Introduction

Welcome to First Choice Physical Therapy’s patient resource about Peroneal Tendon Problems.

Problems affecting the two peroneal tendons that lie behind the outer ankle bone (the lateral malleolus) are common in athletes. These problems mainly occur in the area where the two tendons glide within a fibrous tunnel behind the lateral malleolus.

This guide will help you understand:

• how peroneal tendon problems develop
• how doctors diagnose the condition
• what can be done to treat this problem

Anatomy

The peroneals are two muscles and their tendons that lie along the outside of the lower leg bone (the fibula) and cross behind the lateral malleolus (the outer ankle bone). The term medial refers to a point closer to the center of the body. So the ankle bump on the inside edge of the ankle (closest to your other ankle) is the medial malleolus. The term lateral refers to structures furthest from the center. Major muscles that support the lateral part of the ankle are the peroneus longus and the peroneus brevis.

The tendons of these two muscles pass together in a groove behind the lateral malleolus. (Tendons attach muscles to bones.) The tendons are kept within the groove by a sheath that forms a tunnel around the tendons. The surface of the tunnel is reinforced by a band of tissue called a retinaculum. Contracting the peroneal muscles makes the tendons glide in the groove like a pulley. The pulley action causes the foot to point downward (plantarflexion) and outward (eversion).

Downward (Plantarflexion)

Outward (Eversion)

Animation of plantarflexion	Animation of eversion

The peroneus brevis tendon connects to a bump on the base of the fifth metatarsal. This spot can be felt midway down the outer edge of the foot.

Peroneus Brevis Tendon

The peroneus longus tendon lies behind and below the peroneus brevis tendon. It wraps down and under the foot by way of the cuboid bone, the outer tarsal bone just in front of the heelbone (the calcaneus). The peroneus longus tendon angles forward under the sole of the foot and connects to the bottom of the main bone of the big toe. This tendon stabilizes the arch of the foot when walking.

Peroneus Longus Tendon

Related Document: First Choice Physical Therapy’s Guide to Ankle AnatomyMuscles of the Anklehttps://api.vidyard.com/playbackengine/xc3f1dJ8gm6yCVNeQ5sPpA/?autoplay=0&iframe=trueindex

Causes

Why do I have this problem?

Peroneal tendon problems mostly occur where the tendons glide within the pulley behind the lateral malleolus. Their movement can cause irritation of the lining of the tendons. This condition is called tenosynovitis. The irritation can also occur after an ankle injury, such as a blow to the outside of the ankle or an ankle sprain.

Repetitive ankle motions in sports, such as running and jumping, can lead to wear and tear on the tendons inside the groove. A high arch puts extra tension on the peroneal tendons within the groove and has also been found to cause peroneal tendon problems.

Peroneal tendon problems commonly occur from an ankle sprain. During the typical inversion ankle sprain, the foot rolls in. This type of injury sprains or tears the ligaments that support the lateral part of the ankle. The forceful stretch on the peroneals when the foot rolls in can also cause a lengthwise tear in the peroneal tendons.

An inversion ankle sprain can also cause the peroneal tendons to momentarily slip out of the groove. This is called subluxation. Peroneal tendonitis often occurs during the recovery period after an ankle sprain. Because the ankle is unstable, the peroneals may need to work harder to give needed support to the damaged lateral ankle ligaments. The overwork sets them up for subluxation.

Related Document: First Choice Physical Therapy’s Guide to Peroneal Tendon Subluxation

In some patients, a peroneal tendon problem is caused by degenerative changes in the tendons themselves rather than by inflammation around the tendons. The tendon itself becomes abnormal. Doctors call this condition tendonosis.

In tendonosis, the tendon becomes weakened. Tendons are made up of strands of a material called collagen. (If you think of a tendon as a nylon rope, the collagen is the nylon strands.) Degeneration in a tendon causes a loss of the normal arrangement of the collagen fibers that join together to form the tendon. Some of the individual strands of the tendon become jumbled due to the degeneration, some fibers break, and the tendon loses strength.

Collagen

Degeneration

Over time, the tendon thickens as scar tissue tries to repair the damaged tendon. The area of tendonosis in the tendon is weaker than normal tendon. The weakened, degenerative tendon may tear. This usually causes a lengthwise split in the peroneal tendons rather than a rupture. These splits or tears are most common in the peroneus brevis tendon, probably because it lies in front of the peroneus longus. It is more vulnerable to friction because it rubs against the groove in the fibula bone.

Tendon Splits

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Symptoms

What do peroneal tendon problems feel like?

Patients with peroneal tendon problems usually describe pain in the outer part of the ankle or just behind the lateral malleolus. This pain commonly worsens with activity and eases with rest. Patients may have swelling behind or under the lateral malleolus. They may notice more pain when pressure is applied along the tendons.

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Diagnosis

The diagnosis of peroneal tendonitis is usually made by examination of the ankle. The physical examination helps determine where the tendons are inflamed, ruptured, or degenerated. Your Physical Therapist at First Choice Physical Therapy will move your ankle into different positions, checking the peroneal tendons by holding your foot up and out against the therapists downward pressure. Stretching the foot up and in can also be used test whether the tendons hurt.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.index

Our Treatment

Nonsurgical treatment for peroneal tendon problems helps control symptoms. Surgery is usually not considered until it has become impossible to control symptoms without it.

Non-surgical Rehabilitation

Even if you don’t require surgery, you may need to follow a program of rehabilitation exercises. The Physical Therapists at First Choice Physical Therapy can create a program to help you regain normal ankle function, improving strength and coordination your ankle.

Initial treatments may involve resting and protecting the sore tendons. We may need to immobilize your foot and lower leg in a short-leg walking boot for two to four weeks. In less severe cases, we may have you use a stirrup ankle brace, arch support, or lateral heel wedge to take tension off the sore tendons.

Your Physical Therapist may use heat, ice, and ultrasound treatments to reduce pain and swelling. Stretching, strengthening, and ankle coordination exercises are sometimes added as symptoms ease.

Post-surgical Rehabilitation

Patients with peroneal tendon problems are usually placed in a short-leg cast for four to six weeks after surgery, then a special walking boot may be worn for another four weeks. Rehabilitation after surgery can be a slow process. Although recovery varies for each patient, as a guideline, you may need to attend Physical Therapy sessions at First Choice Physical Therapy for one to two months, and you should expect full recovery to take up to four months.

Your first few Physical Therapy treatments at First Choice Physical Therapy are designed to help control pain and swelling from the surgery. Our therapist may use ice and electrical stimulation treatments during your first few Physical Therapy sessions, in addition to massage and other hands-on procedures to ease muscle spasm and pain. We also provide treatments to help improve ankle range of motion without putting too much strain on the healing tendons.

It is possible that, after about four weeks you may be able to incorporate more active exercise. Your Physical Therapist will slowly add exercises improve the strength in your peroneal muscles. We will also help you regain position sense in the ankle joint to improve its overall stability.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, improve your range of motion, and maximize strength and control in your ankle. When you are well under way, regular visits to our office will end. Although we will continue to be a resource,  you will be in charge of doing your exercises as part of an ongoing home program.

First Choice Physical Therapy provides Physical Therapy services in Lynn Haven and Panama City Beach.index

Physician Review

Your doctor may order X-rays to make sure there is no fracture or other problem. A magnetic resonance imaging (MRI) scan of your ankle may also be done. MRI images can show if there is abnormal swelling or scar tissue in the tendons and can also show lengthwise tears in the tendons.

Your doctor may also prescribe medications. Anti-inflammatory medications can help ease pain and swelling and get you back to activity sooner. These medications include common over-the-counter drugs such as ibuprofen.

In rare cases, cortisone can be injected into the sore tendons to relieve symptoms that won’t go away. Cortisone is a powerful anti-inflammatory medication. Because there is a risk that cortisone will cause a tendon to rupture, doctors are very cautious about injecting cortisone into the peroneal tendons.index

Surgery

Tendon Release

When the lining of the tendon is painful and inflamed (as in tenosynovitis), the goal of surgery is to remove the irritated tissue from around the tendon. This operation is called tendon release. This procedure is done by carefully dividing the tendon sheath that encloses the tendon. Once the sheath is opened, the surgeon clears away the irritated tissues around the tendon. The sheath is not stitched back together. The gap in the sheath will eventually fill in with scar tissue. The skin is closed with sutures.

Sheath Opened

Irritated Tissues Removed

Debridement

The procedure for surgically treating tendonosis is similar to the method used for tenosynovitis. However, extra measures are taken to thoroughly remove (debride) the degenerated tissue around and within the involved tendon.

Tendon Repair

Tendonosis may require repair if a preoneal tendon is split down its length. This type of tear mainly affects the peroneus brevis. The surgeon fixes this problem by first dividing the sheath around the tendons. If the split is smaller than one-third the width of the tendon, the torn portion may simply be removed. Larger splits are sutured along the length of the tendon. The tendon sheath is repaired, and the skin is closed with sutures.

Dividing the Sheath

Sheath Repaired

Introduction

Physical Therapy in Lynn Haven and Panama City Beach for Ankle

Welcome to First Choice Physical Therapy’s patient resource about Peroneal Tendon Subluxation.

