ATHLETIC EDGE
Sports Medicine
Sports Injury Prevention & Rehabilitation
 540 BRYANT ST, PALO ALTO, CA 94301
(650) 815-6552

Voted Best Sports Therapy Clinic in the San Francisco Bay Area 2010-2016!

Other Ankle Injuries






 Ankle Sprain (Medial Ligament)
(Also known as Deltoid Ligament Sprain, Medial Ligament Sprain)
 
Note - The term 'ankle sprain' will be used in this document to describe the injury known as a medial ligament sprain of the ankle.

What is an ankle sprain?
An ankle sprain is a condition characterised by damage and tearing to the soft tissue and ligaments of the ankle.
A ligament is a strong band of connective tissue which attaches bone to bone. The medial ligament of the ankle (also known as the deltoid ligament) comprises of strong connective tissue which joins the tibia (shin bone) to several small bones located in the inner ankle region.
The medial ligament acts to prevent the foot and ankle from turning outwards excessively (eversion). When this movement is excessive and beyond what the ligament can withstand, tearing to the ligament occurs. This is known as a medial ligament ankle sprain and may range from a small partial tear resulting in minimal pain, to a complete rupture resulting in significant pain and disability.

Causes of an ankle sprain
An ankle sprain involving the medial ligament most commonly occurs during weight bearing activities requiring rapid changes in direction, especially on uneven surfaces. These typically occur in basketball, football, volleyball and tennis. The usual mechanism of injury is extreme eversion (outward turning of the ankle) during weightbearing.

Signs and symptoms of an ankle sprain
Patient with this condition may notice an audible snap or tearing sound at the time of injury, with subsequent pain and swelling at the inner aspect of the ankle. The patient may be unable to weight bear at the time of injury due to pain and may develop bruising and stiffness over the coming days.

Diagnosis of an ankle sprain
A thorough subjective and objective examination from a doctor is sufficient to diagnose an ankle sprain involving the medial ligament of the ankle. Investigations such as an X-ray, MRI or CT scan are often required to confirm diagnosis and rule out other injuries (particularly fractures)

Treatment for an ankle sprain
Most patients with a medial ligament ankle sprain heal well with appropriate rehabilitation. The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient allows their body to heal naturally by avoiding activities that further damage the affected tissue. The patient can determine if an activity damages or aggravates their condition based on their symptoms. Generally an activity aggravates the condition if:
  • Pain increases during that activity OR
  • Pain increases upon rest following that activity OR
  • Pain increases the morning after that activity.
It is therefore vital that the patient rests from any activity that increases their pain during activity, after activity or the following morning. Appropriate treatment in the first 48 – 72 hours is vital to reduce bleeding, swelling and inflammation. This should involve following RICE which comprises of rest from aggravating activity (crutches or an ankle brace are often required), regular icing, the use of a compression bandage and elevation of the affected limb. Anti-inflammatory medication may also be particularly useful in this early phase.
It is also important for patients to perform pain-free flexibility, strength and balance exercises early in the rehabilitation process to prevent stiffness, weakness and instability from developing and to ensure the ankle is functioning correctly. These exercises should be implemented as soon as pain allows and under guidance by the treating therapist. A gradual return to activity should occur once the patient is pain-free, provided symptoms do not increase.

Prognosis of an ankle sprain
In cases of a minor to moderate medial ligament ankle sprain (grades I and II), return to sport or normal activity can usually occur in 3 – 8 weeks with appropriate management. Patients with more severe injuries (e.g. a complete rupture – grade III) will require a longer period of rehabilitation to gain optimum function.

Physical therapy for an ankle sprain
Physical therapy treatment is vital for all patients with an ankle sprain and can hasten the healing process, reduce the likelihood of recurrence and ensure an optimal outcome. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • joint mobilization
  • ankle taping
  • ankle bracing
  • ice or heat treatment
  • exercises to improve flexibility, strength and balance
  • education
  • activity modification advice
  • prescription of crutches
  • biomechanical correction
  • a gradual return to activity program

Other intervention for an ankle sprain
Despite appropriate management, a small percentage of patients with a medial ligament ankle sprain do not improve adequately. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may involve investigations such as an X-ray, CT scan or MRI or review with a specialist who can advise on any procedures that may be appropriate to improve the condition. Surgical reconstruction of the medial ligament is occasionally required when all conservative measures fail.





 Antero-Lateral Ankle Impingement
(Also known as Antero-Lateral Impingement Syndrome)
 
What is antero-lateral ankle impingement?
The talus is a small bone of the ankle responsible for transferring weight bearing forces from the shin to the foot. During the movement of ankle dorsiflexion and ankle eversion, the bottom of the shin bone approaches the talus. This places compressive forces on the structures at the outer / front aspect of the ankle joint. If these forces are excessive or beyond what the ankle can withstand, damage and inflammation of these structures may occur. This condition is known as antero-lateral ankle impingement. Occasionally, bony spurs can also form at the outer / front aspect of the ankle joint which may contribute to the problem.
 
Causes of antero-lateral ankle impingement
Antero-lateral ankle impingement may occur following repeated ankle sprains or following a major sprain. It may also occur following activities requiring repeated forced dorsiflexion.
 
Signs and symptoms of antero-lateral ankle impingement
Patients with this condition typically experience pain at the outer / front aspect of the ankle that increases with excessive dorsiflexion or weight bearing activity such as running.
 
Treatment for antero-lateral ankle impingement
It is recommended that patients with antero-lateral ankle impingement undergo a physical therapy program as the first line of treatment. One of the key components of this program is that the patient rests sufficiently from any activity that increases their pain until they are symptom free. This allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to activity is indicated provided there is no increase in symptoms.
 
Ignoring symptoms or adopting a 'no pain no gain' attitude is likely to aggravate the condition and may lead to the problem becoming chronic. Immediate appropriate treatment is essential to ensure a speedy recovery.
Patients with this condition should follow RICE in the initial phase of injury. R.I.C.E is beneficial in the first 72 hours following injury or when inflammatory signs are present (i.e. morning pain or pain with rest). R.I.C.E. involves rest from aggravating activities (crutches may be required), regular icing, the use of a compression bandage and keeping the leg elevated. Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.
A graduated and pain-free flexibility, strength and return to activity program under direction from a physiotherapist is vital to ensure an optimal outcome.
Alternative exercises placing minimal weight bearing forces through the ankle should be performed to maintain fitness such as swimming, cycling, and water running.
 
