Don’t Just Recover. Conquer. R. Kent Kurfman, PT, DPT, OCS, MTC Proaxis Therapy Greenville, South Carolina.

Don’t Just Recover. Conquer.

R. Kent Kurfman, PT, DPT, OCS, MTCProaxis Therapy

Greenville, South Carolina



Most common athletic / sports injury Highest percentage (15%) of any regional

injuries in NCAA study (Hootman JM J Athl Train 2007)

Most common injury in several sports, such as soccer (Ekstrand/Tropp – Foot/Ankle – 1990)

10-15% of all football injuries (Garrick JG. J Sports Med 1977)

75% of all ankle injury = ligamentous sprain, 85% of these = lateral ligaments (Garrick JG Clin Sports Med 1988)



20-70% lead to chronic pain/instability - CAI (Barrett/Bilisko – Sports Med 1995, Gerber JP Foot Ankle Int 1998, McKay GD et al BR J Sports Med 2001, Verhagen RA et al Arch Orthop Trauma Surg 1995)

Reinjury rates = up to 70-80%



Landings◦ Unexpected surface (on another athletes foot,

sloped surface).◦ Improper foot positioning prior to landing

(excessively inverted and plantarflexed) whether walking, running or landing from jumps

Sudden stops and cutting movements



Greatest: history of previous sprain ◦ 4-5x more likely to re-injury

Distribution by gender: essentially the same (Beynnon)

Structural – limited information linking foot structural characteristics (Morrison, J Athl Train 2007)

◦ High medial longitudinal arch/pes cavus ◦ Greater than normal foot width◦ High 1st MTP dorsiflexion ROM



Technical skill – Body mass – higher BMI = suspected

greater risk for ankle injury Footwear selection

◦ Inappropriate choices made , particularly during training – Running footwear use for court activities



Proprioceptive deficits: Impairment in feedback◦ Aberrant ankle position sense is primary

problem in landing-related injuries – foot too inverted, due to diminished position sense

◦ Primary sensory input comes from cutaneous pressure receptors and muscle spindles – less from joint capsule receptors



Long term disruption of sensory-motor control: Central changes in sensorimotor system function◦ Diminished motoneuron pool excitability◦ Mismatch of reaction time of peroneals,

compared to rapidity of ankle inversion stress/stretch during aberrant landing.



Bottom line: deficits in those with CAI are not only peripheral but are also central – maladaptive changes to movement. ◦ We need to train global coordination to gain more

complete recovery (Hass CJ AJSM 2010).



Differ, based on history of the athlete◦ Previously uninjured – no definitive approach!

No evidence that use of preventative bracing/taping/neuromuscular training will prevent an ankle sprain

Need to emphasize what we can encourage Appropriate footwear selection Proper practice /skill acquisition – role of coach



Previously injured and CAI: a great deal of evidence that we can affect future injury occurrence!◦ Remainder of presentation will emphasize

preventative measures in those previously injured/CAI.



Most commonly used supports.◦ Both are effective, shown via multiple studies.

Bracing:2010 study – preventative. Expense: bracing cheaper Taping:

◦ Support loss from taping:◦ Don’t underestimate proprioceptive effect.

Kinesiotaping



Recommendation: Continue taping/bracing after LAS for at least 6 months



Purposes : ◦ Traction, protect feet from abrasion/contact◦ Shock absorption – less certain

Shoes act as a filter to our proprioception We adjust the stiffness of our legs based

on cushioning (footwear and surface).◦ Hard surfaces: more hip/knees/ankle flexion. ◦ Softer surfaces – less hip/knee/ankle flexion



Shoes can confound this - too much cushioning on a hard surface = increased lower leg stiffness, greater force transmission .◦ No midsole material available yet that

compensates /adjusts for this



High top vs. Low top◦ Mixed findings in the literature◦ In general, high tops can have a combined effect

with bracing /taping in prevention of re-injury



Athlete should choose the shoe with the least amount of midsole that they are able to properly/comfortably train/compete in.

Less stack height = less chance of injury ◦ More plantarflexion (heel height) = more chance

of injury. ◦ High tops = matter of preference.