The peroneals are two muscles and their tendons that attach along the outer edge of the lower leg. The peroneal tendons are enclosed in a fibrous tunnel that runs behind the outside ankle bone (the lateral malleolus). Damage or injury to the structures that form and support this tunnel may lead to a condition in which the peroneal tendons snap out of place. This condition is called peroneal tendon subluxation.

This article will help you understand:

• how peroneal tendon subluxation happens
• how doctors diagnose the condition
• what can be done to treat this problem

Anatomy

The primary muscles supporting the lateral (outer) part of the ankle are the peroneals. These two muscles and their tendons lie along the outside of the lower leg bone (fibula) and cross behind the lateral malleolus (the outside ankle bone).

Lateral Part of Ankle

The tendons of the peroneal muscles pass together through a groove behind the lateral malleolus. The tendons are kept within the groove by a sheath that forms a tunnel around the tendons. The surface of this sheath is reinforced by a band of ligament called a retinaculum. Contracting the peroneals makes the tendons glide in the groove like a pulley. This pulley action points the foot downward (plantarflexion) and outward (eversion).

Related Document: First Choice Physical Therapy’s Guide to Ankle AnatomyMuscles of the Anklehttps://api.vidyard.com/playbackengine/xc3f1dJ8gm6yCVNeQ5sPpA/?autoplay=0&iframe=trueindex

Causes

Tendons attach muscles to bone. Tightening a muscle puts tension on the tendon, which can move bone. Many tendons in the body are held in place by supportive connective tissue, such as a ligament or retinaculum. If the supportive tissue has been damaged or injured, the tendon may be free to slip out of its normal position. This is called subluxation. When the subluxed tendon slips back into place, this is called relocating. A tendon that forcefully snaps out of position and can’t relocate has dislocated.

Damaged Supportive Tissue

Subluxation

The main cause of peroneal tendon subluxation is an ankle sprain. A sprain that injures the ligaments on the outer edge of the ankle can also damage the peroneal tendons. During the typical inversion ankle sprain, the foot rolls in. The forceful stretch on the peroneals can rip the retinaculum that keeps the peroneal tendons positioned in the groove. As a result, the tendons can jump out of the groove. The tendons usually relocate by snapping back into place.

The injury to the retinaculum may be overlooked at first while treatment focuses on the injury to other ankle ligaments. This means the subluxation may begin much later, and it may not seem to be caused by the initial ankle sprain. If not corrected, this snapping of the tendons can become a chronic and recurring problem.

An acute dislocation of the peroneal tendons is rare. It occasionally happens during sport activities that force the foot up and in, for example during skiing, ice skating, or soccer. At the moment the foot turns up and in, the peroneals violently contract to protect the ankle. This can cause the retinaculum to tear, allowing the tendons to slip out of the groove.

Differences in the anatomy of the groove may predispose some people to peroneal tendon subluxations. The groove may be too shallow. Or the ridge that helps deepen this groove may be too small or even absent. Sometimes, the retinaculum that keeps the tendons in the groove may be too loose. In these cases, patients may not recall any injury to explain the persistent snapping of the peroneal tendons.index

Symptoms

What does peroneal tendon subluxation feel like?

Patients describe a popping or snapping sensation on the outer edge of the ankle. The tendons may even be seen to slip out of place along the lower tip of the fibula. It is common to feel pain and tenderness along the tendons. There may also be swelling just behind the bottom edge of the fibula.

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Diagnosis

Diagnosis of peroneal subluxation begins with an examination of the ankle. Your Physical Therapist at First Choice Physical Therapy will move your ankle into different positions to see when the tendons snap out of place and if they relocate. One test involves holding pressure down on the ankle as you pull your foot up and out. Our Physical Therapist feels behind the fibula during this test to determine if the tendons are popping out of place. If your Physical Therapist in Lynn Haven and Panama City Beachsuspects a tear in the retinaculum, you may be referred for additional medical evaluation by a doctor.index

Our Treatment

Non-surgical Rehabilitation

Nonsurgical treatment for peroneal tendon subluxations includes a program of rehabilitation exercises to help control symptoms. At First Choice Physical Therapy, our Physical Therapists will create a specialized program to help you improve the strength and coordination of your ankle, and more quickly regain normal ankle function.

Post-surgical Rehabilitation

When you visit First Choice Physical Therapy, your initial treatments will be used to help control pain and swelling from the surgery. Our Physical Therapist may apply ice and electrical stimulation during your first few Physical Therapy sessions, as well as massage and other hands-on treatments to ease muscle spasm and pain. Our Physical Therapy is designed to help improve ankle range of motion without putting too much strain on the injured area.

Typically, after about six weeks of treatment, our therapist will help you increase your activity level. Your First Choice Physical Therapy Physical Therapist will slowly add exercises to improve the strength in your peroneal muscles and help you regain position sense in your ankle joint to improve its overall stability.

Rehabilitation after surgery can be a slow process, but our professionals will custom design a Physical Therapy program to speed your recovery. Recovery and rehabilitation varies for each patient, but as a guideline, you may expect to attend our therapy sessions for two to three months, with full recovery typically requiring up to six months.

At First Choice Physical Therapy, our goal is to help manage your pain, improve your range of motion, and maximize strength and control in your ankle. When your recovery is well under way, regular visits to our office will end. We will continue to be a supportive resource, but you will be in charge of doing your exercises as part of an ongoing home program.

First Choice Physical Therapy provides Physical Therapy services in Lynn Haven and Panama City Beach.index

Physician Review

If your doctor suspects a tear in the retinaculum, X-rays may be taken to determine if the torn retinaculum has pulled off a piece of the fibula bone. This is called an avulsion fracture. X-rays are also used to look for other injuries to the ankle.

Your doctor may also order a magnetic resonance imaging (MRI) scan of your ankle. MRI scans can show abnormal swelling and scar tissue or tears in the tendons. However, MRIs won’t always show subluxation of the peroneal tendons.

If your injury is acute, treatment without surgery may involve placing your ankle in a short-leg cast for four to six weeks. Your physician may also prescribe medications. Anti-inflammatories can help ease pain and swelling and get you back to activity sooner. These medications include common over-the-counter drugs such as ibuprofen. The goals are to allow the torn retinaculum to heal and to prevent chronic subluxation. Your doctor may advise you to begin Physical Therapy once the cast is removed.index

Surgery

Many patients with peroneal tendon subluxation will eventually require surgery, especially when symptoms have not been controlled with nonsurgical measures. The following are different surgical procedures designed to help the peroneal tendons remain in their proper position.

Retinaculum Repair

Retinaculum repair is gaining popularity. This procedure restores the normal anatomy of the retinaculum that covers and reinforces the tendon sheath around the peroneal tendons.

In surgery to repair the retinaculum, the surgeon first makes an incision along the back and lower edge of the fibula bone. This lets the surgeon see the spot where the retinaculum is torn.

Incision

The surgeon uses a burr to create a trough along the fibula bone next to the original attachment of the retinaculum. The torn edge of the retinaculum is then pulled into the trough and sutured in place. The skin is closed with stitches.

Sutured

Groove Reconstruction

Groove reconstruction is done to deepen the groove so the peroneals stay in place behind the bottom tip of the fibula. In this procedure, the surgeon first makes an incision along the back and lower edge of the fibula bone.

Incision

The surgeon cuts a small flap in the bone near the bottom corner of the fibula. The surgeon then carefully folds the flap back, like a hinge. With the hinge held open, the doctor scoops out a small amount of bone under the flap to deepen the groove.

Deepen the Groove

The surgeon closes the flap on its hinge and tamps it in place. A screw may be used to hold the flap down.

Closing the Flap

Next, the tendons are returned to their location behind the tip of the fibula. Repair of the retinaculum may also be required with this procedure (see above). The skin is closed and sutured.

Bony Blocks

The purpose of a bony block is to form a barrier that keeps the tendons from slipping out of place. The block is usually formed with bone taken from the lower end of the fibula bone.

To create a bony block, the surgeon opens the skin along the lower edge of the fibula. The surgeon then measures a small area on the back of the fibula, near the lower tip of the bone. A special tool is used to cut this small section of the fibula. The cut only goes partway through the bone.

The surgeon slides the small block of bone backward, out of its original spot. The bone may be rotated slightly to create a solid barrier that will help keep the tendons from sliding around the lower edge of the fibula. A screw is inserted through the small block of bone into the fibula. The screw keeps the bony block in its new location until it heals.

The surgeon checks the fit to make sure the tendons can glide behind the new block of bone without slipping out of place. The skin is then closed and sutured.

Introduction

Physical Therapy in Lynn Haven and Panama City Beach for Shin Splints

Welcome to First Choice Physical Therapy’s patient resource about Shin Splints.

Pain along the front or inside edge of the shinbone (tibia) is commonly referred to as shin splints. The problem is common in athletes who run and jump. It is usually caused by doing too much, too quickly. The runner with this condition typically reports a recent change in training, such as increasing the usual pace, adding distance, or changing running surfaces. People who haven’t run for awhile are especially prone to shin splints after they first get started, especially when they run downhill. Shin splints on the front of the tibia are called anterior shin splints. Posterior shin splints cause pain along the inside edge of the lower leg.

