Rehabilitation of Lower Leg Injuries

Doug Halverson, MA, ATC, CSCS
Christopher J. Hirth, MSPT, PT, ATC

The lower leg consists of the tibia and fibula and 4 muscular compartments that either originate on or traverse various points along these bones. Distally the tibia and fibula articulate with the talus to form the talocrural joint. Because of the close approximation of the talus within the mortise, movement of the leg will be dictated by the foot, especially upon ground contact. This becomes important when examining the effects of repetitive stresses placed upon the leg with excessive compensatory pronation secondary to various structural lower extremity malalignments.83,84 Proximally, the tibia articulates with the femur to form the tibiofemoral joint, as well as serving as an attachment site for the patellar tendon, the distal soft tissue component of the extensor mechanism. The lower leg serves to transmit ground reaction forces to the knee as well as rotatory forces proximally along the lower extremity that may be a source of pain, especially with athletic activities.⁶⁰

Compartments of the Lower Leg

All muscles work in a functionally integrated fashion in which they eccentrically decelerate, isometrically stabilize, and concentrically accelerate during movement.⁵³ The muscular components of the lower leg are divided anatomically into 4 compartments. In an open kinetic chain (OKC) position, these muscle groups are responsible for movements of the foot, primarily in a single plane. When the foot is in contact with the ground, these muscle– tendon units work both concentrically and eccentrically to absorb ground reaction forces, control excessive movements of the foot and ankle to adapt to the terrain, and, ideally, provide a stable base to propel the limb forward during walking and running.

The anterior compartment is primarily responsible for dorsiflexion of the foot in an OKC position. Functionally, these muscles are active in the early and midstance phase of gait, with increased eccentric muscle activity directly after heel strike to control plantar flexion of the foot and pronation of the forefoot.²² Electromyographic (EMG) studies have noted that the tibialis anterior is active in more than 85% of the gait cycle during running.⁵⁸

The deep posterior compartment is made up of the tibialis posterior and the long toe flexors and is responsible for inversion of the foot and ankle in an OKC. These muscles help control pronation at the subtalar joint and internal rotation of the lower leg.^22,58 Along with the soleus, the tibialis posterior will help decelerate the forward momentum of the tibia during the midstance phase of gait.

The lateral compartment is made up of the peroneus longus and brevis, which are responsible for eversion of the foot in an OKC. Functionally, the peroneus longus plantar flexes the first ray at heel-off, while the peroneus brevis counteracts the supinating forces of the tibialis posterior to provide osseous stability of the subtalar and midtarsal joints during the propulsive phase of gait. This is a prime example of muscles working synergistically to isometrically stabilize during movement. EMG studies of running report an increase in peroneus brevis activity when the pace of running is increased.⁵⁸

The superficial posterior compartment is made up of the gastrocnemius and soleus muscles, which in OKC position are responsible primarily for plantar flexion of the foot. Functionally, these muscles are responsible for acting eccentrically, controlling pronation of the subtalar joint and internal rotation of the leg in the midstance phase of gait, and acting concentrically during the push-off phase of gait.^22,58

REHABILITATION TECHNIQUES FOR SPECIFIC INJURIES

Tibial and Fibular Fractures

Pathomechanics

The tibia and fibula constitute the bony components of the lower leg and are primarily responsible for weightbearing and muscle attachment. The tibia is the most commonly fractured long bone in the body, and fractures are usually the result of either direct trauma to the area or indirect trauma such as a combination rotatory/compressive force. Fractures of the fibula are usually seen in combination with a tibial fracture or as a result of direct trauma to the area. Tibial fractures will present with immediate pain, swelling, and possible deformity and can be open or closed in nature. Fibular fractures alone are usually closed and present with pain on palpation and with ambulation. These fractures should be treated with immediate medical referral and most likely a period of immobilization and restricted weight-bearing for weeks to possibly months, depending on the severity and involvement of the injury. Surgery such as open reduction with internal fixation of the bone, usually of the tibia, is common.