Contributing factors to the development of antero-lateral ankle impingement
There are several factors which can predispose patients to developing antero-lateral ankle impingement. These need to be assessed and corrected with direction from a therapist. Some of the factors which may contribute to the development of this condition include:
  • joint stiffness or swelling
  • muscle tightness
  • poor foot biomechanics
  • inappropriate training (including technique, footwear or training surfaces)
  • inadequate rehabilitation following previous injury
  • a history of ankle trauma
 
Physical therapy for antero-lateral ankle impingement
Physical therapy treatment is vital to hasten the healing process and ensure an optimal outcome in all patients with this condition. Treatment may comprise:
  • soft tissue massage
  • joint mobilization
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • stretches
  • ankle taping
  • ankle bracing
  • the use of crutches
  • ice or heat treatment
  • exercises to improve flexibility, strength and balance
  • education
  • activity modification advice
  • biomechanical correction
  • a gradual return to activity program

Other intervention for antero-lateral ankle impingement
Despite appropriate rehabilitation management, some patients with this condition do not improve. When this occurs the treating doctor can advise on the best course of management. This may involve investigations such as an X-ray, MRI or CT scan, pharmaceutical intervention, corticosteroid injection or review with a specialist who will advise on any procedures that may be indicated to improve the condition. Occasionally, surgical intervention may be indicated to remove the bony spur or damaged tissue. Review with a podiatrist for appropriate footwear advice and possible orthotics may also be indicated.





 Calcaneal Stress Fracture
(Also known as Stress Fracture of the Calcaneus)
 
What is a calcaneal stress fracture?
The calcaneus is the anatomical name given to the heel bone. Several muscles attach to the calcaneus so that when they contract, they exert a pulling force on the bone. Furthermore, weight bearing activity places compressive forces through this bone. When these forces are excessive or too repetitive and beyond what the bone can withstand, bony damage can gradually occur. This initially results in a bony stress reaction, however, with continued damage may progress to a calcaneal stress fracture.

Causes of a calcaneal stress fracture
Stress fractures of the calcaneus typically occur over time with excessive weight bearing activity such as marching or running. They often present following a recent increase in activity or change in training conditions.

Signs and symptoms of a calcaneal stress fracture
Patients with this condition typically experience a pain on either the inner or outer aspect of the heel bone that increases with impact activity such as marching, running, jumping or landing. In severe cases, walking may be enough to aggravate symptoms. Other symptoms may include night ache or pain on firmly touching or squeezing the heel bone.

Diagnosis of a calcaneal stress fracture

A thorough subjective and objective examination from a doctor is sufficient to diagnose a calcaneal stress fracture. Investigations such as an X-ray, MRI, CT scan or bone scan are usually required to confirm diagnosis.

Treatment for a calcaneal stress fracture

Treatment for a stress fracture of the calcaneus typically involves an initial period of rest, usually involving reduced weight bearing activity. This may include the use of crutches or a protective boot. This initial period of reduced weight bearing may occur for approximately 6 weeks. Following this, a gradual increase in weight bearing activity and exercise can usually take place provided symptoms do not increase. This should occur over a period of weeks to months with direction from the treating physiotherapist and will vary depending on the severity of the injury.
Alternative exercises placing minimal weight bearing forces through the affected bone should be performed to maintain fitness such as swimming, cycling, and water running. Exercises to restore flexibility, strength, balance and function should also be performed to ensure the foot and ankle are functioning correctly. The treating therapist can advise which exercises are most appropriate and when they should be commenced.

Contributing factors to the development of a calcaneal stress fracture

Several factors may contribute to the development of a calcaneal stress fracture. These factors need to be assessed and corrected where possible with direction from the treating therapist and may include:
  • poor foot posture
  • muscle weakness
  • poor flexibility
  • ankle joint stiffness
  • poor footwear
  • inappropriate or excessive training (particularly on hard or uneven surfaces).

Physical therapy for a calcaneal stress fracture
Physical therapy treatment is vital for all patients with a calcaneal stress fracture to hasten healing, reduce the likelihood of recurrence and ensure an optimal outcome. Treatment may comprise:
  • soft tissue massage
  • joint mobilization
  • electrotherapy (e.g. ultrasound)
  • taping
  • the use of crutches
  • biomechanical correction
  • education
  • hydrotherapy
  • exercises to improve strength, balance and flexibility
  • a graduated return to activity program.

Other intervention for a calcaneal stress fracture
Occasionally a review with a podiatrist for possible orthotics may be indicated to ensure an optimal outcome. The treating doctor can advise if this is required.





 Complex Regional Pain Syndrome
(Also known as Reflex Sympathetic Dystrophy, Sympathetically Mediated Pain, C.R.P.S.)

What is Complex Regional Pain Syndrome of the Ankle?
Complex Regional Pain Syndrome (C.R.P.S.) is a condition of the nervous system which, although uncommon, can occur following trauma or significant injury. The nature of CRPS is unusual and the cause is not clearly understood.

Causes of Complex Regional Pain Syndrome
Although the cause of this condition is not clearly understood it can occur following trauma or significant injury (such as a fracture or severe ankle sprain) or following excessive immobilization.

Signs and symptoms of Complex Regional Pain Syndrome

Patients with this condition may experience:
  • Pain out of proportion to the injury
  • Temperature or color changes of the affected body part
  • Swelling
  • Abnormal sweating
  • Delayed recovery from injury.

Diagnosis of Complex Regional Pain Syndrome

A thorough subjective and objective examination from a doctor is usually sufficient to diagnose this condition.

Treatment for Complex Regional Pain Syndrome
Since early treatment of this condition significantly improves prognosis, early diagnosis is imperative. Therefore, seeing a doctor as soon as possible to have symptoms assessed and the likelihood of C.R.P.S. determined is vital. Early mobilization of the affected body part and avoidance of surgery are two important factors in effective management of this condition. Medication can also be useful. If the pain does not settle, chemical or surgical blockade of nerves may sometimes be indicated.





 Distal Tibiofibular Joint Injury
(Also known as Inferior Tibiofibular Joint Injury)
 
What is a distal tibiofibular joint injury?
The tibia and fibula are the two long bones of the lower leg. Together, these bones form a joint known as the distal tibiofibular joint (or inferior tibiofibular joint) which lies just above the ankle. Here the tibia and fibula are connected by strong connective tissue and ligaments. This connective tissue helps to keep the tibia and fibula together. When this connective tissue is placed under too much stress, tearing of the connective tissue can occur. This is known as a distal tibiofibular joint injury and can range from a small tear resulting in minimal pain, to a complete tear resulting in significant pain and disability.

