Evidence-based rehabilitation of

the foot and ankle

William A. Cannarozzi PT

Kettering Sports Medicine Symposium

November 11, 2016

Why an interest in foot/ankle

rehab? Interested as a

student

Senior symposium

Worked with Gary

Gray on continuing

education course that

went on to become

Scapular Reaction

Objectives Demonstrate

understanding of

foot/ankle anatomy and

biomechanics

Articulate understanding

of evidence-based

updates for rehabilitation

of the foot and ankle as it

pertains to

Therapeutic exercise

Manual therapy

Orthotic intervention

Bony structure of foot/ankle

Full disclosure Some slides and research

taken from MedBridge course by: Alexis Wright PT, PhD, DPT, FAAOMPT

Not focusing on thrust-type manipulation. Why? Because I don’t want to

Most research from last 10-years.

Presenting research can be boring—bear with me

Majority of literature focuses on ankle sprains, chronic ankle instability (CAI), heel pain syndromes,

Anatomy

Anterior compartment muscles

NWB action=DF

FWB action=Decelerate

pronation at heelstrike

Tibialis anterior

Extensor hallucis longus

Extensor digitorum

longus

Peroneus tertius

Innervation from deep

peroneal nerve

Lateral compartment muscles NWB

action=Eversion

FWB

action=Decelerate

inversion/supination

Peroneus longus

Peroneus brevis

Innervation from

superficial peroneal

nerve

Deep posterior compartment

muscles NWB action=PF

FWB action=

deceleration of DF

through midstance

Tibialis posterior

Flexor digitorum

longus

Flexor hallucis longus

Popliteus

Innervation from tibial

nerve

Superficial posterior

compartment muscles

Same action as

deep posterior

compartment

muscles

Gastrocnemius

Soleus

Popliteus

Innervation from

tibial nerve

The Manual Therapy “Six-pack”

From Whitman et. al.

But wait—there’s more! Don’t forget:

Intertarsal

Tarsometatarsal

Intermetatarsal

MTP, especially

1st

How ‘bout that foot binding?!?

Manual therapy techniques

used

Most may be done as mobilization or manipulation

Medial/Lateral glides and INV/EVE

mobilization/manipulation

Proximal tibiofibular joint thrust

mobilization/manipulation

Distal tibiofibular joint mobilization/manipulation

Rearfoot distraction thrust mobilization/manipulation

Talocrural joint anterior to posterior

mobilization/manipulation

Alternate method of talocrural joint AP

mobilization/manipulation (weight-bearing MWM)

Medial/Lateral calcaneal

glide Subtalar

mobilization:

Stabilize talus by

table or

manually

Medial glide of

calcaneus

Lateral glide of

calcaneus

Rearfoot distraction

mobilization

Wrap fingers around

talus and proximal

mid-foot

Provide traction force

to distract talus out of

ankle mortise

May be done as a

grade 5 manipulation

Proximal tibiofibular

mobilization Subject’s leg

stabilized by table

Clinician stabilizes tibia

Anterior/posterior mobilizing force through fibula

Beware paresthesia and protect peroneal nerve

Talocrurual Joint mobilization

Clinician stabilizes

ankle mortise

Anterior/posterior

mobilizing force

provided through

talus

I believe this is easier

to do with Kaltenborn

wedge.

But DON’T do this with it!

Distal Tibiofibular joint

mobilization

Clinician stabilizes

Tibia

Anterior/posterior

mobilizing force

through fibula

Mobilization With Movement Pioneered by Brian

Mulligan

Patient in FWB

Clinician stabilizes talus

Clinician provides anterior glide of mortise through belt

Clinician facilitates DF movement

Can also be done PWB or NWB

Mobilization with Movement-

MWM

Weight bearing Non weight bearing

What does the literature say? Prepare now:

Drink your coffee now

Steal some of Chris’s 5-

hour energy!

Initial Changes in Posterior Talar Glide and Dorsiflexion of

the Ankle After Mobilization With Movement in Individuals

with Recurrent Ankle Sprain—JOSPT 2006, Branjerdporn et. Al.

Subjects: N = 16 (history of 2 ankle sprains each)

• Treatment conditions: 3 groups

• Weight bearing MWM (10 sec

hold x 4 sets of 4 glides)

• Non weight bearing MWM (10

sec hold, 4 sets of 4 glides)

• No treatment control group

• Outcome Measures:

• Posterior talar glide

• Weight-bearing ankle

dorsiflexion

Results—Does it work?

