Rehabilitation of Ankle and Foot Injuries



Rehabilitation of Ankle and Foot Injuries

Patrick O. McKeon, PhD, ATC, CSCS
Erik A. Wikstrom, PhD, ATC, FNATA, FACSM
William E. Prentice, PhD, PT, ATC, FNATA
Steven M. Zinder, PhD, ATC

After reading this chapter,
the athletic training student should be able to:

  • Review the functional mechanics, anatomy, and demands of the foot and ankle.
  • Identify the various injuries that occur at the foot and ankle.
  • Explain the general treatment approach for all foot and ankle injuries.
  • Recognize unique rehabilitation concerns for different foot and ankle injuries.


The bony configuration of the foot and ankle is complex. The foot has 26 bones (plus 2 sesamoid bones). These bones are separated into 3 distinct foot regions—the rearfoot (the talus and calcaneus), the midfoot (the navicular, cuboid, and 3 cuneiforms), and the forefoot (the metatarsals and phalanges). The rearfoot also articulates with the tibia and fibula to form the 2 articulations of the ankle complex known as the talocrural joint and the subtalar joint. As a whole, the foot and ankle complex combines the structural and functional contributions of the talocrural, subtalar, midtarsal, tarsometatarsal, metatarsophalangeal, and the interphalangeal joints. The result is more than 50 joints that arise from the articulations of these 26 bones. In the following sections, the functional anatomy and biomechanics of these joints are described.

Talocrural Joint

The true ankle joint, or talocrural joint, is a hinge joint that is formed proximally by the tibial plafond and fibula referred to as the ankle mortise.96 The talus provides a link between the lower leg (the crural region) and the foot. The talus, the second largest tarsal and the main weightbearing bone of the articulation, rests on the calcaneus and articulates with the tibia (medial) and fibula (lateral) through the mortise. The relatively square shape of the talus affords the talocrural joint 2 primary movements: dorsiflexion and plantar flexion. Because the talus is wider anteriorly than posteriorly, the more stable position of the ankle is with the foot in dorsiflexion. In this position, the wider anterior aspect of the talus glides posteriorly into the mortise. This bony configuration provides the most stability to the joint beyond any of the surrounding soft tissue structures. By contrast, as the ankle moves into plantar flexion, the talus glides anteriorly, moving the narrower posterior aspect of the talus into the mortise, creating a less stable position than in dorsiflexion.96

The ligamentous support of the talocrural joint consists of the articular capsule, 3 lateral ligaments, 2 ligaments that connect the tibia and fibula, and the medial or deltoid ligament (Figure 23-1). The 3 lateral ligaments are the anterior talofibular, the posterior talofibular, and the calcaneofibular. The distal anterior and posterior tibiofibular ligaments bind the tibia and fibula to form the mortise in conjunction with the distal portion of the interosseus membrane. The thick deltoid ligament provides primary resistance to foot abduction (eversion). The bands of this ligament represent thickened areas of the articular capsule that encases the talocrural joint.

The Rearfoot: Subtalar Joint

The subtalar joint consists of the articulations among the talus, calcaneus, and the navicular.112 These articulations are typically broken down into the talocalcaneal joint (also known as the anatomical subtalar joint) and the talocalcaneonavicular joint (also known as the functional subtalar joint)5 (Figure 23-2). Inversion and eversion are normal movements that occur at the subtalar joint, but these are complex motions based on the subtalar joint’s triplanar, triaxial orientation.25,85,86,88 For simplification of the complexity, we will refer to eversion as the triaxial, triplanar motion of pronation and inversion as the triaxial, triplanar motion of supination throughout the rest of this chapter.

The subtalar joint is supported passively by 5 main ligaments, which include the calcaneofibular ligament on the lateral side and the tibiocalcaneal ligament on the medial side of the talocrural joint; the medial, posterior, and lateral talocalcaneal ligaments; and the interosseous ligament complex. The interosseous ligament complex is the largest subtalar ligament and provides the most stability to the functional subtalar joint.85

Because of its unique orientation, the subtalar joint moves across multiple axes that do not exist in a cardinal plane. Rather, motion of the subtalar joint is described using the 3 cardinal axes at the same time to represent the triplanar, triaxial motions of pronation and supination.85 In weightbearing, pronation across the ankle and foot consists of a combination of dorsiflexion, abduction, and eversion, whereas supination represents a combination of plantar flexion, adduction, and inversion.57,85 When describing the motions of the subtalar joint in relation to the rest of the foot, these terms will be used.


Figure 23-1. Ligaments of the talocrural joint. (A) Lateral aspect. (B) Medial aspect.

The Midfoot: Transverse Tarsal Joint

The transverse tarsal joint consists of 2 distinct joints: the calcaneocuboid and the talonavicular joint.112 Because of the interdependence of the talus, navicular, calcaneus, and cuboid, the subtalar and midtarsal joints have been referred to as 1½ joints with the functional subtalar joint as 1 and the calcaneocuboid joint as a ½ joint highly influenced by the functional subtalar joint.113 The transverse tarsal joint depends mainly on ligamentous and musculotendinous tension to maintain position and integrity. There are numerous ligamentous connections among the calcaneus, the talus, the navicular, the cuboid, the cuneiforms, and the base of the 5 metatarsals. Most of these ligaments are named for the bones they connect and their anatomical orientation. Key ligaments include the plantar calcaneonavicular ligament (also known as the spring ligament) and the calcaneocuboid ligament (also known as the short plantar ligament). These ligaments provide support of the connection between the subtalar joint and midtarsal joints on the plantar surface of the foot. On the dorsum of the foot, the bifurcate ligament provides a connection between the calcaneus and the navicular and cuboid.57 A key biomechanical consideration for the transverse tarsal joint is the alignment of the axes of rotation for the talonavicular and calcaneocuboid joints. During rearfoot and forefoot pronation, these axes run parallel to each other, allowing an unlocking of the midfoot. This unlocking affords the foot the ability to absorb forces and accommodate to the ground. Rearfoot supination combined with forefoot pronation results in the axes of rotation crossing, effectively locking the midfoot. This locking affords the foot the ability to be a rigid lever for propulsion.29


Figure 23-2. The ankle joint is formed by the tibia, fibula, and talus. The subtalar joint is formed by the talus and calcaneus.

