Foot+and+ankle


 * __ Plantar Fasciitis __**

When the plantar fascia is repetitively stretched it develops micro-tears and becomes inflamed1. With chronic inflammation, tissue degeneration begins to occur2. This painful inflammatory condition is termed plantar fasciitis. The plantar fascia is an investing layer of connective tissue that runs from the calcaneus fanning out to the forefoot on the plantar aspect of the foot. It plays an important role during weight bearing by helping to maintain the longitudinal arch of the foot, helping create a rigid surface for push off during gait, and for shock absorption during gait1.
 * Definition**:

-Pain and tenderness in the medial plantar aspect of the heel -Limited ankle dorsiflexion - Stiffness and pain in the heel upon initial steps in the morning - Pain that radiates from the heel up the back of the calf or down into the toes 3,1
 * Signs & Symptoms**:

-Obesity or sudden weight gain: more weight pressing down on the arch of the foot with each step, especially if the body has not had time to adapt due to sudden gain in weight, causing the arch to flatten and the plantar fascia to stretch and tear -Biomechanical problem: those with high or low arches have increased stress to the plantar fascia -Achilles tendon tightness or shortened calf muscles -Acute heel injury -Repetitive trauma or stress: both in athletes and those whose occupation requires long bouts of standing or walking 4,1
 * Mechanism of Injury:**

//Therapeutic Exercise//: Stretches to help plantar fasciitis include a calf stretch for medial and lateral heads of the gastrocnemius, soleus, and Achilles tendon; and pulling the big toe back into extension with the ankle at 90 degrees to stretch the plantar fascia4. Exercises include toe gripping and towel scrunching to strengthen foot muscles to better stabilize the longitudinal arch. Having the patient grab small items from the floor with his/her toes and dropping the items into a cup can achieve the toe gripping exercise. Towel scrunching is achieved by spreading a towel out on the floor and having the patient rest his/her foot on top of it then using just his/her toes to pull and scrunch up the towel toward his/her leg, making sure to never lift the heel. Ankle and leg strengthening exercises are also needed to create a more stable ankle joint, such as dorsiflexion with inversion (for anterior tibialis), eversion (for peroneals), and straight dorsiflexion using the resistance of the theraband.
 * Treatment:**

//Education//: Educate the patient about the anatomy of the plantar fascia and the structures that could be contributing to pain, especially those that were found to be weak during the objective evaluation, and why it is painful. Also instruct the patient of how you plan to strengthen the muscles of the anterior leg and stretch the muscles of the posterior and lateral leg to create a balanced and stable ankle. Instruct the patient to wear comfortable and supportive shoes to help prevent further damage to the plantar fascia during treatment. Since pain is usually worst in the morning when the fascia in cold and stiff, the patient should do ankle pumps to warm up before taking his/her first steps out of bed1.

//Assistive// //Equip//ment: Orthotics or shoes with a heel cup and arch support should be worn to help distribute body weight more evenly over the entire foot surface. Night splints can be used to stretch the fascia and prevent plantarflexion during sleep3.

//Manual// //Therapy//: Soft tissue massage of the medial and lateral heads of the gastrocnemius and peroneals and can help the muscles increase flexibility, especially when paired with stretching. Transverse massage of the Achilles tendon can help increase the flexibility of the tendons of the gastroc and peroneal muscles. Further, massaging the plantar fascia and foot can help increase blood flow to aid in healing5.

//Home Exercise Program//: The patient should continue stretching and strengthening exercises performed in therapy4. The calf and plantar fascia stretches are easy to do at home and require no special equipment. The patient can also use a tennis ball or something comparable to further stretch and massage the plantar fascia at home, by placing the ball on the floor under the arch of his/her foot then applying pressure downwards and rolling the ball back and forth through the range of the arch. Good exercises for home include dorsiflexion, inversion, and eversion with theraband, picking up small items with the toes and dropping them into a cup, and towel scrunching.