Tibial and fibular fractures can be managed with cast immobilization or open reduction and internal fixation. If treated with immobilization, the patient is placed on a restricted weightbearing status for a time to facilitate fracture healing. Immobilization and restricted weightbearing of a bone, its proximal and distal joints, and surrounding musculature will lead to functional deficits once the fracture is healed. Complications following immobilization include joint stiffness of any joints immobilized, muscle atrophy of the lower leg and possibly the proximal thigh and hip musculature, as well as an abnormal gait pattern. Bullock-Saxton demonstrated changes in gluteus maximus EMG muscle activation after a severe ankle sprain.14 Proximal hip muscle weakness is magnified by the immobility and nonweightbearing action that accompanies lower leg fractures. Obremskey et al⁵⁴ investigated the management of stable tibial shaft fractures. They found that when treated with intramedullary nailing, tibial fractures had improved clinical and functional outcomes at 3 months compared to patients treated with cast immobilization. Patients treated with an intramedullary nail also had a lower incidence of malalignment or malunion. Depending on the severity of the fracture, there also may be postsurgical considerations such as an incision and hardware within the bone.

It is important that the athletic trainer perform a comprehensive evaluation of the patient to determine all potential rehabilitation problems, including range of motion (ROM), joint mobility, muscle flexibility, strength and endurance of the entire involved lower extremity, balance, proprioception, and gait. The athletic trainer must also determine the functional demands that will be placed on the patient upon return to competition and set up short- and long-term goals accordingly. Upon cast removal it is important to address ROM deficits. This can be managed with passive, then active, ROM exercises in a supportive medium such as a warm whirlpool (Figures 22-1 through 22-4, 22-9, and 22-14 through 22-17). Joint stiffness can be addressed via joint mobilization to any joint that was immobilized (see Figures 13-61 through 13-68). It is possible to have posttraumatic edema in the foot and ankle after cast removal that can be reduced with massage. Strengthening exercises can help facilitate muscle firing, strength, and endurance (Figures 22-5 through 22-8 and 22-10 through 22-17). Balance and proprioception can be improved with single-leg standing activities and balance board activities (Figures 22-22 through 22-25). Cardiovascular endurance can be addressed with pool activities including swimming and pool running with a floatation device, stationary cycling, and the use of an upper body ergometer (Figures 22-16, 22-26, and 22-27). A stair stepper is also an excellent way to address cardiovascular needs as well as lower extremity strength, endurance, and weightbearing (Figure 22-17).

Once the patient demonstrates proficiency in static balance activities on various balance modalities, more dynamic neuromuscular control activities can be introduced. Exercise sandals (Orthopedic Physical Therapy Products) can be incorporated into rehabilitation as a closed kinetic chain (CKC) functional exercise that places increased proprioceptive demands on the patient. The exercise sandals are wooden sandals with a rubber hemisphere located centrally on the plantar surface (Figure 22-28). The patient can be progressed into the exercise sandals once he or she demonstrates proficiency in barefoot single-leg stance. Prior to using the exercise sandals, the patient is instructed in the short foot concept—a shortening of the foot in an anteroposterior direction while the long toe flexors are relaxed, thus activating the short toe flexors and the foot intrinsics (Figure 22-36).⁴⁰ Clinically, the short foot appears to enhance the longitudinal and transverse arches of the foot. Once the patient can perform the short foot concept in the sandals, he or she is progressed to walking in place and forward walking with short steps (Figure 22-29). The patient is instructed to assume a good upright posture while training in the sandals. Initially, the patient may be limited to 30 to 60 seconds while acclimating to the proprioceptive demands. Once the patient appears safe with walking in place and small-step forward walking, the patient can follow a rehabilitation progression (Figures 22-29 through 22-34).

The exercise sandals offer an excellent means of facilitating lower extremity musculature that can be affected by tibial and fibular fractures. Bullock-Saxton et al noted increased gluteal muscle activity with exercise sandal training after 1 week.¹⁵ Myers et al also demonstrated increased gluteal activity, especially with high-knees marching in the exercise sandals.⁵¹ Blackburn et al have shown increased activity in the lower leg musculature, specifically the tibialis anterior and peroneus longus, while performing the exercise sandal progression activities.¹¹ The lower leg musculature is usually weakened and atrophied from being so close to the trauma. The exercise sandals offer an excellent means of increasing muscle activation of the lower leg musculature in a functional weightbearing manner.