The Midfoot: Tarsometatarsal Joints

The tarsometatarsal joints are composed of the cuboid; first, second, and third cuneiforms; and the bases of the metatarsal bones. These bones allow for rotational forces when engaged in weightbearing activities. They move as a unit, depending on the position of the transverse tarsal and subtalar joints. Also known as the Lisfranc joint, the tarsometatarsal joints provide a locking device that enhances foot stability. At the metatarsals, the transverse metatarsal ligaments provide a connection among the metatarsals at their base and heads.

The Forefoot: Metatarsophalangeal Joints

The metatarsophalangeal joints are composed of the distal heads of the metatarsals and the proximal digits of the phalanges. The first metatarsophalangeal joint is also known as the “ball of the foot” and represents the primary weightbearing area during the propulsion phase of gait.

Muscular Support of the Foot and Ankle Complex

Extrinsic Foot Muscles

One of the key features of the talocrural joint is that no muscles attach to the talus. Therefore, muscular control of the talus is the result of extrinsic foot muscle support proximally and distally. The extrinsic foot muscle bellies are located in the lower leg and can be broken down into 4 compartments separated by boundaries created by the crural fascia in its relation to the tibia and fibula. The anterior compartment contains the anterior tibialis, the extensor digitorum longus, the extensor hallucis longus, and the fibularis tertius. Together, these muscles dorsiflex the foot and extend the toes (extensor digitorum and hallucis longus). The lateral compartment contains the fibularis longus and brevis which serve to plantar flex and evert the foot. There are 2 posterior compartments (superficial and deep). The superficial compartment contains the gastrocnemius, the soleus, and the plantaris. Together, these muscles insert into the calcaneus and produce plantar flexion. The deep posterior compartment contains the tibialis posterior, the flexor digitorum longus, and the flexor hallucis longus. Together, these muscles plantar flex the foot while also flexing the toes (extensor digitorum and hallucis longus). The last critical muscle of the deep posterior compartment is the popliteus, which controls internal and external rotation of the tibia. Beyond their individual contributions, the extrinsic foot muscles act synergistically to produce a variety of motions. For example, active inversion is produced from the co-contraction of the anterior and posterior tibialis firing together, whereas eversion is produced from the fibularis longus, brevis, and tertius firing together.96 The individual and collective contributions of the extrinsic foot muscles provide a robust ability to produce complex foot motions.

Intrinsic Foot Muscles

The intrinsic foot muscles provide dynamic support to the subtalar, midtarsal, and metarsophalangeal joints. These muscles work synergistically with the extrinsic foot muscles to provide dynamic support for the functional half dome. There are 4 layers of plantar intrinsic foot muscles that provide longitudinal and localized support for the many foot joints. These muscles are directly aligned with the configuration of the key functional areas of local joint deformation and are thought to not only provide muscular support but also act as dynamic sensors of foot deformation during weightbearing activities.79

The Plantar Fascia

The plantar fascia is a broad band of fascial tissue that spans from the medial and lateral condyles of the calcaneus to the base of the proximal phalanges. Functionally, the plantar fascia works as a tension element within the foot, similar to a windlass mechanism. When the metatarsophalangeal joints are in a neutral position and the talocrural joint is plantar flexed (heel rocker), the plantar fascia is on slack and the foot is allowed to be supple and adaptive. This corresponds to the talonavicular and calcaneocuboid axes running parallel. However, when the metatarsophalangeal joints are extended and the talocrural joint dorsiflexed, the plantar fascia is placed on tension, which then raises and supports the functional half dome to help create a rigid foot for propulsion during the forefoot rocker. Combined with the locking of the mid-tarsal joints and the local stability of the intrinsic foot muscles, the foot has many strategies for transitioning from a supple platform to a rigid lever.79

The Foot Core System

As can be seen from the anatomy discussed previously, the foot has many interacting component parts, including bones, joints, ligaments, fascia, muscles and tendons, and the nerves that innervate them. Rather than viewing these many component parts independently, it is important to see them as functionally and structurally interdependent. This interdependence has best been expressed in the foot core system paradigm. Drawing from insights in the lumbo-pelvic core concepts, the foot core is comprised of 3 subsystems (Figure 23-3). The passive subsystem contains the bones, ligaments, and plantar fascia. The active subsystem contains the intrinsic and extrinsic foot muscles. The neural subsystem contains the sensory and motor nerves that relay information about foot deformation via sensory receptors within the active and passive subsystems and produce coordinated responses through the active subsystem. In this way, the active, passive, and neural subsystems interact structurally and functionally through their ability to provide mechanical and sensorimotor control.79


Figure 23-3. The foot core system. The neural, active, and passive subsystems interact to produce the foot core system that provides stability and flexibility to cope with changing foot demands. (Reprinted with permission from McKeon PO, Hertel J, Bramble D, Davis I. The foot core system: a new paradigm for understanding intrinsic foot muscle function. Br J Sports Med. 2015;49[5]:290.)