//Modalities/Pain Control//: Cryotherapy with ice or commercial cold packs, especially during the acute phase of injury, applied to the plantar fascia will help reduce pain and control inflammation. Moreover, it will reduce the metabolic rate in that region and help prevent further, chronic damage, especially after exercise5. 1Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill. 2 Kennedy, B. & Pluym, B. (2001). Plantarfasciitis. Retrieved from http://www.physio-pedia.com 3Vorvick, L. J. & Ma, C. B. (2012). Plantar fasciitis. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/ 4Mayo Clinic. (2011). Plantar fasciitis. Retrieved from http://www.mayoclinic.com 5Prentice, W. E., Quillen, W. S., & Underwood, F. (2011). Therapeutic modalities in rehabilitation. New York, NY: McGraw-Hill.
 * References**

__** Hypomobile Ankle **__

Hypomobile ankle is a significant decrease in normal ankle passive range of motion. The hypomobility can result from numerous possible abnormalities, including; impaired arthrokinamatics, edema, boney/ cartilaginous deformities, or tight musculature, joint capsule or other soft tissue contractures4.
 * Definition**

The mechanism of injury for hypomobile ankle is variable. Primarily it is due to immobilization of the ankle joint. The ankle is often immobilized after an injury, such as a sprain or fracture. Pain, such as from arthritis or complex regional pain syndrome can lead to guarding of the joint and decreased movement. Immobilization affects the arthrokinamatics of the joint, preventing the normal roll and glide of the joint surfaces. Immobilization causes cross-links to develop within the collagen of the tissues, which leads to adhesions within the joint capsule and other soft tissue around the ankle joint, as well as a reduction in the number of sarcomeres in the muscles3.
 * Mechanism of Injury**

Other factors associated with a decrease in the range of motion of the ankle include: the degenerative changes on the articulating surfaces of the joint resulting from osteoarthritis and rheumatoid arthritis, the fibrous thickening of the joint capsule due to inflammatory proliferation, some metabolic diseases, edema, and the formation of scar tissue.

The muscular spasticity or loss of voluntary movement resulting from neurological conditions can also lead to contractures of the ankle joint4.


 * Signs/ Symptoms**

The signs of symptoms of hypomobile ankle vary, depending on the cause of the decreased range of motion. The patient will most likely present with some form of foot or leg pain, swelling, and difficulty walking3.

Upon assessment, the physical therapist will find a decrease in the available joint range of motion. This decreased range may be within only one direction or it may affect several or all directions of motion. If the entire joint capsule is involved a specific pattern of hypomobility will present, known as the capsular pattern. The capsular pattern of the ankle is: the loss of plantarflexion is greater than the loss of dorsifleixion, and loss of inversion more than eversion4.

An abnormal end feel will be noted. This may present as a change in the quality of the end feel and/or a change in the position.

Gait deviations will also be seen. Examples include: flat foot or toes first initial contact, heel lift during mid-stance, rather than terminal stance, insufficient transfer of weight from the lateral heel to the medial forefoot, and toe drag or increased knee flexion during swing5.

The patient may also present with other signs and symptoms associated with the primary cause of the ankle hypomobility.


 * Treatment Strategy**

//Modalities/pain control// Heating modalities, such as ultrasound, diathermy, hot whirlpool, or hot packs, increase tissue extensibility, decrease muscle tone/ spasm, and also have an analgesic affect. If the goal is to decrease pain and spasms, moderate heating of 2° C is recommended. If the goal is to increase tissue extensibility, vigorous heating of 4° C is recommended. The heat modalities should always be combined with therapeutic exercises6.

//Manual therapy// Joint mobilizations and manipulations are commonly used to increase motion at the joint. For joint mobilizations, a grade III or IV is used to improve motion2. By following the convex-concave rule, the physical therapist can perform the appropriate glide at any of the articulations within the ankle joint, depending on where the motion is limited. For example, if the patient is limited in dorsiflexion, a posterior glide would increase the dorsiflexion range of motion.

//Assistive device// Due to the viscoelastic behavior of the muscle fibers, passive stretching will gradually lengthen the muscle. One theory suggests that when the muscle is held in a stretched position for several days, it is believed that there is an increase in the number of sarcomeres, which allows the sarcomeres to return to their pre-stretched length, but keeps the muscle in the elongated position, therefore increasing the joints range of motion1. For this reason, splinting/ serial casting is used. Splinting/ serial casting would be used primarily for the neurological conditions, to bring the joint into a functional position and/or maintain that position.

//Education// The patient should be educated on what contributed to their hypomoble ankle, as well as the importance of regaining their range of motion. It is also important to explain each exercise/ modality that will be performed during therapy and in their home exercise program; how to perform it properly, how it should feel, while doing it and after, how it will benefit them, and how to progress them. They should also be given instructions on what to do if any pain/ discomfort is noted during/ after their exercises and the proper use of any assistive devices.

