Ankle Rehabilitation Research to Reality Joe Lueken, MS, LAT, ATC Carrie L. Docherty, PhD, LAT, ATC
Conflict of Interest Statement The views expressed in these slides and today s discussion are ours. Our views may not be the same as the views of the GLATA or NATA. Participants must use discretion when using the information contained in this presentation.
On June 17, 2002, Milwaukee Brewers outfielder Geoff Jenkins lunged back to third base, and caught his cleats on the bag while his leg kept moving forward. DX: dislocated ankle and ligament damage, but no broken bones.
On June 17, 2002, Milwaukee Brewers outfielder Geoff Jenkins lunged back to third base, and caught his cleats on the bag while his leg kept moving forward. DX: dislocated ankle and ligament damage, but no broken bones.
Epidemiology Ankle Sprains are the most frequent injury in athletics o NCAA Injury Surveillance System 15% of all injuries (Hootman et al) o.83 sprains per 1000 athlete exposures (Hootman et al)
Epidemiology General population it is more difficulty to calculate o 2 million patients in the US sustain an ankle sprain each year (Soboroff et al 1984) o Only 50% of LAS patients may seek formal care (Valderrabano et al 2009; Nieuwe Weme 2015)
Epidemiology Approximately 40% of people sustaining an ankle sprains will have: o Recurrent injuries o Feelings of instability, pain, and/or swelling o Osteoarthristis
Anatomical Structures Ankle sprains cause damage to the ligaments, but also the muscles, tendons, and nerves that cross the joint Sprains may also contribute to ankle joint degeneration All of these structures must be considered in the rehabilitation process
Treatment and Rehabilitation Limited and/or abbreviated rehabilitation 7 sessions 9 sessions
Treatment and Rehabilitation Limited and/or abbreviated rehabilitation Expedited return to activity
Are we returning athletes to activity too quickly?
Healing Cycle Phases Hemorrhage and inflammation Proliferation and replacement Maturation and remodeling www.health-disciplines.ubc.ca/whiplash.bc/module1/
We under estimate the o Time it takes for healing to occur o Potential residual symptoms as a result of improper rehabilitation Inflammatory Phase Proliferation Phase Maturation Phase 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 Days Post Injury
Conservative Treatment Goals o Treat Acute symptoms o Protect against future injury o Return the injured ankle to pre-injury status Range of motion Muscle strength Neuromuscular control Functional activities
Acute Phase Goals: - Protect from further injury - Pain relief - Control swelling - Reduce secondary hypoxic injury PRICE
Acute Phase: Protection PRICE o Provides support to the joint o Provides proprioceptive and sensory feedback PRICE o o Neoprene or lace up brace should be intermittently used during strength, balance, and functional exercises (Mattacola & Dwyer 2002) Limited/conflicting evidence that reports the effectiveness and specific treatment parameters of ICE NATA position statement graded a Level C
Protect Optimal Loading Ice Compression Elevation
Acute Phase: Protection injury and severity dependent LAS lace up brace Syndesmotic Sprain high ankle sprain walking boot/aircast minimum 3-10 days crutches use until gait WNL
Acute Phase: Pain/swelling control STM with elevation elevation with AROM (ankle pumping) cryotherapy ace wrap or stretch tape focal pad
Other interventions to reduce swelling Contrast bath during subacute phase (limited to no published research) Hyperbaric Oxygen Therapy o No effect on reducing volume (Borromeo et al 1997) Low-level laser treatment o Significantly reduced edema after 1 treatment (Stergioulas 2004)
Acute Phase: Pain/swelling control modality use HIVAMAT with elevation electical stim/ice/elevation Game Ready with elevation low level laser manual resistance isometrics medication use Prescribed or OTC
Recent evidence related to reducing swelling Kinesiology tape Instrument Assisted Soft Tissue Mobilization
Results of Early Investigation: Graston Technique Small sample size In vivo investigation No change in volumetric measures Coincidental Findings Suggestive of further investigation oreturn to participation od/c of assistive devices odecrease in symptoms
Acute Phase: Total Body continue UE lifting continue core work use of brace/tape support while working these activities **carried on throughout rehab process
Sub-Acute Phase Continue to work on pain/swelling Continue to protect prn with bracing Initiate functional rehabilitation o Restore ROM- esp. dorsiflexion o Restore muscular strength o Restore sensorimotor function
