Physical Therapy Series: Foot and Ankle

Foot and ankle issues are a common reason why patients visit an orthopedic surgeon or a podiatrist. In younger patients, the most common diagnosis and sports injury is an ankle sprain. Middle aged and older patients are usually treated for tendonitis and occasionally arthritis in the foot and ankle. The more common diagnoses in this group of patients are plantar fasciitis, Achilles tendinitis, and posterior tibial tendonitis. Physical therapy is critical to make a full recovery from all these ailments, but let's look at the function and requirements of the foot and ankle to determine why these types of injuries are so common.

Foot Functionality

From an evolutionary standpoint, our feet are modified ape hands. Other primates use their feet for climbing and grasping, but human feet have far less dexterity. For approximately 5 million years we have used our feet for walking upright which requires our feet to be more rigid to push and propel us off the ground. We also need them to be elastic enough to absorb energy as our foot strikes the ground. As our feet evolved, our big toes became more rigid and our ligaments became stiffer. The compromise between rigidity and elasticity is the beauty of our foot's design. It is also the reason for our species being injury prone. Another theory is that our footwear is weakening our feet and making them even more prone to injury. Our feet were designed to walk barefoot rather than wearing tight, cushioned-heeled shoes to walk on concrete. Fossil records have shown foot problems long before modern shoes were invented, so shoes are only part of the issue. 

Cultures who are barefoot have stronger feet. It seems children who are barefoot have better arches than those who are in constrictive shoes. The benefits of a child being barefoot in our society is stronger well formed feet. Published a few years ago, the book, Born to Run, by Christopher Mcdougall is a fascinating look at barefoot running and the Tarahumara Indians. This book energized the trend of barefoot running and barefoot or minimalist shoes. Some runners found that the barefoot shoes forced them to land on the ball of their foot as opposed to a heel strike and this prevented hip and knee soreness. However, this drastically different running style needs to be adapted slowly as it could introduce other foot and ankle issues. This happened to me. I read the book, bought the shoes, and headed out on my Saturday 8 mile run. The first 4 miles were amazing until my calves gave out due to the altered running style. I limped home and it took me several weeks to recover.

Ankle Sprains

Our need for flexibility in the foot and ankle results in a large number of sprains to the lateral ankle ligaments. Many of these sprains are sports related and often unavoidable. Sprains could also occur during activities of daily living. If you suffer an ankle sprain, I think it’s important to ask yourself if it was unavoidable. Could a lack of agility or increased body weight have contributed to the injury or the severity of the injury? When someone injures their ankle a medical provider will often use the “Ottawa Rules” to make sure the ankle is not broken. This means pushing on several bones. If they are painful, an x-ray could be required. An MRI is not usually required in ankle sprains because whether the ligaments are stretched, partially torn, or completely torn the treatment is conservative and the vast majority of patients will heal. Surgery is usually reserved for patients with chronic instability. For this reason, MRIs are reserved for patients who fail to progress. Once a sprain is confirmed treatment will be started. The goal of the first few days is to decrease swelling and return to normal walking. This often requires a few days of RICE- rest, ice, compression, and elevation. Some patients may need crutches or a walking boot for a few days. It is important to realize that not all ankle sprains are created equal. A grade 1 sprain will have minimal swelling and a quick return to activities, grade 2 will have moderate swelling and a more delayed return to activity, and grade 3 will have significant swelling and a prolonged return to full activity. Regardless of the severity of the sprain, early therapy to stretch and strengthen the ankle is critical in the first few days. Many patients will feel better quickly, but will feel like their ankle is 100 years old when they wake up, try to walk up and down steps, or try to return to sports. If you want to avoid feeling like this, you need to commit to your therapy. In the first few days therapy is simple. I instruct patients to flex and extend their ankle several times a day and do 20-50 repetitions of this each time. As you progress, you can use a band, towel, or belt around your foot to stretch in extension and apply some resistance to strengthen in flexion. The final exercise is to use your big toe to draw the alphabet. This will take your ankle through the whole range of motion.

The following video is a simple and straightforward program you can do at home to progress in your therapy.

This video is an excellent explanation of lateral ankle sprains, early therapy, and return to sports therapy.