The Arches, Columns, and the Half Dome

Key to understanding the structure and function of the foot core system is an appreciation of the complex joint interactions described previously. These interactions, traditionally referred to as the 4 arches, provide a functional framework to absorb forces across the entire system. The medial longitudinal arch is composed of the functional subtalar joint and the first, second, and third ray (the combination of the first, second, and third cuneiforms and their respective metatarsals). These articulations are referred to as the medial column of the foot. The lateral longitudinal arch is created by the calcaneocuboid joint and the fourth and fifth rays (the cuboid and the fourth and fifth metatarsals). These articulations are also referred to as the lateral column. In addition, based on the bony configurations of the midfoot and forefoot joints, there are 2 transverse arches that span cross the base and heads of the metatarsals and are referred to as the proximal and distal transverse arches, respectively. Within the foot core system, these arches function interdependently as a half dome that is capable of complex, 3-dimensional deformation and reformation (Figure 23-4). Within this functional half dome, the talus is the cornerstone of its configuration. Controlling the motion of the talus then translates to controlling the motion of all the bones, columns, arches, and half dome of the foot core system.79

To understand how the talus is controlled, it is first necessary to understand the strategies used to control its position. As described earlier, the bony configuration of the talus, mortise, and calcaneus in combination with the talocrural and subtalar ligaments provide the majority of the constraints for talar positioning. Internal rotation of the tibia during weight-bearing is coupled with pronation (half dome deformation), whereas tibial external rotation is coupled with supination (half dome reformation). The rest of the support and control comes from contributions from the active and passive subsystems of the foot core system that have indirect control of the foot’s half dome. The intrinsic foot muscles play an important role in half dome deformation and reformation based on their unique alignments across the rearfoot, midfoot, and forefoot regions (Table 23-1).


Based on the functional anatomy and biomechanics of the foot core system, it is important to understand the functional demands of the ankle and foot complex. These 3 main functional demands include (1) the ability to dissipate external forces arising from contact with the ground (absorption), (2) the ability to propel the body by generating internal forces that exceed the external forces from the ground contact (propulsion), and (3) the ability to provide a stable platform to allow transition between absorption and propulsion (stability).


Figure 23-4. Functional half dome proposed by McKenzie. Note the origin of the dome is considered to be the dome of the talus. (Reprinted with permission from McKeon PO, Hertel J, Bramble D, Davis I. The foot core system: a new paradigm for understanding intrinsic foot muscle function. Br J Sports Med. 2015;49[5]:290.)

Table 23-1 Functional Qualities of the Intrinsic Foot Muscles and Their Corresponding Evidence-Based Descriptions

Functional Quality Description

Supportive of the foot arches

Diminished function of the intrinsic foot muscles leads to deleterious alterations in foot posture whereas training the intrinsic foot muscles enhances foot posture.

Activity dependent

Intrinsic foot muscles are more active in dynamic activities such as walking compared to standing.

Load dependent

As postural demands increase, such as from double to single limb stance, so does the activity of the intrinsic foot muscles.


The intrinsic foot muscles work together as a unit to provide dynamic arch support during the propulsive phase of gait.


The intrinsic foot muscles support the foot in its role as a platform for standing and lever for propelling the body during dynamic activities.

Reprinted with permission from McKeon PO, Hertel J, Bramble D, Davis I. The foot core system: a new paradigm for understanding intrinsic foot muscle function. Br J Sports Med. 2015;49(5):290.

In the functional demand of absorption, the foot and ankle must accommodate to the external forces that act upon them. Key to this concept is that all structures within the foot core system are capable of absorbing external forces, some better than others. Bones absorb forces through compression, tension, and bending. Ligaments absorb tension forces. Muscles and their tendons absorb tension forces through eccentric contractions. An eccentric contraction occurs when the external force acting upon the muscle (resistance) exceeds the muscle’s internal force generated from contraction (effort) and therefore the muscle lengthens during contraction. Tendons absorb tension forces as well. Due to their viscoelastic composition, tendons also have the ability to store potential energy during absorption. Nerves can also absorb tension and compression forces, but not well. In the neural subsystem, nerves and their receptors serve to communicate information to and from the central nervous system. Other force absorbers within the ankle and foot complex include the skin and subcutaneous fat pads, which can absorb tension, compression, and shear forces.

In the functional demand of propulsion, the foot core active subsystem works in conjunction with the muscles of the entire lower extremity to generate enough force to propel the body. To do this, the foot must act as a rigid lever. The rigidity of the foot during this functional demand is produced from the interdependence of the unique configurations of the joints within the half dome and the muscles that support it.79 Where bones, ligaments, and muscles are capable of absorption, only muscles and tendons actively generate forces for propulsion. This functional demand is accomplished through concentric muscular contractions in which muscles generate more effort than the external forces acting upon them. To aid the effort of the muscles, the energy stored in the tendons during the absorption phase can be used in conjunction with the muscle contraction to enhance the muscle effort produced. The configuration of the midfoot joints, forefoot joints, and the plantar fascia within the foot half dome helps to provide a platform for the muscles to generate force. The key motions of propulsion include plantar flexion of the ankle, supination of the foot (half dome reformation), and extension of the metatarsophalangeal joints.

Lastly, the third functional demand of stability is the ability to toggle between the 2 functional demands of absorption and propulsion. The majority of the prime movers of absorption and propulsion are the long and broad muscles aligned with the sagittal plane, including the proximal gluteus maximus and quadriceps, as well as the soleus and gastrocnemius. Muscles that provide stability are those that dynamically change effort to reduce the amount of motion around joints. By toggling back and forth between concentric and eccentric contractions, these muscles serve to aid the foot in transitioning from an accommodating platform to a rigid lever for push-off. The muscles that function as stabilizers are often very close to the joints they control. In the foot and ankle, these include the deep posterior compartment muscles and the intrinsic foot muscles.