Causes of a distal tibiofibular joint injury

Distal tibiofibular joint injuries typically occur traumatically during more severe ankle sprains whereby forces push the tibia and fibular apart.

Signs and symptoms of a distal tibiofibular joint injury
Patients with this condition usually experience a sudden onset of pain during the causative activity. Symptoms may increase during weight-bearing activity and on rotation or twisting of the ankle. The patient may be unable to weight bear at the time of injury due to pain and may develop bruising and stiffness over the coming days. Symptoms are commonly felt in the front of the ankle, although occasionally the back and / or sides of the ankle may be affected. Pain may also increase on firmly touching the distal tibiofibular joint.

Diagnosis of a distal tibiofibular joint injury
A thorough subjective and objective examination from a doctor is usually sufficient to diagnose a distal tibiofibular joint injury. Investigations such as an X-ray, MRI or CT scan are often required to confirm diagnosis and rule out other injuries (particularly fractures)

Prognosis of a distal tibiofibular joint injury
Most patients with minor distal tibiofibular joint injuries heal well with an appropriate physical therapy program. In these instances recovery is usually a matter of weeks. Patients with more severe injuries whereby the tibia and fibula are separated on X-ray may require surgery with a lengthy rehabilitation period to follow. It is important that this is detected early as untreated severe injuries may rapidly lead to ankle joint arthritis. It is therefore recommended that all patients see their physiotherapist as soon as possible for accurate assessment and diagnosis.

Treatment of a distal tibiofibular joint injury

Most patients with minor to moderate distal tibiofibular joint injuries heal well with appropriate physical therapy. The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient allows their body to heal naturally by avoiding activities that further damage the affected tissue. The patient can determine if an activity damages or aggravates their condition based on their symptoms. Generally an activity aggravates the condition if:
  • Pain increases during that activity OR
  • Pain increases upon rest following that activity OR
  • Pain increases the morning after that activity.
It is therefore vital that the patient rests from any activity that increases their pain during activity, after activity or the following morning.
Appropriate treatment in the first 48 – 72 hours is vital to reduce bleeding, swelling and inflammation. This should involve following RICE, which comprises of rest from aggravating activity (crutches or an ankle brace are often required), regular icing, the use of a compression bandage and elevation of the affected limb. Anti-inflammatory medication may also be particularly useful in this early phase.
It is also important to perform pain free flexibility, strengthening and balance exercises early in the rehabilitation process to prevent stiffness, weakness and instability from developing and to ensure the ankle is functioning correctly. These exercises should be implemented as soon as pain allows and under guidance by the treating physical therapist. A gradual return to activity should occur once the patient is pain-free, provided symptoms do not increase.

Physical therapy for a distal tibiofibular joint injury
Physical therapy treatment is vital for all patients with a distal tibiofibular joint injury. Treatment can hasten the healing process, reduce the likelihood of recurrence and ensure an optimal outcome. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • joint mobilization
  • ankle taping
  • ankle bracing
  • ice or heat treatment
  • exercises to improve flexibility, strength and balance
  • education
  • activity modification advice
  • prescription of crutches
  • biomechanical correction
  • a gradual return to activity program
 
Other intervention for a distal tibiofibular joint injury

Despite appropriate therapy management, some patients with a distal tibiofibular joint injury do not improve adequately. When this occurs the treating therapist or doctor can advise on the best course of management.  This may involve investigations such as an X-ray, CT scan or MRI, pharmaceutical intervention, corticosteroid injection or review with a specialist who can advise on any procedures that may be appropriate to improve the condition.





 Fibula Stress Fracture
(Also known as Stress Fracture of the Fibula)
 
What is a fibula stress fracture?
The fibula is a long bone which lies on the outer aspect of the lower leg and is responsible for transferring some weight bearing forces from the shin to the foot. Several muscles attach to the fibula so that when they contract, they exert a pulling force on the bone. Furthermore, weight bearing activity places compressive forces through the fibula. When these forces are excessive or too repetitive and beyond what the bone can withstand, bony damage gradually occurs. This initially results in a bony stress reaction, however, with continued damage may progress to a fibula stress fracture.

Causes of a fibula stress fracture
Stress fractures of the fibula typically occur over time with excessive weight bearing activity such as running. They often present following a recent increase in activity or change in training conditions.

Signs and symptoms of a fibula stress fracture
Patients with this condition typically experience a localised pain in the outer lower leg that increases with weight bearing activity. In severe cases, walking may be enough to aggravate symptoms. Other symptoms may include night ache or pain on firmly touching the fibula.

Diagnosis of a fibula stress fracture
A thorough subjective and objective examination from a doctor may be sufficient to diagnose a stress fracture of the fibula. Investigations such as an MRI, CT scan or bone scan are usually required to confirm diagnosis.

Treatment for a fibula stress fracture
Treatment for patients with this condition typically involves an initial period of rest from weight bearing activity which may include the use of crutches or a protective boot. Treatment is progressed symptomatically with rest from activity until pain settles.
Once the patient is pain-free a gradual increase in weight bearing activity and exercise can occur provided symptoms do not increase. This should occur over weeks to months with direction from a doctor and will vary depending on the severity of the injury. Alternative exercises placing minimal weight bearing forces through the affected bones should be performed to maintain fitness such as swimming, cycling, and water running. Exercises to maintain flexibility, strength and balance are also important to ensure the ankle and knee are functioning correctly. The treating doctor can advise which exercises are most appropriate and when they should be commenced.

Contributing factors to the development of a fibula stress fracture
There are several factors that may contribute to the development of a stress fracture of the fibula. These should be assessed and where possible corrected with direction from a physiotherapist and may include:
  • poor foot mechanics
  • inappropriate or excessive training or footwear
  • joint stiffness
  • poor flexibility
  • muscle weakness
  • poor balance

Physical therapy for a fibula stress fracture
Physical therapy treatment is essential for all patients with this condition to hasten healing, prevent recurrence and ensure an optimal outcome. Treatment may comprise:
  • soft tissue massage
  • joint mobilization
  • electrotherapy (e.g. ultrasound)
  • taping or bracing
  • the use of crutches
  • biomechanical correction
  • exercises to improve flexibility, strength and balance
  • education
  • a gradual return to activity plan.

Other intervention for a fibula stress fracture
A review with a podiatrist may be indicated for appropriate orthotics and footwear advice. Occasionally, a specialist review may be required in patients who are not progressing adequately.





