Rehabilitation of the Foot and Ankle

STEPHEN REISCHL

LISA M. NOCETI-DEWIT

RICHARD D. FERKEL

INTRODUCTION

The examination and treatment of patients with foot and ankle disorders are challenging for health care professionals. The anatomy, with its wide variations of “normal,” demands an in-depth understanding of the structures of the foot and ankle. Likewise, the biomechanics of the foot and ankle are complex and variable in nonpathological and pathological feet. When a patient with foot and ankle disorders requires operative treatment and postoperative care, a careful progression of rehabilitation is required to return the patient to the highest level of available function. To accomplish this goal, constant communication is needed between the patient, the surgeon, and the rehabilitation team, allowing safe and systematic return to activity. At times, communication between the “team” is ineffective as the terminology describing movement and position of the foot and ankle has been varied among the different health care professionals. This chapter will utilize terminology that is consistent between the Foot and Ankle Special Interest Group, a component of the orthopedic section of the APTA and the American Orthopaedic Foot and Ankle Society (AOFAS).

FIGURE 21-1. The goal of rehabilitation is to return the injured person to all preinjury activities. (Illustration by Susan Brust.)

This chapter will present the foot and ankle as a functional unit during daily, recreational, and career (especially sports) activities. To maximize recovery, the rehabilitation process must integrate the foot and ankle into the function of the lower extremity and trunk. The terminology of observational gait analysis developed at Rancho Los Amigos Medical Center (RLAMC) and the work of Jacquelin Perry, MD, will be used to describe walking. Functional movements, including walking and running, will be described as they pertain to the rehabilitation process of individuals following arthroscopy. To do this successfully, a good understanding of joint anatomy, kinematics, kinetics, and muscle activity is required. The goal of rehabilitation is to return the patient to full functional preinjury activities following arthroscopic surgery of the foot and ankle (Fig. 21-1).

Framework of Patient Interaction: The International Classification of Functioning, Disability, and Health (ICF) Model

The ICF model of health and disability has been used in various health care settings.¹ The framework can be viewed in Figure 21-2. The components of the model are participation, activity restriction, body structure and function, health condition, and contextual factors. The figure demonstrates that all these factors are related and interact with each other. Participation is defined as the limitation the person has in his or her role in society. This could be in work, recreation, or sports to their role as a parent or child. Activity restrictions are specific activities that the person is unable to do such as running, ascending stairs, or jumping. Body structure and function are the systems and structures that may be in dysfunction from direct or indirect cause of the health condition. These may be weakness in a muscle or muscle group or lack of mobility at a particular joint, or a larger multisystem involvement such as a decreased ability to balance on one leg. The health condition may be the pathology that has occurred from the injury, or some other issue. In patients who are involved with postsurgical conditions, the health condition may be quite specific, but during rehabilitation, the changes that may occur in conjunction with the pathology and the surgery must be considered. Lastly, the contextual factors are unique to each patient with whom the health care provider has contact. Family issues, fears, and avoidance issues become important.

FIGURE 21-2. International Classification of Function, Disability, and Health (ICF) model of health and disability. The framework of the ICF model showing the interaction of each component in relation to the individual and his or her health condition.

These factors develop a framework for the assessment of the patient at the time of intervention. When operative treatment is indicated, a change in one’s societal role occurs due to activity restrictions related to health conditions and changes in body structure and function. Contextual factors of the individual are also paramount in the decision-making process by the surgeon and patient. The factors that are of concern between the surgeon and patient are important when the patient comes to postoperative rehabilitation. The rehabilitation specialists learn which health conditions have been altered by the operation (repair, resection, augmentation, arthrodesis, osteotomy) from the surgeon. Surgery creates the swelling and the requirement of immobilization and altered weight bearing. These changes alter the body structure and function of other systems. These may include, but are not limited to, muscular atrophy and central changes from limb immobilization, and integumentary changes due to surgical incision.