The functional demands of absorption, propulsion, and stability afford us the ability to walk, run, land, cut, etc. These activities are highly complex, and there are several determinants based on pelvic, hip, knee, and foot/ankle motions. Key to understanding gait is the determinants associated with the foot and ankle. The foot and ankle rockers provide a clinically relevant framework for understanding foot and ankle biomechanics in the context of absorption and propulsion functional demands.

The Normal Biomechanics of Gait

The actions of the lower extremity during a complete stride in walking can be divided into 2 phases. The first is the stance phase, which starts with initial contact at heel strike and ends at toe-off. The second is the swing phase. This represents the time immediately after toe-off in which the leg is advanced from behind the body to a position in front of the body in preparation for heel strike. Within these phases there are distinct arcs of plantar flexion and dorsiflexion motion in the foot and ankle complex, with 3 occurring in stance (plantar flexion, dorsiflexion, plantar flexion) and 1 occurring in swing (dorsiflexion).89

While there are several determinants of normal gait when considering the functional demands of absorption and propulsion, the most important relate to the plantar flexion and dorsiflexion arcs of motion. These arcs have been functionally described as the heel, ankle, and forefoot rockers during the stance phase and the foot clearance arc in the swing phase.89 These arcs are responsible for absorption in the first half of stance (heel and ankle rocker) and propulsion (forefoot rocker and foot clearance) in the second half of stance into the swing phase. These plantar flexion and dorsiflexion arcs afford the body a smooth system for moving the whole body forward (Figure 23-5).

Absorption, Propulsion, Transition Through the Rockers

During walking, stance phase begins with the heel rocker through contact of the lateral aspect of the calcaneus with the ankle dorsiflexed and the foot supinated. To prepare for weight acceptance, the rest of the foot rocks around the heel and is eccentrically lowered to the ground (first plantar flexion arc) by contractions of the anterior compartment muscles of the lower leg. Once the foot is flat on the ground, the tibia and fibula begin their advance forward over the stationary foot, representing the first dorsiflexion arc (ankle rocker). The soleus controls the rate of tibial advancement through an eccentric contraction with assistance from the posterior tibialis, flexor digitorum and hallucis longus, and fibularis longus and brevis. During pronation, the long axes of the talonavicular and calcaneocuboid joints run more parallel and thus allow more motion. Because the transverse tarsals joint is “unlocked,” the foot behaves like a “loose bag of bones.”25,83 More motion at the midfoot leads to more deformation of the half dome.


Figure 23-5. The foot and ankle rockers in the context of the functional demands of absorption, propulsion, and stability.

The first ray is also stabilized by the attachment of the fibularis longus tendon, which inserts into the base of the first metatarsal. The fibularis longus tendon passes posteriorly around the base of the lateral malleolus and then through a notch in the cuboid to cross the foot to the first metatarsal. The cuboid functions as a pulley to increase the mechanical advantage of the peroneal tendon and pull the forefoot into pronation. Stability of the cuboid is essential in this process.


Upon completion of the ankle rocker, the talocrural joint has moved into maximum dorsiflexion in combination with maximum pronation of rearfoot and forefoot (foot half dome deformation). As the heel lifts off the ground, the axis of rotation for the foot shifts forward to the metatarsophalangeal joints to initiate the second plantar flexion arc, the forefoot rocker. Based on the concentric contractions from the gastrocnemius and soleus, the rearfoot supinates while the forefoot continues to pronate. During rearfoot supination, the long axes of the talonavicular and calcaneocuboid joints become more oblique. Both allow less motion to occur at this joint, making the foot very rigid and tight. Since less movement occurs at the calcaneocuboid joint, the cuboid becomes hypomobile. The long peroneal tendon has a greater amount of tension because the cuboid has less mobility and thus will not allow hypermobility of the first ray. In this case, the majority of the weight is borne by the first and fifth metatarsals (Figure 23-5). In this way, the ankle rocker serves as a key transition factor between absorption and propulsion.

Upon heel lift, the stored energy within the tendons of these muscles plays a critical role in helping the rearfoot move into supination while the forefoot continues to pronate. The combination of rearfoot supination and forefoot pronation locks the midtarsal joints. As well, during the forefoot rocker, the extension of the metatarsophalangeal joints combined with dorsiflexion of the ankle increases tension on the plantar fascia. These 2 factors help to create a rigid foot for push-off. This dynamic interdependence of the foot core system affords a highly adaptable foot during absorption and stable foot during propulsion with many redundant contributions.


Figure 23-6. Foot and ankle injury rehabilitation progression. The progression of rehabilitation strategies for optimizing recovery after injury moves from the injury (red) to return to play (green) through (1) POLICE (protection, optimal loading, ice, compression, elevation) to reduce pain and swelling and control tissue loading; (2) restoring mobility and stability of the injured area and surrounding musculature; (3) integrating sensorimotor control training; and (4) restoring the functional demands of absorption, propulsion, and stability. Upon return to play, it is critically important to continue a maintenance program to ensure that the 4 elements of progression are retained.


When examining the differences between walking and running, there are changes in the functional demands of absorption, propulsion, and stability. Our sensorimotor system organizes the rockers to meet the functional demands. Walking at a constant speed requires the control of forward momentum. The heel rocker helps to meet this absorption demand. The ratio of absorption to propulsion during walking then is 2:1. The heel and ankle rockers meet absorption demands whereas the forefoot rocker meets propulsion. When transitioning from walking to running, the forward momentum must be retained to increase acceleration and the heel rocker is eliminated. With only the ankle and forefoot rockers retained, there is a 1:1 ratio of absorption to propulsion. When transitioning from running to sprinting, propulsion demands must be much higher than absorption demands and even the ankle rocker is reduced to maximize time spent in the forefoot rocker (eg, we run on our toes during a sprint) making the ratio 0.5:1. Slowing down then requires us to absorb forward momentum and the ankle and heel rockers are reincorporated.