//Exercise// Stretching and range of motion exercises will be a primary focus with hypomobile ankle. Both the gastrocnemius and soleus stretches should be performed. Range of motion exercises include windshield wipers (from a seated position and heal stationary on the floor, slide the toes from side to side), calf raises, and toe raises7. These exercises can be initiated in a seated position and progress to increased difficulty by increasing weight bearing and/or adding resistance.

//Home Exercise Program// The number of exercises given to the patient will depend primarily on the patient’s compliance, and willingness to perform that amount of exercise. The patient should be given a routine to perform, based on the exercises learned in therapy. An additional activity that could be given to them to be performed numerous times throughout their day are the alphabet exercises, drawing the alphabet with their toes, by moving their ankle in the air7.

1 De Deyne, P. G. (2001). Application of passive stretch and its implications for muscle fibers. //Journal of the American Physical Therapy Association//, //81//, 819-827. 2 Landrum, E. L., Kelln, B. M., Parente, W. R., Ingersoll, C. D., & Hertel, J. (2008). Immediate effects of anterior-to-posterior talocrural joint mobilization after prolonged ankle immobilization: a preliminary study. //Journal of Manual and Manipulative Therapy//, //16//, 100-105. 3 McKinley, W. (n.d.). Presentations. //VCU Physical Medicine and Rehabilitation//. Retrieved January 24, 2012, from www.pmr.vcu.edu/presentations/pps/EffectsofImmobilization.pps 4 Norkin, C. C., & White, D. J. (2009). //Measurement of joint motion: a guide to goniometry// (4th ed.). Philadelphia: F.A. Davis. 5 O'Sullivan, S. B., & Schmitz, T. J. (2007). Examination of gait. //Physical rehabilitation// (5th ed., pp. 317-363). Philadelphia, PA: F.A. Davis. 6 Prentice, W. E. (2011). //Therapeutic modalities in rehabilitation// (4th ed.). New York: McGraw-Hill Medical. 7 Sandor, R., & Brone, S. (n.d.). Ankle exercises. //Camino medical group//. Retrieved January 26, 2012, from www.pamf.org/Orthopedics/mountainview/handouts/AnkleExercises.pdf
 * References**


 * __ Medial Tibial Stress Syndrome __**

Pain felt along the middle or distal two-thirds of the posteromedial border of the tibia at least 5 cm in length. The pain is exacerbated during weight-bearing activity and subsides shortly after exercise is complete.
 * __Definition:__**

-typically in runners, but also in sports played on hard surfaces such as volleyball, basketball, etc. -pain on posteromedial border of tibia at least 5cm in length -pain with activity: generally the pain is worst at beginning or end of activity, but will progress to throughout and continue after exercise; pain usually subsides quickly once activity is over -mild swelling of the tibia -pain with active dorsiflexion and passive plantarflexion -differential diagnosis: stress fracture and chronic exertional compartment syndrome present similarly to medial tibial stress syndrome (MTSS). -exertional compartment syndrome (ECS): burning, aching or cramping pain in lower leg while exercising, usually pain felt in muscles, not tibia. Sensory abnormalities may accompany ECS. Palpation at rest is usually not painful. -stress fracture: dull pain throughout exercise, progressing to pain during night and without activity. Upon palpation, pain is more focal and is either in the anterior or posteromedial tibia. Pain with percussion and with single-leg hop. -periostitis due to traction forces on the tibia from tibialis posterior, flexor digitorum longus or soleus -altered bending mechanism: bone resorption is greater than reformation in area where tibial diaphysis is weakest (junction of middle and distal thirds) -running on hard or uneven surfaces -improper shoe wear: less shock-absorbption ability in shoes with 300-500 miles -increasing exercise regimen too much -female gender: less bone density -overpronation at midfoot (navicular drop test) or subtalar joint -increased hip IR/ER, although another study showed decreased hip IR is a risk factor -lean calf girth -decreased plantarflexor strength -increased BMI //Therapeutic Exercise:// The plantarflexors should be strengthened for endurance. Weak plantarflexors can lead to overuse of the pre-tibial muscles which would cause additional strain on the tibia. Stretching of the gastrocnemius and soleus should be performed. The hips and gluteal muscles should be strengthened to improve shock absorption ability. The quadriceps and hamstrings should be assessed to check for imbalances between the two. Proprioceptive training should be introduced to teach the affected leg how to react to uneven surfaces and strengthen ankle and hip stabilizers. Single-leg squats and agility ladder exercises should be incorporated to asses landing mechanics on each leg and prepare for return to sport.
 * __Signs and Symptoms:__**
 * __Mechanism of Injury:__**
 * __Treatment:__**

//Education:// Rest from high-impact activities should be stressed to the patient. Non-impact cross-training options such as swimming or cycling should be given so the patient can maintain aerobic endurance. Rest periods range from 2-6 weeks depending on the case. The patient should be educated the etiology of MTSS and how the PT plans on correcting it.