This guide will help you understand:

• how shin splints start
• what shin splints feel like
• how this condition is treated

Anatomy

What parts of the leg are involved?

The lower leg is made up of two bones. The shinbone is the larger of the two bones. It is called the tibia. The small, thin bone that runs alongside the tibia from the knee to the ankle is the fibula.

The tibia and fibula provide a connecting point for several muscles that move the foot. The main muscle that bends the foot upward connects on the front (anterior) of the tibia. It is called the anterior tibialis. The posterior tibialis, which pulls the foot down and in, attaches along the back (posterior) and inside edge of the tibia. Together, the anterior and posterior tibialis muscles are called the tibialis muscles.

The tibialis muscles have tiny fibers that fasten the muscle to the bony surface of the tibia. This bony covering, or membrane, is called the periosteum (peri means around, and osteum means bone).

Related Document: First Choice Physical Therapy’s Guide to Ankle AnatomyMuscles of the Anklehttps://api.vidyard.com/playbackengine/xc3f1dJ8gm6yCVNeQ5sPpA/?autoplay=0&iframe=trueindex

Causes

Why do I have shin splints?

Shin splints usually result from overuse. Repeated movements of the foot can cause damage where the tibialis muscles attach to the tibia. Soon the edge of the muscles may begin to pull away from the bone. The injured muscle and the bone covering (the periosteum) become inflamed.

Overuse commonly happens after changes in training. Increasing running speed and distance and running on hard or angled surfaces can contribute to overuse. Overuse can also occur from running in flimsy footwear or in shoes with soles that are worn out.

Anterior shin splints tend to affect people who take up a new activity, such as jogging, sprinting, or playing sports that require quick starts and stops. The unfamiliar forces place a heavy strain on the anterior tibialis muscle, causing it to become irritated and inflamed. This commonly happens when people who aren’t regular runners decide to go on a long jog. The anterior tibialis muscle must work hard to control the landing of the forefoot with each stride. Running downhill puts even more demands on this muscle in order to keep the forefoot from slapping down. People who run on the balls of their feet or who run in shoes with poor shock absorption also tend to get anterior shin splints.

Posterior shin splints are generally caused by imbalances in the leg and foot. Muscle imbalances from tight calf muscles can cause this condition. Imbalances in foot alignment, such as having flat arches (called pronation), can also cause posterior shin splints. As the foot flattens out with each step, the posterior tibialis muscle gets stretched, causing it to repeatedly tug on its attachment to the tibia. The posterior tibialis muscle attachment eventually becomes damaged, leading to pain and inflammation along the inside edge of the lower leg.

A stress fracture in the tibia is a serious problem that at first may have the same symptoms as shin splints. A stress fracture is a crack in a weakened area of bone. Continual stresses from running on hard surfaces or from heavy strain in the tibialis muscles can weaken and eventually fracture the tibia. People with shin pain who try to work through it sometimes end up developing a stress fracture in the tibia.

A concerning complication of shin splints is compartment syndrome. Compartment syndrome is a condition where pressure from muscle damage and swelling builds up inside a section, or compartment, within the body. There are four compartments in the lower limb. As the pressure builds in the compartment, the small blood vessels (called capillaries) that supply blood to the muscles in the compartment are squeezed shut. This happens when the pressure in the compartment is higher than the blood pressure that keeps the small blood vessels open. When the muscle loses its blood supply it begins to ache, like a muscle cramp.

If the pressure continues to rise, it can squeeze the larger blood vessels and nerves as well. Patients may feel coldness, numbness, and swelling in the lower leg and foot. If pressure builds up and is not treated, it can cause serious tissue damage in the leg and foot.

Pressure

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Symptoms

What do shin splints feel like?

Dull, aching pain is felt where the involved tibialis muscle attaches to the tibia. Redness and swelling can also occur in this area. Tenderness is felt where the muscle attaches to the bone.

Anterior shin splints are usually felt on the front of the tibia, especially when using the anterior tibialis muscle to bend your foot upward.

Posterior shin splints produce symptoms along the inside edge of the lower leg. Small bumps may also be felt along the edge of the tibia in this area.

Symptoms of shin splints generally get worse with activity and ease with rest. Pain may be worse when you first get up after sleeping. The sore tibialis muscle shortens while you rest, and it stretches painfully when you put weight on your foot.index

Diagnosis

The diagnosis of shin splints is usually made through physical examination and evaluation of your medical history. When you visit First Choice Physical Therapy, our Physical Therapists will ask questions about your training schedule, footwear and may also want to know whether you’ve recently begun a new sport that requires running or jumping.

The physical examination allows us see exactly where your leg hurts. We may move your ankle in different positions and have you hold your foot against applied pressure. By stretching the tibialis muscles, and by feeling where these muscles attach on the tibia, we can begin to tell where the problem is.

A test for measuring pressure in the sore leg may be needed if you have symptoms of compartment syndrome. Our Physical Therapist checks pressures within the tissues of the leg, before and after exercise, to see if exercise causes the pressure readings to go up.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.index

Our Treatment

Non-surgical Rehabilitation

The Physical Therapists at First Choice Physical Therapy will help you recover through treatments designed to reduce pain and inflammation and, whenever possible, address the underlying problems causing your shin splints. The length of the Physical Therapy program varies for each patient, but as a guideline, you might expect to devote four to six weeks to your recovery and rehabilitation.

Reducing Inflammation

The purpose of your initial treatments at First Choice Physical Therapy will be to reduce inflammation.Some of our patients suffering from shin splints receive iontophoresis, a technique where a mild electrical current is used to push a topical steroid medicine into the sore area. Ultrasound treatments, often used in combination with topical steroids, are also effective in halting pain and inflammation.To speed your recovery, our Physical Therapists may also use deep tissue massage along the junction where the sore tibialis muscle meets the tibia, followed by gentle stretching of the calf and tibialis muscles.

Our Physical Therapists will show you how to properly ice, rest, and if necessary, tape the injured area. Special taping techniques may be used to support the sore tissues and ease pain. However, we recommend that taping be used to help the area heal, not as a way to keep on training.

Foot Support

Your First Choice Physical Therapy specialist will evaluate your posture and alignment to see if you have problems with pronation (arch flattening), a condition that we commonly see associated with posterior shin splints. Sometimes a small heel wedge, placed under the inside edge of the heel, is enough to ease tension on the posterior tibialis muscle. For more severe problems of pronation, we may recommend foot orthotics to support the arch and reduce stresses on the posterior tibialis muscle.

Rest and Recovery

During your recovery, stop doing the activity that caused the problem and avoid heavy training and sports activity for three to four weeks, or at least until the symptoms are under control. Rest and the application of cold packs play a key role in decreasing pain and inflammation in the early stages of treatment. Only after the pain starts to go away, should you begin to resume your normal routine.

Resuming Activity

As your pain starts to go away and you begin doing more normal activities, we will help you develop a recovery program to avoid overuse while training. This may include evaluating your running style, and suggesting tips on footwear and the use of shock-absorbing insoles. Knowing your training schedule, pace, and the surface you use can guide us in making personal recommendations as you attempt to safely resume your sport.

Post-surgical Rehabilitation

If surgery is required, your First Choice Physical Therapy rehabilitation program will have some additional elements. You may need to use crutches for several days after surgery. Many patients are able to bear some weight on their foot within the first week. A protective dressing will cover your incisions, and the stitches are usually removed within 10 to 14 days (unless they are absorbable stitches, which will not need to be taken out).

Our Physical Therapists will help you recover and gradually return to your normal activity level. We may recommend the use of a stationary bike within 10 to 14 days of your surgery. If you are a runner, our Physical Therapy program may enable you to begin a light jogging program within six weeks and resume full activity within eight to 10 weeks, although the time required for recovery and rehabilitation varies for each individual.

First Choice Physical Therapy provides Physical Therapy in Lynn Haven and Panama City Beach.index

Physician Review

Your doctor may order X-rays to make sure you don’t have a stress fracture. However, recent stress injuries may not show up on X-ray for the first few weeks. In these cases, a bone scan may be ordered. A bone scan involves injecting tracers into your blood stream. The tracers then show up on special X-rays of your leg. The tracers build up in areas of extra stress to bone tissue. The extra stress can be caused by a stress fracture or an inflamed periosteum (bony covering). This condition is called periostitis.

Your doctor may also order a magnetic resonance imaging (MRI) scan. An MRI scan is a special imaging test that uses magnetic waves to create pictures of your body in slices. The MRI scan shows tendons as well as bones. It also shows abnormal swelling or scar tissue. An MRI is painless and requires no needles or injections.index

Surgery

Surgery is rarely needed to correct problems of shin splints. However, shin splints that are complicated by compartment syndrome may require surgery, sometimes immediately.

If compartment syndrome is discovered and diagnostic tests show high pressures within the tissues of the lower leg, surgery may be recommended right away. The procedure to remove the pressure is called fasciotomy. Fascia is the connective tissue around and between muscles and organs. The surgeon makes a few small incisions on either side of the lower leg. The nearby layer of fascia within several compartments is cut and removed to reduce the pressure within the compartment. The incisions are left open at first. Tissue pressures are checked over a period of two to three days. The wounds are then closed.

