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Table of Contents
Title Page
Abstract
Introduction
Injury Scenario and Mechanism of Injury
Predisposing Factors and Signs & Symptoms
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Rehabilitation of a Tibial/Fibular Fracture
A.J. Ola
Therapeutic Rehabilitation
McKendree University
Dr. Hankins
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Abstract
This paper gives an injury scenario for a tibia/fibula fracture and how the athlete will
recover from such an injury. With this injury the athlete has multiple surgery choices and could
have done some things to further prevent the injury from happening. This paper outlines the first
six weeks of the athlete’s rehabilitation and will give an idea of what it is like to go through such
a program. The reader will also learn the anatomy of the lower leg. For example, where the
tibialis anterior attaches and what you use it for. The occurrence of tibia, fibula and ankle
fractures in the United States per year is 492,000; according to the National Center for Health
Statistics (Praemer, Furner, & Rice, 1992). Of 339 patients, admitted to Trondheim Regional and
University Hospital, 11 of them suffered tibial fractures, about 3% (Sahlin, 1989). These
accidents were a direct result of downhill skiing.
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INTRODUCTION
History of Downhill Skiing
Downhill skiing has been around for hundreds of years but did not make it to America
until the early 1900’s. The winter games in 1924 had five original games and two of them were
Nordic combined and ski jumping and in 1932 they featured cross country skiing. People living
in the Telemark region of Norway are credited turning skis into a sport in the 1700’s. They also
invented the Christie and Telemark turns to control downhill descent speed. Downhill skiing is
one of the variations of alpine skiing and the names are usually used interchangeably. The rules
were established in 1921 by Sir Arnold Lunn for the British National Ski Championships.
Downhill is one of the more dangerous events because of the great speed athletes travel at not to
mention having to turn multiple times and navigate jumps and hills. Competing in downhill
requires great strength and expertise to navigate at high speeds.
Injuries in Downhill Skiing
By far the most common injury in downhill skiing involves injury to the knee ligaments.
Knee injuries account for thirty to forty percent of all injuries. Of that thirty to forty percent
medial collateral ligament (MCL) tears comprise twenty to twenty five percent and the other ten
to fifteen percent are anterior cruciate ligament (ACL) tears. MCL tears usually happen in the
“snowplow” position. This position is used for beginners and is basically just rotation of the hip
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joints externally. A valgus load is applied to the knees as a result of a fall, crossing skis or
widening of the stance. There are several mechanisms of injury for ACL tears but the most
common is the “phantom foot” fall. This can happen when the skier’s uphill arm is back, the
skier is off balance to the rear, the hips are below the knees, bodyweight is carried on the inside
edge of downhill ski tail, the uphill ski is unweighted or the upper body is facing the downhill
ski. The more of these positions present; the more likely the athlete is to get an ACL injury.
Medial meniscus injuries account for about five to ten percent of all injuries and a fracture of the
tibial plateau is rare and only makes up one percent of the total. If an athlete tears the ACL,
MCL, and medial meniscus it is referred to as the “Triad of Donohue” or the “Terrible Triad”.
Upper extremity injuries are usually either a dislocated shoulder, fractured thumb, injured thumb
or an injured wrist. Most skiing deaths are caused because of a head injury after a high-speed
collision. Head injuries are mainly concussions but cervical fractures do occur and should always
be suspected. With all the risk and skill needed to be a good downhill skier one must be in tip top
shape and always aware of the variable terrain. Other injuries of the lower extremities may also
occur such as: fractures of the tibia, fibula, ankle and foot.
INJURY
Injury Scenario and Mechanism of Injury
Zachary Wreath, a world class downhill skier, was expertly navigating his gates when he
hit an unexpected jump on the course. Upon landing, his ski caught in the snow causing his left,
lower leg to bend awkwardly. The force applied by his landing snapped both his tibia and fibula
causing massive amounts of pain. Paramedics rushed to the scene and quickly splinted Zachary’s
leg and air lifted him to the nearest emergency care center. X-rays showed his bones had broken
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in an oblique pattern resulting from the direction of the shear force applied to his leg. While this
injury is fairly uncommon, the extreme stress applied by the awkward landing was enough to
snap both bones. Zach would need surgery to fix the fracture in his leg.
Predisposing Factors & Signs and Symptoms
Some factors that may cause a fracture of the tibia and/or fibula are direct and indirect
trauma. Direct trauma would indicate a blunt force to the fractured area; while indirect trauma
would occur from a sharp twist that caused a spiral fracture in the bones. The signs and
symptoms of such a fracture includes: deformity at the injury site, discoloration, increased
temperature, swelling and a positive squeeze and percussion test. If these tests and prerequisites
are met then the athlete may require surgery to fix the break.
SURGICAL OPTIONS
Casting
According to Murthy and Hoppenfeld (2000) in order to be casted for a tibia/fibula