Specific patient goals can be estimated and determined prior to surgical intervention and expressed during rehabilitation. The patient’s goals of the surgery process will be some change in societal roles (participation). Societal roles are broken down to include specific activities that the patient must complete to return to full participation. The activities will vary and depend on the societal role. An activity restriction is located in the center and has lines leading to various body structure and function realms. These body structure and function realms can be individually assessed and reassessed to determine if a change is occurring
(Fig. 21-3A). An example using this concept is an individual returning to tennis (Fig. 21-3B). Some of the changes of body structure and function may be more important at a specific time frame in the healing of the health condition following surgery of the foot and ankle. The rehabilitation specialist can utilize this framework to explain these changes and how they impact the patient’s goals and return to his or her societal roles.

FIGURE 21-3. (A) Activity restriction surrounded by systems. The different systems involved in function during activity. (B) How the various systems may be involved in a person returning to tennis.

PHYSICAL THERAPY ASSESSMENT

The patient with foot and ankle surgery will undergo rehabilitation to restore the highest level of function. This return to function will be quite variable depending on the many factors discussed in the use of the ICF model. The time frame following the surgery will dictate the level of intensity of the rehabilitation.

STRUCTURE AND FUNCTION

Although the anatomy of the foot and ankle has been well documented and described in Chapter 5, a brief review can be helpful. The talocrural joint (or ankle) is a modified hinge joint, working on a transverse axis to provide dorsiflexion and plantar flexion movements. It unites the leg to the foot complex and is composed of three main bones—the tibia, fibula, and talus (Fig. 21-4)—firmly bound by strong ligaments. Included are the medial and lateral collateral ligaments, which assist by inhibiting unwanted inversion and eversion during weight bearing (WB) onto the joint (Fig. 21-5).

FIGURE 21-4. Oblique drawing of the foot and ankle.

The foot complex is composed of much smaller bony elements, also bound by an integrated ligamentous system. Most proximal are the talus and calcaneus, also known as the hindfoot. The cuboid and navicular, articulating with the three cuneiforms, make up the midtarsal region. The five metatarsals, followed by the proximal and distal phalanges, are components of the forefoot.

The vital subtalar joint is enclosed in the foot complex. It is chiefly composed of the talus articulating with the calcaneus. The anterior talocalcaneal articulation is continuous with the talonavicular articulation, thus forming the foot’s largest synovial joint. It moves around a triplanar oblique axis to provide the whole foot with pronation and supination in both WB and non-weight-bearing (NWB) positions (Fig. 21-6). The
movements that combine to produce pronation and supination are shown in Table 21-1. This joint is especially important in providing and accommodating the foot in normal gait patterns.

FIGURE 21-5. Coronal cross section (anterior view) of the foot and ankle with the surrounding stabilizing ligaments.

FIGURE 21-6. Axis of rotation of the ankle and subtalar joints. (A) Lateral projection showing the anterior inclination of the subtalar joint is 29° to 47°. (B) Dorsiplantar projection showing the subtalar joint inclination medially is about 8° to 24°.

Table 21-1. Movements of the Foot That Produce Pronation and Supination

	Calcaneal Position	Talus Position	Mid Foot	First Ray
NWB supination	Inversion	Stable	Inversion Adduction	–
WB supination	Inversion	Adduction Dorsiflexion	Inversion Adduction	Plantar flexion
NWB pronation	Eversion	Stable	Eversion Abduction	–
WB pronation	Eversion	Abduction Plantar flexion	Eversion Abduction	Dorsiflexion

PATIENT EXAMINATION

The initial patient examination, including the interview and physical examination, will dictate the starting point of the rehabilitation process. It is important that the patient is consistently reexamined to appropriately progress their rehabilitation.

Gathering of Background Information

Generally, there are written postoperative orders from the surgeon. These may be specific, due to the nature of the operation and what was done to the health condition (repair, resection, augmentation, arthrodesis, osteotomy). The following are more specific background areas to consider.

Prescription

Depending on practice parameters, the prescription may be provided for general information, insurance considerations, or legal reasons. It should include postoperative diagnosis, current contraindications, and surgeon guidelines or comments, such as weight-bearing status.

Past Medical History

It is important to adequately review a patient’s comorbidities that may hinder healing or alter other body structures and functions (i.e., surgery in the lower extremity or previous orthopedic injury), as the assessment and/or treatment may be significantly impacted.