When landing from a jump, rather than using our heel rocker to absorb forward momentum, we use a reverse forefoot rocker (eccentrically controlling dorsiflexion after landing on our toes). Vertical momentum is therefore absorbed through the gastrocnemius and soleus. Understanding the patterns of how the rockers can be used to meet functional demands helps us explain mechanisms of injury and make therapeutic decisions to get patients back on their feet.


Rehabilitation for the foot/ankle complex will mirror the rehabilitation process for other parts of the body. In brief, we recommend the following:

  1. Follow an assess-treat-assess approach.26,33 As students, you are often shown images like Figure 23-6. While rehabilitation is a progression and each step is built on the previous step, it is important to remember that each patient and injury are different. As a result, some injuries (eg, a lateral ankle sprain) may present with significant range of motion (ROM) deficits but no strength deficits, while others may present with significant ROM, strength, and balance deficits. The assess-treat-assess model emphasizes the fact that clinicians should spend their focus treating the impairment noted in our evaluation and that we should continuously reassess progress to ensure that our treatments are working. After all, why would we spend time strengthening muscles that are not weak?
  2. The foundation for good functional movements is mobility and stability. Mobility is the ability meet the functional demands of absorption to propulsion, whereas stability is the ability to limit motion through rapidly switching between those 2 functional demands. As a result, we think of foot and ankle rehabilitation as 3 separate but overlapping phases: (1) the initial phase, which should focus on controlling inflammation, swelling, and pain to assist in optimizing the healing environment; (2) restoring ROM and strength (concentric and eccentric contractions); and (3) restoring the coordination and control of absorption, propulsion, and stability.
  3. Progression of tasks and environmental challenges for sensorimotor control of the functional demands to more difficult levels should only be done once a patient has consistently demonstrated the capacity to correctly complete exercises at easier levels.18,80 For example, a patient with a lateral ankle sprain has been asked to complete 10 clockwise rotations while seated in a smooth and controlled manner on a BAPS board. This patient should not be progressed to a more difficult level (eg, standing with rotations) until the initial goal can be consistently attained in a smooth and controlled manner.


Stretching Exercises


Figure 23-7. Seated Biomechanical Ankle Platform System (BAPS) board (Spectrum Therapy Products) exercises are an active ROM exercise that are useful in regaining normal ankle motion.


Figure 23-8. Seated ankle plantar flexors stretch using a towel.


Figure 23-9. Standing ankle plantar flexors stretch. (A) Gastrocnemius. (B) Soleus. (C) Stretching may also be done using a slant board.


Figure 23-11. Plantar fascia stretches. (A) Manual. (B) Prostretch (Medi-Dyne).

Isometric Strengthening Exercises


Figure 23-12. Isometric inversion against a stable resistance. Used to strengthen the posterior tibialis, flexor digitorum longus, and flexor hallucis longus.


Figure 23-13. Isometric eversion against a stable resistance. Used to strengthen the peroneus longus, brevis, tertius, and extensor digitorum longus.


Figure 23-14. Isometric plantar flexion against a stable resistance. Used to strengthen the gastrocnemius, soleus, posterior tibialis, flexor digitorum longus, flexor hallucis longus, and plantaris.


Figure 23-15. Isometric dorsiflexion against a stable resistance. Used to strengthen the anterior tibialis and peroneus tertius.


Figure 23-16. Inversion exercise. (A) Using a weight cuff. (B) Using resistive tubing. Used to strengthen the posterior tibialis, flexor digitorum longus, and flexor hallucis longus.

Isotonic Strengthening Exercises


Figure 23-17. Eversion exercise. (A) Using a weight cuff. (B) Using resistive tubing. Used to strengthen the peroneus longus, brevis, tertius, and extensor digitorum longus.


Figure 23-18. Dorsiflexion exercise. (A) Using a weight cuff. (B) Using resistive tubing. Used to strengthen the anterior tibialis and peroneus tertius.


Figure 23-19. Plantar flexion exercise using surgical tubing. Used to strengthen the gastrocnemius, soleus, posterior tibialis, flexor digitorum longus, flexor hallucis longus, and plantaris. (A) Body weight resisted. (B) Using surgical tubing.


Figure 23-21. Toe raises. Used to strengthen the gastrocnemius, soleus, posterior tibialis, flexor digitorum longus, flexor hallucis longus, and plantaris. (A) Extended knee strengthens the gastrocnemius. (B) Flexed knee strengthens the soleus.


Figure 23-22. Towel-gathering exercise. (A) Toe flexion. Used to strengthen the flexor digitorum longus and brevis, lumbricals, and flexor hallucis longus. (B) Inversion/eversion exercises. Used to strengthen the posterior tibialis, flexor digitorum longus, flexor hallucis longus, peroneus longus, brevis, tertius, and extensor digitorum longus.

Closed Kinetic Chain Strengthening Exercises


Figure 23-23. Lateral step-ups.


Figure 23-24. Slide board exercises.


Figure 23-25. Shuttle MVP exercise machine.

Isokinetic Strengthening Exercises


Figure 23-26. Isokinetic inversion/eversion exercise. Used to improve the strength and endurance of the ankle inverters and everters in an open chain. Also can provide an objective measurement of muscular torque production. (Reprinted with permission from Biodex Medical Systems.)

