Member Case Study: Foot Stability Rehabilitation Exercises

author : AMSSM

comments : 1

While stability can be obtained through external supports such as casting and bracing, the best brace is your own muscles, ligaments and tendons. Achieve this stability by training with instability.

Question from Lobstergirl
The first week of January, while trail running, my foot landed (sideways) in a muddy divot in the road, and I fractured my 5th metatarsal (avulsion fracture, not displaced), aka the bump on the outside of my foot. I spent 4 weeks in a hard cast and will spend another 4 weeks in the aircast. Luckily, surgery isn't needed. The ortho's parting words were: "I don't think an active person like you really needs PT. When you're out of the aircast, go ahead and begin training again."

My question is what is the best way to begin strengthening the calf and foot stability muscles in preparation for walking quickly, and ultimately, running? Is it true that the bone will be stronger at the point where it has knit back together? How can I overcome my fear of breaking it again? When can I start running, and do I run through the pain, or should I only begin running when I'm pain-free?

My Season Goals: Attempt my fourth Olympic-distance triathlon in early June, a few Sprints during the summer, and attempt my first 1/2 Iron in mid-August. Fall = my first marathon, the goal being just to finish in under 4.5 hours. Other considerations: I have access to a pool, a great gym, and indoor stationary bike trainer.

I'm basically starting from scratch, as I haven't been able to do anything for 6+ weeks...Advice most welcome!!

Answer by Michael Ross, MD, Member AMSSM

You already mentioned the key to rehabilitation of your foot and ankle, stability. While stability can be obtained through external supports such as casting and bracing, the best brace is your own muscles, ligaments and tendons. Generally speaking, the way to achieve this stability is by training with instability. For example; doing one leg squats on level ground may not sound difficult, but the same exercise performed on a wobble board or a Bosu ball will train all of the muscles that aid in stabilization of the foot and ankle.

Some exercises that I recommend:

1. Stand on the injured foot and bend the knee slightly. Use the other foot to trace a wide arc. Perform sets of 20 three times a day.

2. Stand on the injured foot. Bend the opposite knee. Squat on the injured foot. Perform sets of 20 three times a day.

When these exercises become easy, increase instability instead of adding weight. Use the following progression to decrease stability.

1. Uninjured foot rests on a stability ball.

2. Uninjured foot rests on a stability ball. Injured foot on foam pad.

3. Uninjured foot rests on a stability ball. Injured foot on Bosu board.

4. Uninjured foot rests on a stability ball. Injured foot on wobble board.

"Is it true that the bone will be stronger at the point where it has knit back together?"
No. This is a myth has been perpetuated. There is a recent medical article in JAMA (Journal of the American Medical Association) (2007;297: 387-394) that has shown that once a bone has been broken, it is more likely to be broken again.

"How can I overcome my fear of breaking it again?"
Overcoming the fear of re-injury comes from the knowledge that you have adequately prepared yourself for the return to sports. This means that aside from your rehabilitation, you need to examine the factors that led to your injury in the first place. There are two types of factors involved: intrinsic and extrinsic. Intrinsic factors include biomechanical problems such as leg length discrepancy and weak arches.

As part of a thorough return to training, be sure to have a biomechanical assessment with your local sports medicine physician. You should also examine your extrinsic factors such as training plans, especially if increased mileage led to fatigue and lack of stability. Other extrinsic factors such as running downhill and on uneven surfaces should be avoided while getting back to “race shape”.

"When can I start running, and do I run through the pain, or should I only begin running when I'm pain-free?"
Pain is your friend. Pain tells you when you need to back off. Trying to run, ride or swim through joint, tendon or fracture pain will only lead to more time off from training. Push yourself physically , some mild discomfort is OK but if pain continues or becomes more severe be sure to see your physician.

Michael Ross, MD
Member AMSSM
Wynnewood, PA

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date: February 21, 2007