 Flexor Hallucis Longus Tendinitis
(Also known as Flexor Hallucis Longus Tendinopathy, Flexor Hallucis Longus Tendonitis, Flexor Hallucis Longus Tendinosis)
 
Note - Although research suggests that 'flexor hallucis longus tendinopathy' is the more appropriate term to describe overuse injuries to the flexor hallucis longus tendon, we will use the term 'flexor hallucis longus tendinitis' in this document as it is more widely known
 
What is flexor hallucis longus tendinitis?
The flexor hallucis longus muscle originates from the back of the fibula (outer lower leg bone), it then travels down along the inside of the lower leg and ankle where it inserts into the base of the big toe via the flexor hallucis longus tendon. The flexor hallucis longus muscle is primarily responsible for bending the big toe. It also assists with pointing the foot and ankle down (plantarflexion), rising up onto your toes and maintaining the arch of your foot.
 
Whenever the flexor hallucis longus muscle contracts or is stretched, tension is placed through the flexor hallucis longus tendon. If this tension is excessive due to too much force or repetition, damage to the flexor hallucis longus tendon may occur. Flexor hallucis longus tendinitis is a condition characterized by damage to the tendon with subsequent degeneration and inflammation.
 
Causes of flexor hallucis longus tendinitis
Flexor hallucis longus tendinitis may occur traumatically due to a high force going through the tendon beyond what it can withstand or more commonly due to gradual wear and tear associated with overuse. This is particularly common in ballet dancers who spend significant time rising onto their toes.
 
Signs and symptoms of flexor hallucis longus tendinitis
Patients with this condition typically experience pain in the region of the inner ankle which may travel down into the big toe. In less severe cases, patients may only experience pain with rest following activities requiring strong or repetitive contraction of the flexor hallucis longus muscle such as standing on the balls of the feet, running (especially uphill or on uneven surfaces), jumping, hopping etc. They may also experience pain and stiffness upon waking the following morning. As the condition progresses, patients may also experience pain during these activities affecting performance. The pain associated with this condition tends to be of gradual onset which progressively worsens over weeks to months with continuation of aggravating activities. Patients with this condition may also experience pain on firmly touching the flexor hallucis longus tendon.
 
Diagnosis of flexor hallucis longus tendinitis
A thorough subjective and objective examination from a doctor may be all that is necessary to diagnose flexor hallucis longus tendinitis. An MRI or ultrasound may be required to confirm diagnosis.
 
Treatment for flexor hallucis longus tendinitis
Most patients with flexor hallucis longus tendinitis heal well with an appropriate rehabilitation program. The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient rests sufficiently from any activity that increases their pain until they are symptom free (crutches may be required). This allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
 
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the condition becoming chronic. Once chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence. Immediate appropriate treatment in all patients with flexor hallucis longus tendinitis is vital to ensure an optimal outcome.
 
Following RICE particularly with regular icing and anti-inflammatory medication may help to significantly reduce inflammation in the initial phase of this condition. A graduated flexibility, strength and balance program under direction from a physiotherapist is vital to ensure an optimal outcome.
 
In the final stages of rehabilitation, a gradual return to activity or sports should occur under guidance from the treating practitioner and provided there is no increase in symptoms.
 
Contributing factors to the development of flexor hallucis longus tendinitis
There are several factors which can predispose patients to developing a flexor hallucis longus tendinitis. These need to be assessed and corrected with direction from the treating therapist and may include:
  • poor foot biomechanics (especially flat feet)
  • poor flexibility
  • inappropriate training or footwear (especially wearing shoes that are too big)
  • inadequate warm up
  • muscle weakness
  • incorrect technique (especially in ballet dancers)
  • inadequate rehabilitation following previous injury
 
Physical therapy for flexor hallucis longus tendinitis
Physical therapy treatment is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence in all patients with this condition. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • stretches
  • joint mobilization
  • ice or heat treatment
  • taping
  • the use of crutches
  • exercises to improve strength, flexibility and balance
  • education
  • activity modification advice
  • biomechanical correction
  • footwear advice
  • a gradual return to activity program
Prognosis of flexor hallucis longus tendinitis
Most patients with this condition heal well with an appropriate rehabilitation program. This, however can be a length process and may take several months in patients who have had their condition for a long period of time. Minor cases of this condition that are identified and treated early can usually settle within a few weeks. Early treatment is vital to hasten recovery and ensure an optimal outcome.
 
Other intervention for flexor hallucis longus tendinitis

Despite appropriate management, some patients with flexor hallucis longus tendinitis do not improve. When this occurs the treating doctor can advise on the best course of management. This may involve further investigations such as an X-ray, Ultrasound, CT scan or MRI, pharmaceutical intervention, corticosteroid injection, autologous blood injection, or review by a specialist who can advise on any procedures that may be appropriate to improve the condition. A review with a podiatrist for the prescription of orthotics and appropriate footwear advice may also be indicated.





 Navicular Stress Fracture
(Also known as Stress Fracture of the Navicular)
 
What is a navicular stress fracture?
A navicular stress fracture is a condition characterized by an incomplete crack in the navicular bone. The navicular is the anatomical name given to one of the bones in the mid-foot. It is located at the top of the arch of the foot.
A muscle (known as the tibialis posterior) attaches to the navicular bone. When this muscle contracts, a pulling force is exerted on the bone. Furthermore, weight bearing activity places compressive force through the navicular. When these forces are excessive or too repetitive and beyond what the bone can withstand, bony damage can gradually occur. This initially results in a bony stress reaction, however, with continued damage may progress to a navicular stress fracture.

Cause of a navicular stress fracture
A stress fracture of the navicular typically occurs over time with excessive weight bearing activity such as running, sprinting, jumping or dancing. They often occur following a recent increase in activity or change in training conditions.

Signs and symptoms of a navicular stress fracture

Patients with this condition typically experience a poorly localized pain in the inner arch of the foot or ankle that increases with impact activity and decreases with rest. Occasionally, pain may radiate to the outer aspect of the foot, the second and third toes or the inner aspect of the heel bone. In severe cases, walking may be enough to aggravate symptoms. Other symptoms may include night ache or pain on firmly touching the navicular bone.

Diagnosis of a navicular stress fracture
A thorough subjective and objective examination from a doctor may be sufficient to diagnose a navicular stress fracture. Further investigations such as an X-ray, MRI, CT scan or bone scan are usually required to confirm diagnosis and determine the severity of injury.