Returning To Activity

The decision when to return to sports and activity can be tricky. There are a few things anyone who suffers an ankle injury should be mindful of: if you commit to therapy you will return more quickly and if you continue your therapy you will be more resistant to a repeat injury. I would especially recommend all athletes work with a therapist or trainer to supervise their therapy. Ultimately, they should continue a home program to maintain their ankle health long after they have made a full recovery. I will usually keep athletes in a brace for 6-12 months after an injury. Taping would be another option. My general rule for returning to sport activities is when you can walk without pain you can try to jog, when you can jog without pain you can try to run, when you can run without pain you can try to cut, accelerate, decelerate and jump. When you can do all of these movements without pain you can play. There will always be a grey area for athletes as they likely want to return as soon as possible. If you're too cautious you could miss out on playing the sport you love, but if you return too soon you could risk injury and risk missing even more time. You may also need to consider who you are as an athlete. If you are the star of the team you may be more cautious to avoid a recurrent injury in early season practice or less meaningful games. On the other hand, if you are less established you are likely aware you can not make the club in the tub. In other words, you need to get back as soon as possible to make the team or get playing time. In these cases it can be helpful to have a physician who understands sports and your situation in forming a treatment plan.

The following video covers a few simple test to help you determine if you are ready to return to activity.

Shin Splints

Medial tibial stress syndrome or what is more commonly known as shin splints is a frequent reason runners of all ages visit the orthopedic clinic. In general, therapy and rest will heal shin splints. However, there is a possibility a patient with shin pain could have a stress fracture. A stress fracture will not always show up on x-ray, so an MRI may be needed to confirm diagnosis. Imaging is not always necessary though because the initial treatment for both shin splints and stress fractures is rest and therapy. In either case, it is important to be patient because recovery could take up to 9-12 months. It is still possible to stay active during your rest period while you cut back or eliminate running. Cycling and swimming are excellent options. Eventually you should have a graded return to running. 

Achilles Tendonitis

Achilles tendon issues are the ultimate “Weekend Warrior” injury. All aging athletes should be mindful of stretching the achilles to avoid tendonitis or a rupture. Some ruptures such as New York Jets quarterback Aaron Rodgers are likely unavoidable. His foot got caught in the artificial turf with such great force something had to give. In most cases, the rupture occurs when the aging athlete jumps or accelerates with a tight Achilles. I often tell my friends to stretch their Achilles before we play our old man sports. Doing stretches and therapy exercises can decrease your chance of rupturing the tendon. In the case of a tendon rupture, some are treated with surgery and some are treated with immobilization. This is something the patient and the surgeon should evaluate together taking into account the tendon gap after the tear and the patient's activity level. The athlete hoping to return to the NFL might be treated differently than the athlete returning to golf or pickleball. You should also communicate with your surgeon what other injuries you have. If bad knees or a bad back keep you from activities that require explosive movements you may not need surgery. Whether you are trying to prevent an injury, trying to heal Achilles tendinitis, or are recovering from a rupture (hoping to not go through it again on the opposite side) therapy is critical.

This video will take you through 4 phases of recovery with increasing stretching and strengthening in each phase up to plyometric (jumping) exercises and return to sports.

This video will explain the difference between tendinitis and tendinosis. You can think of tendinitis as inflammation of the tendon and tendinosis as scarring of the tendon. The treatment includes massage, stretching, and strengthening exercises.

Plantar Fasciitis

Plantar Fasciitis is a disorder of the connective fascia that supports the arch of the foot. It can occur in both active and inactive patients and can result in significant heel pain or arch pain. Chronic inflammation of the fascia may result in calcification of the fascia where it connects to the bone of the heel. This will appear as a heel spur on x-ray. This is an incidental finding and does not change treatment. Heel pads can be helpful and night splints will help keep the fascia stretched while you sleep. 

These videos will teach you how to fix your plantar fasciitis with stretching and strengthening exercises. Rolling a frozen water bottle under your foot is another helpful treatment option.

I would advise patience in your recovery of your foot or ankle ailment. A cortisone injection could relieve the pain, but it will likely come back if you do not do therapy. In all honesty, an injection into the foot or ankle is one of the more painful injections because the foot is designed to be sensitive. Other treatments like shock wave therapy and surgery are reserved for the rare case that is resistant to therapy. 

Posterior Tibial Tendonitis

Posterior tibial tendonitis is a primary cause of medial ankle pain in older patients. The posterior tibial tendon runs along the inside of the calf and behind the bony prominence on the inside of the ankle. Tendonitis here can be debilitating. Once again, therapy is the first line of treatment. Additional treatments could include bracing and orthotics. 

If you review the videos you will see the common theme for foot and ankle therapy is massage, stretching, and strengthening. These elements are incorporated in most functional strength training programs and you should consider adding some into your fitness routine.