fracture the stability must include displacement fifty percent or less of the tibial width and
shortening of one centimeter or less. Also, the alignment should return rotation and angulation to
within five to ten degrees of the uninjured tibia, in all planes. The biomechanics of a cast are
stress-sharing and the mode of bone healing is secondary.
Intramedullary Rod
The biomechanics of this technique can be either stress-sharing or stress-shielding
depending on whether the nails are dynamically interlocked or statically interlocked. The mode
of bone healing in this option is also secondary. “This treatment is the gold standard for unstable
and segmental tibial fractures or those that cannot be adequately aligned and immobilized by
non-operative means” (Taylor, 2000, p. 367). It also allows for early mobilization of the patient
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along with knee motion returning sooner. For this surgery process an intramedullary rod will be
run down the intramedullary shaft of the tibia with a drill. After the rod has been placed it is
secured with screws that run through the width of the bone.
External Fixator
This method is used more often in open fractures resulting in significant bone loss and
treatment should be considered provisional until the skin graft can achieve soft tissue coverage.
It is also usually followed up with the placement of an intramedullary rod. Biomechanics are
considered stress-sharing and the mode of bone healing is secondary.
Open Reduction and Internal Fixation with Plates
For this surgical option, the biomechanics are stress-shielding and the mode of bone
growth is actually primary. It is not commonly done in this area because of the demands it
withholds. There must be scraping of the periosteum and violation of the soft tissues to make
room for the plates and to allow for proper healing. This technique is usually used on nonunion
fractures for these reasons.
ANATOMY
Dorsiflexors
The tibialis anterior originates on the lateral condyle and upper two thirds of the lateral
surface of the body of the tibia, interosseous membrane, and the deep crural fascia while
inserting at the base of the first metatarsal and the medial and plantar surfaces of the medial
cuneiform bone. It collects nerve supply from the deep peroneal nerve and the nerve roots at
located at L4, L5, and S1. The extensor hallicus longus originates on the medial surface of the
body of the fibula and the interosseous membrane and inserts into the base of the distal phalanx
of the great toe. It is supplied neural activity by the deep peroneal nerve and the nerve roots are
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L4, L5, and S1 (Reese 2005). The extensor digitorum longus gains neural supply from the deep
peroneal nerve and also has nerve roots at L4, L5, and S1. It originates at the lateral tibial
condyle, anterior surface of the body of the fibula and interosseous membrane and it inserts at
the dorsum of the middle and distal phalanges of the second, third, fourth and fifth toes (Reese
2005).
Plantarflexors
The gastrocnemius has two heads; the medial head originates on the medial condyle and
adjacent popliteal surface of the femur and the lateral head originates on the lateral condyle of
the femur. Both heads insert via the tendo calcaneus (Achilles’ Tendon) into the posterior surface
of the calcaneus. The nerve supply is the tibial nerve and the roots stem from S1 and S2. The
soleus gains nerve supply from the tibial nerve also and the roots stem from S1 and S2 as well. It
originates on the posterior surface of the head and proximal one third of the body of the fibula,
soleal line and middle one third of the medial border of the tibia. Insertion occurs via the
Achilles’ tendon into the posterior surface of the calcaneus (Reese 2005). The flexor hallicus
longus is supplied neural activity by the tibial nerve and has nerve roots at L5 and S1. It
originates on the posterior aspect of the body of the fibula, and the interosseous membrane and it
inserts onto the base of the distal phalanx of the great toe. The flexor digitorum longus originates
on the posterior aspect of the body of the tibia and inserts into the base of the distal phalanges of
the second, third, fourth, and fifth toes (Reese 2005).
Inverters and Everters
The tibialis posterior has a nerve supply from the tibial nerve and nerve roots at L5 and
S1. It originates on the posterior aspect of the interosseous membrane, posterior surface of the
body of the tibia, and proximal two thirds of the medial surface of the fibula and it inserts at the
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tuberosity of the navicular bone, all three cuneiform bones, and bases of the second, third and
fourth metatarsals (Reese 2005). The tibialis anterior originates on the lateral condyle and upper
two thirds of the lateral surface of the body of the tibia, interosseous membrane, and the deep
crural fascia while inserting at the base of the first metatarsal and the medial and plantar surfaces
of the medial cuneiform bone. It collects nerve supply from the deep peroneal nerve and the
nerve roots at located at L4, L5, and S1. The peroneus longus originates on the head and upper
two thirds of the lateral surface of the fibula and inserts on the base of the first metatarsal, and
the lateral aspect of the medial cuneiform. The superficial peroneal nerve supplies the muscle
and the nerve roots are located at L4, L5, and S1. The peroneus brevis is also supplied by the
superficial peroneal nerve and L4, L5, and S1 are the nerve roots. It originates on the distal two
thirds of the lateral surface of the fibula and inserts at the tuberosity of the fifth metatarsal (Reese
2005).
REHAB
Week 1

