Overview ●  Lateral ankle sprains are the most common sports injury (Godges & Klingman, 2014)

●  Conservative treatment: o  Aggressive rehabilitation, bracing, taping, and/or orthotics

(UW Sports Medicine, 2014)

●  20% of lateral ankle sprains can lead to chronic pain and instability (UW Sports Medicine, 2014)

●  Surgical treatment: o  Indications: third degree ankle sprains, chronic instability (w/ extreme

laxity), interference with ADLs, and/or limitations in activity level (Starkey, 2013)

●  Anterior Talofibular Ligament (ATFL)

●  Calcaneofibular Ligament (CFL) ●  Posterior Talofibular Ligament

(PTFL) ●  Chronic ankle instability:

o  Mechanical insufficiencies o  Functional insufficiencies o  Combination of both

(Brigham and Women’s Hospital, 2010; Hertel, 2002; Kraemer, 2014)

Anatomy of the Ankle

www.methodistorthopedics.com

www.comstockpt..com

Nonaugmented (Anatomic) Lateral Ankle Repair ●  Brostrom, modified Brostrom techniques

o  Primary repair of the ruptured ligaments !  Preferred method - does not cross the subtalar joint, !  Can result with a 85% success rate and return to sport rate

o  Accelerated rehab with no immobilization (faster return to play) (de Vries et al., 2011; Karlsson, 1999; Miyamoto, 2014)

Surgical Procedures

Augmented (Tenodesis) Lateral Ankle Reconstruction ●  Evans, Watson-Jones, Elmslie-Trillat, Chrisman-Snook

o  A portion of the peroneus brevis tendon is used to reconstruct the lateral ligaments

o  Used with more severe cases (greater extent of ligament damage) o  “Satisfactory stabilization in > 90% of patients after 10 years”

(Stapp et al., 1996) !  Poor long term results (persistent pain, degenerative changes,

restricted subtalar motion)

(Baumhauer & O’Brien, 2002; OrthopedicsOne, 2014; Starkey, 2013; William Beaumont Army Medical Center, 2005)

Surgical Procedures

Surgical Procedures

Nonaugmented Repair Augmented Reconstruction

(Starkey, 2013)

●  Initial Rehabilitation (0-6 weeks) o  Phase I: Weeks 1-2

!  Pain management o  Phase II: Weeks 3-6

!  Reconst.: Minimize quad atrophy and deconditioning

!  (Repair: early mob. " ankle ROM, no PF or inv.)

●  Beginning Strengthening (6-12 wks) o  Phase III: Weeks 6-10

!  Ankle rehab (WB in boot) o  Phase IV: Weeks 11-12

!  Full ROM (WB in shoe)

Timeline

(Minnesota Orthopedic Sports Medicine Institute, 2014; Workers’ Compensation Board, 2005)

●  Advanced Strengthening (12-16 weeks) o  Phase V: Weeks 12-16

!  Strength, proprioception o  Phase VI: Weeks 16+

!  Endurance, specificity

●  Return to Sport

Phase I: Weeks 1-2 ●  Goals:

o  Rest and recovery from surgery o  Control swelling and pain o  Increase ADL

●  Interventions: o  Rest and elevation to control swelling o  Physician prescribed medications for pain o  Hip and knee AROM o  Patient education

!  Sutures removed at 10-16 days, back in cast for another 4 weeks

Initial Rehabilitation

(Minnesota Orthopedic Sports Medicine Institute, 2014)

Treatment

(orthoinfo.aaos.org, 2014)

(madclouds.com, 2014)

*Avoid all strenuous physical activity – keep foot elevated!

Initial Rehabilitation Phase II: Weeks 3-6 ●  Goals:

o  Edema control / reduction o  Protect healing tissue o  Maintain upper body, core, hip, knee strength and ROM

●  Interventions: o  Elevation to control swelling o  Core exercises o  Hip / knee: AROM, strengthening, stretching o  Patient education

!  Cast removed at 6 weeks (Minnesota Orthopedic Sports Medicine Institute, 2014)

●  Core exercises o  Abdominal recruitment o  Crunches, scissors, bicycle

●  Hip: AROM

o  Strength: clamshells, sidelift (plank), glut max (donkey kicks), SLR

●  Knee: AROM

o  Strength: SLR, theraband press (flexion/extension)

Initial Rehab Exercises ●  Stretching

o  Gluteus maximus and medius, piriformis, rectus femoris, hamstrings

●  Upper body

o  All upper body exercises as tolerated

o  UBE

●  Ankle exercises (healthy ankle) o  Strength/ROM to increase blood

flow to opposite ankle

(Minnesota Orthopedic Sports Medicine Institute, 2014)

Initial Rehab Exercises

Hip Clam Shells (durablehealth.net, 2014)