Sub-Acute Phase: Pain/swelling control Prolonged immobilization has a detrimental effect on joint structures Early motion (within 48-72 hours post injury) o Reduces muscle atrophy (Booth 1987) o Prevent ligamentous creeping or excessive scarring (Woo 1990) o Stimulated ligament healing (Tipton 1970) o Expedited return to activity (Ardevol 2002)
Sub-Acute Phase: Pain/swelling control STM with elevation ASTM elevation with AROM cryotherapy modalities elastic stretch tape focal pad
Sub-Acute Phase: ROM initiate more aggressive AROM write a letter in CWP stressing pain free motion alphabet writing quicker with increased AROM ankle pumps while elevated seated to standing BAPS
Sub-Acute Phase: ROM return to near/or full ROM joint mobilization techniques for deficits calf stretching for DF and sitting on heels for PF
Restricted dorsiflexion Decrease in contralateral limb stride length Decrease in overall stride or walking speed Shortened single limb support on the involved side Crosbie et al 1999
Sub-Acute Phase: Proprioception Progression: firm surface to unstable surface eyes open to eyes closed bilateral to unilateral stance positions steps ups with opposite leg hip flexion and hold
Sub-Acute Phase: Proprioception adding difficulty
Sub-Acute Phase: Strengthening manual resistance band work heel raises step ups/downs
Sub-Acute Phase: Strengthening Impulse
Sub-Acute Phase: Strengthening/functional Balance with movement and strengthening step ups/downs/overs touch downs
Sub-Acute Phase: Strengthening - Functional PNF
Sub-Acute Phase: Functional walking cariocas walk on toes/heels retro walking side stepping walking cutting * done with protection prn * advance to quicker pace
Sub-Acute Phase: Functional monster band walks speed skaters forwards and backwards
Sub-Acute Phase: Strengthening (Proximal joint) Patients with ankle injuries: o Hip Abduction and Adduction strength deficit (Nicholas et al 1976) o Delayed hip muscle activation during inversion stress (Beckman and Buchanan 1995) Greater focus should be placed on Gluteus medius strengthening for Prevention and Rehabilitation of ankle injuries
Long Term Rehabilitation Usually starts about 7-10 days post injury Normal gait and pain-free to palpation Goals: o Continue to protect healing ligaments o Return to full ROM o Return to full concentric and eccentric strength o Restore sensorimotor control o Progress to functional activities
Interrelationship between phases of rehabilitation Balance Training Coordination Training Strength Training Strength Balance Tropp1988; Gauffin et al 1988; Wester et al 1996
Interrelationship between phases of rehabilitation Balance Training Coordination Training Strength Training Balance Proprioception Bernier 1998; Holme 1999; Blackburn et al 2000
Interrelationship between phases of rehabilitation Strength Balance Training Coordination Training Strength Training Proprioception Docherty et al 1998; Blackburn et al2000
Long Term Rehabilitation: Restore Neuromuscular control Alteration in motor conduction velocity of the peroneal nerve is common following a LAS Decreased neurological reaction time can persist for 12 weeks while strength has returned to normal (Kleinrensink et al 1996)
Long Term Rehabilitation: Function Final stages of rehabilitation Restore dynamic strength, balance and power
Long Term Rehabilitation Goals: monitor pain/swelling prn full AROM/PROM/RROM full functional stability/ability return to sport
Long Term Rehabilitation: Proprioception
Long Term Rehabilitation: Proprioception advance difficulty
Long Term Rehabilitation: Proprioception
Long Term Rehabilitation: Functional/Strengthening combined for final rehabilitation phase most activities geared towards return to play sport specificity
Long Term Rehabilitation: Functional/Strengthening
Long Term Rehabilitation: Functional/Strengthening hopping/jumping drills all directions perform bilaterally
Long Term Rehabilitation: Functional/Strengthening
Long Term Rehabilitation: Functional/Strengthening Running: start straight line and add more basic and then advanced cutting activity increase speed as able add stops for maintaining balance do all functional running - cariocas, side stepping, retro
Long Term Rehabilitation: Functional activities
Long Term Rehabilitation: Functional/Strengthening RTP: limited return to drills while protected increase according to pain/swelling/function full RTP decrease and finally stop protection as able
Conclusion
Conclusion
Conclusion Comprehensive, long-term rehabilitation protocols need to occur following an ankle sprain While acute systems may resolve, neuromuscular damage persist Without sufficient rehabilitation of these deficits functional ankle instability or persistent symptoms of pain and giving way continue Greatest predictor of future ankle sprains is the history of previous sprains