Post on 02-Jun-2015
Chronic ankle sprain Rehab Concepts
& Application
B.KANNABIRANSenior Sports Physio
Ankle Sprains in Sports 53% - Basketball19% - Soccer9.3% - Football7.2% - Running
physical therapy guideline for an chronic ankle complaint.
Impaired ankle function
Acute Chronic
TRAUMATICA
TRAUMATIC
POST TRAUMATIC
SYSTEMIC
INFECTION
OSTEOARTHRITIS
POST TRAUMAT
IC
FUNCTIONAL INSTABILITY
SUBTALAR INSTABILITY
DISTAL TIBIOFIBULAR SYNDESMOTIC
RUPTURE
OSTEOCHONDRAL LESIONS & OSTEOPHYTE
SINUS TARSI SYNDROME
WITH NEW DAMAGE
WITHOUT NEW
DAMAGE
ACUTE ANKLE SPRAIN
GUIDELINES
CHRONIC ANKLE SPRAIN
GUIDELINES
WITH SOFT TISSUE
IMPINGEMENT
WITHOUT SOFT TISSUE
IMPINGEMENT
LOOSE BODIES/OCD
DISCUSS WITH
REFERRING
PHYSICISN
Factors involved functional instability Mechanical instability Disturbed Proprioception and balance Reduced muscle strength Slow muscle reaction times Reduced mobility Inappropriate complaint-related
behaviourInadequate acute ankle sprain rehab
Physical therapy treatment goals
To achieve optimal functional recovery.
The highest achievable or desired level of activities.
To prevent relapses, exacerbations and further
dysfunction.
Functional Rehabilitation
Prolonged immobilization of ankle sprains is a common treatment error.
Functional stress stimulates the incorporation of stronger replacement collagen.
The four components of rehabilitation are: 1. Range-of-motion rehabilitation 2. Progressive muscle-strengthening exercises 3. Proprioceptive training 4. Activity-specific training
Range of Motion
• Range of motion must be regained before functional activity is initiated.
• Regardless of weight-bearing capacity, Achilles tendon stretching should be instituted within 48 to 72 hours after the ankle injury because of the tendency of tissues to contract following trauma.
INCREASING THE RANGE OF MOTIONAchilles tendon stretch,
Range of Motion
Alphabet exercises, Move ankle in multiple planes of motion by drawing letters of alphabet (lower case and upper case).
Repeat four to five times a day. Exercises can be performed in conjunction with cold therapy.
ABCs Inversion / Eversion Ankle Pump
PROGRESS ONCE ROM IS REGAINEDOnce range of motion
is regained, and swelling and pain are controlled, the patient is ready to progress to the strengthening phase of rehabilitation.
Training strengthStrengthening of
weakened muscles conditioning of the
peroneal musclesStrengthening begins
with isometric exercises and progresses to dynamic resistive exercises
Muscle Strengthening Isometric exercises, Plantar flexion, Dorsiflexion, Inversion, Eversion,
For each exercise, hold 1 second for concentric component and perform eccentric component over 4 seconds; do three sets of 10 repetitions; repeat two times a day.
Muscle Strengthening
Toe curls and marble pickups, Two sets of 10 repetitions; repeat two times a day. Toe curls can be done throughout the day, at work or at home.