Rehabilitation Progression

Management of a post-immobilization fracture requires good communication with the physician to determine progression of weight-bearing status, any assistive devices to be used during the rehabilitation process, such as a walker boot, and any other pertinent information that can influence the rehabilitation process. It is important to address ROM deficits immediately with active ROM, passive stretching, and skilled joint mobilization. Isometric strengthening can be initiated and progressed to isotonic exercises once ROM has been normalized. After weightbearing status is determined, gait training to normalize walking should be initiated. Assistive devices should be used as needed. Strengthening of the involved lower extremity can be incorporated into the rehabilitation process, especially for the hip and thigh musculature. It is important for the therapist to identify and address this hip muscular weakness early on in rehabilitation through open and closed chain strengthening. Balance and proprioceptive exercises can begin once there is full pain-free weightbearing on the involved lower extremity.

As ROM, strength, and walking gait are normalized, the patient can be progressed to a walking/jogging progression and a sport-related functional progression. It must be realized that the rate of rehabilitation progression will depend on the severity of the fracture, any surgical involvement, and length of immobilization. The average healing time for uncomplicated nondisplaced tibial fractures is 10 to 13 weeks; for displaced, open, or comminuted tibial fracture, it is 16 to 26 weeks.54

Fibular fractures may be immobilized for 4 to 6 weeks. Again, an open line of communication with the physician is required to facilitate a safe rehabilitation progression for the patient.

Criteria for Full Return

The following criteria should be met prior to the return to full activity: (a) full ROM and strength, compared to the uninvolved side; (b) normalized walking, jogging, and running gait; (c) single-leg objective (ie, distance or timed) functional testing such as a single-leg hop for distance can be compared to the uninvolved limb to help determine return to play time line—the involved limb should be greater than 90% of the uninvolved limb before progressing to return to play; and (d) successful completion of a sport-specific functional test.

Tibial and Fibular Stress Fractures

Pathomechanics

Stress fractures of the tibia and fibula are common in sports. Studies indicate that stress fractures of the tibia occur at a higher rate than those of the fibula.^7,8,48 Stress fractures in the lower leg are usually the result of the bone’s inability to adapt to the repetitive loading response during training and conditioning of the athlete. The bone attempts to adapt to the applied loads initially through osteoclastic activity, which breaks down the bone. Osteoblastic activity, or the laying down of new bone, will soon follow.^57,82 If the applied loads are not reduced during this process, structural irregularities will develop within the bone, which will further reduce the bone’s ability to absorb stress and will eventually lead to a stress fracture.^8,28

Repetitive loading of the lower leg with a weightbearing activity such as running is usually the cause of tibial and fibular stress fractures. Romani et al reports that repetitive mechanical loading seen with the initiation of a stressful activity may cause an ischemia to the affected bone.⁶³ He reports that repetitive loading may lead to temporary oxygen debt of the bone, which signals the remodeling process to begin.⁶³ Also, microdamage to the capillaries further restricts blood flow, leading to more ischemia, which again triggers the remodeling process—leading to a weakened bone and a setup for a stress fracture.⁶³

Stress fractures in the tibial shaft mainly occur in the mid anterior aspect and the posteromedial aspect.^7,48,59,82 Anterior tibial stress fractures usually present in patients involved in repetitive jumping activities with localized pain directly over the mid anterior tibia. The patient will complain of pain with activity that is relieved with rest. The pain can affect activities of daily living (ADLs) if activity is not modified. Vibration testing using a tuning fork will reproduce the symptoms, as will hopping on the involved extremity. A triple-phase technetium-99 bone scan can confirm the diagnosis faster than an X-ray, as it can take a minimum of 3 weeks to demonstrate radiographic changes.^57,59,82 Posterior medial tibial pain usually occurs over the distal one third of the bone with a gradual onset of symptoms. This is considered a low risk stress fracture due to the low probability of complications during the healing process.62 Focal point tenderness on the bone will help differentiate a stress fracture from medial tibial stress syndrome (MTSS), which is located in the same area but is more diffuse upon palpation.

The procedures listed above will be positive and will implicate the stress fracture as the source of pain. Fibular stress fractures usually occur in the distal one-third of the bone with the same symptomatology as for tibial stress fractures. Although less common, stress fractures of the proximal fibula are noted in the literature.^48,78,93