Both MWM treatment techniques significantly

improved posterior talar glide deficit by 55%

and 50%, respectively

Both MWM treatments significantly improved

weight-bearing ankle dorsiflexion by 26%

compared to 9% for the control condition

Conclusion: positive effect of a MWM treatment

on improving posterior talar glide and dorsiflexion

ROM in individuals with chronic recurrent lateral

ankle sprain.

Predicting Short-Term Response to Thrust and Non-

thrust Manipulation and Exercise in Patients Post

Inversion Ankle Sprain-JOSPT 2009, Whitman et. al.

Subjects: N = 85; status post grade I or II inversion ankle

sprain within 1 year

Goal: to develop Clinical Prediction Rule (CPR)

• Treatment conditions: 1-2 visits

• Ankle/foot thrust and non-thrust manipulation,

ROM/stretching, advice to maintain usual activity, ice and

elevation

• 2 manipulation attempts max, 5 x 30 seconds for

mobilizations grade III or IV

• Outcome measures: NPRS, Foot and Ankle Ability

Measure (FAAM), LEFS, Beck Anxiety Index (BAI), GROC

Exercise techniques

used Achilles tendon stretch, non-weight

bearing with the knee extended (towel stretch)

Achilles tendon stretch, weight bearing (runner’s stretch)

Ankle Alphabet exercises

Ankle eversion self-mobilization

Dorsiflexion self-mobilization

Results-Does it work? 64 of the 85 (75%) participants had a positive

result w/treatment program based on outcome

measures

CPR: Identified 4 predictors of + response to

rehab:

Symptoms worse on standing

Night pain

Navicular drop > 5mm

Distal tibofibular hypomobility

Manual Physical Therapy and Exercise vs Supervised Home

Exercise in the Management of Patients Status post inversion

ankle sprain: a multi-center randomized clinical trial, JOSPT

2013, Cleland et. al.

Subjects: 74 patients post inversion ankle

sprain

• Treatment Conditions: Manual therapy (from

Whitman) plus ther-ex (2x/week x 4 weeks) OR

Home exercise program (HEP) only (1x/week x 4

weeks in clinic)

Used same exercises for both groups

• Outcomes Measures: FAAM, LEFS, NPRS tested at

baseline, 4 weeks, and 6 months

Does it work? Outcomes: Improvements in all outcome measures and

pain significantly greater at

both the 4 week and 6

months in favor of the MTEX

group

Conclusions: MTEX is superior to HEP in the treatment of

inversion ankle sprains

Efficacy of Thrust and Nonthrust Manipulation and Exercise With

or Without the Addition of Myofascial Therapy for the

Management of Acute Inversion Ankle Sprain: A Randomized Clinical Trial, JOSPT 2013, Truyols-Dominguez et. al.

Subjects: 50 patients post acute inversion ankle sprain

• Treatment Conditions (1x/week x 4 weeks):

– MTEX (Whitman-again-and traditional ther-ex

– MTEX plus myofascial therapy

• Outcomes Measures: NPRS, ankle function at Discharge and 1 month

Does it work? Kinda:

Improvement in MFR group was statistically significant

However, gains most likely not clinically significant based on clinically significant change on outcome measure

A Combined Treatment Approach Emphasizing

Impairment-Based Manual Physical Therapy for Plantar Heel Pain: A Case Series, JOSPT 2004, Walker, et. al.

Subjects: N = 4; unilateral heel pain or

plantar fasciitis

• Treatment conditions:

1. Calf-stretching, A/P talocrural

mobs, subtalar distraction manip

2. Calf-stretching, A/P talocrural

mobs, subtalar distraction manip,

lateral subtalar joint glides, A/P –

P/A first TMT joint

3. Subtalar joint distraction manip,

stretching, orthosis

4. Subtalar joint distraction manip,

stretching, foot intrinsics

• Outcome Measures: NPRS and Self-

reported functional status

Does it work? Results:

• Rx duration between 8-49 days

• Sessions ranged from 2-7

• All 4 reported a decrease in

NPRS from an average

of 5.8±2.2 to 0/10 (>2 significant)

Conclusions:

• Impairment-based PT approach emphasizing manual

therapy demonstrated complete

pain relief and full return to

activities

Manual Physical Therapy and Exercise Versus Electrophysical

Agents and Exercise in the Management of Plantar Heel Pain: A Multicenter Randomized Clinical Trial, JOSPT 2009, Cleland et. al

