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)