//Assistive Equipment:// Over-the-counter orthotics have been effective in reducing MTSS symptoms most likely by increasing medial longitudinal arch support. Pneumatic leg braces have been proposed for treating MTSS but have proven ineffective in decreasing recovery time.

//Manual Therapy:// Anterior and posterior talocrural glides would help in gaining plantarflexion and dorsiflexion range of motion. Cross-frictional massage and/or trigger point release to the soleus, flexor digitorum longus and tibialis posterior would be beneficial because these muscles are responsible for the traction force on the tibia which in turn causes the periostitis.

//Home Exercise Program:// Gastrocnemius/soleus stretching should be performed at least twice per day. Strengthening exercises should include standing calf raises and standing hip in all 4 motions, progressing to the anti-gravity positions and a bridge. The patient can use ice/cold pack at home but should be educated that the pack should not stay on longer than 15-20 minutes.

//Modalities/Pain Control:// Cryotherapy (ice or cold pack) should be used particularly in the acute phase to control pain and swelling. Cryotherapy also is effective in reducing myofascial trigger points, which may be present in the pre-tibial muscles or plantarflexors. Ultrasound or ice massage could be done to the area of pain, most likely the insertion of tibialis posterior. One study demonstrated a reduction of symptoms in MTSS subjects with extracorporeal shock wave therapy; however, the study was of poor quality.

1. Galbraith, R. M., & Lavallee, M. E. (2009). Medial tibial stress syndrome: conservative treatment options. Current reviews in musculoskeletal medicine, 2(3), 127-33. Springer. doi:10.1007/s12178-009-9055-6 2. Moen, M. H., Bongers, T., Bakker, E. W., Zimmermann, W. O., Weir, A., Tol, J. L., & Backx, F. J. G. (2010). Risk factors and prognostic indicators for medial tibial stress syndrome. Scandinavian journal of medicine & science in sports, 22(1), 34-39. doi:10.1111/j.1600-0838.2010.01144.x 3. RR, K. (2010). Integration of manual therapy, rehabilitation and acupuncture in the treatment of a 17-year-old male professional football player with chronic medial tibial stress syndrome. Journal of the Acupuncture Association of Chartered Physiotherapists (J ACUPUNCTURE ASSOC CHARTER PHYSIOTHER). 4. Bouche, RT, and CH Johnson. "Medial tibial stress syndrome (tibial fasciitis): a proposed pathomechanical model involving fascial traction." //Journal of the American Podiatric Medical Association//. 97.1 (2007): 31-6. Web. 28 Jan. 2012. . 5. Bandholm, T, L Boysen, S Haugaard, MK Zebis , and J Bencke. "Foot medial longitudinal-arch deformation during quiet standing and gait in subjects with medial tibial stress syndrome.." //Journal of Foot & Ankle Surgery//. 47.2 (2008): 89-95. Web. 28 Jan. 2012. . 6. De Winter, Theodorus C., Maarten H. Moen, Miriam Steunebrink, Johannes L. Tol, and Adam Weir. "Medial Tibial Stress Sydrome: A Critical Review." //Sports Medicine//. 39.7 (2009): 523. Web. 28 Jan. 2012. 7. Loudon, JK, and MR Dolphino. "Use of foot orthoses and calf stretching for individuals with medial tibial stress syndrome.." //Foot & Ankle Specialist//. 3.1 (2010): 15-20. Web. 28 Jan. 2012. . 8. Prentice, W. E., Quillen, W. S., & Underwood, F. (2011). Therapeutic modalities in rehabilitation. New York, NY: McGraw-Hill. 9. Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill.
 * __References:__**