Treatment for a navicular stress fracture

Treatment for a stress fracture of the navicular typically involves an initial period of rest from weight bearing activity. This most commonly involves a period of 6 - 8 weeks of non-weight bearing immobilization in a plaster cast. Following this, a gradual increase in weight bearing activity and exercise can usually occur as tolerated, provided symptoms do not increase. This should take place over a period of weeks to months with direction from the treating physiotherapist and will vary depending on the severity of the injury.
Patients should also perform pain-free flexibility and strengthening exercises (following the initial period of immobilization) as part of their rehabilitation to ensure an optimal outcome. Alternative exercises placing minimal weight bearing forces through the affected bone should be performed to maintain fitness such as swimming, cycling and water running. The treating doctor can advise which exercises are most appropriate for the patient and when they should be commenced.

Contributing factors to the development of a navicular stress fracture

There are several factors which may contribute to the development of this condition. These need to be assessed and corrected with direction from the treating doctor. Some of these factors include:
  • poor foot posture (especially flat feet)
  • muscle weakness
  • poor flexibility
  • ankle joint stiffness
  • inappropriate footwear
  • inadequate diet
  • inappropriate or excessive training (particularly on hard or uneven surfaces).

Physical therapy for a navicular stress fracture
Physical therapy treatment for patients with this condition is vital in to hasten healing, prevent injury recurrence and ensure an optimal outcome. Treatment may comprise:
  • soft tissue massage
  • joint mobilization
  • electrotherapy (e.g. ultrasound)
  • dry needling
  • the use of crutches
  • activity modification advice
  • taping
  • bracing
  • biomechanical correction
  • exercises to improve strength, balance and flexibility
  • education
  • a gradual return to activity plan

Other intervention for a navicular stress fracture

Despite appropriate therapy management, some patients with this condition do not improve and require other intervention to ensure an optimal outcome. The treating doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, extended periods of plaster cast immobilization, review with a podiatrist for possible orthotics or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the navicular stress fracture. Occasionally, patients with this condition may require surgery to stabilize the stress fracture and aid healing.





 Peroneal Tendon Rupture
(Also known as a Completely Torn Peroneal Tendon)
 
What is a peroneal tendon rupture?
There are several muscles which lie on the outside of your lower leg and are collectively known as the peroneal muscles. These originate from the outer lower leg bone (fibula) then travel down along the outside of your leg where they insert into various bones in the foot via the peroneal tendons.
The peroneal muscles are responsible for moving the foot and ankle away from the midline of the body (eversion). Whenever the peroneal muscles contract or are placed under stretch, tension is placed through the peroneal tendons. If this tension is excessive due to too much force or repetition, damage to the peroneal tendons may occur. This can range from minor tearing of the tendon with subsequent inflammation to a complete peroneal tendon rupture.

Cause of peroneal tendon rupture
Peroneal tendon rupture most commonly occurs traumatically during severe ankle sprains. The usual mechanism of injury is an excessive turning of the foot inwards (inversion) during weight bearing. This may occur during activities or sports requiring rapid changes in direction such as basketball, football, volleyball or netball on uneven surfaces or following an awkward landing from a jump or height.

Signs and symptoms of peroneal tendon rupture
Patients with this condition may notice an audible snap or tearing sound at the time of injury, with subsequent pain and swelling on the outside of the foot or ankle. They may be unable to weight bear at the time of injury and frequently develop bruising and stiffness over the coming days. Patients may also experience significant weakness on moving the foot and ankle away from the midline of the body (eversion).

Diagnosis of peroneal tendon rupture

A thorough subjective and objective examination from a doctor may be all that is necessary to diagnose a peroneal tendon rupture. Diagnosis may be confirmed with an MRI scan or ultrasound investigation.

Treatment for peroneal tendon rupture
All patients who potentially have a peroneal tendon rupture should see a doctor immediately so their condition can be assessed and the likelihood of them having a ruptured peroneal tendon determined. This is important as delayed treatment may result in a poor outcome. The treating doctor may refer for further investigation such as an MRI or ultrasound to assist with diagnosis. Patients who have a peroneal tendon rupture may be referred to a specialist for an opinion regarding the suitability of surgery. This may or may not be required to ensure an optimal outcome.
For all patients with this condition, whether managed conservatively or surgically, rehabilitation under direction by a physical therapist is vital to ensure an optimal outcome. Patients should perform pain free flexibility, strengthening and balance exercises to restore normal function to the ankle. The treating physiotherapist can advise which exercises are most appropriate and when they should be commenced. In the final stages of rehabilitation, a gradual return to activity or sport should occur as guided by the treating practitioner.

Physical therapy for peroneal tendon rupture
Physical therapy treatment is vital to hasten healing and ensure an optimal outcome in all patients with this condition. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • stretches
  • joint mobilization
  • taping
  • bracing
  • the use of crutches
  • ice or heat treatment
  • exercises to improve flexibility, strength and balance
  • education
  • activity modification advice
  • biomechanical correction
  • footwear advice
  • a gradual return to activity program


 Peroneal Tendon Sublaxation
(Also known as Peroneal Tendon Dislocation)
 
What is a peroneal tendon subluxation?
There are several muscles which lie on the outside of the lower leg and are collectively known as the peroneal muscles. These originate from the outer lower leg bone (fibula) and travel down along the outside of the leg where they insert into various bones in the foot via the peroneal tendons. The peroneal tendons travel behind the bony prominence at the outside of the ankle and are firmly held in position by strong connective tissue known as the peroneal retinaculum.
Occasionally the peroneal retinaculum can be torn. As a result, the peroneal tendons are no longer held in place by the retinaculum and therefore may slip out of position and flick over the bony prominence on the outside of the ankle. This condition is known as peroneal tendon subluxation or dislocation.
Once dislocated, the peroneal tendons may remain in the dislocated position, or they can spontaneously return to their original position. Because the peroneal retinaculum is no longer intact, the tendons are then prone to recurrent subluxation or dislocation.

Causes of peroneal tendon subluxation
The usual mechanism of injury for this condition is an excessive turning of the foot inwards (inversion) sometimes in combination with the knee moving forward over the toes (dorsiflexion) during weight bearing. It frequently occurs in combination with an ankle sprain, during activities requiring rapid changes in direction (e.g. basketball, football, volleyball or tennis) or on uneven surfaces.

Signs and symptoms of peroneal tendon subluxation
Patients with this condition often notice an audible snap or tearing sound at the time of injury, with subsequent pain and swelling on the outside of the ankle. They may be unable to weight bear at the time of injury and frequently develop bruising and stiffness over the coming days. The patient may also notice a flicking sensation at the outer aspect of the ankle with certain movements coinciding with the moving of the peroneal tendon in and out of its original position.