Proprioceptive Neuromuscular Facilitation Strengthening Exercises


Figure 23-28. Diagonal 1 pattern moving into flexion. (A) Starting position, ankle plantar flexed, foot everted, toes flexed. (B) Terminal position, ankle dorsiflexed, foot inverted, toes extended.


Figure 23-29. Diagonal 1 pattern moving into extension. (A) Starting position, ankle dorsiflexed, foot inverted, toes extended. (B) Terminal position, ankle plantar flexed, foot everted, toes flexed.


Figure 23-31. Diagonal 2 pattern moving into extension. (A) Starting position, ankle dorsiflexed, foot everted, toes extended. (B) Terminal position, ankle plantar flexed, foot inverted, toes flexed.

Exercises to Reestablish Neuromuscular Control


Figure 23-32. Standing single-leg balance activity. Used to activate the lower leg musculature and improve balance and proprioception of the involved extremity. (A) Foam surface. (B) BOSU balance trainer, bubble surface (BOSU). (C) BAPS board. (D) Rocker board.


Figure 23-34. Single-leg stance on an unstable surface while performing functional activities.


Figure 23-35. Single-leg standing rubber tubing kicks. Using kicks resisted by surgical tubing of the uninvolved side while weightbearing on the involved side may encourage neuromuscular control.


Figure 23-36. Leg press.


Figure 23-37. Mini-squats.

Exercises to Improve Cardiorespiratory Endurance


Figure 23-38. Pool running with floatation device. Used to reduce impact weightbearing forces on the lower extremity while maintaining cardiovascular fitness level and running form.


Figure 23-39. Ergometers. Used to maintain cardiovascular fitness when use of a lower extremity ergometer is contraindicated or too difficult to use. (A) Upright stationary exercise ergometer. (B) Upper body ergometer.

Initial Treatment and Rehabilitation

During the initial rehabilitation phase of any foot and ankle condition, the major goals are reduction of post-injury swelling96 and pain as well as protecting the structures involved to allow healing. These 2 factors are highly linked. Pain is the result of chemical mediators released from the damaged tissues that hypersensitize free nerve endings. There are a variety of established patient-reported outcomes (eg, visual analog scale) to assess pain over time. The figure 8 method is a highly reliable and easy measurement technique to assess ankle edema over time.73

To achieve these goals, acute management has traditionally involved rest, ice, compression, elevation (RICE). A combination of RICE is prescribed to reduce secondary injury, limit neural inhibition, and promote proper alignment of new collagen fibers. Emerging evidence has resulted in a more detailed acronym— POLICE—to outline initial treatment strategies.10 POLICE represents protection, optimal loading, ice, compression, elevation.


It is important to allow the inflammatory process a chance to accomplish what it is supposed to during the first 24 to 48 hours before incorporating aggressive exercise techniques. However, rest does not mean that the injured patient does nothing. Data from a variety of animal models support the benefits of short periods of rest (ie, unloading) and the dangers of aggressive ambulation.12,30,72 However, longer duration rest periods unload the tissue and result in adverse adaptations to tissue biomechanics and morphology.

Hence, the move from rest to protection; protection shields the injured tissues from unnecessary and potentially harmful stress early in the rehabilitation process but does not completely eliminate external loads. Contralateral exercises may be performed to obtain cross-transfer effects on the muscles of the injured side. Isometric exercises may be performed very early in rehabilitation to prevent atrophy without fear of further injury to the tissue. Similarly, active plantar flexion and dorsiflexion may be initiated in a pain-free range early after an ankle sprain because they also do not endanger the healing ligament.


Figure 23-40. Commercially available Aircast ankle stirrup. (Reprinted with permission from DonJoy.)

Several devices are available to achieve early protected motion during and after treatment sessions for both the foot and ankle97,107 (Figure 23-40). When a commercially available product is not feasible, a similar protective device may be fashioned from thermoplastic materials such as Hexalite (DUROplastic Technologies) or Orthoplast (Rolyan Splinting; Figure 23-41). These devices are important to protect the injured tissue but also in helping the athlete slowly increase the mechanical load placed on the tissues.

Optimal Loading

Optimal loading suggests that rest should be replaced with a balanced and incremental program of early but controlled loading to promote better morphological characteristics of the injured tissue.12,72 For these reasons, early loading, even if only touchdown weightbearing, is essential.58 Aquatic therapy may also be beneficial, in that it allows light to moderate weightbearing in a gravity-reduced environment that can be modified over time to slowly increase load.39 Functional rehabilitation of a minor foot/ankle injury is often a good example of how optimal loading can be used. These injuries are treated with early but controlled weight-bearing while supported, often with an external support, to progressively load the tissues. There is no common dosage or strategy that can be deployed for all injuries, so it is important to develop your loading strategy based on the unique mechanical stresses that will be placed on the injured tissue by that specific patient. It is important to remember that incorporating optimal loading does not eliminate the need for crutches, braces, and/or supports. Rather, these devices should be strategically leveraged to help the patient progressively load his or her tissues during rehabilitation.


Figure 23-41. Molded Hexalite ankle stirrup.

As the tissues heal, the patient should be directed toward partial weightbearing from nonweightbearing and/or toe-touch weight-bearing. Using crutches or other devices can help limit the chance of aggravating the injured tissues and also help to reduce muscle atrophy, proprioceptive loss, and circulatory stasis. A good mechanical loading progression will also inhibit tendon contracture, which can lead to tendinitis when athletes “jump” back into participation.