Single Leg Raise

(emi2hips.com, 2014) Upper Body Lift

(sprouthealthlifestyle.com, 2014) *Repairs: avoid plantarflexion and inversion exercises (Starkey, 2013)

Phase III: Weeks 6-10 ●  Goals:

○  Control edema and pain ○  Return ankle strength to 80% of

uninjured side ○  MMT 4/5 (week 8-9) ○  Weight Bearing ○  Improve proprioception and

stability of ankle ○  Min. gait deviations on surface ○  Decrease post-op scar tissue

■  Joint mobilizations (posterior: DF)

Beginning Strengthening ●  Example Exercises:

○  Isometric Dorsi-/Plantarflexion ○  AROM ABC’s ○  Standing bilateral heel raises ○  T-Ball Squats ○  Pool therapy ○  Proprioceptive Single Leg Stance ○  Stretching (gastroc and soleus)

●  Cardiovascular Exercise: ○  UBE (upper body ergometer) ○  Stationary Bike

(Minnesota Orthopedic Sports Medicine Institute, 2014; Sandor, 2007; Tripler Army Medical Center, 2005)

Exercises

T-Ball Squat (learning.summitrehab.ca, 2014)

Ankle ABC’s (scoutingmagazine.org, 2014)

Cardiovascular Exercise

(sw.org, 2014)

*Avoid: -vigorous plantarflexion and inversion exercises -anterior joint mobilizations (Stapp et al., 1996)

Phase IV: Weeks 11-12 ●  Goals:

o  Full PROM/AROM (≥ 95%) o  MMT 5/5 o  Prevent re-injury with return

to sport o  Discharge to home or gym

program o  Decrease post-operative scar

tissue !  Joint mobilizations

(posterior: DF and anterior: PF)

Beginning Strengthening ●  Example Exercises:

○  Theraband Resisted ABC’s ○  Proprioceptive Single Leg Stance on

uneven surface ○  Resisted 4-way hip ○  Single Leg Rebound Ball Toss ○  ¼ Body Weight Squats ○  Stretching (gastroc and soleus)

●  Cardiovascular Exercise: ○  Walking on Treadmill ○  Walking on Stairs

(Chelsea and Westminster Hospital, 2012; Minnesota Orthopedic Sports Medicine Institute, 2014)

Exercises

Bodyweight Squats (nofaplife.com, 2014)

Cardiovascular Exercise (gymwolf.com, 2014)

Proprioceptive Single Leg Stance

(anklesprainrecovery.org, 2014)

*Avoid plyometrics and full speed, change of direction workouts

Phase V: Weeks 12-16 ●  Goals:

o  Prevent re-injury o  Gait Training o  Proprioception o  Full strength o  Power

Advanced Strengthening ●  Example Exercises:

○  Proprioceptive Single Leg Balance on uneven surface

○  Single Leg Dot Drills ○  Agility Ladder Drills ○  Single Leg Hops ○  90 ° Body Weight Squats ○  Body Weight Single Leg Squats ○  4 - way Slide Board ○  Stretching (gastroc and soleus)

●  Cardiovascular Exercise: ○  Running on Treadmill ○  Swimming ○  Cycling

(Minnesota Orthopedic Sports Medicine Institute, 2014; Royal National Orthopeadic Hospital, 2009)

Exercises

Single Leg Hops (womenshealthmag.com, 2014)

Single Leg Squats (physiohub.com, 2014) Agility Ladder

(steelcitycrossfit.com, 2014)

*Avoid re-injury; listen to body; continuing using ice after workouts

Phase VI: Weeks 16+ ●  Goals:

o  Return to Play o  Endurance o  Sport specificity o  Prevent re-injury

Advanced Strengthening ●  Example Exercises:

○  Weighted 90° Squats ○  Single Leg Stance - Body Blade ○  Side Lunges ○  Box Jumps ○  T-test agility ○  Sport specific drills ○  Stretching (gastroc and soleus)

●  Cardiovascular Exercise: ○  Sprint Intervals ○  Swimming ○  Running on Treadmill

(Minnesota Orthopedic Sports Medicine Institute, 2014)

Exercises

Box Jumps (bicycling.com, 2014)

T-Test (sportsscience.co, 2014)

Side Lunge

(saveourbones.com, 2014)

*Avoid re-injury; continue stretching and strengthening lower leg and ankle

●  Stretching / ROM exercises o  Weeks 6-16+

●  Strengthening o  Weeks 6-16+

●  Cardiovascular endurance o  Week 3 → Week 12+

Conclusion

●  Proprioception o  Week 12+

●  Speed o  Week 12+

●  Power o  Week 12+

●  Agility o  Week 12+

Rehab Program Goals

(Minnesota Orthopedic Sports Medicine Institute, 2014; Tymms & Bedi, 2011)

1.  Ankle OCD surgery rehabilitation guidelines. Tripler Army Medical Center Web site. www.tamc.amedd.army.mil/offices/musculoskeletal/treatement_guidelines/Ankle%2520Surgery% 2520May%25202005.doc+&cd=2&hl=en&ct=clnk&gl=us Updated May 2005. Accessed September 19, 2014.

