Anna Nelsen

Spring 2022
D1 Lacrosse Player Tarsal Tunnel Surgery Rehab: A Case Study by Anna Nelsen
 I. Introduction to Subject and Needs

The subject is a D1 female lacrosse player who had surgery on February 1st, 2022 to
release her tarsal tunnel syndrome. Tarsal tunnel syndrome is the compression of the
posterior tibial nerve, which causes inflammation, irritation, and pain, and is released
with the surgery. Tarsal tunnel syndrome is typically treated conservatively first, but
requires surgery if pain does not improve. In her right foot, the athlete has a history of
two stress fractures, and a cist. The cist was removed in 2021, but the athlete still
experienced cramping in muscles of toes and foot. Dr. Porter diagnosed it as likely being
tarsal tunnel syndrome and tendonitis of the anterior tibialis, as this muscle was
constantly contracted. She got tested for compartment syndrome and was negative for it.
The athlete also got nerve conductivity testing done twice, which confirmed the tarsal
tunnel syndrome diagnosis. She was treated conservatively after the diagnosis with
cortisone shots, and manual soft tissue work by her athletic trainer. Pain still continued,
so the decision was made to undergo surgery.

II. Rehab Plan

Walk to Run Progression

● 2/21: Underwater treadmill - 15 min. @ 2-2.2 mph (use handrails for support most
of time)
● 2/22: Indoor bike - 35 min. in training room, 10 min. on your own
● 2/23: Underwater treadmill - 15 min. @ 1.8 mph (progress to 1 min. without
hands on handrails, 2 min. with hands on handrails)
● 3/3: Underwater treadmill - 20 min. @ 2.2 mph
○ 2.6 mph for the last 2-5 min.
○ Walked about 0.6-0.7 mi total
● 3/4: Athlete did stairmaster, elliptical, and bike on her own at the HRC to
maintain cardio and work on her walk progression
● 3/18: Underwater treadmill - 2 min. 30 sec walking warm-up @ 2.2 mph; 15 min.
of continuous running @ 4.4 mph
○ Ran 1 mi total
● 3/21: Underwater treadmill - 20 min. run on the underwater treadmill (athlete ran
21 min. total) @ 4.8 mph for 15 min., and able to increase to 5 mph for the last
5-6 min.
○ Ran 1.6 mi total
○ Majority of time without holding handrails to work on true gait and
balance
● 3/23: Underwater treadmill - 20 min. run @ 5 mph
 ● 4/5: Underwater treadmill - 20 min. run @ 7 mph
● 4/7: Running on turf (land for first time) - 4 half field laps - walk the long sides,
jog the short sides
○ Athlete will now run 3x a week, with 1 rest day in between each run
○ Ran without brace by mistake
● Not sure on the date for this: Running on turf (land for 2nd time) - walk the short
sides, jog the long sides (progression from 1st time running on land)
○ Ran with a brace this time
● 4/12: Underwater treadmill - 25 min. Run @ 5.5 mph
○ Ran 2.2 mi total
● 4/18: Running on turf (land for 3rd time) - 4 full laps (30 sec active walking rest
in between each lap)
○ Ran 1 mi total
● 4/21: Running on turf - 4 full laps
● 4/26: Running on turf - 4 full laps
○ Will progress in speed or volume depending on how the athlete feels

Exercise Progression

Week 1:
● Nothing yet—had surgery 2/1/22

Week 2:
● Mobility:
○ Toe flexion “curls” - 2x12
○ Seated toe extension - 2x10
● Pain Management:
○ Nerve desensitization - once a day
■ With cotton ball or blanket
Week 3:
● Mobility:
○ Standing non-weight bearing toe raises (extension) - 2x12
■ Progression from seated toe raises (extension)
○ Toe flexion “curls” - 2x12
● Strengthening:
○ Full weight-bearing on right foot (hold onto something for stability) -
bouts of 20 sec on, 20 sec off for 3 min. Total
○ Marble pick-ups - ½ of the cup of marbles
■ Also for proprioception
 ● Strength & Mobility:
○ Banded ankle pumps (plantar flexion, inversion, eversion, dorsiflexion) -
2x10 with red TheraBand
○ Ankle ABCs

Week 4:
● Mobility:
○ Marble pick-ups - full cup
● Strengthening:
○ 2/24: 20 calf raises (progress from in pool to on land), and continuing
strength & mobility exercises on her own (progressed from red TheraBand
to green TheraBand today for her banded ankle pumps)

