A therapist guides a client through an exercise that will improve his strength and stability, thus reducing his risk for injury.

At Centinela Freeman Medical Center in Inglewood, Calif, staff physical therapist Scott Lockwood, PT, encounters quite a few foot and ankle problems. Those most frequently seen are postoperative fractures, followed by plantar fasciitis and sports-related strains and sprains.

But no matter the problem, when it comes to working with lower-extremity patients, there is a single, overarching goal: improve strength and stability in order to reduce the potential for re-injury.

“We’ve found that patients can be strong, but if they lack endurance and their muscles fatigue easily, then they’re at a higher risk of further harm,” Lockwood says.

No argument on that point from Nancy Krepelka, MS, PT, manager of outpatient orthopedics at Good Shepherd Outpatient Rehabilitation at Schnecksville, Pa, who also sees lower-extremity strength and flexibility as a key to prevention of initial injury. “Injuries most often occur in people who are out of shape, then suddenly become very active,” she says. “An illustration is the person who doesn’t do anything all winter long, then goes out and plays five straight hours of softball on the first pleasant weekend of spring. This person is also very likely to be middle-aged. The problem for people in their 40s and 50s is that they don’t realize how much strength and flexibility they’ve lost to age. The substance of soft tissue changes as people get older. They lose elasticity in their tendons and ligaments, for example. Then, when they suddenly become very active after a prolonged period of inactivity, those less-elastic structures can more easily tear.”

Edward W. Bezkor, PT, DPT, MTC, makes the point that injuries also occur because of the intricate interrelationship among lower-extremity joints, tendons, and ligaments. “If something goes wrong with the hip, for instance, injuries can show up in the knee and farther down the kinetic chain,” says Bezkor, a clinical specialist serving in the outpatient physical therapy section of NYU Medical Center’s Rusk Institute of Rehabilitation Medicine, New York City. “For the sake of discussion, let’s assume your hip is in a position of internal rotation because of tight muscles. In volleyball or basketball, where you’re doing a lot of compressive landing, having your hip in this position may cause your knee to be in a position of valgus, which will in turn place tremendous stress on the ligaments and articular cartilage of the knee itself. In other words, you’re going to have an increase of the forces transmitted through the knee. By improving your hip control and strength of external rotation, it’s possible to decrease a lot of those detrimental forces going through the knee joint.”

Bezkor also offers the scenario of a patient with either weak or tight quadriceps. “Both conditions can cause an increase in patella femoral joint compression resulting in increased risk of articular changes and osteoarthritis, among other problems,” he says. “What we want to do here in response is increase quad strength and length.”


The starting point for any corrective intervention is, of course, the initial assessment.

“Lower-extremity patients who come in postoperatively, we want our assessment of them to include the collection of information about the cause of initial injury so that we can develop a clear sense of where they currently are with the surgery—if surgery is behind them now or if more operations are still ahead,” Lockwood says. “Then we conduct an exam to find out about their biomechanical capabilities, with an eye on discovering where the deficits are, the weaknesses and the restrictions. Once we’ve identified those, then we can proceed to treatment and do so with confidence that we can help the patient get back in the game.”

Often underestimated—if not outright overlooked—are the issues and ramifications surrounding neuromuscular control, Bezkor proffers. “Many times we focus so much on strength and flexibility, but the key component of a patient returning to athletic play and regaining full normal motor control is the central nervous system and how it affects movement and posture,” he says. “Researchers have found that receptors in the joints, muscles, and ligaments are all compromised after injury. Part of why that might be is because of the immobility that occurs after injury or possibly because of direct trauma and swelling. They’ve found that two patients can have the exact same physiological dysfunction—whether it’s the size of the tear or location—and yet have two drastically different outcomes. They think the reason is that patients recover their neuromuscular control differently.”

To help his own patients regain neuromuscular control, Bezkor routinely uses balance stability and coordination drills, along with perturbation training. “We have the patient stabilize their knee in response to unexpected surface changes—starting off in one plane, then as they progress we’ll add more planes and change the amplitude and velocity of the perturbation in order to really work on the stability at the knee,” he says. “Eventually, we work into multitasking where they’re doing ball-throwing and catching, hand-eye coordination activities, while we simultaneously provide perturbations throughout the lower extremity. The final stage is aimed at returning them to sport-related activities—cutting, figure-eight drills, side-to-side drills, those sorts of things.”

In cases where the problem is either weak or tight quadriceps, the work emphasizes strengthening of the gluteus medius and preventing muscle imbalance, Bezkor reports. “We have our patients participate in exercises where, for instance, the leg is planted and the torso rotated away from the hip and then back to neutral while subjecting them to different perturbations. Another approach would involve ample stretching to affect the internal rotator structures.”


Among patients with lower-extremity injuries who undergo surgery, the ones hardest to rehab are those in pain, Krepelka observes.

“They go home and sit because its hurts too much to do anything but that,” she laments. “So, if we want to increase their strength and range of motion, pain control is the first thing that needs to happen.”

Krepelka attempts to rein in pain with the help of electrical stimulation, ice, retrograde massage (to relieve edema), and, occasionally, myofacial release. She also tries to find out how well each patient is complying with the medication regimen prescribed by his or her physician. “Some patients don’t like taking the medications they’ve been given because they feel those pills are too strong,” she says. “If that’s the case, I suggest they try as an alternative over-the-counter products to see if they can tolerate those and obtain enough pain relief to allow them to perform at least some exercise. And once we achieve enough relief to permit exercise, the main thing then is to get that postop foot or ankle moving—it can be as simple as repetitions of raising the foot, bringing it back down, and putting it through in-and-out motions. Or, it can involve closed-chain activities, such as walking and bicycling, which are advantageous for patients who don’t have clinical equipment at home.”