Injury Mechanism

Anterior tibial stress fractures are prevalent in patients involved with jumping and are often described as the “dreaded black line” on the anterior medial tibial cortex in 15% to 20% of cases.⁶² Several authors have noted that the tibia will bow anteriorly with the convexity on the anterior aspect.^19,57,60,82 This places the anterior aspect of the tibia under tension that is less than ideal for bone healing, which prefers compressive forces. Anterior tibial dyaphysis stress fractures are considered higher risk due to the possibility of fracture propagation, displacement of the fracture site, and delayed and nonunion of healing.⁶² Repetitive jumping will place greater tension on this area, which has minimal musculotendinous support and blood supply. Other biomechanical factors may be involved, including excessive compensatory pronation at the subtalar joint to accommodate lower extremity structural alignments such as forefoot varus, tibial varum, and femoral anteversion. This excessive pronation might not affect the leg during ADLs or with moderate activity, but might become a factor with increases in training intensity, duration, and frequency, even with sufficient recovery time.^32,82 Increased training may affect the surrounding muscle–tendon unit’s ability to absorb the impact of each applied load, which places more stress on the bone. Stress fractures of the distal posteromedial tibia will also arise from the same problems as listed, with the exception of repetitive jumping. Excessive compensatory pronation may play a greater role with this type of injury. This hyperpronation can be accentuated when running on a crowned road, such is the case of the uphill leg where the athlete will have a functional leg-length discrepancy during the workout.⁶⁵ Also, running on a track with a small radius and tight curves will tend to increase pronatory stresses on the leg that is closer to the inside of the track.⁶⁵ Excessive pronation may also play a role with fibular stress fractures. The repeated activity of the ankle inverters and long toe flexors and calf musculature pulling on the bone may be a source of this type of stress fracture.⁵⁶ Training errors of increased duration and intensity along with worn-out shoes will only accentuate these problems.⁶⁵ Other factors, including menstrual irregularities, diet, bone density, increased hip external rotation, tibial width, and calf girth, also have been identified as contributing to stress fractures.^8,31

Rehabilitation Concerns

Immediate elimination of the offending activity is most important. The patient must be educated on the importance of this to prevent further damage to the bone. Many patients will express concerns about fitness level with loss of activity. Stationary cycling and running in the deep end of the pool with a floatation device can help maintain cardiovascular fitness (Figures 22-16 and 22-26). Eyestone et al demonstrated a small, but statistically significant, decrease in maximal aerobic capacity when water running was substituted for regular running.²⁴ This was also true with using a stationary bike.²⁴ These authors recommend that intensity, duration, and frequency be equivalent to regular training. Wilder et al note that water provides a resistance that is proportional to the effort exerted.⁸⁹ These authors found that cadence, via a metronome, gave a quantitative external cue that with increased rate showed high correlation with heart rate.⁸⁹ Nonimpact activity in the pool or on the bike will help maintain fitness and allow proper bone healing. Proper footwear that matches the needs of the foot is also important. For example, a high arched or pes cavus foot type will require a shoe with good shock-absorbing qualities. A pes planus foot type or more pronated foot will require a shoe with good motion control characteristics. Evidence-based reviews indicate that shock-absorbing insoles can have a preventative effect with tibial stress fractures.70 A detailed biomechanical exam of the lower extremity, both statically and dynamically, may reveal problems that require the use of a custom foot orthotic. Stretching and strengthening exercises can be incorporated in the rehabilitation process. The use of ice and electrical stimulation to control pain is also recommended.

The use of an Aircast (DJO Global) with patients who have diagnosed stress fractures has produced positive results.²¹ Dickson and Kichline speculate that the Aircast unloads the tibia and fibula enough to allow healing of the stress fracture with continued participation.²¹ Swenson et al reported that patients with tibial stress fractures who used an Aircast returned to full unrestricted activity in 21 ± 2 days; patients who used a traditional regimen returned in 77 ± 7 days.⁸¹ Fibular and posterior medial tibial stress fractures will usually heal without residual problems if the previously mentioned concerns are addressed.⁷⁸ Stress fractures of the mid anterior tibia can take much longer, and residual problems might exist months to years after the initial diagnosis, with attempts at increased activity.^19,23,59,60 Initial treatment may range from short leg cast and nonweightbearing for 6 to 8 weeks to surgical intervention with an intrameduallary nail being used to stabilize the stress fracture. Robertson and Wood found in a review that intrameduallary nailing had higher rates of return to sports than conservative care (96% compared to 71%).⁶²

Batt et al noted that use of a pneumatic brace in those individuals allowed for return to unrestricted activity an average of 12 months from presentation.⁴ The proposed hypothesis for use of a pneumatic brace is that elevated osseous hydrostatic and venous blood pressure produces a positive piezoelectric effect that stimulates osteoblastic activity and facilitates fracture healing.⁹² Rettig et al used rest from the offending activity as well as electrical stimulation in the form of a pulsed electromagnetic field for a period of 10 to 12 hours per day. The authors noted an average of 12.7 months from the onset of symptoms to return to full activity with this regimen.⁶⁰ Chang and Harris noted good to excellent results with a surgical procedure involving intramedullary nailing of the tibia with individuals with delayed union of this type of stress fracture.¹⁹ Surgical procedures involving bone grafting have also been recommended to improve healing of this type of stress fracture.