The initial use of ice has its basis in constricting superficial blood flow to prevent hemorrhage, as well as in reducing the hypoxic response to injury by decreasing cellular metabolism. However, clotting for most injuries takes just a few minutes, and cryotherapy is typically not applied for 5 to 10 minutes post injury.65 Therefore, cryotherapy does not prevent hemorrhage, but it can reduce hypoxic (ie, secondary) injury, which can prevent further edema formation.62 Ice also has an analgesic effect, which can help to reduce muscle guarding.58,95 Many clinicians still think that ice can only be applied for 20 minutes and anything longer than that would result in vasodilation (ie, the hunting response). This is absolutely false.95

The duration of ice application should be based on several factors. The first factor is the depth of the target tissue, as deeper tissues are cooled via conduction only after the superficial tissues are cooled. In other words, a deeper target may require a longer cooling period.44 Having said this, deeper tissues also take longer to rewarm, and this should be considered in your overall treatment plan. The second factor is the degree of cooling desired. There is a direct relationship between tissue temperature and tissue oxygen consumption.9 In other words, greater cooling results in greater reductions in the metabolic needs of the cells and therefore less hypoxic injury. Location of superficial nerves should also be considered and avoided when possible because extended cryotherapy treatments of such nerves can produce transient nerve palsy.28

To maximize tissue cooling, ice should be applied directly to the skin whenever possible.117,125 If a patient is allergic to cold, an elastic bandage should be wet, and the ice bag placed upon it for the desired time.104 Further, the ice bag should be large enough to more than cover the target area and should be held in place with an elastic bandage. The compression from the elastic bandage increases the amount of cooling beyond an ice bag in isolation.62 Flexi-wrap should not be used when trying to maximize tissue cooling and compression.

Ice can be used during all phases of rehabilitation,64 but it is most effective early in rehabilitation to help control pain and prevent edema.95 Transitioning to heat can occur as soon as the secondary signs of inflammation have been controlled (eg, heat, swelling, pain, redness) which will vary based on the injury severity and patient. Thus, the switch to heat, if you and your patient chose to do so, should be made based on symptomatology rather than a strict time schedule.


Immediately following injury and evaluation, a compression wrap should be applied to the injured structure.58 An elastic bandage should be firmly (~75% of stretch) and evenly applied, wrapping distal to proximal. To add more compression, a felt pad (eg, horseshoe shaped) may be inserted under the wrap over the area of maximum swelling. Other devices are available that apply external compression to the ankle to control or reduce swelling. These can be used both initially and throughout the rehabilitative process. Most of these use either air or cold water within an enclosed wrap customized for a specific body part to provide pressure to reduce swelling, such as a Game Ready compression unit (Figure 23-42). Elastic bandages have been preferred because they resulted in the greatest average pressure on the injured structure and the great cooling when combined with an ice bag applied directly to the skin relative to other cold/compression devices.20 While more advanced devices have flooded the marketplace, the comparative effectiveness of these devices relative to elastic bandages remains unclear.


Figure 23-42. Game Ready unit provides external compression to the ankle to control or reduce swelling.


Elevation is an essential part of edema control. Elevation allows gravity to work with the lymphatic system rather than against it, decreases hydrostatic pressure to decrease fluid loss, and also assists venous and lymphatic return through gravity.95 Patients with foot and ankle injuries should be encouraged to maintain an elevated position as often as possible, particularly during the first 24 to 48 hours following injury. An attempt should be made to treat in the elevated position rather than the gravity-dependent position. Any treatment done in the dependent position will allow edema to increase.95,103

Rehabilitation Progression

As swelling is controlled and pain decreases, tissue healing has started to transition from the inflammatory to the repair phase of healing. A key milestone for foot and ankle rehabilitation in this early phase is weightbearing tolerance.39 While optimal loading should still be incorporated into your rehabilitation plan, loads can be increased significantly as your protocol becomes more aggressive. However, you must continually monitor the process of your patient for both physiological and psychological signs of being too aggressive. Ensure that your patient has the ability to find and maintain a neutral foot position and actively model foot core during weightbearing.

Cardiorespiratory Endurance

Cardiorespiratory and resistance training should be incorporated by the athletic trainer and/or strength and conditioning team during the entire rehabilitation process. However, all parties must understand that it is almost impossible to keep an athlete “game fit” following injuries that require prolonged rehabilitation periods. Pedaling a stationary bike (Figure 23-39A) or an upper extremity ergometer (Figure 23-39B) with the hands can provide cardiovascular exercise with little to no stress on the foot/ankle complex. Pool running using a float vest and swimming are also good cardiovascular exercises (Figure 23-38). If weight-bearing is tolerated but the additional impact of walking or running is not, elliptical machines may offer another alternative to achieve cardiovascular exercise.

Range of Motion

In the earliest stages of rehabilitation (ie, initial treatment), active and/or passive motions that stress the involved tissues should be avoided. However, any active and passive motions that do not stress the tissues should be encouraged. Similarly, motions that might elicit pain (ie, stress the tissues) can still be incorporated as long as the motion is limited to the portions of the movement that are not painful. There is also evidence that joint mobilizations (eg, Maitland, grade 2 and/or 3) can be used in the earliest phase of rehabilitation. This is especially true for lateral ankle sprains121 (see Figures 13-63 through 13-66). Also, keep in mind the arthrokinematics of the rearfoot, midfoot, and forefoot. Joint mobilizations of the transverse tarsal and tarsometatarsal joints are important for promoting appropriate half dome deformation and reformation.