Diagnosis of peroneal tendon subluxation
A thorough subjective and objective examination from a doctor may be all that is necessary to diagnose peroneal tendon subluxation. Diagnosis may be confirmed with an MRI scan or ultrasound investigation.

Treatment for peroneal tendon subluxation

All patients with potential peroneal tendon subluxation or dislocation should see a doctor as soon as possible. This will allow their condition to be assessed and the likelihood of them having peroneal tendon subluxation determined. Treatment for subluxed or dislocated peroneal tendons is usually surgical replacement of the tendons in their original location with repair of the retinaculum.
Following surgical intervention, rehabilitation under direction by the surgeon and physical therapist is vital to ensure an optimal outcome. Patients should perform pain free flexibility, strengthening and balance exercises to restore normal function to the ankle. The treating physical therapist can advise which exercises are most appropriate and when they should be commenced. In the final stages or rehabilitation, a gradual return to activity or sport should occur as guided by the treating practitioner.

Physical therapy for peroneal tendon subluxation
Physical therapy treatment is vital to hasten healing, reduce the likelihood of recurrence and ensure an optimal outcome in all patients with peroneal tendon subluxation. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • stretches
  • joint mobilization
  • taping
  • bracing
  • the use of crutches
  • ice or heat treatment
  • exercises to improve flexibility, strength and balance
  • education
  • activity modification advice
  • biomechanical correction
  • footwear advice
  • a gradual return to activity program




 Referred Ankle Pain

What is referred ankle pain?

Referred ankle pain is a term given to pain that is felt in the ankle although it originates from another region of the body. This is commonly seen in clinical practice.
There are several structures in the body that, when injured, may cause the patient to experience pain in the ankle region. This can occur even though there may be nothing wrong with the ankle itself.

Causes of referred ankle pain
The lower back and sciatic nerve are two of the most common structures in the body that when injured, may result in pain being felt in the ankle region. This can occur with or without pain being felt in the lower back or sciatic nerve. The superior tibiofibular joint can also be a source of referred pain to the ankle. Increased neural tension (tight nerves) may also contribute to the development of symptoms.
Some of the more common conditions which may cause these symptoms include:
  • Lumbar Disc Bulge
  • Lumbar Facet Joint Sprain
  • Spinal Degeneration (Lumbar)
  • Piriformis Syndrome
  • Sciatica

Signs and symptoms of referred ankle pain
Patients with ankle pain that is referred from another source may or may not experience symptoms from the originating source. Patients typically experience a dull ache in the ankle that is poorly localized and may vary in severity or location. They may also experience pain or stiffness in other locations in the body such as the lower back or buttock. Occasionally pain may also be felt in the thigh, knee, lower leg, or foot. These symptoms are usually experienced on the same side of the body as the ankle pain, although sometimes, the opposite side or both sides may be affected. Occasionally patients may also experience pins and needles or numbness in the affected leg. This most commonly affects the foot and can sometimes affect the other leg or both legs.
Patients with referred ankle pain normally experience restricted movement and abnormalities on assessment (such as tenderness on palpation) in the specific region of the body causing the pain. Local assessment of the ankle may demonstrate no significant abnormalities although patients may experience tenderness on firmly touching the ankle region. In long standing cases of ankle pain that is referred form another source, patients may develop muscle tightness or weakness in the muscles of the ankle.

Diagnosis of referred ankle pain
A thorough subjective and objective examination from a doctor is usually sufficient to diagnose referred pain to the ankle and the underlying cause of symptoms. Further investigations such as X-rays, MRI or CT scans are often required to assist with diagnosis.

Treatment for referred ankle pain

Treatment for patients with ankle pain that is referred from another source varies greatly depending on the cause. Accurate diagnosis from a doctor is therefore required to determine the most appropriate treatment. Treatment of the underlying cause of symptoms should result in improvement in the ankle pain.




 Stress Fracture of the Medial Malleolus
(Also known as Medial Malleolar Stress Fracture, Stress Fracture of the Tibia, Tibial Stress Fracture)
 
What is a stress fracture of the medial malleolus?
The bony lump on the inside of the ankle is known as the medial malleolus. This arises from the lower end of the shin bone (tibia). During weight bearing activity compressive forces are placed through the medial malleolus. When these forces are excessive or too repetitive and beyond what the bone can withstand, bony damage gradually occurs. This initially results in a bony stress reaction, however, with continued damage may progress to a stress fracture of the medial malleolus.

Causes of a stress fracture of the medial malleolus
Stress fractures of the medial malleolus typically occur over time with excessive weight bearing activity such as running. They often present following a recent increase in activity or change in training conditions.

Signs and symptoms of a stress fracture of the medial malleolus

Patients with a stress fracture of the medial malleolus typically experience localised pain on the inner aspect of the ankle that increases with impact activity such as running or jumping. In severe cases, walking may be enough to aggravate symptoms and may cause the patient to limp. Other symptoms may include night ache or pain on firmly touching the affected bone.

Diagnosis of a stress fracture of the medial malleolus
A thorough subjective and objective examination from a doctor may be sufficient to diagnose a stress fracture of the medial malleolus. Investigations such as an MRI, CT scan or bone scan are usually required to confirm diagnosis.

Treatment for a stress fracture of the medial malleolus
Treatment for a stress fracture of the medial malleolus typically involves an initial period of rest from weight bearing activity. This may include the use of crutches, a protective boot, an air-cast brace or plaster cast immobilization. This initial period of reduced weight bearing may be for up to 6 weeks. Following this, a gradual increase in weight bearing activity and exercise can usually occur provided symptoms do not increase. This should take place over a period of weeks to months with direction from the treating doctor and will vary depending on the severity of the injury.
Alternative exercises placing minimal weight bearing forces through the affected bone should be performed to maintain fitness such as swimming, cycling, and water running. Exercises to maintain flexibility, strength and balance are also important to ensure the ankle and lower leg are functioning correctly. The treating doctor can advise which exercises are most appropriate and when they should be commenced.