=__**Achilles Tendinopathy**__=

__Definition __: Achilles Tendinopathy is a general term used for an overuse injury to the achilles tendon. This term is used instead of achilles tendinitis or achilles tendinosis because it makes no assumption about the cause of the injury. Achilles tendinitis is inflammation of the tendon typically caused by an acute injury. Achilles tendinosis is a chronic degeneration of the tendon that occurs due to microtearing of the tendon. Achilles tendinopathies are typically treated the same way achilles tendinosis injuries are treated. __Signs and Symptoms: __ The main symptom is pain which may get worse during activity. Swelling, decreased ROM, crepitus, and tenderness with palpation of the achilles tendon are also typical symptoms. Patients can sometimes experience loss of strength as well. __Mechanism of Injury: __ Injury can be caused by trauma, an increase in intensity of activity, or wearing improper shoes for a foot type. Overuse injuries are a major factor with running being the most common cause. __Treatment __: //Modalities/Pain control // Rest, Ice, Compression, and Elevation are typically used as the initial treatment for achilles tendinopathy. NSAIDS can also be used for short term pain control. Ultrasound has been shown to decrease swelling and increase collagen formation in the tendon which will help the injury heal quicker.

//<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Manual Therapy // <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">There is not a lot of research pertaining to manual therapy and achilles tendinopathy. One research study said soft tissue mobilization of the calf can be done but there was little evidence to show it was an effective treatment.

//<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Assistive Devices // <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Ankle-foot orthotics and walking casts are used to keep the foot from going through full range of motion to decrease the strain being placed on the achilles tendon. Foot orthotics and heel wedges can be used to decrease the strain on the tendon by elevating the heel while also providing a cushion to decrease forces being placed on the heel from walking or running.

//<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Education // <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">The patient should be educated about the potential causes of their injury. If the cause of their tendinopathy is suspected to be a footwear issue then the patient should be educated on how to choose the right shoe for their foot type. The patient should understand that achilles tendinopathy takes time to heal and that they need to give it time off from activity or it will not heal and possibly get worse. The patient should fully understand the use of any modalities or exercises they have been prescribed so they know the importance of keeping up with them. They should know what to look for in case of future injury and how they can prevent it.

//<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Therapeutic Exercise // <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Strengthening and stretching exercises have been shown to be effective for helping treat achilles tendinopathy by restoring normal range of motion to the ankle. Eccentric exercises of the gastrocnemius and the soleus seem to be the most effective type of exercise because it promotes the formation of new collagen which will strengthen the achilles. Stretching could include wall stretches for the gastrocnemius and for the soleus. Exercises could include toes raises or theraband resisted ankle flexion.

//<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Home Exercise Program // <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">The patient should initially rest the injury. When getting back into exercise, the patient should start at a low intensity and work back up to high intensity. Warming up before exercising and stretching after exercise has been completed are good ways to help prevent future injuries. Icing after exercising is also recommended. The patient should continue with the treatment protocol prescribed in therapy and progress their exercises based on their therapists instructions.

"Achilles Tendinitis.” Mayo Clinic, 29 April 2010. Web. 27 Jan 2012. <http://www.mayoclinic.com/health/achilles-tendinitis/DS00737/DSECTION=treatments-and-drugs>.
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">References: **

Maffulli, Nicola, Pankaj Sharma, and Karen L. Luscombe. "Achilles tendinopathy; Aetiology and Management." //Journal of the Royal Society of Medicine//. 97.10 (2004): 472-76. Web. 29 Jan. 2012. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1079614/>.

Paavola, Mika, Pekka Kannus, Tero A H Jarvinen, and Karim Khan. "Current concepts review: Achilles tendinopathy." //Journal of Bone and Joint Surgery//. 84.11 (2002): 2062-75. Web. 29 Jan. 2012. <http://proquest.umi.com/pqdlink?Ver=1&Exp=01-21-2017&FMT=7&DID=242817211&RQT=309&cfc=1>.

Simpson, Michael R., and Thomas M. Howard. "Tendinopathies of the foot and ankle." //American Family Physician//. 80.10 (2009): 1107-14. Web. 29 Jan. 2012. <http://www.ncbi.nlm.nih.gov.proxy.kumc.edu:2048/pubmed/19904895>.

"Tendon Injury (Tendinopathy)." . Everyday Health, 06 Dec 2010. Web. 27 Jan 2012. <http://www.everydayhealth.com/health-center/tendon-injury-tendinopathy.aspx.