If the problem has been present for more than three months, the surgeon may only need to make one or two incisions to cut the layer of fascia and reduce pressure inside a single problem compartment.

Introduction

Physical Therapy in Lynn Haven and Panama City Beach for Lower Leg Fractures

Welcome to First Choice Physical Therapy’s guide to lower leg fractures.

In this guide we are concerned with fractures of the lower leg between the knee and ankle. The two bones in the lower leg are the tibia and fibula. We will limit this discussion to fractures of the shaft, or mid section of these two bones. Fractures of the lower end of the tibia and fibula are covered in ankle fractures. Fractures of the upper end of the tibia are covered in knee fractures.The tibia bone is the largest and most important bone of the lower leg. It is quite vulnerable to injury. There is no overlying muscle to cushion impact on the front and inner side of the bone. The tibia is relatively easy to fracture with twisting or bending forces. As a result, fracture of the tibia is one of the most common major long bone fractures encountered in adults. Fracture of the tibia has a reputation for complications including failure to heal, or nonunion, so the management of this injury needs a careful approach from orthopaedic surgeons.

Usually, when the shaft of the tibia is broken the fibula, the smaller bone of the lower leg, is broken as well. This bone serves mainly as an anchor point for muscle and hardly bears any weight. As a result it does not need to be perfectly straight when it heals. It is sometimes surprising to patients that the doctors pay so much attention to the tibia and so little to the fibula.

This guide will help you understand:

• what parts of the lower leg are involved
• what the symptoms are
• what can cause these fractures
• how health care professionals diagnose these fractures
• what the treatment options are
• the First Choice Physical Therapy’s approach to rehabilitation

Anatomy

What structures are most commonly injured?

The tibia is shaped a little like an inverted trumpet with a long straight shaft flaring out at the knee. The shaft has a triangular shaped cross-section and the inner front portion of the bone has only skin overlying it. If you put your finger on the inner side of the knee and run it down all the way to the inside of the ankle you can feel bone all the way down.

There are muscles surrounding the tibia on the outer side and at the back; the fibula is completely surrounded. Because the bone is just under the skin it is quite common for the jagged end of the bone to come through the skin when it breaks, causing an open fracture. Fractures occur almost anywhere along the shaft of the tibia but the most common site is about two thirds the way down.

The blood vessels and nerves that supply the foot are quite close to the bone. It is not uncommon for fractures of the shin, especially open fractures to involve damage to either the blood supply to the foot or the nerve supply or both.

Related Document: First Choice Physical Therapy’s Guide to Ankle AnatomyMuscles of the Anklehttps://api.vidyard.com/playbackengine/xc3f1dJ8gm6yCVNeQ5sPpA/?autoplay=0&iframe=true

Related Document: First Choice Physical Therapy’s Guide to Knee AnatomyKnee Anatomy Introductionhttps://api.vidyard.com/playbackengine/X26cXS9FYs8J8f8dhG6cWA/?autoplay=0&iframe=trueindex

Causes

How do fractures of the lower leg commonly happen?

The tibia and fibula can be broken by a number of different forces, impact against the leg, compression, bending forces or twisting forces. It is possible to break the fibula in isolation, without fracturing the tibia, although this is an uncommon situation caused by a direct blow to the outer side of the leg. Isolated fracture of the tibia is slightly more common but usually both bones break.

It is important to remember that whenever bones are broken there is also damage to muscle, tendon, ligament and often nerves and skin. This soft tissue injury does not show on X-ray but it contributes greatly to the pain and swelling of the injury – and may affect the eventual outcome.index

Types

What Types of fractures can occur?

The different patterns of fracture of the tibia and fibula relate to the different mechanisms of injury. Oblique fractures are usually caused by a bending force or direct impact. Transverse fractures result from compression and spiral fractures result from twisting forces.

The more force applied; the more likely it is that there will be multiple fragments. The term used to describe multiple fragments is comminution; a fracture of this type is referred to as a comminuted fracture. It is also more likely that the displacement of the fracture fragments by the greater force will push one or more of them out through the skin, causing an open fracture.

Fractures of the tibia are common in high energy accidents such as MVAs or falling from a height. The leg may get caught in machinery causing severe fractures with extensive skin loss and potential for major injuries to muscle, tendons, nerves and arteries. Sports such as skiing, contact sports and tobogganing all cause their share of leg fractures. Falls in the elderly do sometimes cause fractures of the shin bone; in these cases the fractures should be considered fragility fractures. Pathological fractures through abnormal deposits in bone occur rarely.

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Symptoms

What symptoms do lower leg fractures cause?

People who suffer a fracture of the tibia and fibula have immediate pain at the site of the fracture. The pain is made worse by any movement of the limb. Often the leg is deformed, either twisted or bent, and sometimes there is a wound where the bone has come out through the skin.

In the case of an isolated fracture of the fibula you may be able to walk, but with nearly all other fractures it is impossible to bear weight. Within a few minutes of the injury the leg will swell up. If there have been injuries to the nerves or arteries the foot may be numb or cold.

Within hours of the injury there will be significant bruising. Fracture blisters are seen quite often after fractures of the tibia. Pain, swelling and bruising are evident for weeks after a break regardless of the treatment. This is because of the soft tissue injury, bleeding into the muscle compartments, and compromised circulation in the injured area. The worse the soft tissue injury the more likelihood there is of stiffness or weakness of the nearby knee and ankle joints.

Aching discomfort in the affected area and some pain on stressing it may continue for many months while the fracture is healing and consolidating. It should gradually diminish as the fracture heals and regains normal strength. Where metal implants have been used to treat the fracture, tenderness, mild aching, and cold intolerance may persist until the implants are removed.



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Evaluation

How will my fracture be evaluated?

First aid treatment at the scene of the accident should consist of keeping the victim warm, splinting the leg, and transporting him/her to hospital. An assessment at the scene should include dressing any wounds and checking for numbness of the foot. It is not usually necessary to straighten the leg unless it cannot be splinted otherwise.

In the Emergency Room the focus is on treating shock, making the patient comfortable, ruling out other injuries, and getting the correct x-rays to evaluate the fracture. It is important to obtain x-rays that include the ankle and knee. If an isolated fracture of the shaft of the fibula is diagnosed this may be treated by the emergency doctor and followed by your family doctor. Fractures of the shaft of the tibia usually result in referral to an orthopaedic surgeon.

The orthopaedic assessment may include an evaluation of the general medical status of the patient and the risks of anesthesia. The history of the accident and the forces causing the fracture will be assessed and the limb carefully examined for wounds, blistering, skin problems, neurological or vascular loss and for signs of injury to the knee or ankle. The X-rays will be reviewed and more X-rays obtained if necessary.

The treatment plan will be discussed with the patient giving consideration to the nature of the fracture, the patient’s health status, level of activity, occupation and expectations. The most important feature of the fracture is whether it is stable or not. An unstable fracture is likely to shorten, angulate or rotate and may need treatment with surgery.index

Our Treatment

What treatments should I consider?

An isolated fracture of the fibula may be treated in a cast for protection or may be left alone. The bone will heal without interference and the aims of treatment are to manage the pain. Using crutches for a few weeks is usually recommended.

The treatment of fractures of the tibia is controversial. Some orthopaedic surgeons take the view that most such fractures should be treated by operation. This is supported by scientific studies that show with surgery the fracture healed more reliably and with better alignment. Others prefer to avoid an operation unless it is clear that the outcome will be poor without surgery.

There is also controversy about the type of operation best suited to this injury. There is such variation in the patterns of injury and treatment that research studies to answer some of these questions are very difficult to organize. Most orthopaedic surgeons would agree that treatment has to be individualized and matched to the patient’s injury pattern, medical status and expectations.

Nonsurgical Treatment

Treatment in a cast may be recommended when the fracture pattern is stable, there are no other major injuries and the patient is fit enough to carry the weight of a cast around. The pattern of injury most suited to cast treatment is a spiral fracture because it is inherently stable. Transverse fractures are also relatively stable. Oblique fractures are inherently unstable and likely to shorten. However, the amount of shortening is unpredictable and may be acceptable.

It is not unusual to begin treatment with a cast and then change course. In order to avoid an operation, cast treatment may be started initially and surgery later recommended if the bone fragments move and the position becomes unacceptable.

In some situations the cast can be applied without an anesthetic. The lower leg is hung over the side of the bed so that gravity keeps it straight. The cast is applied from toes to knee in this position and this splints the fracture in the reduced (straight) position. Then the leg is lifted onto the bed and the cast is continued up above the knee to form a long leg cast. The knee is bent about 40 degrees in the cast to prevent rotation and allow the leg to swing through during crutch walking.

Quite often it would be too painful to apply a cast without a general or regional anesthetic. The procedure is then done in the OR, the fracture is manipulated into a good position and the long leg cast applied. X-rays may be taken at this stage to confirm that the fracture is in a good position. If it is not, further manipulation may be undertaken or the surgeon may decide to operate. The option to continue on to an operation if closed treatment is not acceptable would be discussed with the patient ahead of time.