Modalities
o After exercise rest, ice, compression, elevation and stabilization (RICES) should
be applied with electrical stimulation set to premod.


Precaution should be taken to not place electrodes by screws and plates
Warm Up
o Stretching and ankle circles

Range of Motion
o AROM ankle plantar/dorsiflexion (sitting on elevated surface)

3 sets of 10 repetitions once a day
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
1 rep every 4 seconds (approximately)
o AROM ankle inversion/eversion


3 sets of 10 reps once a day

1 rep every 4 seconds (approx.)
Isometrics
o Isometric ankle plantarflexion

1 set of 10 reps once a day


Hold each rep 10 seconds
1 minute rest between sets
o Isometric ankle inversion/eversion

1 set of 10 reps once a day


Hold each rep 10 seconds
1 minute rest between sets
o Quad sets

1 set of 10 reps once a day



Hold each rep 10 seconds
1 minute rest between sets
Gait
o Stand/pivot transfers on non-involved leg

1 set for 30 seconds
o Weight bear as tolerable

Cardio
o Arm bike for 10 minutes at a steady pace
10

Upper Body Strengthening
o DB bench press

2 sets of 10 reps with 30 lb dumb bells
o Bicep cable curls


2 sets of 10 reps with 15 lb weight
Lower Body Strengthening
o Straight leg raises


3 sets of 10 reps, alternating legs
Core Exercises
o Dead bug for 1 minute
o Cobra position for 30 seconds for 3 sets

30 seconds rest between sets
o Supine leg lifts


3 sets of 15 reps

1 minute rest between sets
Cool Down
o Arm bike for 5 minutes at a comfortable pace
Weeks 2 & 3

Modalities
o Scar tissue massage and removal of staples and sutures
o Ice and premod for 15 minutes after activity to reduce any chance of re-injury

Warm Up
o Stretching and ankle ABC’s
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o 5 minute arm bike at comfortable pace