History Related to Current Condition

The patient’s subjective examination is vastly important to a patient’s recovery and should include, at a minimum, the following:

Past and current mobility levels: This allows the health care practitioner to review current weight-bearing status and obtain the patient’s prior level of functioning.
The 24-hour pain pattern and other related symptoms: This will aid in determining how aggressive rehabilitation may be. The use of the visual analog scale (VAS) or numeric analog scale (NAS) can be used to have the patient rate his or her symptoms with certain activities and with resting and worse symptoms.²
Determination of complete timeline of injury: At times, this can be quite straightforward and at other times convoluted if there was a chronic problem.
Preoperative interventions and strategies: There have often been nonsuccessful attempts.
Current postoperative care and/or complications: Though the time from surgery to initial evaluation will vary, it is important to determine the existence of surgical complications. Additionally, other issues may have developed since the patient last saw the surgeon, and from the author’s experience, these may be changes in pain, a recent fall, infection, or as serious as the appearance of deep vein thrombosis (DVT).³

Self-Reported Outcome Studies

Self-reported outcome (SRO) measures are used to allow the patients to score themselves as to the change in their status over a period of time. However, the concern is that these measures must have strong validity and reliability to determine changes. The Lower Extremity Functional Scale (LEFS),⁴ Foot Functional Index-Revised (FFI-r),⁵ and the Foot and Ankle Ability Measure (FAAM)⁶ have been shown to be valid and reliable. It is suggested the chosen SRO measure is repeated at 4- to 6-week intervals.

PHYSICAL EXAMINATION

The variability of the type of foot and ankle surgery a rehabilitation specialist will see requires the use of the above information to determine the extent of the initial assessment. It is important to establish baseline information regarding changes in body structure and function that are present and will require specific interventions.

Neurological and Circulatory Screen

The neurological screen includes sensation testing, myotomal testing, and reflex testing. Sensation testing is preferably performed in a dermatomal pattern for segmental level of the spinal cord or via peripheral nerve distribution. Individual nerve changes and segmental/peripheral overlap in the sensory nerves need to be taken into consideration.

Assessment of the arterial and venous systems of the foot and ankle begins with observation of color and appearance of veins and appearance of the location of swelling and edema. Circulation tests will begin with the palpation of peripheral pulses of posterior tibialis and dorsalis pedis artery. However, it has been reported that up to 15% of the population does not have a palpable dorsal pedis artery.⁷ Temperature can be compared from side to side or an area either proximal or distal. Reflex testing of the Achilles may or may not be appropriate in the postsurgical patient.

Assessment of Edema

Postsurgical edema may vary significantly with the patient presentation. The gold standard of edema and swelling measurement is a volumetric recording documenting and comparing each side. If unavailable, another frequently used method is the figure-of-eight measure (Fig. 21-7). Pugia et al. showed good correlation of the figure-of-eight measure of the ankle and foot to the volumetric measure.⁸ Girth measures of the calf and across the forefoot can also be helpful to determine the extent of swelling.

FIGURE 21-7. Figure-of-eight measurement for edema. Figure-of-eight measurement is used to monitor edema over the course of rehabilitation. Patient position, long sitting with ankle dorsiflexed to 90°; placement of the tape measure, beginning of the tape is between the tibialis anterior tendon and lateral malleolus, then drawn toward the navicular tuberosity, then pulled laterally across the arch and up the base of the fifth metatarsal, and then back to the tibialis anterior tendon. Continue the tape around the ankle joint distal to the tip of the medial malleolus, across the Achilles tendon, then just distal to the tip of the lateral malleolus, and end tape where it began.

Observational Gait Assessment

Assuming that the patient is weight-bearing on the involved lower extremity, gait analysis may be observed following the first patient greeting. Many authors have discussed various methods of observational gait analysis. The patterns of motion and gait mechanics used in walking are complex; the end result is the kinematics, kinetics, and muscle activity that are studied in laboratory settings. Rehabilitation specialists must use their knowledge and observation of normal gait and determine if a deviation exists that may relate to their patient’s loss of function. Observation of gait should begin with the patient barefoot to see the movement of the segments of the foot. Afterward, the patient may be observed in the footwear and/or other assistive device (i.e., brace).