Once the cast has been applied it may be split to allow the leg swelling to occur without undue compression of the tissues. As the swelling goes down the cast may become loose and need to be tightened or replaced. Follow-up in the cast clinic at frequent intervals is usually recommended. X-rays will be taken to confirm good position of the fracture and assess healing as it takes place.

If the fracture has moved, it may be possible to correct the position by wedging the cast. This involves cutting the cast three-fourths the way around at the level of the fracture leaving a hinge of intact cast on the convex side of the deformity. The leg can then be straightened and a wedge inserted into the opening in the cast on the concave side to hold the cast – and the bones – in the new position. Once x-rays have confirmed that the new position is acceptable, more plaster is applied over the cast to make it rigid once again.

Casting material is either plaster of Paris (POP) or some form of fiberglass. POP is cheaper and easier for the surgeon to work with, molding the cast to the shape of the leg. Fiberglass is lighter and more durable. Unlike POP is doesn’t disintegrate if it becomes wet. However, if it does get wet the soggy padding may cause skin problems. It is better to keep any cast dry.

Casts are normally changed after six weeks. If there is x-ray evidence of healing the surgeon may select a shorter, patellar tendon bearing cast or brace and allow some weight bearing. It is normal for some form of splinting to continue for at least three months. The length of time the fracture needs to be protected by a cast or brace depends on the amount of healing. There is a risk of re-fracture until full healing of the fracture has been achieved. So, there is no “normal” length of time to be in a cast after a tibia fracture.index

Surgery

All open fractures need surgery to clean up and irrigate the wound. It does not follow that the fracture should be treated surgically as well as the wound. However, in many cases cleansing the wound is followed by fixing the fracture. It is believed on the one hand that an immobile fracture is less likely to get infected and is easier to treat if it does; on the other, surgery disturbs the blood supply and increases the exposure of the bone to contaminants so may increase the risk of infection. A compromise approach is to delay definitive fixation of the fracture until the open fracture wound has started to heal. Either way, an open fracture is a compelling reason for surgery on the wound.
Surgery on the fracture may consist of open reduction and internal fixation with a plate, closed reduction and fixation with an intramedullary rod, or reduction and external fixation. The fundamental reason for undertaking surgery is the surgeon’s opinion that the result of surgery would be better than the outcome following cast treatment. In this context “better” means healing faster, stronger, in better position with less complications with quicker return to normal function.

Open Reduction and Internal Fixation (ORIF)

The operation involves exposing the fracture and moving the fragments back into the correct position. This position is then held by a metal plate secured above and below the fracture with screws. Plates are now available which match the shape of the tibia almost exactly. This allows a minimally invasive approach to plating the tibia where the plate is introduced under the skin.

Intramedullary Rod Fixation

In this procedure the fracture is straightened (reduced), a small hole is made in the bone just below the knee and a guide wire is passed across the fracture inside the bone. A reamer is often used to make sure the fit is tight. Then a rod is slid into the hole inside the bone from the top. It is passed over the guide wire and into the lower fragment. To prevent the fracture shortening the bone is secured to the rod with transverse (locking) screws. The big advantage of this technique is that the fixation is very strong.

External Fixation

The bone is held in the correct alignment and length using a frame outside the leg. This is attached to the bone with transfixing pins or screws. This technique allows access to the wound, it is minimally invasive preserving the blood supply and it can adjusted later to correct any deformity. External fixation is more commonly used with more severe open injuries and very unstable fractures.

After the surgery a splint may be used for pain relief. However, there is no need for prolonged cast immobilization of the fracture – the metal hardware holds it still. In most cases the wound is dressed and movement of the foot, ankle and knee is encouraged. Weight bearing through a fracture treated with surgery is not usually recommended until x-rays show there are signs of healing (six weeks).

Hardware Removal

After the fracture has healed the metal implants may cause minor symptoms. Plate and screw areas may be tender; more rarely the hardware irritates tendons that should move over the bone. In some people there is a dull constant ache and cold intolerance. If these symptoms become significant enough, the hardware can be removed. This is a relatively simple operation but the issue of hardware removal causes many patients a lot of concern.

It is often uncertain what the benefits of hardware removal surgery will be. People are concerned that the bone will be weakened and re-fracture or that they will experience discomfort as bad as the pain they had after the original surgery. Hardware removal does require an operation to expose the plate or the rod but the incidence of re-fracture of the tibia is low and the pain after surgery is less severe and short lived. The long-term results of hardware removal have been studied and shown to be very satisfactory with few problems and a high rate of satisfaction.

How long does it take to heal?

There is no “typical” fracture of the tibia and recovery depends to a large extent on the severity of the original injury. Clearly the outcome expected from a stable closed spiral fracture will be different from the result after the leg has been mangled in machinery.

The normal healing times are six weeks to achieve 50 percent of eventual strength, three months to reach 80 percent of eventual strength, and 18 months to complete the process of consolidation and remodeling of the fracture. If this is the only injury this time scale usually suggests change to weight bearing with some protection at six weeks (e.g., walking cast); unrestricted weight bearing and gradual return to sports or heavy working activities at three months; and consideration of hardware removal after 18 months.index

Rehabilitation

If you have been immobilized, rehabilitation with a Physical Therapist at First Choice Physical Therapy will begin once the brace or cast is removed. Prior to this, simple toe wiggling exercises will be your only exercise. In cases where your full cast has been replaced by a patellar tendon bearing cast/brace (which allows knee motion) then it is important to also maintain knee range of motion even if you are not able to weight bear through that leg.  

If you have had surgery to fixate your lower leg fracture, then rehabilitation at First Choice Physical Therapy will begin as soon as your surgeon recommends it. Sometimes therapy will be recommended even before you are allowed to fully weight bear. In other cases, rehabilitation will not be recommended until full weight bearing begins. Each surgeon will set his own specific restrictions based on the type of fracture, surgical procedure used, personal experience, and whether the fracture is healing as

expected.
Even if Physical Therapy for the injured leg has not yet begun, at First Choice Physical Therapy we highly recommend maintaining the rest of your body’s fitness with regular exercise.  You can use an upper body bike if you are non-weight bearing or a stationary bike once weight bearing is allowed. If the surgeon fits you with a brace that allows you to take partial weight through your leg (i.e. walking cast) then you can even use a stationary bike while wearing it. Weights for the upper extremities and other leg are also strongly encouraged. Your Physical Therapist can provide a program for you to maintain your general fitness while you recover from your fracture.

If you are using crutches, your Physical Therapist will ensure you are using them safely and confidently and that you are abiding by your weight bearing restrictions. We will also ensure that you can safely use them on stairs. If you are no longer using crutches, your Physical Therapist will assist with gait re-education. Until you are able to walk without a significant limp, we recommend that you continue to use your crutches, or at least one crutch or a cane/walking stick. Improper gait can lead to a host of other pains in the knee; hip and back so it is prudent to use a walking aid until near normal walking can be achieved. Your Physical Therapist will advise you regarding the appropriate time for you to be walking without any support at all.

When the initial cast or brace is removed, patients may experience pain when they start to move their ankle joint or bear weight through the lower leg. This pain is from not using the joints regularly while you were immobilized, or it may be from concurrent soft tissue injury that occurred when you fractured your leg. Your Physical Therapist will focus initially on relieving your pain. We may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the fracture site or anywhere down the extremity. In addition, our Physical Therapist may massage the leg and ankle to improve circulation and assist with the pain.

The next part of your treatment will focus on regaining the range of motion and strength in your ankle, foot, and entire lower limb. Your extremity will look and feel quite weak and atrophied after the period of immobilization. Your Physical Therapist will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program. These exercises may include stationary cycling and the use of theraband to provide some resistance for your lower leg. We may even give you exercises for areas such as your hip or back as these areas help to support the lower limb when you are weight bearing. If necessary your Physical Therapist will mobilize your joints. This hands-on technique encourages the stiff joints of your ankle, foot, and lower leg to move gradually into their normal range of motion. Fortunately, the initial phases of gaining range of motion and strength after a lower limb fracture go quickly. You will notice improvements in the functioning of your limb even after just a few treatments with your First Choice Physical Therapy Physical Therapist. As your range of motion and strength improve, we will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows.

As a result of any injury, the receptors in your joints and ligaments that assist with balance and proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility and reduced weight bearing will add to this decline. Your Physical Therapist will also prescribe exercises for you to regain this balance and proprioception. This might include exercises such as standing on one foot or balancing with both feet on an unstable surface such as a wobbly board or a soft plastic disc. Advanced exercises will include agility type exercises such as hopping or moving side to side.  Eventually we will encourage exercises that mimic the quick motions of the sports or activities that you enjoy participating in.  

Generally, the strength and stiffness one experiences after a lower limb fracture responds very well to the Physical Therapy we provide at First Choice Physical Therapy. With our initial one-on-one Physical Therapy treatment along with the exercises of your home program, the strength, range of motion, and proprioception gradually improve towards near full recovery/function over a period of 3-6 months even though the actual final stages of bone healing won’t occur for another 6-12 months after that. If your pain continues longer than it should or therapy is not progressing as your First Choice Physical Therapy Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the fracture site is tolerating the rehabilitation well and ensure that there are no hardware issues that may be impeding your recovery.

Complications

What are the potential complications of this fracture?