ROM
o AROM ankle plantar/dorsiflexion (sitting on elevated surface)

3 sets of 10 reps once a day

1 rep every 4 seconds
o AROM ankle inversion/eversion

3 sets of 10 reps once a day

1 rep every 4 seconds
o AROM knee flexion/extension (patient lies on stomach)


3 sets of 10 reps once a day

1 rep every 4 seconds
Isometrics
o Isometric ankle plantarflexion

1 set of 10 reps once a day


Hold each rep for 10 seconds
1 minute rest between each set
o Isometric ankle inversion/eversion

1 set of 10 reps once a day


o
Hold each rep for 10 seconds
1 minute rest between each set
Isometric knee extension

1 set of 10 reps once a day

Hold each rep 10 seconds
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

1 minute rest between each set
Upper Body Strengthening
o Bench press

2 sets of 10 reps with 75 lbs

1 minute rest between sets
o Tricep extensions (sitting)

2 sets of 10 reps with 50 lbs

1 minute rest between sets
o DB curls


2 sets of 10 reps with 25 lbs

1 minute rest between sets
Lower Body Strengthening
o Straight leg raises

3 sets of 10 reps with 2 lb sand weights, alternating legs

1 minute rest between sets
o Quad sets


3 sets of 10 reps, alternating legs

1 minute rest between sets
Cardio
o 10 minute arm bike at steady pace

Core
o Dead bug for 1 minute
o Reverse crunches
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
3 sets of 10 reps

1 minute rest between sets
o Diagonal crunches


3 sets of 10 reps

1 minute rest between sets
Gait
o Stand/pivot transfers on uninvolved side
o Weight bear as tolerated
Week 4

Modalities
o Premod e-stim with ice as tolerated by athlete

Warm Up
o Stretching and 5 minute stationary bike

Aquatics (Beginner Program)
o Athlete is in water up to C7
o Warm Up

Stretch in pool

Walk half width of pool

Backwards walk back to starting position
o Upper Body Workout (3 sets of 10 reps)

Bicep curls with green Styrofoam weights

Wall push ups

Shoulder lateral raises with green Styrofoam weights
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o Lower Body Workout (3 sets of 10 reps)

Ankle circles and ABC’s

Calf raises

Arms on top of wall knee circles

Sideways gait
o Core Workout (3 sets of 15 reps)

Arms on wall, knees flexed, rocking side to side

Arms on wall, knees extended, bring knees up till hips are flexed to 90
o Cardio (10 minutes)

Freestyle swim around pool
o One foot stances with slight knee bend

Upper Body Strengthening
o Pull ups

2 sets of 10 reps
o Push ups


2 sets of 15 reps
Lower Body Strengthening
o Straight leg raises

3 sets of 10 reps with a 5 lb sand weight

1 minute rest between sets
o Leg curls

3 sets of 10 reps with a 2.5 lb sand weight

1 minute rest between sets
15

Core
o Hanging knee tucks

3 sets of 10 reps

1 minute rest between sets
o Diagonal sit ups


3 sets of 15 reps

1 minute rest between sets
Cardio
o 10 minutes on stationary bike at mediocre pace

Cool Down
o 5 minutes on stationary bike at comfortable pace
Week 5

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References
Murphy L., Hoppenfeld, Stanley & Vasantha (2000). Treatment & Rehabilitation of
Fractures. Philadelphia, PA: Lippincott Williams & Wilkins.
http://www.skylarkmedicalclinic.com/Skiinjuries.htm
Praemer, A., Furner, S., & Rice, D.P. (1992). Musculoskeletal Conditions in the United States.
Park Ridge, IL: American Academy of Orthopedic Surgeons.
Sahlin, Y. (1989). Alpine Skiing Injuries [Abstract]. Br J Sports Med, 23, 241-244.
Reese, N.B. (2005). Muscle and Sensory Testing, Second Edition. Philadelphia, PA: Elsevier
Inc. 316-338.
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