Subjects: N = 60; primary report of plantar heel pain and LEFS ≤ 65

• Treatment conditions: 2x/week x 2 weeks; 1x/week x 2 week; 6 visits

total over 4 weeks

• Control: Electrophysical agents + exercise (EPAX)

• Ultrasound, ionto with dexamethasone, ice, gastroc-soleus & plantar

fascia stretch, intrinsic foot strengthening, self-mob; 3x/day x 4 weeks

• Treatment group: Manual therapy + exercise (MTEX); individualized

STM, rearfoot eversion mobilization, ankle eversion self mobs, manual

STM of plantar fascia, + gastroc/soleus stretches

• Impairment based mobs at the hip, knee, ankle, foot

• Outcome Measures: 4 weeks; 6 months including LEFS, Foot and

Ankle Ability Measure (FAAM), NPRS, Beck Anxiety Index (BAI), Global

rating of change scale

Does it work? Both groups

demonstrated

statistically significant

improvement in all

measures

MTEX clinically greater

improvement in LEFS

and FAAM at 4 & 6

wks

Acute effects of rearfoot manipulation on dynamic

standing balance in healthy individuals; Manual Therapy, Wassinger, et. al., 2014

Design:

20 healthy

participants

Treatment group

underwent rearfoot

distraction

mobilization

Control group did

nothing

Both groups tested

on Y-balance test

Results:

Dynamic balance improved for overall balance and posteromedial excursion direction

The Effect of Sesamoid Mobilization, Flexor Hallucis

Strengthening, and Gait Training on Reducing Pain and Restoring

Function in Individuals with Hallux Limitus: A Clinical Trial, JOSPT 2004, Shamus et. al.

Subjects: N = 20; hallux limitus (“turf toe”,

MPJ sprain)

• Treatment conditions: 3x/week x 4 weeks

Control group: whirlpool,

gastroc/hamstring stretch, pulsed

ultrasound, PROM 1st MPJ, grade III dorsal

glides and distraction 1st MPJ, heel raises,

great toe strengthening, e-stim, ice

Treatment group: Above + grade III

sesamoid joint mobilizations, FHL strengthening, gait training

• Outcome measures: ROM, strength

Does it work?

Control group

demonstrated

statistically significant

improvement in:

Pain level (via

NPRS)

FHL strength

MTP extension

ROM

Achilles pain, stiffness, and muscle power deficits:

Achilles tendinitis; JOSPT, Carcia et. al 2010 APTA clinical practice

guidelines based on meta-

analysis

Protocol 1: (Curwin & Stanish)

– 3 sets of 10 reps eccentrics

– Increased load weekly

– Speed of movement

changed daily

– 95% of patients reported

symptom resolution in 6-8

weeks

• Protocol 2: (Alfredson et al)

– Unilateral heel raises with no

concentric component

– 3 sets of 15 reps, 2x/day, 12

weeks

Does it work?

Strong evidence

supports use of

eccentric loading to

resolve symptoms in 6-

8 weeks

Also suggests

clinicians consider

Modalities (laser,

ionto)

Manual therapy

Other ther ex.

Ill tempered sea-

bass?

Eccentric overload training in patients with chronic

Achilles tendinopathy: a systematic review; British

Journal of Sports Med; Kingma et. al

Similar results found by:

Kingma et. al.

Root et. al. *

Mafi et. al. *

Alfredson et. al. *

Silbernagal et. al. *

*Articles not available on

pub med

Nonsurgical Management of Posterior Tibial Tendon Dysfunction With

Orthoses and Resistive Exercise: A Randomized Controlled Trial; Physical

Therapy; Kulig et. al. 2009

Subjects: 36 adults with stage 1 or 2 posterior tib

tendinopathy

• Treatment conditions: 12 week program

– Orthotics & stretching

– Orthotics, stretching, concentric PREs

– Orthotics, stretching, eccentric PREs

• Outcomes Measures: FFI, 5 minute walk, pain

Results:

All groups improved

Orthotics, stretching, and ECCENTRIC PRE group improved most

Orthotic and stretching only group improved least

Effectiveness of exercise therapy and manual mobilisation in

ankle sprain and functional instability: a systematic review; Aust J Physio; Wees et. al. 2006

Meta-analysis of 17

studies

Moderate evidence

exists that:

TherEx (including

wobble board)

effective in preventing

recurrent ankle sprains

for both acute sprain

and CAI

No effect on postural

sway

Initial improvement in

ankle DF

Six Weeks of Balance Training Improves Sensorimotor Function in

Individuals With Chronic Ankle Instability; JOSPT, Sefton et. al. 2009

Subjects: N = 21; 12 w/CAI and 9 healthy

Treatment group: 3x/week x 6 weeks

consisting primarily of balance-board

training

Control group: continue with normal ADLs

Outcome Measures: baseline & 6 weeks

Ankle Injury History Questionnaire

Functional Ankle Instability Index

(FAII)

Single limb stance

Star excursion balance test

Motoneuron pool excitability

recurrent inhibition protocol (EMG)

Joint kinesthesia measurements

(Biodex)

Results:

Enhanced dynamic balance

Inversion joint position sense

Changes in motorneuron pool excitability compared to healthy controls who did not train

Conclusions: Balance board training protocols may produce improvements in the daily functioning of individuals

with CAI

Wobble Board Training After Partial Sprains of the Lateral

Ligaments of the Ankle: A Prospective Randomized Study; JOSPT; Wester et. al. 1996

Subjects: N = 48; primary ankle sprains

• Treatment group: 12

week training program

with a wobble board 15

min/day

• Control: no training

• Outcome measures:

Volumetric measures

Resting pain

Walking pain

Recurrent ankle sprains

Results:

• Recurrent ankle sprains: 25% in

treatment group; 54% in control

• Edema: no differences between

groups

• Return to sport: no differences

Conclusions:

Wobble board training for 12

weeks beginning 1 week after the

ankle sprain was effective in

reducing the number of recurrent

ankle sprains and prevent

functional instability of the ankle in

patients with primary ankle

sprains.

Patellofemoral Joint and Achilles Tendon Loads

During Overground and Treadmill Running; JOSPT, Willy et. al.

2016

Design:

18 healthy runners on treadmill and over ground

3-D motion analysis analyzing PF Joint and Achilles Tendon:

Peak load

Rate of loading

Cumulative load / 1K of running

Results:

No differences at PF Joint for treadmill or road running

Significant differences in all 3 measures for Achilles tendon worse for treadmill

The effect of stride length on the dynamics of barefoot and shod

running; Journal of Biomechanics; Thompson et. al.; 2014

Evaluated effect of

footwear and stride

length on LE

biomechanics during

running

N=11 healthy runners

Ran over ground at

normal stride and at

+/- 5 & 10%

(metronome induced)

both barefoot and

shod

Evaluated 3-D motion capture and force-plate analysis of:

A/P GFRs

Vertical GFRs

Sagittal plane motion of knee, foot, and ankle

Conclusion: At same stride length, no difference in LE biomechanics between barefoot and shod running

Stride-length may be injury-reducing factor

Overall conclusions

Rehabilitation can treat

a myriad of foot/ankle

conditions

Manual therapy

works—use it

Therapeutic exercise

works—use it

There is a place for

modalities—especially

low-level laser

References Branjerdporn, M. (2006). Initial Changes in Posterior Talar Glide and Dorsiflexion of the Ankle After Mobilization With Movement in Individuals With Recurrent Ankle Sprain. Journal of Orthopaedic and Sports Physical Therapy. doi:10.2519/jospt. Carcia, C. R., Martin, R. L., & Wukich, D. K. (2010). Achilles Pain, Stiffness, and Muscle Power Deficits: Achilles Tendinitis. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy, 40(9). doi:10.2519/jospt.2010.0305 Cleland, J. A., Abbott, J. H., Kidd, M. O., Stockwell, S., Cheney, S., Gerrard, D. F., & Flynn, T. W. (2009). Manual Physical Therapy and Exercise Versus Electrophysical Agents and Exercise in the Management of Plantar Heel Pain: A Multicenter Randomized Clinical Trial. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy, 39(8), 573-585. doi:10.2519/jospt.2009.3036 Cleland, J. A., Mintken, P., Mcdevitt, A., Bieniek, M., Carpenter, K., Kulp, K., & Whitman, J. M. (2013). Manual Physical Therapy and Exercise Versus Supervised Home Exercise in the Management of Patients With Inversion Ankle Sprain: A Multicenter Randomized Clinical Trial. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy, 43(7), 443-455. doi:10.2519/jospt.2013.4792 Hong, Y., Wang, L., Li, J. X., & Zhou, J. H. (2012). Comparison of plantar loads during treadmill and overground running. Journal of Science and Medicine in Sport, 15(6), 554-560. doi:10.1016/j.jsams.2012.01.004