Stiffness

This consequence of the treatment of a fracture of the tibia makes it clear that the process can sometimes take a long time. Not using the muscles and joints for an extended period can result in deterioration and an increased risk of posttraumatic osteoarthritis of the knee or ankle. This was more common when long leg casts were used for extended periods. The injury itself does not damage the joints (although the muscles may certainly be injured) so early mobilization is effective in preventing this complication. In order to prevent this complication an exercise program as outlined in the Rehabilitation section is needed once the bone is healed strongly enough to withstand stress.

Fat Embolism Syndrome (FES)

This rare but serious condition can occur after about one in fifty tibial fractures. Fat globules from the bone marrow enter the blood circulation via damaged vessels and pass to the lungs and brain. Under certain conditions this sets up an inflammatory response compromising lung function and clouding consciousness. Often the first sign is confusion, followed by respiratory problems. The condition itself is short lived and self-limiting but the patient may need intensive care, including ventilator support, in the short term. Formerly, this rare condition was fatal in 10 percent of FES cases; with early recognition and aggressive supporting treatment this figure is now much less. However, it does remain one of the few complications of otherwise straightforward fractures that can provoke an emergency.

Infection

Open fractures are common tibial injuries and have an increased risk of infection because the bone comes through the skin and is contaminated at the scene of the accident. Surgical site infections can also occur when a fracture is operated on. This means that infections caused by bacteria are seen in a number of patients with tibial fractures (two to five percent). Most patients who have an open fracture or an operation receive antibiotics to reduce the chance of this complication. An infection is suspected when the wound remains red, tender, and swollen longer than normal. If it breaks open, if pus drains from the wound, or if bacteria are cultured from the wound, the diagnosis is confirmed.
High doses of antibiotics are given intravenously and in most cases the wound is opened to clean out dead and infected tissue and prevent pressure build up. In some situations, beads containing antibiotics are placed in the wound for a few days to achieve high local levels of the medication.

Fixation of the fracture is usually maintained until the fracture is healed. Then the implants may be removed because cracks or scratches on the surface may harbor bacteria.

The aim of treatment is to heal the infection and the fracture. Established bone infection may be very difficult to eliminate and may cause failure of healing. Most often the measures taken to treat the infection do result in healing the fracture and eliminating the infection. It is undeniable, however, that an infection results in a lot more trouble and usually some additional surgery.

Compartment Syndrome

Compartment syndrome occurs when bleeding into the muscle compartments in the leg raises the intra-compartment pressure to levels that slow or stop blood flow in those compartments. Muscles in the leg (and arm, hand and foot) are contained inside compartments bounded by tough inelastic sheets of fibrous tissue. There are four compartments in the leg. The anterior compartment is the soft region in the front outer side of the leg – to the outer side of the shin bone. The lateral compartment is on the outer side and there are two posterior compartments in the calf at the back of the leg.

Even quite a small amount of bleeding into one or more of these compartments can cause a problem. This problem can be made worse if the leg is compressed from the outside by a cast or tight dressing. The fundamental problem is that the muscle tissue will die if there is insufficient blood supply. Dying muscle is very painful and unremitting pain is the most reliable sign of a compartment syndrome. However, all fractures are painful and it is sometimes difficult to distinguish between the pain that is normally present after a fracture and the pain of a compartment syndrome. In the latter case the pain is made worse by contracting or stretching the affected muscle; this is one of the reasons the doctors, nurses, and Physical Therapists insist that patients move their toes, feet and ankles after a fracture.

If a compartment syndrome is diagnosed an emergency operation is needed to release the pressure. This is called a fasciotomy and may involve a big opening of the skin of the leg. Once the skin is opened the muscle compartments are also split open and the pressurized contents allowed to bulge out. This relieves the pressure and the blood supply to the muscle can resume. If this procedure is done before any muscle dies the long-term outlook is good, although the wound may require skin grafting and be unsightly. If some muscle death (necrosis) has occurred these parts may shorten up causing contractures and clawing of the toes as well as weakness of the affected muscle.

Chronic exertional compartment syndrome sometimes occurs months or years after the injury. When the patient returns to heavier activities or sports he/she finds that the leg rapidly becomes painful. The pain is made worse by moving the foot or pressure over the muscle and is slowly relieved by resting. This condition can be investigated by measuring the intra-compartment pressures before and after exercise. It is relieved by fasciotomy and the outcome after treatment is usually satisfactory.

Nonunion

Of all the long limb bones the tibia has the worst reputation for not healing. Nonunion is a clinical diagnosis. It means that in the doctor’s opinion, the bone will not heal without further intervention. Delayed union is the state where the bone is taking longer than normal to heal but there is sill a chance it will heal without surgery. Obviously there is an overlap between these two complications as all “nonunions” were “delayed unions” at an earlier point.

Clinically, a non-united tibia is found to be painful and to hurt more on bearing weight or on stressing the leg. The pain does not get better with time as occurs with normal healing. Often one cannot feel any movement at the fracture site, but in florid cases one can. The x-ray shows a gap between the fracture fragments and in some cases the formation of a pseudo-joint. It may be necessary to get a CT scan of the region to make sure of the diagnosis. Getting a good image is often made difficult by the presence of metal implants used to treat the fracture.

Treatment of a nonunion is individualized to each different case. Nonunion is more common if the original injury was treated nonoperatively. If surgery has not been undertaken before, the treatment will likely be rigid internal fixation and bone grafting. Bone grafting alone has been used and may be combined with removal of a small section of the fibula if it is thought that the healed fibula is holding the fracture fragments apart. If the fracture has already been operated on the fixation will most likely be replaced with some other system that imposes compression on the fracture site.

In really difficult cases, the Ilizarov technique may be used. The nonunited segment of bone is removed and freshened ends of normal bone are held together with an external frame. A second cut is made in the normal bone higher up the leg and the frame is used to lengthen the bone over time.
In most cases of nonunion surgery does achieve healing and the long- term outlook is good. Infected nonunion is a particularly difficult problem with a higher failure rate. The main adverse long-term outcome is loss of function caused by the prolonged treatment. If it takes years to heal the bone the muscles and joints of the leg are unlikely to recover fully.

Malunion

If the bone heals in a position that is shortened, angulated, or rotated it may be said to be mal-united. Often this is not a significant problem and does not interfere with long-term function. Studies of malunion have not shown a significant risk of later arthritis of the knee or ankle.
Sometimes the degree of shortening or rotation may not be acceptable. Treatment would then require surgical correction of the malalignment. Surgical correction of a malunion requires cutting the bone, restoring the alignment then fixing the tibia using either internal fixation with a plate, intramedullary rod or external fixation device. These methods are usually successful in correcting the problem and giving a good long-term outcome.

Summary

A fracture of the leg below the knee usually involves both bones of the shin, the tibia and the fibula. Fractures of the tibia are serious injuries which take many months to heal. There is a wide spectrum of injury from simple stable spiral fractures to severe open injuries with bone loss and massive damage to muscle, nerve and blood vessels. In most cases treatment is successful in its aims of saving the patient’s life and limb, healing the fracture, and restoring function, but treatment can be prolonged and there are many complications to avoid.

Introduction

Physical Therapy in Lynn Haven and Panama City Beach for Ankle Issues

Welcome to First Choice Physical Therapy’s guide to psoriatic arthritis.

Psoriasis is a disease that most people think of as primarily a skin disease because the condition causes a persistent rash in various areas of the body. Psoriatic arthritis is a type of joint disease that occurs in roughly seven percent of people who have psoriasis. Psoriatic arthritis affects people of all ages, but most get it between the ages of 30 and 50. Usually a patient has psoriasis (the skin rash) for many years before the arthritis develops, and usually the arthritis comes on slowly, however, this is not always the case. No matter what, patients with psoriatic arthritis must unfortunately manage both the outbreaks of itchy, scaly skin and the pain and stiffness of arthritis.

This guide will help you understand:

• how psoriatic arthritis develops
• how doctors diagnose the condition
• what can be done for the problem
• what First Choice Physical Therapy’s approach to rehabilitation is

Anatomy

Where does psoriatic arthritis develop?

Psoriatic arthritis can affect any joint. Its symptoms often seem like the symptoms of rheumatoid arthritis (RA) or degenerative arthritis of the spine. X-rays can be used to show the difference between psoriatic arthritis and other diseases. In psoriatic arthritis, X-rays show a very distinctive type of bone destruction around the joints as well as certain patterns of swelling in the tissues surrounding the joints.

Patients with psoriatic arthritis fall into three groups. The first group involves patients who have what is called asymmetric arthritis. This means that only a few joints are involved and that it does not occur in the same joints on both sides of the body. (For example, only one wrist and one foot are affected.)

An equal number of patients fall into the second group and suffer from symmetric polyarthritis. This means that arthritis occurs in several corresponding joints on both sides of the body. (For example, both elbows, both knees, and both hands are affected.) The polyarthritis type of psoriatic arthritis is much like RA.

A third group has mostly axial disease. This refers to arthritis of the spine, the sacroiliac joint (where the pelvis and bottom of the spine meet), or the hip and shoulder joints. Patients do not necessarily stay in the same category. Over time, the pattern may change. Doctors use these categories to better understand the disease and to follow the progression of the arthritis but the overall treatment is basically the same.