Initial observation of the gait pattern should begin with estimation of gait velocity. Age-related changes in gait velocity have been investigated along with changes often occurring in pathologic conditions. The three tasks of gait that occur during normal walking were developed at RLAMC. The tasks of gait as defined by Perry are weight acceptance, single-limb support, and limb advancement.⁹ Each task has specific joint range of motion and muscle activity (Fig. 21-8A, B; Table 21-2).

WEIGHT ACCEPTANCE

There are two phases of weight acceptance: initial contact and loading response. Best seen from the posterior view, heel contact is made on the lateral calcaneus imparting eversion during initial contact. Anterior compartment muscles eccentrically control the ankle joint as it moves into relative plantar flexion and the foot moves into pronation, resulting in internal rotation of the lower leg.

SINGLE-LIMB SUPPORT

Single-limb support is comprised of midstance and terminal stance. Foot pronation should reach maximum during midstance,¹⁰, ¹¹ while the ankle dorsiflexes and the knee and hip extend. During terminal stance, the heel comes off the ground; the knee and hip remain in extension, while ankle dorsiflexion and a rigid foot allow the body to advance over the forefoot. This phase requires increasing eccentric muscle activity of the calf and other perimalleolar muscles of the lower leg.

LIMB ADVANCEMENT

The first phase of limb advancement, preswing, occurs while the limb is still in contact with the ground. As the contralateral limb contacts the ground, the reference limb shortens through knee flexion and ankle plantar flexion.

FIGURE 21-8. Stages of gait. (A) From left to right, initial contact, loading response, midstance, terminal stance, and preswing. (B) Phases of gait in combination.

The swing phase, composed of initial, mid-, and terminal swing, begins when the forefoot leaves the surface. During initial swing, the foot remains in plantar flexion but moves into dorsiflexion and supination through the activation of the anterior compartment muscles and remains in this position through terminal swing.

Often following surgical intervention, there is reduction in stance time on the involved side, which shortens the contralateral swing phase. Gait analysis is an assessment tool that is valuable throughout the rehabilitation process as the normalization of stance time, stride length, and velocity is a precursor to higher-level activities.

Table 21-2. Gait Summary

Task and Phases of Gait	Kinetics	Muscle Activity	Foot Motion	Ankle Motion
Weight acceptance Initial contact Loading response	Ground reaction force (GRF) increases as weight moves onto limb.	Tibialis anterior (TA), EHL, EDC	Supination into pronation	Neutral to plantar flexion
Single limb support Midstance Terminal stance	GRF increases to 1.2 times body weight at terminal stance.	Gastrocnemius, soleus, tibialis posterior, FHL, FDL, PL, PB	Pronation into supination	Plantar flexion to dorsiflexion
Limb advancement Preswing Initial swing Midswing Terminal swing	GRF diminishes when contralateral limb is beginning to accept weight.	Diminishing calf and perimalleolar muscles, as foot leaves ground, TA activates	Maximum MTP extension in preswing and foot supination	Dorsiflexion into plantar flexion; at end of swing returns to dorsiflexion

Observation of Balance

Balance has been defined as an integrative process involving multiple afferent and efferent pathways depending on:

1. Somatosensory, visual, and vestibular input for the reception of intrinsic (body) and extrinsic information

2. The brain for the integration of this information and the formation of a motor plan

3. The musculoskeletal system for the production of adequate movements to execute the plan¹²

FIGURE 21-9. Single-limb balance. For standardization, the arms are crossed and stance foot is under the body. Flex the contralateral knee and ensure the legs are not touching. Eyes open can be tested first and other changes can be made to the test. Timing each side and comparison made for baseline and during rehabilitation.