Week 5:
● Mobility:
○ Active assisted toe curls -
■ 3 times a week
○ Tandem ankle mobility - 2x6
■ Athlete was able to do 2x8 today
○ Scar tissue mobilization - every day
○ Marble pick-ups - one full cup
○ Ankle ABCs
● Strengthening:
○ Double leg (DL) calf raise to single leg eccentric down - 20 reps
● Strength & Mobility:
○ Banded ankle pumps (plantar flexion, inversion, eversion, dorsiflexion) -
2x10 with green TheraBand
● Balance:
○ Single leg (SL) balance - 20 sec to start—too easy, so changed to 45 sec
on 15 sec off for 3 min. total
■ Use fingers on table to balance as needed
● Strength exercises 3x per week, mobility every day

Week 6:
● This week was Butler’s Spring Break, so I was not able to closely monitor the
athlete. Upon returning to campus after break, she reported that she continued her
exercises on her own, and that her mom assisted her with scar tissue
mobilizations, and attempted active assisted toe curls two times this week.

Week 7:
 ● Mobility:
○ Tandem ankle mobility - 2x8
○ 3/18: Active assisted toe curls - 15 consecutive reps
● Strengthening:
○ 3/15: DL calf raise to SL eccentric down
○ 3/18: SL calf raises - 2x10 (progression from DL calf raises on 3/15)
○ 3/18: SL bunny hops in the pool - 1 min.
● Strength & Mobility:
○ Banded ankle pumps (plantar flexion, inversion, eversion, dorsiflexion) -
2x10 with silver TheraBand
■ Progression from green TheraBand
● Balance:
○ SL balance with ball toss - 3x15

Week 8:
● Mobility:
○ 3/21: Tandem ankle mobility - 2x10
○ 3/21: Marble pick-ups - one full cup
● Strengthening:
○ 3/21: SL calf raises - 2x10
■ Use fingers on table to balance as needed
○ 3/24: Bodyweight (BW) squat with heels elevated - sets and reps are same
as those prescribed by the strength coach for lift days in the weight room
■ Good to get her back in the weight room for not only physical
aspect, but mental and social aspects of return to sport
■ Also tested lunge today, but not quite ready for it yet due to ankle
mobility still improving
○ 3/24: DL bunny hops on land - 3x1 min.
■ Progression from SL bunny hops in the pool
● Balance:
○ 3/24: SL balance with eyes closed - 3x45 sec
■ This is a progression from the SL balance ball toss
■ Also works on proprioception

Week 9:
● Strength and mobility:
○ Athlete is continuing exercises at home on her own - silver band is getting
easier
● Balance:
○ Focusing on improving SL balance with eyes closed
 Week 10:
● Mobility:
○ Athlete is continuing exercises at home on her own - tandem ankle
mobility is getting easier
● Strengthening:
○ BW squat with heels elevated is improving
● Strength & Mobility:
○ Silver band is fairly easy
● Pain Management:
○ Continuing nerve desensitization with blanket as feeling is continuing to
come back

Week 11:
● Athlete is still continuing exercises at home on her own
● Pain management:
○ Water massage - a few minutes (as much as desired by athlete)
■ Athlete self-adjusted intensity as tolerable
■ Focused on lower leg (posterior tib), ankle, and foot

Week 12:
● Athlete is still continuing exercises at home on her own
● Strengthening:
○ Continuing to do modified lift with the team (BW only is still prescribed)
● Mobility & Pain Management:
○ Aggressive calf stretching has been previously prescribed for 3-5 times a
day (athlete has been stretching calves once a day - taking a small step and
progressing to twice a day)
Week 13:
● Strengthening:
○ Bunny hops - 3x45 sec
● Continued balance exercises

III. Weekly Progress Reports

Week 1: In this first week, we focused on decreasing pain, and controlling swelling?
(look back at what Ralph said about the first 24-48 hours after injury)

Week 2: This week, it had been one week since her surgery, so the athlete still had a lot
of pain and swelling. Due to the nerve block and previous nerve damage, she did not have
a lot of feeling in her foot and ankle, but she did have a little feeling in her posterior foot
up into her lower leg along the posterior/proximal portion of her scar. Initial ROM
measurements were taken with a goniometer to assess mobility, and ankle girth
measurements to track swelling. She is at 112° of dorsiflexion, and 132° of plantar
flexion. Her pain this week was moderate to high, and she had about one inch of
swelling, as determined by her right ankle girth measurement of 20 in., compared to her
left ankle girth measurement of 19 in. She can tolerate up to about 90 degrees of passive
dorsiflexion. This week, she was able to move her fifth toe by itself for the first time.
Treatments this week performed by her athletic trainer included a flush massage to work
on getting the swelling out, cleaning the wound, and changing the dressings to prevent
infection. She is in a boot and using two crutches to get around. The athlete did
desensitation of the area around her scar using a cotton ball or blanket to help desensitize
the area as her feeling comes back so that it is not too overwhelming when it does come
back.

