Anatomy/Pathology: Fascia is a type of connective tissue found in the body. It is comparable to a thick saran wrap covering and its purpose is to compartmentalize different groups of muscles together that have a common purpose. It is found throughout the body, but is most commonly referred to when it becomes irritated in the plantar region (on bottom of the foot). Here, the fascia compartmentalizes the tendons, ligaments, and muscles of the bottom of your foot. When too much strain is placed on this region, an inflammatory process begins within this pocket and break down of the fascia can occur. Fascia is made up of collagen. Collagen is the main component of all soft tissue in our bodies and is therefore the type of cell that is used to scar over or fill in the broken down areas of our feet. There are 28 total types of collagen. Types I and II are smooth and can be found in healthy tissue. However, when our bodies are trying to quickly repair a broken down structure, type IX collagen is often included. Type IX collagen has higher concentrations of fat cells and contains more free nerve endings, thus creating the gristly feeling and exquisite point tenderness of the damaged tissue. When the fascia becomes inflamed, the type IX collagen is laid down in the damaged regions, thus increasing pain as stress is placed upon this area.
Physical Therapy Treatment: Physical therapy treatment is centered on reversing the inflammatory process and the breakdown of tissue. In efforts to do so, strength, flexibility and balance (dynamic control) of the lower leg and foot must be assessed in order to target the weak and vulnerable area. In addition, measures must be taken in order to break down the type IX collagen in order to allow more types I and II to predominate the tissue.
Symptoms: Symptoms typically consist of point tenderness under the arch and/or heel region(s) of the foot. The pain is typically worse first thing in the morning or after prolonged sitting. However, your pain may also get worse as the day goes along. Symptoms can also sometimes be described as a “stone bruise” on the heel.
Diagnosis: Diagnosis is typically based upon a physical examination that includes gait analysis (studying the way you walk), palpation (feeling for tender areas), flexibility testing, strength testing, medical history and explanation of symptoms.
Frequency: There is a 10% incidence over the course of a lifetime. It is estimated that 2 million Americans suffer from plantar fasciitis.
Physician Treatment: Physicians may prescribe night splints (braces that hold your foot in a neutral position while you sleep in order to keep the ligament from becoming shortened over night), anti-inflammatory medications, oral steroid medications, or a steroid injection to aid in healing and decrease inflammation.
Surgery: Surgical intervention may be considered when conservative measures fail. This consists of releasing the lateral third of the plantar fascia to reduce the stress on the affected area. It is important to take measures to control scar tissue formation and restore strength and ROM following this procedure.
Anterior Talofibular Ligament (ATFL) Sprain
Anatomy: The anterior talofibular ligament (ATFL) is located on the outer portion of the ankle. It runs from the anterior portion of the fibular malleolus (the outer prominent ankle bone) to the talus, which is one of the main lateral bones in the midfoot region of the foot. The ATFL is thought of as a thickening of the anterior joint capsule, which comes forward in a fibrous ligament to provide lateral stability and prevent anterior motion of the foot relative to the lower leg. This ligament is in a rectangular shape, measuring approximately 20mm x 10mm. The ATFL is considered the weakest of the foot/ankle ligaments which lends to its propensity for sprains. The positioning of the ankle will have a great affect upon the ATFL’s function, with the most stress occurring when the foot is placed in a position that combines weight bearing, plantar flexion, and inversion. Standing on a single leg, in tip toe with toes pointed inward, is an excellent visual of this position.
Symptoms: A sprain is defined as the stretching and/or tearing of the fibers of a ligament. The ATFL is normally injured when the foot is in the tip toe position described above, and then the balance shifts laterally, stretching the ligament beyond its capabilities. Pain and tenderness along the lateral ankle joint, a popping sound during the injury, swelling, bruising/discoloration, and difficulty weight bearing are all typically noted with an ATFL sprain. The severity of symptoms will coincide with the severity of the sprain/ damage to the ligament.
Diagnosis: There are manual tests that can be used to assess the severity of an ATFL sprain. The most common is called the Anterior Drawer test, which assesses the ability of the ligament to resist the forward motion of the foot versus the lower leg. X-rays may be used to determine if there is any damage to the bony structures around the ATFL, and an MRI may be required in the most severe cases, to determine if there is a complete rupture of the ligament or further damage to surrounding soft tissues. There are three grades of sprains, I-III, that will be used to classify the damage to the ATFL, with I being the least amount of damage and III being a complete rupture.