"Tendon Injury (Tendinopathy)." //WebMD//. N.p., 06 Dec 2010. Web. 27 Jan 2012. <http://firstaid.webmd.com/tc/tendon-injury-tendinopathy-topic-overview>.

"Tendinopathy- from basic science to treatment." //Medscape Education//. Nature Clinical Practice Rheumatology, n.d. Web. 27 Jan 2012. <http://www.medscape.org/viewarticle/569113>.

An ankle sprain is the stretching and/or tearing of the ligaments beyond their normal range of motion. A low ankle sprain consists of stretching/tearing of the anterior talofibular, calcaneofibular or posterior talofibular ligaments. The anterior talofibular ligament is the most commonly sprained. A high ankle sprain is a stretching/tearing of the interosseous membrane between the fibula and tibia, as well as the anterior inferior tibiofibular ligament.
 * Ankle Sprain **
 * Definition ** :

**Grade 1:** stretched ligament/slight tear  Slight pain/swelling  No functional loss or instability **Grade 2:** incomplete tear  Moderate pain/swelling  Slight functional loss and instability **Grade 3**: full tear  Severe pain/swelling  Loss of function and mechanical stability Special Tests  Anterior Drawer: tests for anterior talofibular ligament stability  Inversion Stress Test: tests for calcaneofibular ligament stability  Squeeze Test: tests for syndesmosic injury of high ankle sprain
 * Signs & Symptoms ** :

Severe inversion and plantarflexion of the foot its beyond normal ROM:  Most common  Low ankle sprains  Landing wrong from a jump  Cutting  Stepping down from curb Eversion and or hyper-dorsiflexion  High ankle sprains // Therapeutic Exercise // : As with all therapeutic exercise, the treatment can be broken up into phases following ankle sprains. The first phase will focus on increasing the ROM of the ankle and typically coincides with the acute inflammatory response phase of healing. The second phase focuses on increasing strength/resisted ROM, and coordinates with the remodeling/fibroblastic phase of healing. Finally the third phase promotes return to sport via the maturation phase of healing. Exercises for each phase may include the following: 1) ROM  Ankle pumps   Seated Gastroc Towel Stretch   Seated Heel/Toe Raises   Ankle Alphabet  2) Strength and Proprioception  Standing Gastroc Stretch  4-way theraband ankle  Standing heel/toe raises  SLS with advancing unstable ground 3) Return to sports  BAPS/balance board   Jumping/Running   Agility Ladder   Sport-Specific Exercise // Education // :  The anatomy of the injury should first be addressed with the patients, covering the ligaments affected and expected time frames for healing. Next, the therapist should inform the patient of pain and swelling reduction measures they may choose to take at home. The therapist may want to review assistive devices, their proper use, and the process of weaning from NWB to FWB as tolerated. Next, after the patient has progressed from assistive devices, the therapist should educate the patient in proper gait mechanics and ensure normalized gait. After this, more advanced jumping/landing mechanics should be reviewed to ensure decreased chances of re-injury. Finally, injury prevention should be reviewed including taping during sport, and exercises to continue after discharge from therapy to ensure ankle stability.
 * Mechanism of Injury: **
 * Treatment: ** Based on a lateral ankle sprain. High-ankle sprains require increased NWB status time and slightly adjusted treatment plans.

// Assistive // //Equip//ment: Patients are usually WBAT and therefore use assistive devices as needed. Crutches and walkers are good for the acute phase of the injury, until the patient can bear weight without significant pain. Bracing in the initial phase also increases ankle stability. A variety of equipment including aircasts and ankle support orthotics (ASO) are recommended.

// Manual // //Therapy//: Grade 1-2 (1-2 bouts of 20 seconds) talocrural joint distraction: decrease pain Grade 3-4 (3-5 bouts of 60 seconds) talocrural joint mobilizations: increase ROM & joint play  Posterior: dorsiflexion  Anterior: plantarflexion: Likely there will not be a lack in motion of plantarflexion because the mechanism of injury is typically excessive plantarflexion and eversion, so this mobilization would not be indicated. Should the patient present to the clinic following a period of imobilization and therefore have plantarflexion loss, this mobilization may be useful. Cross-friction massage: promote healing; prevent scar tissue Manual Lymphatic Drainage: decrease edema