Week 3: As of February 15th, she was able to walk with one crutch and a boot. She felt
more mobile because of the flush massage. Her swelling continues to track up her leg,
and the swelling around her scar is like edema because it is sitting in thick pockets.

The athlete got her stitches out on February 16th. She was given instruction to remain in
the boot during the day from 8 am until 4 pm, and progress to a brace and a shoe in the
evenings. She is able to bear full weight on her right foot when holding onto a table.

As of February 18th, she was able to walk in just the boot without crutches, and was able
to resume daily life activities such as grocery shopping.

Her dorsiflexion increased to 105° by the end of the week, and her plantar flexion
improved significantly at 155°. Her right ankle girth varied between 19 ¾ in. and 20.5 in.
Her pain ranged from 3 to 9, with nerve pain increasing by the end of the week as she
regained feeling.

Treatments performed by the athletic trainer this week included flush massages to help
move the swelling out of the area, heat, ice, and she was also able to use the GameReady
for the first time. The AT continued cleaning her wound and changing her bandages as
the wound closed up and underwent the healing process.

On February 16th, she was given an ASO brace that mimics ankle tape to fully support
and stabilize her ankle and foot when she wears it with a shoe in the evenings.
Week 4: The athlete’s scar is healing up really well, and the bruise on the lateral side of
her foot is almost healed. Some of her swelling pockets have improved She is gaining
more feeling on the bottom of her foot and heel. The athlete was able to fairly quickly
move between plantar flexion and dorsiflexion, and was eager to start driving again. The
athletic trainer put her through a few tests, and determined that her ankle was not quite
there yet, but that she should be able to drive soon and needed to practice in an empty
parking lot before driving on the road.

She had not quite gotten her normal gait back due to her limited ankle ROM, and was
pretty straight-legged when walking because she was not able to contract her calf, and her
foot felt tight. Her exercises continued to progress in difficulty.

On February 21st, she started walking on the underwater treadmill. She said she felt like
most of her weight was on the outside of her foot due to the tightness she felt on her
medial ankle and foot. We watched as she walked to make sure that she was maintaining
proper gait. She started out using the handrails, and we had her gradually not use them as
much to work on balance and proper gait.

Her dorsiflexion got up to 96 ¼°, and her plantar flexion got up to 158°. She still had ¾
inch to an inch of swelling as indicated by her right ankle girth measurements. She had a
couple of higher pain days than she had been having at a 4 or 4.5 as she regained feeling
in her foot and was increasing exercise with biking, the underwater treadmill, and rehab
exercises.

Week 5: The athlete was alternating daily between the brace, and boot. She still does not
have feeling all the way back in her foot, especially the bottom of her foot, side, and her
upper foot near her toes. She still has a bruise on the bottom of her foot that the athletic
trainer has not been able to get out because that area is too sensitive for her, but the bruise
appears to be lighter and further along in the healing process than in previous weeks.

As of March 3rd, she started driving very short distances. She was also able to walk
around at home without a brace. The athlete was experiencing soreness and a tight
achilles due to the constrictive nature of the brace. She still felt like she was unable to
activate her calf, and was also experiencing pain on her arch due to the tight muscles that
attach there. On March 4th, she was finally able to curl her big toe on her own during
active assisted toe curls. She continued to try to get movement in this distal joint, and we
continued to monitor this movement as she completed marble pick-ups to ensure she was
curling her toe at that joint rather than folding her toes in.
Her exercises were all progressed to work on strength, mobility, and balance, and she
continued nerve desensitization as well. She was able to get up to 95° of dorsiflexion, and
159° of plantar flexion, and had between 0.5 in. and 2 in. of swelling this week. Her pain
was at a consistent 4 for most of the week, which is on track for our goal of consistent 3s.
I started taking all of her measurements for this week and on, and her athletic trainer took
all of her previous measurements in weeks two through four.