Effective in prevention of future injury – Balance training alone = 36% reduction in

ankle sprain Multiple-intervention training (balance,

weight, plyometric, agility/sport specific training)= 50% reduction in ankle sprain injuries

Consideration of study problems



Retraining guidelines:◦ Dosage: Typical = 6 weeks, 3-5 sessions/week◦ Wobble boards – common denominator◦ 4 constructs: static balance, joint position sense,

dynamic balance, motoneuron pool excitability (via agility and plyo work).

◦ Strength - only a component◦ Bottom line: Since balance control is

multifactorial, work on all factors during a session



Program components:◦ Static single leg balance – easiest to retrain,

acts as a base for all other activities. Goal: 60” eyes open, 30” eyes closed.

◦ Position sense retraining –essential for landing control Technique accuracy is essential



◦ Dynamic balance and neuromuscular control. A progression of balance board / soft surface

training. Emphasize speed of control, range of control . Add distractions – throwing/catching Balance with reaching



Agility: progression back to “real activity” – hopping, cutting activities.◦ Concentrate on doing these activities on very

firm surfaces.◦ Proprioceptive/kinesthetic confusion issues on

soft surfaces.



Typical tools used: ◦ Simple tools work well

Wobble board Half-rolls AIREX BOSU



Week 1 Week 2 Week 3 Week 4 Week 5 Week 6Posturalstability

Single legstance onAirex® cushion:(3 minutes)

Single legstance on tiltboard: (3minutes)

Single leg stanceon BOSU® ball:(3 minutes)

Single leg stance onBOSU® ball withrebounding ballcatches: (3 minutes)

Anterior jump lands fromReebox® step: (2 sets × 10reps with 10 secondstabilization)

Lateral jump lands fromReebox® step(2 sets × 10reps with 10 secondstabilization)

Strength Double legheel raises: (3sets × 12 reps)Double legbridge: (2 sets× 10 reps)Clam-shellgluteus medius:(2 sets × 10reps - each side)

Double legheel raises:(3 sets × 12reps)Double legbridge: (2 sets× 10 reps)Clam-shellgluteusmedius:(2 sets × 10reps - eachside)

Single leg heelraises: (2 sets ×10 reps - eachside)Single leg bridge:(3 sets × 12 repseachside)Figure-4 gluteusmedius: (2 sets ×10 reps - eachside)

Single leg heel raises:(2 sets × 10 reps - eachside)Single leg bridge:(3 sets × 12 repseachside)Figure-4 gluteusmedius: (2 sets × 10 reps- each side)

Single leg heel raises withweight (15 kg): (3 sets × 12reps - each side)Double leg squats: (3 sets ×12 reps)Resisted lateral side-steps:(3 sets × 12 reps/step - eachsides)

Single leg heel raises withweight (20 kg): (3 sets × 12reps - each side)Single leg squats: (3 sets ×10 reps - each side)Resisted lateral side-steps:(3 sets × 12 reps/step -each sides)

Plyometics Tuck jump: (3sets × 10 reps)

Broad jumps:(3 sets × 10reps)

180° tuck jumps:(3 sets × 5 reps ineach direction)

90° hop turns:(10 reps - clockwise andanti-clockwse)

Double leg lateral jumpsover mini-hurdle: (3 sets ×10 reps)

Single leg lateral jumpsover mini-hurdle: (3 sets ×10 reps)

Speed/Agility

Figure of 8runs: (10 mcourse,5 reps in eachdirection)

Ladder:forward runthrough:(10 reps)

Ladder: lateralrun through: (10reps - each way)

Ladder: lateral hopthrough: (10 reps - eachway)

Ladder: hopping slalomdrill: (10 reps)

Lateral shuttle runs: (10 mcourse, 2 sets × 10 reps)

O’Driscoll et al. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2011, 3:13. http://www.smarttjournal.com/content/3/1/13



Lateral ankle sprain = high injury rate Highest risk = previous ankle sprain Important to address deficits aggressively to

prevent CAI Multifaceted approach is best

◦ Bracing/taping◦ Shoe selection◦ Aggressive neuromuscular retraining with

attention to quality of movement



Thank you

Don’t Just Recover. Conquer. R. Kent Kurfman, PT, DPT, OCS, MTC Proaxis Therapy Greenville, South Carolina.

Documents

south carolina slide

ankle sprain

common injury

br j sports med

mtp dorsiflexion rom

athletes foot

landingrelated injuries

gerber jp foot ankle