by Adrian Masoni, PT, DPT
April, 2013
With many injuries of the foot and ankle a period of immobilization is required to ensure proper tissue healing. Immobilization may be created with plaster casting, an air cast, or with removable walking boots. Traditionally, immobilization is required to stabilize the affected areas following surgery, fractures, significant ligamentous sprains, and chronic instabilities. Early physical therapy intervention following periods of immobilization has been proven beneficial for increasing functional outcomes and decreasing time and money spent on rehabilitation.
During periods of immobilization, muscle atrophy (wasting) occurs early. As soon as muscle activity is impeded, the rate of tissue degradation outweighs formation. In a study of muscle volume of the calf following a four-week period of casting, 25% loss is observed 1. Additionally, strength losses occur rapidly as the muscle fibers atrophy and are not exposed to constructive, resistive forces.
Without normal mobility of the soft tissues, collagen synthesis and concentration increase. This leads to increased stiffness in the muscles, decreased soft tissue mobility, and poor muscular performance 2. Joints suffer similar loss of flexibility during these times and unless properly addressed, this limitation will severely limit post-immobilization outcomes and return to functional and recreational activities.
Articular cartilage lies on the joint surfaces and protects them from the mechanical stresses of movements and load. During periods of immobilization, the cellular matrixes of the cartilage change which results in softening and thinning 3. Due to their lack of blood flow and neural input, articular cartilage has very poor healing. Regaining mobility and support surrounding the joints is an integral step in rehabilitation to promote joint health and long-term success.
Physical therapy is an essential step in rehabilitation following immobilization of the ankle. While certain precautions may remain in place (weight bearing, range of motion, activity, etc), many treatments can be utilized to address the aforementioned changes and allow for faster and more appropriate rehabilitation. Such treatments include manual stretching, soft tissue mobilization, neuromuscular re-education, therapeutic exercise instruction, proprioceptive training, edema treatment, and joint mobilization. Early restoration of joint mobility and normal mechanics allows for decreased pain and increased range of motion when compared to immobilization without physical therapy treatment 4.
Early initiation of therapeutic exercises (respecting any precautions) aids in the recovery process. Activity will decrease swelling, stiffness, and pain and it will increase range of motion, strength, soft tissue mobility, and circulation. It will also allow for decreased recovery time and a quicker return to normal activities.
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In many cases, physical therapy is indicated during periods of immobilization. If the method of immobilization is a removable boot, passive treatments such as range of motion, edema management, joint mobilization, and soft tissue mobilization may be indicated. Additionally, the knee, hip, pelvis, and lumbar spine may be limited by the period of immobilization and may suffer similar losses in muscle strength and flexibility. These areas should be addressed for full rehabilitation and correct lower extremity mechanics. Athletes and others concerned about cardiovascular losses during immobilization will benefit from exercise alternatives and a focus on upper body activities.
Physical therapy is an important aspect of rehabilitation following injuries of the foot and ankle. The need for physical therapy increases due to the effects of immobilization to allow for decreased recovery time, improved functional outcomes, and a return to normal daily and recreational activity.
Adrian Masoni PT, DPT has been a practicing physical therapist since 2008 and is currently the Director of Rehabilitation at BreakThrough Physical Therapy in Sunnyvale, CA
References:
1. Grosset JF, Onambele-Pearson G. Effect of foot and ankle immobilization on leg and thigh muscles’ volume and morphology: a case study using magnetic resonance imaging. Anat Rec (Hoboken). 2008 Dec;291(12):1673-83.
2. Christensen B, Dyrberg E, Aagaard P, et al. Effects of long-term immobilization and recovery on human triceps surae and collagen turnover in the Achilles tendon in patients with healing ankle fracture. J Appl Physiol. 2008 Aug;105(2):420-6.
3. Vanwanseele, B., Lucchinetti, E., & Stüssi, E. (2002). The effects of immobilization on the characteristics of articular cartilage: current concepts and future directions. Osteoarthritis and Cartilage, 10(5), 408-419.
4. Landrum E, Kellin B, Parente W, Ingersoll C, Hertel J. Immediate Effects of Anterior-to-Posterior Talocrural Joint Mobilization after Prolonged Ankle Immobilization: A Preliminary Study. J Man Manip Ther. 2008; 16(2): 100–105.