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Causes

Why do I have this problem?

The exact cause of psoriatic arthritis is not known. Many factors seem to be involved in its development. Heredity plays a major role. People who are closely related to someone with psoriatic arthritis are 50 times more likely to develop the disease themselves. Recent studies have located genetic markers shared by most people who have the disease.
Sometimes injuries seem to set off psoriatic arthritis. Infections also contribute to the disease. It is known that strep infections in children can cause psoriasis. Some researchers think that the arthritis may be an immune system response to bacteria from the skin lesions.

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Symptoms

What does psoriatic arthritis feel like?

All people who suffer from psoriatic arthritis have psoriasis (the skin rash). Some patients have very few areas of rash while other patients have psoriasis over a large portion of their bodies. The skin lesions of psoriasis are reddish, itchy, and have silvery scales. These areas can range in size from the size of a pencil dot to large areas the size of your palm. Psoriasis usually shows up on the elbows, knees, scalp, ears, and abdomen, but it can appear anywhere. In people with psoriatic arthritis, the psoriasis most often affects fingernails or toenails. The nails may have pits or ridges, or they may be discolored or appear to be separating from the skin.

Psoriatic arthritis can affect any joint. Symptoms often seem like those of any other type of arthritis, such as joint swelling and pain. Some joint symptoms are unique to psoriatic arthritis:

• The joints nearest to the fingernails and toenails are affected more. (These joints are called distal interphalangeal, or DIP joints.)
• The affected fingers and toes take on a “sausage-like” appearance.
• The bones themselves become inflamed (called dactylitis).
• The tendons and ligaments become inflamed where they attach to bones. (This is called enthesitis and is especially common in the heels.)
• Bony ankylosis of the hands and feet develops. (This means that the joints stiffen and become frozen in awkward positions.)
• The joints grow inflamed where the bottom of the spine meets the pelvis. (This is called sacroiliitis.) Patients often notice no symptoms, but the inflammation can be seen on X-rays.
• The vertebrae of the spine become inflamed. (This is called spondylitis.)
• The eyes become inflamed.

About five percent of patients with psoriatic arthritis will develop a form of arthritis called arthritis mutilans. This type of arthritis affects the small joints of the hands and feet. It is especially severe and destructive. The destruction caused by arthritis mutilans can result in deformity of the hands and fingers.
Rare symptoms include problems with the aortic heart valve, extra tissue formation in the lungs, and metabolic disorders that affect the tissues.

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Diagnosis

How do health care professionals identify the condition?

A detailed medical history with questions about psoriasis in your family, will help your healthcare professional make a diagnosis. Patients with psoriasis may have other forms of arthritis, and the symptoms of psoriatic arthritis often look like other types of joint disease. This means that your doctor will probably do tests to rule out other diseases.

Blood studies will help rule out RA. (The RA test is usually not positive in patients with psoriatic arthritis.) Efforts are being made to find ways to identify psoriatic arthritis through a blood test. The presence of specific biologic elements called biomarkers (biologic evidence of disease) would make it possible to look for evidence of this disease before it progresses, or even before it starts. Psoriatic arthritis is common in people who test positive for HIV, the AIDS virus. As a precaution, your doctor may test your blood for HIV, especially if your symptoms are severe.

Physicians must also use other diagnostic tools such as X-rays, ultrasonography, and Magnetic Resonance Imaging (MRIs) in order to definitively diagnose psoriatic arthritis.  Each one of these tests provides a little different information. For example, X-rays of affected joints will be studied both to rule out other diseases and to identify characteristics of psoriatic arthritis.

Ultrasonography, the use of sound waves to create a picture of what’s going on inside, provides a better look at the whole package: bones, joints, and soft tissues. This diagnostic test is also noninvasive and does not expose the patient to any radiation. Ultrasound also has the ability to show small changes in the nails and early signs of inflammation in tendons and small joints.

MRIs can show bone marrow edema, tenosynovitis and early joint erosion. Tenosynovitis is the inflammation of the fluid-filled sheath (called the synovium) that surrounds a tendon. Unfortunately reliability is a problem with MRIs because what one examiner sees may not be the same as another observer. Changes in the small joints of the hands and feet don’t show up well on MRIs like they do with ultrasonography.
One advantage MRIs do have over ultrasonography is the availability of whole body MRIs. By scanning the entire body, it is possible to identify areas of inflammation undetected by clinical examination.

Until blood studies are able to find biomarkers indicating the presence of psoriatic arthritis, physicians will have to continue to use a combination of different tests to diagnose the problem. The information these tests provide is important in determining treatment.

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Treatment

What can be done for the condition?

Dealing with psoriatic arthritis involves treating both the skin lesions and the joint pain. Many lotions and creams are made for skin affected by psoriasis.
PUVA therapy, which stands for psoralen combined with ultraviolet A (UVA), may be helpful for the skin lesions. PUVA therapy uses topical cream medications that are rubbed on the skin lesions and affected joints. Following application of the cream, the skin area is placed under a lamp that emits a special ultraviolet light. The light triggers chemicals in the medication cream that treat the rash lesions and in some cases may also help the pain in the joints.

Treatment of arthritis symptoms depends on which joints are affected and the severity of the disease.

The first drugs most doctors prescribe are nonsteroidal anti-inflammatory drugs (NSAIDs). Aspirin and ibuprofen are NSAIDs, as are many prescription pain relievers. Other medications known as disease-modifying antirheumatic drugs (DMARDs) are used in patients with high levels of pain or particularly bad arthritis. These medications work in different ways to regulate the immune system and thereby control the arthritis.
One of the most commonly used disease-modifying medications for the treatment of psoriatic arthritis is methotrexate. DMARDs like methotrexate not only controls symptoms, they also slow the progression of disease.  That’s what makes them “disease-modifying”.  Methotrexate can control bad skin symptoms as well as help the arthritis symptoms. For some patients, it may be necessary to combine methotrexate with another drug (e.g., infliximab) to get the desired results (decreased joint pain, swelling, and stiffness).

Infliximab is a type of disease-modifying medication in a class called anti-tumor necrosis factor (TNF) agents. The anti-TNF agents are a special type of antibody referred to as human monoclonal antibodies. They specifically target (and inhibit) tumor necrosis factor. Tumor necrosis factor (TNF) promotes the inflammatory response, which in turn causes many of the clinical problems associated with autoimmune disorders such as rheumatoid arthritis.

Oral medications (pills taken by mouth) are under investigation and might be available in the future for the treatment psoriatic arthritis.  These include ustekinumab, apremilast, and tofacitinib. Each of these medications works in a slightly different way to regulate the immune system.

Doctors will sometimes prescribe a combination of drugs. Cortisone injections into sore joints can also help relieve pain. Surgery may be called for in the rare cases of unmanageable pain or loss of joint function.
In addition to medicinal treatment your doctor will ask you to see a Physical Therapist to maximize the strength and mobility of your joints.

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Rehabilitation

Treatment for psoriatic arthritis at First Choice Physical Therapy can assist the management of your disease alongside the use of your prescribed medications.  Physical Therapy cannot cure your disease, but it can assist in managing your pain and preventing a decline in your joints due to the disease process. Physical Therapy will focus on the effects of psoriatic arthritis on your joints rather than the skin lesions that are part of the disease.

During your first visit to First Choice Physical Therapy your Physical Therapist will take a detailed history from you. They will want to know when the arthritis first started bothering you, which joints you have pain in, how often they bother you, the level of pain, and what sort of activities irritate or relieve your pain. They will also inquire about the associated skin lesions as well as any family history you may have of the disease, and any previous or current treatments you are undergoing, including which medications you are taking. Finally, they will ask about your work and recreational activities and will want to know if your arthritis limits you in any of these activities.

If your arthritis has affected any joints in your lower extremities your Physical Therapist will want to watch the way you walk to see if your arthritis has affected your gait. They will also assess your overall posture and alignment to determine if you have developed any bad posturing habits or improper alignment due the disease. They will advise you on proper posturing and walking techniques and if needed, will discuss using a walking aid such as a cane/stick if they feel it is necessary to take some of the stress off of your joints.

Next your Physical Therapist will assess and measure the range of motion in any joints that have been affected by the arthritis. Strength of the muscles surrounding these joints will also be determined. For any joints that have a decreased range of motion or are at risk of losing their range of motion, your therapist will prescribe range of motion exercises. Stretches will be prescribed for any muscles around the joints that are deemed to be tight and pulling adversely on the area. Strengthening exercises will be prescribed for any weak muscles or muscles that your therapist determines are at risk of losing strength over time due to the disease process.

Often doing exercises in a warm therapy pool can be easier on your joints and more comfortable so your therapist may encourage this for you.  In addition, cardiovascular exercise can also be done more comfortably while in the pool (ie: water running, water aerobics, or swimming.) Doing a cardiovascular exercise of some sort is extremely important to managing your psoriatic arthritis as it keeps the body and joints limber and is excellent for your overall physical and mental well being.   Stress can make your symptoms worse so cardiovascular exercise is an excellent method of helping to decrease your overall stress. If you are overweight, cardiovascular exercise is particularly important to assist you in weight reduction as the added weight on your joints can accelerate the wear and tear on them and increase any pain you may feel.  If you are not interested in the pool or prefer exercise on the land you could use a stationary cycle, a stepper machine, an elliptical, or simply walk. Your therapist can help to design a cardiovascular program that suits your individual needs, and can advise on which type of exercise would be best for you.

