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)
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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)
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)
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)
(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)
(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.