Contributing factors to the development of a stress fracture of the medial malleolus
There are several factors that may contribute to the development of a stress fracture of the medial malleolus. These should be assessed and where possible corrected with direction from the treating therapist and may include:
  • poor foot biomechanics
  • inappropriate or excessive training (particularly on hard or uneven surfaces)
  • muscle weakness
  • poor flexibility
  • joint stiffness
  • inappropriate footwear
  • poor balance

Physical therapy for a stress fracture of the medial malleolus
Physical therapy treatment is essential for all patients with a stress fracture of the medial malleolus to hasten healing, prevent recurrence and ensure an optimal outcome. Treatment may comprise:
  • soft tissue massage
  • joint mobilization
  • electrotherapy (e.g. ultrasound)
  • taping or bracing
  • the use of crutches or a protective boot
  • biomechanical correction
  • exercises to improve strength, balance and flexibility
  • education
  • a graduated return to activity plan

Other intervention for a stress fracture of the medial malleolus
A review with a podiatrist may be indicated for appropriate orthotics and footwear advice. Occasionally, a specialist review may be indicated in patients who are not progressing adequately.





 Talus Stress Fracture
(Also known as Talar Stress Fracture, Stress Fracture of the Talus)
 
What is a talus stress fracture?
The talus is a small bone of the ankle responsible for transferring weight bearing forces from the shin to the foot. The talus is situated below the tibia and fibula (lower leg bones) and connects with these bones to form the ankle joint. The talus bone also forms joints with several other small bones of the foot including the navicular and calcaneus.
During weight bearing activity compressive forces are placed through the talus. When these forces are excessive, too repetitive and beyond what the bone can withstand, bony damage gradually occurs. This initially results in a bony stress reaction, however, with continued damage may progress to a talus stress fracture.

Cause of a talus stress fracture

Stress fractures of the talus typically occur gradually over time with excessive weight bearing activity such as running. They usually occur following a recent increase in activity or change in training conditions. They commonly present in athletes involved in running sports such as soccer and athletics.

Signs and symptoms of a talus stress fracture
Patients with this condition typically experience a deep ankle pain that increases with weight bearing activity. In severe cases, walking may be enough to aggravate symptoms. Other symptoms may include night ache, pain during certain movements of the foot and ankle or pain on firmly touching the talus.

Diagnosis of a talus stress fracture
A thorough subjective and objective examination from a doctor may be sufficient to diagnose a talus stress fracture. Investigations such as an MRI, CT scan or bone scan are usually required to confirm diagnosis.

Treatment for a talus stress fracture
Most patients with this condition heal well with appropriate management. Treatment typically involves an initial period of rest from weight bearing activity which usually requires the use of crutches or a protective boot. In patients with a confirmed fracture, treatment may sometimes require 6 weeks plaster cast immobilization but this will vary from case to case.
Once the patient is out of the cast (or for those patients who do not require plaster cast immobilization), a gradual increase in weight bearing activity can begin provided there is no increase in pain. This should occur over weeks to months with direction from the treating physiotherapist or specialist and will vary depending on the severity of injury. Alternative exercises placing minimal weight bearing forces through the affected bones should be performed to maintain fitness such as swimming, cycling, and water running. Exercises to maintain flexibility, strength and balance are also important to ensure the ankle is functioning correctly. The treating physiotherapist can advise which exercises are most appropriate and when they should be commenced.

Contributing factors to the development of a talus stress fracture
There are several factors that may contribute to the development of a talus stress fracture. These should be assessed and where possible corrected with direction from the treating doctor and may include:
  • poor foot biomechanics
  • inappropriate or excessive training
  • inappropriate footwear
  • joint stiffness
  • poor flexibility
  • muscle weakness

Physical therapy for a talus stress fracture

Physical therapy treatment is essential for all patients with this condition to hasten healing, prevent recurrence and ensure an optimal outcome. This may comprise:
  • soft tissue massage
  • joint mobilization
  • electrotherapy (e.g. ultrasound)
  • bracing or taping
  • the use of crutches
  • hydrotherapy
  • biomechanical correction
  • exercises to improve strength, balance and flexibility
  • a gradual return to activity program

Other intervention for a talus stress fracture
Despite appropriate physical therapy management, some patients with this condition do not improve and may require other intervention to ensure an optimal outcome. The treating physical therapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, extended periods of plaster cast immoblization, review with a podiatrist for possible orthotics or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the talus stress fracture. Occasionally, patients with this condition may require surgery to stabilize the stress fracture and aid healing.





 Tarsal Tunnel Syndrome
(Also known as Posterior Tibial Nerve Entrapment)
 
What is tarsal tunnel syndrome?
The tarsal tunnel is a groove which lies at the inner aspect of the ankle, behind the bony prominence known as the medial malleolus. A nerve known as the posterior tibial nerve lies within this groove and may become compressed due to trauma such as rolling the ankle or due to repetitive strain associated with an excessively pronated (flat) foot. When this nerve becomes compressed, the condition is known as tarsal tunnel syndrome.

Signs and symptoms of tarsal tunnel syndrome
Patients with tarsal tunnel syndrome typically experience pain radiating into the arch of the foot, heel and occasionally the toes. There may also be pins and needles or numbness on the sole of the foot. Symptoms are typically worse during weight bearing activity such as walking, standing or running.

Diagnosis of tarsal tunnel syndrome
A thorough subjective and objective examination from a doctor may be sufficient to diagnose tarsal tunnel syndrome. Diagnosis can be confirmed with nerve conduction studies.

Treatment for tarsal tunnel syndrome
A rehabilitation program is the first line of treatment for patients with this condition. The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient rests sufficiently from any activity that increases their pain until they are symptom free (crutches may be required). This allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the condition becoming chronic. Once chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence. Immediate appropriate treatment in all patients with tarsal tunnel syndrome is vital to ensure an optimal outcome.
Following RICE particularly with regular icing and anti-inflammatory medication may help to significantly reduce inflammation in the initial phase of this condition. A graduated flexibility, strength and balance program under direction from a physiotherapist is important to ensure an optimal outcome
In the final stages of rehabilitation, a gradual return to activity or sport should occur under guidance from the treating practitioner and provided there is no increase in symptoms.

Contributing factors to the development of tarsal tunnel syndrome
There are several factors which can predispose patients to developing tarsal tunnel syndrome. These need to be assessed and corrected with direction from the treating doctor and may include:
  • poor foot biomechanics (especially flat feet)
  • inappropriate footwear
  • joint stiffness
  • muscle weakness
  • poor balance
  • inappropriate or excessive training or activity

Physical therapy for tarsal tunnel syndrome
Physical therapy treatment is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of injury recurrence in all patients with tarsal tunnel syndrome. Treatment may comprise:
  • electrotherapy (e.g. ultrasound)
  • joint mobilization
  • taping or bracing
  • the use of crutches
  • ice or heat treatment
  • biomechanical correction
  • exercises to improve flexibility, strength and balance
  • education
  • activity modification advice
  • a gradual return to activity program

Other intervention for tarsal tunnel syndrome
Despite appropriate therapy management, some patients with tarsal tunnel syndrome do not improve adequately. When this occurs the treating doctor can advise on the best course of management. This may include review with a podiatrist for possible orthotics, corticosteroid and anaesthetic injection into the tarsal tunnel or review by a specialist who will advise on any procedures that may be appropriate to improve the condition. Occasionally, decompressive surgery is required to alleviate pressure on the posterior tibial nerve.