Rehabilitation Progression

After diagnosis of the stress fracture, the patient may be placed on crutches, depending on the amount of discomfort with ambulation. Ice and electrical stimulation can be used to reduce local inflammation and pain. The patient can immediately begin deep-water running with the same training parameters as his or her regular regimen if he or she is pain-free. Stretching exercises for the gastrocnemius– soleus musculature can be performed 2 to 3 times per day (Figure 22-19). Isotonic strengthening exercises with rubber tubing can begin as soon as tolerated on an every-other-day basis, with an increase in repetitions and sets as the athletic trainer sees fit (Figures 22-5 through 22-8).

Strengthening of the gastrocnemius can be done initially in an open chain and eventually be progressed to a closed chain (Figures 22-5, 22-12, and 22-13). The patient should wear supportive shoes during the day and avoid shoes with a heel, which can cause adaptive shortening of the gastrocnemius–soleus complex and increase strain on the healing bone. Custom foot orthotics can be fabricated for motion control to prevent excessive pronation for those patients who need it. Foot orthotics can also be fabricated for a high-arched foot to increase stress distribution throughout the plantar aspect of the whole foot vs the heel and the metatarsal heads. Shock-absorbing materials can augment these orthotics to help reduce ground reaction forces. The exercise sandal progression can also be introduced to help facilitate lower leg muscle activity and strength (Figures 22-29 through 22-34 and 22-36). As the symptoms subside during a period of 3 to 4 weeks and X-rays confirm that good callus formation is occurring, the patient may be progressed to a walking/jogging progression on a surface suitable to that patient’s needs. The patient must demonstrate pain-free ambulation prior to initiating a walk/jog program. A quality track or grass surface may be the best choice to begin this progression. The patient may be instructed to jog for 1 minute, then walk for 30 seconds for 10 to 15 repetitions. This can be performed on an every-other-day basis with high-intensity/long-duration cardiovascular training occurring daily in the pool or on the bike. The patient should be reminded that the purpose of the walk/jog progression is to provide a gradual increase in stress to the healing bone in a controlled manner. If tolerated, the jogging time can be increased by 30 seconds every 2 to 3 training sessions until the patient is running 5 minutes without walking. This progression is a guideline and can be modified based on individual needs.

Romani et al have developed a 3-phase plan for stress fracture management.63 Phase 1 focuses on decreasing pain and stress to the injured bone while also preventing deconditioning. Phase 2 focuses on increasing strength, balance, and conditioning and normalizing function, without an increase in pain. After 2 weeks of pain-free exercise in phase 2, running and functional activities of phase 3 are introduced. Phase 3 has functional phases and rest phases. During the functional phase, weeks 1 and 2, running is progressed; in the third week, or rest phase, running is decreased. This is done to mimic the cyclic fashion of bone growth. During the first 2 weeks, as bone is resorbed, running will promote the formation of trabecular channels; in the third week, while the osteocytes and periosteum are maturing, the impact loading of running is removed.⁶³ This cyclic progression is continued over several weeks as the patient becomes able to perform sport-specific activities without pain.⁶³

Criteria for Full Return

The patient can return to full activity when (a) there is no tenderness to palpation of the affected bone and no pain of the affected area with repeated hopping; (b) plain films demonstrate good bone healing; (c) there has been successful progression of a graded return to running with no increase in symptoms; (d) gastrocnemius–soleus flexibility is within normal limits; (e) hyperpronation has been corrected or shock-absorption problems have been decreased with proper shoes and foot orthotics if indicated; and (f) all muscle strength and muscle length issues of the involved lower extremity have been addressed.

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Maintaining Cardiorespiratory Fitness During Rehabilitation Restoring Range of Motion and Improving Flexibility Regaining Muscular Strength, Endurance, and Power Rehabilitation of Elbow Injuries Rehabilitation of Injuries to the Spine Rehabilitation of Ankle and Foot Injuries

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