Treatments this week included flush massages to work on pushing out swelling, soft
tissue work around the scar with Graston tools or fingers to break up swelling, and scar
tissue mobilizations to aid in the re-alignment and healing process of the scar tissue.

Week 6: During this week, we did not see the athlete because Butler was on Spring
Break and she was not in town. The athlete reported that she continued her exercises over
break, and that her mom, a nurse, did scar tissue mobilizations, and massaged her foot.
She only did the active assisted toe curls twice over break because her mom did not fully
understand how to do them. There were also no measurements taken as it was Spring
Break.

Week 7: She was still experiencing tightness on the inside of her ankle, and tightness and
sensitivity on the distal ⅔ of her scar. During her double leg calf raise to single leg
eccentric down exercise, she experienced a shooting pain on the inside of her ankle and
leg as well. Her gait looked mostly normal and smooth both with and without the
brace—she is progressing nicely in the brace and shoe. The athlete had a follow-up
appointment with her surgeon on March 17th. Everything looked normal, and the athlete
was given a progress report to share with the athletic trainer. To assist with her nerve
pain, the doctor is going to start her on Neruontin, which she will take for two months
and gradually wean off of as the pain decreases. She was also cleared to start running on
the underwater treadmill, and began a two-week running progression on March 18th.
Additionally, the athlete is out of the brace now, and will only have to wear it during land
running.

This week, the athlete’s dorsiflexion improved to 89°, which is the best it has been
post-surgery. Her plantar flexion is at 158°, and her right ankle girth got to the lowest it
has been thus far at 19 ¼ in. Additionally, her strengthening exercises looked better and
easier for her to get through than before break, specifically the DL calf raise to SL
eccentric down, and the SL balance. There seems to be more mobility with the tandem
ankle mobility exercise, but measurements were not taken for these exercises, so this is
not supported by concrete evidence.
Treatments this week included ankle joint mobilizations, Graston scraping around her
scar, as well as manual soft tissue work.

Week 8: The athlete’s walking gait looks very smooth and natural, and appeared easy for
her. She was experiencing a tingling feeling in her toes, and shooting pains in her foot
when she pressed down on certain areas. This tingling feeling is occurring as she is
regaining nerve function and feeling in certain areas—specifically the distal ventral
portion of the foot and toes. Additionally, er lower leg, foot, and ankle were all sore,
specifically her posterior tibialis. For her measurements this week, dorsiflexion fluctuated
between 77° and 84°, plantar flexion fluctuated between 159° and 173°, and the girth of
her right ankle was the lowest it was been at 19 inches, which is comparable to her
contralateral ankle.

One of her exercises was progressed this week to work on balance, and two were added
to improve strength. It was determined that she was not quite ready for lunges after we
observed her attempt the exercise, but she is able to do a bodyweight squat with her heels
elevated. The lunge will be added once she has increased ankle mobility. She was able to
pick up a full cup of marbles in half the time that she took to pick them all up with her
toes the previous time.

Overall, the athlete was optimistic about the underwater treadmill and being out of the
brace. She was experiencing a little bit of achy pain on her medial ankle when walking,
and is continuing to experience soreness in her calf, and posterior tibialis, which is likely
due to her increase in activity as she is cleared to progress in her rehab exercises and
walk to run progression.

Treatments this week included Graston scraping and manual soft tissue work, varying
based on athlete’s tolerance, to continue pushing the swelling out of the area above and
below her scar. The athlete is also stretching her calves to decrease calf soreness.

Week 9: The athlete has a knot on the bottom of her foot right below where the bruise
was. She was experiencing tightness and pain in her whole ankle and foot due to
increased activity, and regaining feeling.

The athlete is focusing on balance with her exercises as her lack of feeling in her foot
impedes her proprioception, and thus her ability to make adjustments to maintain her
balance. Her dorsiflexion was at 87°, and her plantar flexion was at 167°. Dorsiflexion
was a little higher, and plantar flexion was a little lower than in previous weeks likely due
to the increased activity and pain that she has been experiencing in the past few weeks.
The girth of her right ankle stayed at 19 in., indicating that the swelling has not increased.
The range of motion (ROM) of her contralateral side (left ankle) was measured to
compare to the ROM of her right ankle. Her left ankle plantar flexion was at 176°,
whereas her right ankle plantar flexion was at 166°. Dorsiflexion of her left and right
ankles were the same at 86.5°. These measurements indicate that her ankle mobility is
about the same in her injured and non-injured sides, meaning that she is making progress
towards return to play.