In some cases of psoriatic arthritis, electrotherapy such as transcutaneous nerve stimulation (TENS) may be useful to decrease your joint pain. Your Physical Therapist may also use hands on techniques such as massage for the muscles surrounding your joints, or mobilizations to encourage increased range of motion in your joints.  Often the use of heat can be very soothing for your joints, so this may be used in conjunction with other therapy treatments. If you find the warmth soothing to your joints your therapist will encourage you to apply heat at home as well.

Unfortunately your psoriatic arthritis will not go away. However, there are many treatment options to help you manage this disease. Together with advice from your doctor, your Physical Therapist, and any other healthcare professionals that are involved in your treatment you should be able to find a management program that will work for you.

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Introduction

Physical Therapy in Lynn Haven and Panama City Beach for Ankle

Welcome to First Choice Physical Therapy’s patient resource about ankle problems.

The ankle joint acts like a hinge. But it’s much more than a simple hinge joint. The ankle is actually made up of several important structures. The unique design of the ankle makes it a very stable joint. This joint has to be stable in order to withstand 1.5 times your body weight when you walk and up to eight times your body weight when you run.

Normal ankle function is needed to walk with a smooth and nearly effortless gait. The muscles, tendons, and ligaments that support the ankle joint work together to propel the body. Conditions that disturb the normal way the ankle works can make it difficult to do your activities without pain or problems.

This guide will help you understand:

• what parts make up the ankle
• how the ankle works

Important Structures

The important structures of the ankle can be divided into several categories. These include

• bones and joints
• ligaments and tendons
• muscles
• nerves
• blood vessels

The top of the foot is referred to as the dorsal surface. The sole of the foot is the plantar surface.

Bones and Joints

Ankle Boneshttps://api.vidyard.com/playbackengine/VjEVTpdIA2jhZCyCGZXLhQ/?autoplay=0&iframe=true
The ankle joint is formed by the connection of three bones. The ankle bone is called the talus. The top of the talus fits inside a socket that is formed by the lower end of the tibia (shinbone) and the fibula (the small bone of the lower leg). The bottom of the talus sits on the heelbone, called the calcaneus.

The talus works like a hinge inside the socket to allow your foot to move up (dorsiflexion) and down (plantarflexion).

Talus Works Like a Hinge

Woodworkers and craftsmen are familiar with the design of the ankle joint. They use a similar construction, called a mortise and tenon, to create stable structures. They routinely use it to make strong and sturdy items, such as furniture and buildings.

Mortise and Tenon

Inside the joint, the bones are covered with a slick material called articular cartilage. Articular cartilage is the material that allows the bones to move smoothly against one another in the joints of the body.

The cartilage lining is about one-quarter of an inch thick in most joints that carry body weight, such as the ankle, hip, or knee. It is soft enough to allow for shock absorption but tough enough to last a lifetime, as long as it is not injured.

Cartilage

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Ligaments and Tendons

Ligaments of the Anklehttps://api.vidyard.com/playbackengine/vMM9qWB9h9lPrTy0L5sIwg/?autoplay=0&iframe=true
Ligaments are the soft tissues that attach bones to bones. Ligaments are very similar to tendons. The difference is that tendons attach muscles to bones. Both of these structures are made up of small fibers of a material called collagen. The collagen fibers are bundled together to form a rope-like structure. Ligaments and tendons come in many different sizes and like rope, are made up of many smaller fibers. Thickness of the ligament or tendon determines its strength.

Collagen

Ligaments on both sides of the ankle joint help hold the bones together. Three ligaments make up the lateral ligament complex on the side of the ankle farthest from the other ankle. (Lateral means further away from the center of the body.) These include the anterior talofibular ligament (ATFL), the calcaneofibular ligament(CFL), and the posterior talofibular ligament (PTFL). A thick ligament, called the deltoid ligament, supports the medial ankle (the side closest to your other ankle).

Three Main Ligaments

Ligaments also support the lower end of the leg where it forms a hinge for the ankle. This series of ligaments supports the ankle syndesmosis, the part of the ankle where the bottom end of the fibula meets the tibia. Three main ligaments  support this area. The ligament crossing just above the front of the ankle and connecting the tibia to the fibula is called the anterior inferior tibiofibular ligament (AITFL). The posterior fibular ligaments attach across the back of the tibia and fibula. These ligaments include the posterior inferior tibiofibular ligament (PITFL) and the transverse ligament. The interosseous ligament lies between the tibia and fibula. (Interosseous means between bones.) The interosseus ligament is a long sheet of connective tissue that connects the entire length of the tibia and fibula, from the knee to the ankle.

The ligaments that surround the ankle joint help form part of the joint capsule. A joint capsule is a watertight sac that forms around all joints. It is made up of the ligaments around the joint and the soft tissues between the ligaments that fill in the gaps and form the sac.

Joint Capsule

The ankle joint is also supported by nearby tendons. The large Archilles tendon is the most important tendon for walking, running, and jumping. It attaches the calf muscles to the calcaneus (heelbone) and allows us to raise up on our toes. The posterior tibial tendon attatches one of the smaller muscles of the calf to the underside of the foot. This tendon helps support the arch and allows us to turn the foot inward. 

Achilles Tendon

Posterior Tibial Tendon 

The anterior tibial tendon allows us to raise the foot. Two tendons run behind the outer bump of the ankle (the lateral malleolus). These two tendons, called the peroneals, help turn the foot down and out.

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Muscles

Muscles of the Anklehttps://api.vidyard.com/playbackengine/xc3f1dJ8gm6yCVNeQ5sPpA/?autoplay=0&iframe=true
Most of the motion of the ankle is caused by the stronger muscles in the lower leg whose tendons pass by the ankle and connect in the foot. Contraction of the muscles in the leg is the main way that we move our ankle when we walk, run, and jump.

The key ankle muscles have been discussed earlier in the section on ligaments and tendons. These muscles and their actions are also listed here.

• The peroneals (peroneus longus and peroneus brevis) on the outside edge of the ankle and foot bend the ankle down and out.
• The calf muscles (gastrocnemius and soleus) connect to the calcaneus by the Achilles tendon. When the calf muscles tighten, they bend the ankle down.
• The posterior tibialis muscle supports the arch and helps turn the foot inward.
• The anterior tibialis pulls the ankle upward.

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Nerves

Nerves of the Anklehttps://api.vidyard.com/playbackengine/2h6elm9fM8S330L2QGWATg/?autoplay=0&iframe=true
The nerve supply of the ankle is from nerves that pass by the ankle on their way into the foot. The tibial nerve runs behind the medial malleolus. Another nerve crosses in front of the ankle on its way to top of the foot. There is also a nerve that passes along the outer edge of the ankle. The nerves on the front and outer edge of the ankle control the muscles in this area, and they give sensation to the top and outside edge of the foot.

Tibial Nerve

Nerves on Front and Outer Edge

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Blood Vessels

The ankle gets blood from nearby arteries that pass by the ankle on their way to the foot. The dorsalis pedis runs in front of the ankle to the top of the foot. (You can feel your pulse where this artery runs in the middle of the top of the foot.) Another large artery, called the posterior tibial artery, runs behind the medial malleolus. It sends smaller blood vessels to the inside edge of the ankle joint. Other less important arteries entering the foot from other directions also supply blood to the ankle.

Posterior Tibial Artery

Arteries Entering the Foot

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Summary

As you can see, the anatomy of the ankle is very complex. When everything works together, the ankle functions correctly. When one part becomes damaged, it can affect every other part of the ankle and foot, leading to problems.

Physical Therapy in Lynn Haven and Panama City Beach for Ankle Issues

Welcome to First Choice Physical Therapy’s resource about the ankle.

Ankle injuries can be a real pain, literally and figuratively.  Not only can they lay you up or make you hobble around, they may cause you to banish your favorite pair of stilettos to the closet or cancel that game of touch football that you had planned for the weekend.

If you are currently in pain and suffering from an ankle injury, it is important that you know the facts about this sensitive area.  After all, if your ankle injury is not given the proper attention and healed completely, you run the risk of it occurring again.

In this area of our site you will find various resources on the types of ankle injuries that you could suffer from as well as information about the steps that should be taken for fixing this problem.

Take the time and make sure you get proper attention; after all, you have better things to do than hobble around on a pair of crutches.


Click on a link below to learn more about:

• Ankle Anatomy
• Ankle Issues

Welcome to the First Choice Physical Therapy Injury and Conditions Resource.

We look forward to working with you to reach your goals in health and well being.

This section of our website is designed to provide you with educational information on injuries and conditions.

To explore our educational content, please use the navigation menu. 

 Our Injuries & Conditions resource is for informational purposes only.  Do not diagnose, self treat, or attempt any exercises from the content on this site without contacting First Choice Physical Therapy, your physician or a qualified specialist first.

At First Choice Physical Therapy we offer Physical Therapy.