces to disperse to avoid excessive loading on individual tissues.
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Posterior tibialis:
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Supination and inversion allow the foot to become a rigid lever for push off, which stabilizes the midtarsal joint in the stance phase.
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The broad insertion of the posterior tibialis tendon plantar supports the transverse arch.
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Peroneus longus:
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Supports the transverse arch in the late stage midstance and early heel off
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Primary function is plantarflexion of the first ray
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It is the primary stabilizer of the first ray ( Figure 43-9 ).
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