// Home Exercise Program // : Exercise should mimic 3-4 exercises performed during the previous physical therapy treatment session. Examples according to the patient’s stage of healing are below. Acute  Ice/Compression  Ankle pumps  Gastroc Stretching  Ankle alphabet Fibroblastic  Ice/Compression  4-way ankle Theraband  Walking w/o A.D. Maturation  No A-D  Straight plane jogging - move onto running/jumping  Return to normal activities

// Modalities/Pain Control // : During Acute/Inflammatory Response  Cryotherapy: reduce swelling/pain  Rest  Elevation: reduce swelling  NSAIDS: pain reduction  Electrical Stimulation: reduce pain  Intermittent compression: reduce swelling  Low-power laser: reduce pain  Ultrasound: healing (non-thermal effects) During Fibroblastic-Repair Phase of Injury  Thermotherapy: increase circulation  Electrical Stimulation  Intermittent compression  Low-power laser  Ultrasound

1. Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill. 2. Lateral ankle pain. Park Ridge, Ill.: American College of Foot and Ankle Surgeons, 1997: preferred practice guideline no. 1/97. 3. Prentice, W. E., Quillen, W. S., & Underwood, F. (2011). Therapeutic modalities in rehabilitation. New York, NY: McGraw-Hill. 4. Wolfe, M. W., Uhl, T. L., & McCluskey, C. L. (2001). Management of Ankle Sprains. //American Family Physician,// 63(1):93-105. 5. Ankle Sprain Guidelines. //Vanderbilt Sports Medicine.// Retrieved January 29, 2012, from []
 * References **