As tenderness over the target tissue decreases, ROM exercises in all planes of motion should be encouraged. Examples of ROM exercises for the foot/ankle complex include towel stretching for the Achilles complex (Figure 23-9), stretching for the plantar flexors (Figure 23-8), standing or kneeling stretches for the dorsiflexors (Figure 23-10), and stretches for the plantar fascia (Figure 23-11). Patients are encouraged to do these exercises slowly, without pain, and to use longer duration stretches during static stretches (2 sets of 40). Longer durations are encouraged to leverage neurophysiological processes (ie, autogenic inhibition) that will help improve ROM. Other exercises can assist with ROM in a controlled but more functional manner (eg, pulling a towel from one side to the other by alternately inverting and everting the foot [Figure 23-22], writing the alphabet). Both lower and capital letter in print and cursive can be done on the floor/table or in an ice bath. Completing this exercise in an elevated position (assuming pain is under control) could help alleviate residual swelling by taking advantage of the active muscle contractions that the patient will use to complete the task. An ice bath requires a gravity-dependent position, so it should only be done after swelling is controlled. However, this can be a nice transition exercise if the swelling but not the pain has been controlled. The ice will create an analgesic effect during the ROM exercises to allow the patient to begin ROM exercises while pain is being mitigated.

Exercises performed on unstable surfaces, such as a foam pad, BOSU balance trainer, BAPS board, or rocker board (Figure 23-32), can also be performed to improve ROM in a functional manner and also serve as beginning exercises for regaining sensorimotor control.114 Depending on the status of the patient, you may wish to start with wedge or rocker boards to avoid specific motions (eg, inversion following a lateral ankle sprain) until the patient is ready. All of these exercises should be done seated at first before progressing to standing (Figure 23-7) only after the patient has demonstrated a consistent capacity to complete the exercises correctly. Foam rollers3 and plantar massage81 have also been shown to improve ROM in the gastrocnemius/soleus complex. Regardless of the stage of rehabilitation, patients should be encouraged to maintain their ROM via a combination of techniques to facilitate rehabilitation.


The generation of appropriate muscle contractions and muscular force is key to restoring the ability to meet the functional demands of absorption, propulsion, and stability. There is a 3-tiered approach to restoring strength, moving from isometric to concentric to eccentric muscle contractions. Isometrics may be done in the major motion planes, frontal and sagittal (Figures 23-12 through 23-15), as early as tolerable. Isotonic exercises, within a pain-free arc of motion, can also be incorporated early in the rehabilitation process. As the injured tissues heal further and ROM is restored, strengthening exercises may be begun in all planes of motion. However, clinicians must educate the athlete and provide supervision to ensure that the athlete is not compensating to overcome muscle weakness. As is the case with all rehabilitation goals, pain should be the basic guideline for deciding when to start strengthening exercises with a specific plan of motion or specific exercises in general.

Strengthening exercises should focus on the needs of the athlete when he or she returns to play. Resistive tubing exercises, ankle weights around the foot (Figures 23-16 through 23-19), or a multidirectional Elgin ankle exerciser (Figure 23-20) are excellent methods of strengthening the extrinsic muscles within the active subsystem of the foot core, particularly before weightbearing is tolerated. Tubing has advantages in that it may be used both concentrically and eccentrically. Some athletes may need greater levels of endurance, while others need greater strength and power (Figures 23-21 and 23-23 through 23-25). Isokinetics have advantages in that more functional speeds may be obtained and they provide accommodating resistance (Figures 23-25 through 23-27), but the needed equipment is incredibly expensive. Towel-gathering (Figure 23-22) and short foot exercises (Figure 23-52) are excellent exercises to engage the extrinsic and intrinsic muscles of the foot core, respectively.

Proprioceptive neuromuscular facilitation (PNF) strengthening exercises can be used to improve strength but also help to transition a patient toward sensorimotor control exercises. PNF strengthening exercises can focus on global or isolated motions at the talocrural and more distal joints (Figures 23-28 through 23-31). Perhaps the most important element of strength training during rehabilitation is that strength alone is never enough. Strong muscles can help with performance and even stability, but only when those muscles are activated. For example, research has shown that the response time of the peroneals (ie, reactive sensorimotor control) is too slow to prevent a lateral ankle sprain.63 Thus, strength must be put into context, and patients must learn how and when to use their strength by training their sensorimotor control system.

Excessive Pronation and Supination: Foot Posture Alterations in the Functional Demands of Absorption, Propulsion, and Stability

Often, when we hear the terms pronation or supination, we automatically think of some pathological condition related to gait. We reemphasize that pronation and supination of the foot are normal movements that occur during the functional demands of absorption (pronation), propulsion (supination), and stability (transition between absorption and propulsion). Pronation refers to the deformation of the half dome during absorption. Supination refers to half dome reformation during propulsion. However, if pronation or supination are excessive or prolonged, overuse injuries may develop within the foot core system. Excessive or prolonged supination or pronation is likely to result from some functional deficiency within the foot core system, such as decreased dorsiflexion, limited metatarsophalangeal joint extension, or muscular imbalance in the active subsystem or more proximal muscles and joints that influence/control tibial rotation. These functional deficiencies may lead to structural alterations within the passive, active, and/or neural subsystems of the foot core system. Alternatively, structural alterations from congenital or acquired conditions (Charcot-Marie-Tooth disease, pes cavus, pes planus, diabetes) may result in functional compensations to allow the foot to less effectively absorb, propel, or stabilize. Thus, excessive pronation or supination may be a structural/functional compensation for a functional/structural alteration. Key to this issue is the interdependence of structure and function. Understanding foot pronation (half dome deformation) and supination (half dome reformation) in relation to the rockers helps to articulate their importance.


Figure 23-43. Eversion of the calcaneus on the left foot indicating pronation.

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Sep 18, 2021 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Rehabilitation of Ankle and Foot Injuries

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