2.  Ankle reconstruction / modified Brostrom repair / peroneal tendon repair. William Beaumont Army Medical Center Web site. http://www.wbamc.amedd.army.mil/Documents/PatientCare/PostOpRehabProtocols/Brostrom%20WB08.pdf Updated August 2008. Accessed September 19, 2014.

3.  Baumhauer JF, O’Brien T. Surgical considerations in the treatment of ankle instability. J Athl Train. 2002; 37(4): 458-462. 4.  Coetzee JC, Ebeling PB. Ankle ligament reconstruction rehabilitation protocol. Minnesota Orthopedic Sports Medicine Institute Web site.

http://www.tcomn.com/Portals/10/Documents/Ankle_Ligament_Reconstruction.pdf Accessed September 19, 2014. 5.  de Vries JS, Krips R, Sierevelt IN, Blankevoort L, van Dijk CN. Interventions for treating chronic ankle instability (review). The Cochrane Library. 2011; 8: 1-58. 6.  Godges J, Klingman R. Ankle- Lateral ligament reconstruction and rehabilitation. Loma Linda U DPT Program Web site.

https://xnet.kp.org/socal_rehabspecialists/ptr_library/09FootRegion/30Ankle-LateralLigamentReconstruction.pdf+&cd=1&hl=en&ct=clnk&gl=us Accessed September 19, 2014.

7.  Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002; 37(4): 364-375. 8.  Karlsson J, Lundin O, Lind K, Styf J. Early mobilization versus immobilization after ankle ligament stabilization. Scand J Med Sci Sports. 1999; 9: 299-303. 9.  Kraemer M. Lateral ankle reconstruction case study. AlterG Web site. http://www.alterg.com/case-study/lateral-ankle-reconstruction Accessed September 19, 2014. 10.  Lateral ankle ligament reconstruction, post-operative recovery guidelines. Chelsea and Westminster Hospital, NHS Trust Web site.

https://www.chelwest.nhs.uk/your-visit/leaflets/support/lateral-ankle-ligament-reconstruction Published January 2012. Accessed September 19, 2014. 11.  Miyamoto W, Takao M, Yamada K, Matsushita T. Accelerated versus traditional rehabilitation after anterior talofibular ligament reconstruction for chronic lateral

instability of the ankle in athletes. Am J Sports Med. 2014; 42(6): 1441-1447.

References

12.  Modified Brostrom-Gould repair for chronic lateral ankle instability. Brigham and Women’s Hospital Web site. www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/physical%2520therapy%2520standards%2520of%2520care%2520and%25 20protocols/ankle-brostrom%2520gould%2520repair%2520for%2520lateral%2520ankle%2520instablility.pdf+&cd=2&hl=en&ct=clnk&gl=us Published 2010. Accessed September 19, 2014.

13. Procedure: ankle ligament reconstruction. Workers’ Compensation Board Web site. http://www.worksafebc.com/health_care_providers/assets/pdf/ankle_ligament_reconstruction.pdf Published January 2005. Accessed September 19, 2014.

14. Rehabilitation guidelines for lateral ankle reconstruction. University of Wisconsin Sports Medicine Web site. http://www.uwhealth.org/files/uwhealth/docs/sportsmed/SM-39916_Lateral_AnkleProtocol.pdf Updated June 2014. Accessed September 19, 2014.

15. Rehabilitation guidelines for patients undergoing surgery for lateral ligament reconstruction of the ankle. Royal National Orthopaedic Hospital, NHS Trust Web site. http://www.rnoh.nhs.uk/sites/default/files/patient/11-19_pg_lateral_ligament_repair_web_release.pdf Updated 2009. Accessed September 19, 2014.

16. Sandor, R. Ankle exercises. Camino Medical Group Web site. http://www.pamf.org/Orthopedics/mountainview/handouts/AnkleExercises.pdf Updated January 2007. Accessed September 19, 2014.

17.  Starkey C. Athletic training and sports medicine. Burlington, MA: Jones & Bartlett Learning; 2013: 86-89. 18.  Stapp MD, Smith TF, Challa SF. Chronic lateral ankle instability: repair versus reconstruction. Podiatry Institute Web site.

http://www.podiatryinstitute.com/pdfs/Update_1996/1996_36.pdf Updated 1996. Accessed September 29, 2014. 19. Tymms G, Bedi H. Post operative physiotherapy protocol for lateral ligament reconstruction. Orthosport Victoria Web site.

http://www.osv.com.au/assets/lateral%20ligament%20reconstruction%20post-op%20physio.pdf Published 2011. Accessed September 19, 2014.

References

Questions?