Toe raises, heel walks and toe walks,
Heel walk & Toe walk
Training strength
Training balance & proprioception
747Stable platform747Reverse 747spokes
Reverse 747
Stable platform
747Reverse 747spokes
spokes
Stable platform
747Reverse 747spokes
Training balance and Proprioception
Training balance and Proprioception
Training on the Dyna disc
Training on the Bosu ball
Training on the Bosu ball
Training on the Bosu ball
Functional activities on unstable platform
RETURN TO ACTIVITY-SPECIFIC TRAINING
RETURN TO ACTIVITY-SPECIFIC TRAINING
Complex activity training for football player with chronic ankle sprain
Composite drills
composite drills
STRUCTURE OF REHABILITATION IN SPORTS INJURY
A stepwise approach Increasing the level of difficulty Increasing the speed, duration and dynamic quality of
practiced movements. Training of specific skills Reset Talus in Mortise Peroneal tendon friction massage fibular head mobility
Reset the Talus in the Mortise
• Apply traction with dorsiflexion and eversion• Quick tug to reset the talus in the mortise
Peroneal Tendon Friction Massage
Direct pressure to tendon in perpendicular direction
Increases blood flow to the tendon Increases activity of fibroblasts Decreases fibrosis/adhesions Most effective with stretching and
functional exercise
Correct posterior fibular head – Passive Motion
•Patient supine, knee flexed
•Sit on foot
•Stabilize knee with hand
•Pull fibular head anterolaterally and then push posteromedially repeatedly
Correct posterior fibular head – Muscle Energy
Remember “PIP AID”
For a Posterior fibular head, Invert and Plantarflex
For an Anterior fibular head, Invert and Dorsiflex
Correct posterior fibular head - HVLA
•Patient supine, knee flexed•Physician’s hand in popliteal fossa, 1st MCP joint behind fibular head•Flex knee, externally rotate leg at knee•Thrust patient’s ankle toward buttocks
Exercising functions and skills• A symmetrical and dynamic gait should be strongly encouraged.• All relevant daily life activities should be
exercised.
Training for Return to Activity• When walking a specified distance is no longer limited by pain,
the patient may progress to a regimen of 50 percent walking and 50 percent jogging.
• When this can be done without pain, jogging eventually progresses to forward, backward and pattern running. Circles and figure-eights are commonly employed for pattern running.
• Although these routines are time-consuming, they represent the final phase and are essential for the recovery of ankle stability.
AQUA AEROBICS VERY USEFUL IN EARLY RETURN TO
ACTIVITY
Plyometrics
Relapses prevention
TREAT WITH PRICER NO MORE RICE REGIMEN FOR ANKLE
P.R.I.C.E.R ProtocolsProtectRest limit weight bearing, crutches if necessary,
an ankle brace helps control swelling and adds stability
Ice No ice directly on the skin, no ice more than 20 minutes at a time to avoid frost bite.
Compression can be helpful in controlling swelling and is usually accomplished with an ACE bandage.
Elevate above the waist or heart as neededRehabAOFAS updated Jan 2008
Relapses preventionAfter finishing therapy, to pay attention to
sports specific as well as prevention training.Use new sports shoes
No taping or braces during training sessions use only at high risk sports
Injury PreventionNeuromuscular Control is the ability to
compensate for uneven surfaces or sudden change in surfaces. It is retrained by using balance and agility exercises such as a BAPS board or standing on one leg with eyes closed as well as using a single leg on a mini trampoline.
Take home messageTreatment of ankle sprain should consist of
an exercise program that is as varied and intense as possible to obtain optimal ankle functioning
The target performance level should be achieved at the end of treatment
Do evaluate the eversion “red-headed step child”
Whirl Pool/AquaAerobics If AccessibleOf course Neuromuscular control
Thank you for your attention
Questions?…before hands-on
practice
REFERENCESImmobilisation and functional treatment for acute
lateralankle ligament injuries in adults (COCHRANE Review)Kerkhoffs GMMJ, Rowe BH, Assendelft WJJ, Kelly KD, Struijs PAA, van Dijk CN(2009)
Clinical practice guidelines for physical therapy in patients with chronic ankle sprain RA de Bie PT PhDI, MAMB Heemskerk PTII, AF Lenssen PT MScIII, SR van Moorsel PTIV, G Rondhuis PTV,DJ Stomp PT MScVI, RAHM Swinkels PT MScVII, HJM Hendriks PT PhDVIII(ROYAL DUTCH SOCIETY GUIDE LINE FOR PHYSIO 2003)