In a screening examination, a subject can stand on a single limb with hands placed across the chest while avoiding the opposite leg touching the stance side (Fig. 21-9). The process can be done with eyes open and then closed to reduce the input from the visual system. The somatosensory system may be biased by performing the same activity on a variety of surfaces, such as foam. To bias the vestibular system, the addition of cervical spine rotation on a rigid trunk or the addition of trunk movement on a rigid neck may be applied.

Deficits in proprioception are quite prevalent in individuals with foot and ankle pathology or injury. Bullock-Saxton evaluated changes in lower extremity sensation and muscle function in 20 subjects following a severe ankle sprain against 11 age- and sex-matched controls.¹³ Individuals with severe ankle sprains demonstrated abnormal muscle firing patterns in the hip and low back along with sensory changes in both lower extremities. These results demonstrate the effect a “local injury” has on patients, namely, the necessity for a comprehensive program to restore full neuromusculoskeletal function following a single lower quarter injury.

Functional Testing

Evaluation and documentation of baseline and progression are achieved with use of functional tests. Functional testing may not be appropriate at all times during rehabilitation, but if utilized, the tests may be repeated to determine progress.

Dynamic Testing: Double-Limb and Single-Limb Squat

A double-limb squat allows the patient to do a functional activity as the therapist observes his or her willingness to move. Normal mechanics of a double-limb squat include ankle dorsiflexion and foot pronation. If dorsiflexion is limited on the involved limb, it may be seen from the lateral view. Deviations in the frontal and transverse planes can be observed best from the anterior and posterior views. The practitioner may assess if there is excessive, normal, or lack of calcaneal eversion and its influence on foot or lower extremity motions. To increase muscular demand and potentially view more compensatory mechanisms, the individual can perform a single-limb squat if it is not limited by pain or weight-bearing status.

Dynamic Testing: Bilateral Heel Raise

Normal mechanics of a heel raise include plantar flexion of the ankle and supination of the foot. Calcaneal inversion occurs as the heel rises and the midfoot is stabilized through supination. This occurs with metatarsophalangeal (MTP) joint extension and transference of body weight primarily over the first MTP joint.

Though the bilateral heel raise is a quick screen, important information can be gathered through observation of calcaneal movement and final position of the forefoot. Weight bearing over the first MTP joint is considered typical motion, suggesting the foot is stable as the foot goes into relative supination, while weight bearing over the fifth MTP is considered abnormal mechanics. The single-leg heel rise is used as the strength test for the gastrocnemius and soleus muscles. Normal has been set at 25 single-leg heel rises by Lundsford and Perry.¹⁴

Dynamic Testing: Excursion Tests of Anterior or Medial Reach

Excursion tests can give the rehabilitation specialist significant information. These tests are used to see the amount of motion (excursion of movement) an individual can do at the time the test is administered and through rehabilitation. It will show the willingness of the person to move on the involved versus uninvolved side. The rehabilitation specialist can also observe the deviations of the body as the test is done on both sides. A measurement of the excursion can be done as the person reaches with the opposite limb with an anterior and medial reach. Anterior reach is evaluated using a long, measured board or tape, which is placed on the ground. The distance is measured and compared with an observation of restrictions or deviation from side to side (Figs. 21-10A, B). There are two methods of measuring available. The first method places the patient’s distal tip of the longest toe at the edge of the board, and while standing on a single limb, he or she reaches out with an upper extremity and touches the board with the fingers. The number of inches determines the distance reached,
and the number is compared bilaterally. The second method is to reach forward with one lower extremity while standing on the other, again measuring the distance moved and comparing bilaterally. Medial reaching is performed by placing the foot adjacent to the zero position and measuring the distance reached by the contralateral limb. During the observation of these reach tests, there may be differences not just in the distance in reach but also in the control of the performance of the movement. This may lead the therapist to hypothesize about possible weakness or muscles that may not be activating properly to control the movement requested.

FIGURE 21-10. Anterior and medial reach measures. (A) Anterior reach measure is used as a functional measure of lower extremity excursion; the person reaches the opposite foot forward while keeping the contralateral heel down and controlling the upper body and trunk. The forward reach is measured and compared bilaterally. (B) Medial reach measure is used as a functional measure of lower extremity lateral excursion; the person reaches the opposite foot as far away from the stance side as possible while keeping the contralateral heel down and controlling the upper body and trunk. The medial reach is measured and compared bilaterally.