Krepelka’s strategy is much the same for cases involving chronically painful foot and ankle injuries where surgery is not contemplated. The biggest difference is that the chronic nature of the pain mandates slower introduction of strength and range-of-motion exercises, she says. “The first few times I might give the patient a small number of isometric exercises, then gradually add to those over the next several weeks until the pain is brought under control so that we can then advance to more strenuous activities,” Krepelka explains. “It’s important for the patient to learn that it is okay to exercise, that exercise is not going to make the pain worse.”

Along with pain, edema tends to be another initial primary hurdle to lower-extremity rehabilitation. Lockwood is among those who like to tackle edema by means of hydrotherapy contrast bath, the objective of which is to achieve a revulsive effect that maximizes circulation of well-oxygenated, nutrient-rich, toxin-low blood through the extremity. Some studies have shown that local blood flow can be increased by as much as 95% following immersion of the extremities in a contrast bath lasting 30 minutes (although other studies claim optimal results can be achieved with just 9 minutes of contrast bath—5 minutes of immersion in hot water followed by 4 minutes in cold).

One of Bezkor’s favorite tools for reducing swelling is the Cryo Cuff. This device combines focal compression with cold to control swelling, edema, hematoma, hemarthrosis, and pain; it comes in versions specifically for knees, thighs, calves, ankles, and feet (one model is meant to be used in conjunction with a walking brace). “All you do is fill up the cuff’s cooler compartment with crushed ice and water, hold that above the affected joint or ligament, and then allow gravity to flow the chilled mixture into the chambers of the wrap,” he explains. “This forces the wrap to expand, which is where the compression effect comes from. It’s very effective, I’ve found.”


When it comes to treatment of the lower-extremity injury itself, many enterprises prefer to start therapy with a continuous passive motion (CPM) machine. For example, CPM is customarily ordered for use during a patient’s inpatient stay at Good Shepherd Rehabilitation Hospital, the facility that runs the outpatient clinic at which Krepelka is based. Although CPM is discontinued by the time patients are seen by Krepelka, she nonetheless believes CPM is an imperative for patients immediately after knee-replacement surgery. “It keeps the new joint moving, thus preventing it from stiffening,” she says.

Treadmills are one of the big-ticket pieces of equipment Krepelka does work with regularly at her clinic, where low-tech approaches predominate. “Treadmills are very versatile; you can use them in so many different ways—they’re great,” she enthuses. “Patients can walk on them forward, backward, sideways, uphill, downhill. That gives us significant ability to diagnose and address very specific gait problems. Plus, there’s the added benefit of improving cardiovascular health.”

Walking on an uneven or sloped surface challenges the proprioceptive, neuromuscular, and coordination systems.

Lockwood also likes treadmills, but he seldom uses them. His preference is for the quarter-mile running track next door to the clinic. “Our track is surfaced with shock-absorbent synthetic material, like what you find in collegiate and professional arenas,” he explains. “We also have outdoor exercise areas that are grassy, and others that are concrete and asphalt. For my patients, I feel it’s more productive to have them exercise on the actual surface they play their specific sport on.”

Reestablishing neuromuscular control requires more than a treadmill, so at Rusk the therapists use the NeuroCom International SMART Balance Master. The system provides objective assessment and retraining of the sensory and voluntary motor control of balance, and it accomplishes this with the aid of visual biofeedback on either a stable or unstable support surface operating in an environment of static or dynamic visual surroundings. Possible with this unit are interactive, functional training exercises in which there is a role for visual biofeedback (coupled with sensitive, real-time monitoring of movement). Additionally, exercise protocols can be tailored to meet individual patient needs and easily altered in accordance with patient improvement. “A nice thing about this system is we can make sure the patient is weight-bearing through the entirety of the affected limb, so that strength is indeed being regained,” Bezkor tells. “It also has different settings that allow us to simulate conditions on an uneven field or sloped sidewalk—this prepares patients for the true challenges and stresses waiting for them in the real world. Overall, it’s a good system for safely forcing patients into to awkward positions where their entire limits of stability—the full complement of proprioceptive, neuromuscular, and coordination systems—are challenged.”

Ever of concern to therapists is the question of just how aggressively to treat, regardless of choice of modality. Lockwood suggests the younger and more athletic the patient, the harder he or she can be pushed. But, regardless of the level of aggressiveness involved, Lockwood believes in keeping treatment simple. “The more sophisticated the approach, the more time involved in setup,” he says. “Look, I’ve only got 30 minutes with each patient. I need to have as much of those 30 minutes for actual therapy as possible so that I can accomplish my goals for that session. The simpler the treatment, the less time taken with getting equipment adjusted and readied for use.”

Of course, some treatments that fall outside the definition of simple are better than those that do fit the description because, even though the former may involve more setup time, they are sophisticated enough to deliver good results in a shorter span—and may actually represent a net time savings for the therapist. The important thing is, though, that rehab of the lower extremity is challenging, but the techniques and technologies to achieve good therapeutic results are plentiful.

Rich Smith is a contributing writer for  Rehab Management. For more information, contact