Treatments this week by her athletic trainer included soft tissue massage over the knot on
the bottom of her foot and around her scar, as well as cupping on the area of the posterior
tibialis to aid with soreness.

Week 10: The athlete is regaining some feeling on the bottom of her foot, but still has a
knot there, and also has a few tight painful spots in the proximal ⅓ portion of her leg. She
still has a knot on the bottom of her right foot, and following palpation, her athletic
trainer discovered that she has the same knot in her contralateral foot due to her
biomechanics. The athlete is also still experiencing pain on the bottom of her foot in the
distal portion near her toes and along the side of her foot. Her athletic trainer advised her
to stretch her toes and walk around her house barefoot to continue the nerve
desensitzation and decrease pain from the regaining of nerve function.

The athlete started running on land for the first time this week, and will now run three
times a week on the turf, with a rest day in between each running day. The first run went
well, but she forgot to wear her brace, so she was significantly sore, and her pain level
increased.

The athlete said that a few of her strength and mobility exercises are getting easier. Her
right ankle plantar flexion increased to 174°, which is only 2° away from her left ankle
plantar flexion. Her right ankle dorsiflexion was at 84°, which is an improvement from
last week, and better than her left ankle mobility.

Treatments this week included cupping over the posterior tibialis, scraping around her
scar and foot, joint mobilizations, and manual soft tissue work on the knot and the bottom
and medial side of her foot.

Week 11: The athlete is still experiencing tingling sensations, and paresthesia on the
bottom of her foot, but the shooting pains have ceased. Following lift in the weight room,
she felt unsteady due to significant fatigue in her calves and ankle. However, she did
water massage one day this week and felt decreased soreness/tightness in her posterior
tibialis. The athlete continued running on the underwater treadmill this week.
 Treatments this week included manual soft tissue work below her scar, and on the
posterior tibialis, as well as cupping on her posterior tibialis to continue loosening that
muscle up. No measurements were taken this week because her mobility will remain
consistent for a while, and her swelling and pain are going to keep fluctuating naturally
with the increase in activity. Any changes seen in her scar and mobility would likely be
miniscule.

Week 12: The athlete’s calves have continually been tight, so she has been prescribed
aggressive calf stretching three to five times a day. She is currently only stretching once a
day, so we will take a small step and increase it to twice a day until she can work up to
three to five times a day. Additionally, she is still experiencing the most sensitivity on the
“curve” of her scar—the middle portion.

The athlete ran outside on the turf for the third time, and her previous turf run went well
with the brace on, compared to the first time when she ran with the brace off. It was a bit
of an overwhelming week for her, and she was in a little more pain, so the run day was
pushed back a day this week.

Treatments this week included cupping and flush massage on her calves, scraping on her
foot and calves, and manual soft tissue work on the bottom of her foot.

Week 13: The athlete’s back and calves were sore from lifting in the weight room. To
help alleviate this, her athletic trainer cupped both areas. Additionally, she ran on the turf
again this week the same amount she has been running, but reported that it is feeling
easier. For her next run, her athletic trainer will progress her in either volume or intensity.
After the run, she did three sets of forty five second bunny hops, as well as some balance
exercises. Her athletic trainer is hoping to get her in some drills at practice by the end of
the week.

IV. Final Assessment and Outcome

This case study is not complete quite yet—I am going to continue following the
athlete’s rehab progression until she returns to play. Her criteria for full return to play is
being able to run for thirty minutes straight, or two miles (whichever comes first) without
pain. This serves as a summative assessment, and will determine when she is ready to
return to play. Her ankle mobility has improved greatly from where she started post-op,
and is about the same on both sides, indicating that she checks the box for return to play
from the ankle mobility standpoint. The athletic trainer will also likely ensure that she has
adequate strength and balance to prevent further injury prior to returning to play.
V. Conclusions

Overall, the athlete has made excellent progress in a few short months. Her ROM
has improved in her injured ankle to be equal to her contralateral ankle. The scar tissue
feels excellent and is mobile as it should be. She is close to returning to play, and is
continuing to see her athletic trainer for maintenance work and further rehab
progressions. This case study can not be repeated, but is valuable in demonstrating rehab
progressions for strength, mobility, balance, and walk to run, and includes interesting data
as tarsal tunnel syndrome has a fairly low annual incidence rate.