Knee-to-Wall Dorsiflexion Measure

Proposed as a composite measure of dorsiflexion, this measure can be done with patients in double-limb weight bearing or in single limb¹⁵ (Fig. 21-11). The patient attempts to dorsiflex as much as possible while squatting via hip and knee flexion. This is composite motion of the ankle and foot measured in the sagittal plane movement. The knee is directed to touch the wall, and the measurement made with a ruler is the distance of the longest toe away from the wall with the knee touching the wall and the heel kept in contact with the ground. This measure is recorded in a positive value. With significant restriction of the ankle, the toe may be touching the wall and the knee does not. This distance can be measured and given a negative value. This test can be repeated over the course of rehabilitation and is suggested as one test to assist on determining return to play for athletes following surgery.¹⁶

ACTIVE RANGE OF MOTION

Assessments of active range of motion (AROM) tests are necessary to observe and measure as there may be patients who may be unable to weight bear or tolerate standing assessments upon their initial examination. Active movements that should be observed include ankle dorsiflexion, ankle plantar flexion, foot pronation, foot supination, and toe flexion/extension. These different motions can be compared bilaterally, and a specific degree can be given. The clinician must be cautious when assessing AROM as the
joints of the foot and ankle move in unison, and when testing, motion may be coming from the joints that have similar range. For example, if a patient does not have adequate range of motion when asked to actively dorsiflex, the foot may move into pronation, which may give the impression of more dorsiflexion when actually the motion is coming from the pronation of the foot.

FIGURE 21-11. Knee-to-wall dorsiflexion measure. A functional measure of composite dorsiflexion. The distance from the toe to wall with the knee touching and heel on the ground is compared side to side. Both limbs could be in contact if needed. This picture represents a positive value as the knee is touching the wall, the heel is in contact, and there is a distance between the wall and toe.

PASSIVE RANGE OF MOTION

Passive range of motion (PROM) attempts to isolate an individual joint and measure the available excursion. Individual joints (talocrural vs. talocalcaneal) contribute to movements that the therapist observes the patient perform. For example, ankle plantar flexion is a composite motion of the ankle and foot, requiring supination to obtain the full range of motion. Assessing the passive motion of the talocrural joint versus the talocalcaneal joint will give the therapist information of which joint may be restricted or normal. PROM in the foot and ankle allows the isolation of joints to determine if there is hypermobility, hypomobility, or normal mobility in the joint being tested. In addition to each measurement, a description of the end of motion, called “end-feel,” is documented. Soft, firm, and hard are the descriptions of end-feel that will be used in this examination sequence.

PASSIVE ACCESSORY MOVEMENT

Accessory motion is defined as movement between joint surfaces that is produced by forces applied by an examiner and assesses the specific roll, glide, and slide that occur at the joint surfaces. Decreased accessory motion may be the result of immobilization from trauma, surgery, or other forms of injury.

Joints demonstrating hypermobility are commonly present in the foot and ankle.¹⁷, ¹⁸ This may be from trauma such as an ankle sprain or secondary to congenital laxity or systemic disease process. For example, patients with rheumatoid arthritis often exhibit excessive calcaneal eversion due to hypermobility of the hindfoot.¹⁹ One of the most common examination techniques used at the foot and ankle for testing accessory motion is glides of the talus within the ankle mortise. Limited talocrural dorsiflexion may be limited due to glide restrictions of the talus in the anterior to posterior (A-P) directions (Fig. 21-12). Patients who report feeling the limitation in the anterior ankle when squatting likely have limitations in their joint mobility, while feeling a stretch posteriorly indicates soft tissue restriction. Testing the posterior to anterior (P-A) glide of the talus in the mortise is another frequently used examination technique. This technique is used as an assessment following inversion ankle sprains because it tests the integrity of the anterior capsule and the anterior talofibular ligament (ATFL). This will be discussed further in the special tests section. This assessment is also important when assessing if a joint restriction is contributing to a limitation in ankle plantar flexion.

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