=__**<span style="font-family: 'Arial','sans-serif';">Compartment Syndrome **__= 1. "Volkmann's Uschemic COntracture." MedlinePlus. Bethesda: ADAM, 2010. 2. "Compartment Syndrome." PubMed Health. Bethesda: A.D.A.M., 2012. 3. "Compartment Syndrome." OrthoInfo. (2009) 4. Rasul Jr, MD, A. "Acute Compartment Syndrome."Medscape Reference. (2011) 5. "Chronic Exertional Compartment Syndrome." Mayo Clinic.
 * <span style="font-family: 'Arial','sans-serif';">Definitions
 * <span style="font-family: 'Arial','sans-serif';">Compartment syndrome is most common in the lower leg and forearm, although it can also occur in the hand, foot, thigh, and upper arm.
 * <span style="font-family: 'Arial','sans-serif';">Compartment syndrome may be acute or chronic in nature.
 * <span style="font-family: 'Arial','sans-serif';">Compartment syndrome is a serious condition that involves increased pressure in a muscle compartment.
 * <span style="font-family: 'Arial','sans-serif';">It can lead to muscle and nerve damage and problems with blood flow.
 * <span style="font-family: 'Arial','sans-serif';">Compartment syndrome results primarily from increased intracompartmental pressure.
 * <span style="font-family: 'Arial','sans-serif';">The mechanism involved in the development of increased pressure depends on the precipitating event.
 * <span style="font-family: 'Arial','sans-serif';">Mechanism of Injury
 * <span style="font-family: 'Arial','sans-serif';">Fascia
 * <span style="font-family: 'Arial','sans-serif';">Thick layers of tissue that separate groups of muscles in the arms and legs from each other.
 * <span style="font-family: 'Arial','sans-serif';">Inside each layer of fascia is a confined space, called a compartment.
 * <span style="font-family: 'Arial','sans-serif';">The compartment includes the muscle tissue, nerves, and blood vessels. Fascia surrounds these structures, similar to the way in which insulation covers wires.
 * <span style="font-family: 'Arial','sans-serif';">Fascia does not expand.
 * <span style="font-family: 'Arial','sans-serif';">Any swelling in a compartment will lead to increased pressure in that area, which will press on the muscles, blood vessels, and nerves.
 * <span style="font-family: 'Arial','sans-serif';">blood flow will be blocked.
 * <span style="font-family: 'Arial','sans-serif';">This can lead to permanent injury to the muscle and nerves.
 * <span style="font-family: 'Arial','sans-serif';">muscles may die and the limb may need to be amputated.
 * <span style="font-family: 'Arial','sans-serif';">Swelling that leads to acute compartment syndrome may be caused by:
 * <span style="font-family: 'Arial','sans-serif';">trauma such as a car accident or crush injury
 * <span style="font-family: 'Arial','sans-serif';">Surgery
 * <span style="font-family: 'Arial','sans-serif';">complex fractures
 * <span style="font-family: 'Arial','sans-serif';">soft tissue injuries
 * <span style="font-family: 'Arial','sans-serif';">Long-term (chronic) compartment syndrome can be caused by:
 * <span style="font-family: 'Arial','sans-serif';">repetitive activities
 * <span style="font-family: 'Arial','sans-serif';">Ex: running.
 * <span style="font-family: 'Arial','sans-serif';">The pressure in a compartment only increases during that activity.
 * <span style="font-family: 'Arial','sans-serif';">Signs
 * <span style="font-family: 'Arial','sans-serif';">Pain when the compartment is squeezed.
 * <span style="font-family: 'Arial','sans-serif';">Severe pain when you move the affected area
 * <span style="font-family: 'Arial','sans-serif';">Swollen and shiny skin
 * <span style="font-family: 'Arial','sans-serif';">Symptoms
 * <span style="font-family: 'Arial','sans-serif';">Severe pain that does not go away when you take pain medicine or raise the affected area.
 * <span style="font-family: 'Arial','sans-serif';">Decreased sensation.
 * <span style="font-family: 'Arial','sans-serif';">Paleness of skin.
 * <span style="font-family: 'Arial','sans-serif';">Severe pain that gets worse.
 * <span style="font-family: 'Arial','sans-serif';">Weakness
 * <span style="font-family: 'Arial','sans-serif';">Treatment: Acute
 * <span style="font-family: 'Arial','sans-serif';">Initial treatment of acute compartment syndrome is referral to the emergency room for further evaluation and possible fasciotomy (release of tissue to reduce pressure).
 * <span style="font-family: 'Arial','sans-serif';">Muscle has considerable ability to regenerate by forming new muscle cells. Therefore, it is extremely important to decompress ischemic muscle as early as possible. Compartment pressures return to normal after a fasciotomy.
 * <span style="font-family: 'Arial','sans-serif';">Fasciotomy
 * <span style="font-family: 'Arial','sans-serif';">Surgery is the main treatment of chronic exertional compartment syndrome, and the most effective.
 * <span style="font-family: 'Arial','sans-serif';">Surgery involves operating on the fascia — that inelastic tissue encasing each muscle compartment.
 * <span style="font-family: 'Arial','sans-serif';">Surgical methods include either cutting open the fascia of each affected compartment (fasciotomy) or actually removing part of the fascia (fasciectomy).
 * <span style="font-family: 'Arial','sans-serif';">In either case, this release or decompression means the compartment is no longer trapped by the unyielding fascia, giving it room to expand when pressure increases.
 * <span style="font-family: 'Arial','sans-serif';">Although surgery is highly effective for most people, it's not without risk.
 * <span style="font-family: 'Arial','sans-serif';">Complications of the surgery can include
 * <span style="font-family: 'Arial','sans-serif';">infection
 * <span style="font-family: 'Arial','sans-serif';">permanent nerve damage,
 * <span style="font-family: 'Arial','sans-serif';">numbness and scarring
 * <span style="font-family: 'Arial','sans-serif';">In addition, since your muscles will no longer be encased by fascia, they may bulge out during exercise, creating a cosmetic concern.
 * <span style="font-family: 'Arial','sans-serif';">Treatment: Chronic
 * <span style="font-family: 'Arial','sans-serif';">Treatment for chronic compartment syndrome is based on symptoms.
 * <span style="font-family: 'Arial','sans-serif';">Physical therapy
 * <span style="font-family: 'Arial','sans-serif';">can help with the focus on calf stretching
 * <span style="font-family: 'Arial','sans-serif';">soft tissue mobilization
 * <span style="font-family: 'Arial','sans-serif';">massage and activity modification
 * <span style="font-family: 'Arial','sans-serif';">Medical professionals may also assist in identifying appropriate shoe wear
 * <span style="font-family: 'Arial','sans-serif';">anti-inflammatory medicines are sometimes suggested.
 * <span style="font-family: 'Arial','sans-serif';">Surgical treatment
 * <span style="font-family: 'Arial','sans-serif';">If conservative measures fail, surgery may be an option.
 * <span style="font-family: 'Arial','sans-serif';">Similar to the surgery for acute compartment syndrome
 * <span style="font-family: 'Arial','sans-serif';">skin incision for chronic compartment syndrome is smaller
 * <span style="font-family: 'Arial','sans-serif';">typically an elective procedure, not an emergency
 * References**