Treatment: Non-surgical: The majority of ATFL sprains are not severe enough to require surgery. Normally a patient will have discomfort, discoloration, and pain for approximately 2-4 weeks. Use of crutches and/or an ankle brace is sometimes indicated to prevent increased pain upon the foot in weight bearing and to provide lateral stability to the joint as the ligament scars during the healing process. Occasionally, a walking boot will provide more stability and decrease pain in weight bearing for injury that is classified as more severe. Most people can find themselves back to normal activity levels within 1-2 months after injury. Physical therapy can assist with the return to activity with strengthening the surrounding musculature, reducing pain from swelling, and promoting increased stability of the joint to prevent re-injury and allow you to return to your previous activities.
Surgical: A complete rupture of the ATFL, along with damage to the adjoining bones or other localized soft tissue structures may indicate surgery to reconstruct the damaged structures. Sometimes, a sprain that is not responding to conservative treatment will also require surgery as the ligament’s damage may be too severe for healing on its own. Your physician will use the evidence from manual testing, and any diagnostic tests (X-ray, MRI, etc.) to assess what procedures will be required to reconstruct the damage to the ankle. Normally, a cast or walking boot with limited weight bearing will be indicated post-surgery for several weeks. As the surgical site heals, you will advance through the levels of weight bearing as you are able to tolerate increased pressure on the foot per physician recommendation. Physical therapy will then be used to increase ankle range of motion, tolerance for weight bearing activities, increasing strength and stability of the ankle joint, and returning the patient back to their prior level of function through sport specific or work related activity.
Lis Franc Fracture
A Lis Franc fracture is an injury to the midfoot area of the foot, where all or one of the metatarsal bones is displaced from the tarsal bones (the seven bones that comprise the lower portion of the ankle joint). The midfoot region is comprised of the five metatarsal bones, which are located directly behind the five phalanges (the five toes) and the tarsal bones (the cuboid, navicular, and three cuneiform bones).
There are three types of a Lis Franc fractures: homolateral, isolated and divergent. Homolateral is when all of the metatarsal bones have been moved out of their normal position in the foot, in the same direction, together. Isolated is when one or two of the metatarsal bones have been moved out of their normal position. Divergent occurs when the movement of one metatarsal bone (usually the 1st) occurs towards the instep of the foot and movement of the 2nd through 5th metatarsals in the opposite direction.
A Lis Franc fracture will occur from a direct or indirect injury to the midfoot region. Direct Lis Franc fractures can occur when a heavy object will fall onto the midfoot region, when the foot is flat on the ground. An indirect Lis Franc fracture can occur when the foot is in plantar flexion (the toes are flat on the ground and the heel is in the air), and a rotational force is applied to the midfoot region. Direct injuries can be seen in sports such as football, when a foot or body weight applies an impact directly to the top of the affected foot. Indirect injuries can be seen with sports such as horse riding, when a foot gets caught inside the stirrups during a fall, and force is applied towards the midfoot as the person falls.
Diagnosis of a Lis Franc injury is usually performed by a physician, with a visual and physical examination and x-ray imaging. Occasionally, x-ray imaging will not indicate a fracture, and advanced imaging, such as an MRI (magnetic resonance imaging) or CT scan (x-ray computed tomography) will be used for further examination. These images, plus the examination, will help the doctor to decide if a Lis Franc injury has occurred, and help in determining the appropriate course of treatment.
Once a Lis Franc injury is diagnosed, treatment can include both surgical and non-surgical options. If the displacement of the bones is less than two millimeters, the physician may elect to have the foot casted and direct the patient to maintain a non-weight bearing status with the foot for up to six weeks. However, a more severe injury may indicate a surgical approach. If the bones are too far apart to benefit from casting, an Open Reduction Internal Fixation (ORIF) may be indicated. This is when the bones are surgically returned to their appropriate position with use of metal plates, screws, or guide wires. ORIF implements are often removed once x-ray imaging shows the bones have healed, typically at 6-12 weeks post-surgery. The patient will be directed to be non-weight bearing during the first six weeks to promote healing and reduce unnecessary impact on the bones. Due to the limited weight bearing, immobility of the foot, and possible temporary fixations, a person’s balance, strength, and range of motion will be drastically affected. Physical therapy is needed to assist the patient’s recovery and return to sport or work with focus on addressing the current deficits found in the ankle and foot and aid with returning the patient back to their prior level of function.
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