References (cont) Kingma, J. J., Knikker, R. D., Wittink, H. M., & Takken, T. (2007). Eccentric overload training in patients with chronic Achilles tendinopathy: A systematic review. British Journal of Sports Medicine, 41(6). doi:10.1136/bjsm.2006.030916 Kulig, K., Reischl, S. F., Pomrantz, A. B., Burnfield, J. M., Mais-Requejo, S., Thordarson, D. B., & Smith, R. W. (2008). Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial. Physical Therapy, 89(1), 26-37. doi:10.2522/ptj.20070242

Mcclinton, S., Collazo, C., Vincent, E., & Vardaxis, V. (2016). Impaired Foot Plantar Flexor Muscle Performance in Individuals With Plantar Heel Pain and Association With Foot Orthosis Use. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy, 46(8), 681-688. doi:10.2519/jospt.2016.6482 Sefton, J. M., Yarar, C., Hicks-Little, C. A., Berry, J. W., & Cordova, M. L. (2011). Six Weeks of Balance Training Improves Sensorimotor Function in Individuals With Chronic Ankle Instability. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy, 41(2), 81-89. doi:10.2519/jospt.2011.3365 Shamus, J., Shamus, E., Gugel, R. N., Brucker, B. S., & Skaruppa, C. (2004). The Effect of Sesamoid Mobilization, Flexor Hallucis Strengthening, and Gait Training on Reducing Pain and Restoring Function in Individuals With Hallux Limitus: A Clinical Trial. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy, 34(7), 368-376. doi:10.2519/jospt.2004.34.7.368

References (cont) Thompson, M., Gutmann, A., Seegmiller, J., & Mcgowan, C. (2014). The effect of stride length on the dynamics of barefoot and shod running. Journal of Biomechanics, 47(11), 2745-2750. doi:10.1016/j.jbiomech.2014.04.043 Truyols-Domínguez, S., Salom-Moreno, J., Abian-Vicen, J., Cleland, J. A., & Fernández-De-Las-Peñas, C. (2013). Efficacy of Thrust and Nonthrust Manipulation and Exercise With or Without the Addition of Myofascial Therapy for the Management of Acute Inversion Ankle Sprain: A Randomized Clinical Trial. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy, 43(5), 300-309. doi:10.2519/jospt.2013.4467

Walker, M. J. (2004). A Combined Treatment Approach Emphasizing Impairment-Based Manual Physical Therapy for Plantar Heel Pain: A Case Series. Journal of Orthopaedic and Sports Physical Therapy. doi:10.2519/jospt.2004.1506 Wassinger, C. A., Rockett, A., Pitman, L., Murphy, M. M., & Peters, C. (2014). Acute effects of rearfoot manipulation on dynamic standing balance in healthy individuals. Manual Therapy, 19(3), 242-245. doi:10.1016/j.math.2013.11.001

Wees, P. J., Lenssen, A. F., Hendriks, E. J., Stomp, D. J., Dekker, J., & Bie, R. A. (2006). Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: A systematic review. Australian Journal of Physiotherapy, 52(1), 27-37. doi:10.1016/s0004-9514(06)70059-9

References (Cont) Wester, J. U., Jespersen, S. M., Nielsen, K. D., & Neumann, L. (1996). Wobble Board Training After Partial Sprains of the Lateral Ligaments of the Ankle: A Prospective Randomized Study. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy, 23(5), 332-336. doi:10.2519/jospt.1996.23.5.332

Whitman, J. M., Cleland, J. A., Mintken, P., Keirns, M., Bieniek, M. L., Albin, S. R., . . . Mcpoil, T. G. (2009). Predicting Short-Term Response to Thrust and Nonthrust Manipulation and Exercise in Patients Post Inversion Ankle Sprain. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy, 39(3), 188-200. doi:10.2519/jospt.2009.2940

Willy, R. W., Halsey, L., Hayek, A., Johnson, H., & Willson, J. D. (2016). Patellofemoral Joint and Achilles Tendon Loads During Overground and Treadmill Running. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy, 46(8), 664-672. doi:10.2519/jospt.2016.6494