 Tibialis Posterior Tendon Dislocation

(Also known as Tibialis Posterior Tendon Subluxation)
 
What is tibialis posterior tendon dislocation?
The tibialis posterior muscle originates from the back of the tibia and fibula (lower leg bones), it then travels down along the inside of your leg and ankle where it inserts into various bones in the foot via the tibialis posterior tendon. The tibialis posterior tendon is held firmly in place at the level of the ankle by strong connective tissue known as the tibialis posterior retinaculum. Occasionally this retinaculum can be torn due to strong contraction of the tibialis posterior muscle. As a result, the tendon of the tibialis posterior muscle is free to move in and out of its original position and may flick over the bony prominence at the inside of the ankle. This condition is known as a tibialis posterior tendon dislocation.

Signs and symptoms of tibialis posterior tendon dislocation

Patients with this condition typically experience inner ankle pain and stiffness with local bruising and swelling. Patients may be unable to weight bear and may experience a flicking sensation at the inside of the ankle with certain ankle movements. Pain may also increase on firmly touching the tibialis posterior tendon.

Diagnosis of tibialis posterior tendon dislocation

A thorough subjective and objective examination from a doctor may be all that is necessary to diagnose tibialis posterior tendon dislocation. Diagnosis may be confirmed with an MRI scan or ultrasound investigation.

Treatment for tibialis posterior tendon dislocation

All patients who potentially have a tibialis posterior tendon dislocation should see a doctor immediately so their condition can be assessed and the likelihood of them having a tibialis posterior tendon dislocation determined. This is important as delayed treatment may result in a poor outcome. Meanwhile, initial injury management in the first 48 – 72 hours is vital to reduce bleeding, swelling and inflammation. This should comprise of rest from aggravating activity (crutches are often required), regular icing, the use of a compression bandage and elevation of the affected limb. Anti-inflammatory medication may also be useful in this early phase as guided by the treating doctor or pharmacist.
Immediate surgical relocation of the tibialis posterior tendon and reconstruction of the retinaculum is indicated in patients who have a tibialis posterior tendon dislocation. This is important to ensure optimal function of the foot and ankle. Following surgery, a period of immobilization in either a plaster cast or protective boot is likely.
It is also important for patients to perform pain free flexibility, strengthening and balance exercises to ensure an optimal outcome once the surgeon has indicated that is it safe to do so. The treating physical therapist can advise which exercises are most appropriate for the patient and when they should be commenced. Rehabilitation of these injuries usually takes 6 months or longer with intensive physical therapy.

Physical therapy for tibialis posterior tendon dislocation
Physical therapy treatment is vital to hasten healing and ensure an optimal outcome in all patients with this condition. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • stretches
  • joint mobilization
  • taping or bracing
  • the use of crutches
  • ice or heat treatment
  • exercises to improve flexibility, strength and balance
  • education
  • activity modification advice
  • biomechanical correction
  • footwear advice
  • a gradual return to activity program




 Tibialis Posterior Tendon Rupture
(Also known as a Tibialis Posterior Rupture, Completely Torn Tibialis Posterior Tendon)
 
What is a tibialis posterior tendon rupture?
The tibialis posterior muscle originates from the back of the tibia and fibula, it then travels down along the inside of your lower leg and ankle where it inserts into various bones in the foot via the tibialis posterior tendon. The tibialis posterior muscle is responsible for moving the foot and ankle towards the midline of the body (inversion) and pointing the foot and ankle down (plantarflexion). It also helps to maintain the normal arch of your foot.
Whenever the tibialis posterior muscle contracts or is stretched, tension is placed through the tibialis posterior tendon. If this tension is excessive due to too much force or repetition, damage to the tibialis posterior tendon may occur. This can range from minor tearing of the tendon with subsequent inflammation to a complete tibialis posterior tendon rupture.

Signs and symptoms of tibialis posterior tendon rupture

Patients with a tibialis posterior tendon rupture may experience pain on the inside of their foot, ankle and lower leg. In addition, they may be unable to raise their heel in standing and may have a visibly flattened inner arch of the foot when compared to the normal side. There may also be visible swelling or thickening of the inner lower leg or ankle.

Diagnosis of tibialis posterior tendon rupture
A thorough subjective and objective examination from a doctor may be all that is necessary to diagnose a tibialis posterior tendon rupture. Diagnosis may be confirmed with an MRI scan or ultrasound.

Treatment for tibialis posterior tendon rupture

All patients who potentially have a tibialis posterior tendon rupture should see a doctor immediately so their condition can be assessed and the likelihood of them having a tibialis posterior tendon rupture determined. This is important as delayed treatment may result in a poor outcome. Meanwhile, initial injury management in the first 48 – 72 hours is vital to reduce bleeding, swelling and inflammation. This should comprise of rest from aggravating activity (crutches are often required), regular icing, the use of a compression bandage and elevation of the affected limb. Anti-inflammatory medication may also be useful in this early phase as guided by the treating doctor or pharmacist.
Immediate surgical reconstruction of the tibialis posterior tendon is indicated in patients who have a tibialis posterior tendon rupture. This is important to ensure optimal function of the foot and ankle. Following surgery, a period of immobilization in either a plaster cast or protective boot is likely. Rehabilitation of these injuries usually takes 6 months or longer with intensive physical therapy.

Contributing factors to the development of tibialis posterior tendon rupture
There are several factors which can predispose patients to developing this condition . These need to be assessed and corrected with direction from your physical therapist. Some of these factors include:
  • poor flexibility
  • inappropriate training
  • poor biomechanics
  • poor foot posture
  • inadequate warm up
  • muscle weakness
  • inadequate rehabilitation following a previous injury

Physical therapy for tibialis posterior tendon rupture
Physical therapy treatment is vital to hasten the healing process, reduce the likelihood of recurrence and ensure an optimal outcome in all patients with this condition. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • the use of crutches
  • the use of heel wedges
  • stretches
  • joint mobilization
  • ice or heat treatment
  • exercises to improve strength, flexibility or balance
  • education
  • activity modification advice
  • biomechanical correction
  • a gradual return to activity program