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Rehabilitation of the Athlete Following Ligamentous Injury
Stephanie Albin, DPT, OCS, FAAOMPT
12th Annual C U Sports Medicine Fall Symposium
Friday, September 22, 2017
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Lateral/Inversion Ankle Sprain
• Most common orthopedic injury and sports injury– 23,000 inj/day in US
• 85% of all ankle injuries
• 10-70% of acute injuries become chronic
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Lateral/Inversion Ankle Sprain
• Repeated injury associated with:
– early traumatic arthritic changes
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Mechanism of Injury
• Inversion and plantar flexion
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Mechanism of Injury
• Inversion and plantar flexion
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Landing on Inverted Foot from Ht
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Evidence-Based Examination
• Does exam make sense with patient history?
• Rule out fractures (prox fib tenderness)
• Syndesmotic injury
• Med tenderness
• Suspect OCD
• Tenderness at ant process calc or lat process of talus
– If exam does not make sense, go back to history and REPEAT as necessary
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Treatment - Acute Inversion Ankle Sprains
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Higgs, J, Jones, MA, “”Clinical Reasoning in the Health Professions”, Clin Reasoning in Health CareProfessions, 2nd ed, Oxford: Butterworth-Heinemann, 2000.
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Evidence-Based Treatment - MT• MT and Exercise vs HEP post inversion ankle
sprain (Cleland, 2013)– RCT – 2 groups (MTEX and HEP)– Statistically significant improvements at 4 wks and
6 months favoring MTEX for FAAM, LEFS, Pn
• RCT with 41 acute ankle sprains (Green, 2001): – 2 groups (Control: RICE, Exper: RICE and MT)– Mobilization group – fewer sessions to achieve
WNL DF ROM and improved stride length
• RCT with 52 acute ankle sprains (Lopez-Rodriguez, 2007)– Statistically significant differences between pre-
manip and post-manip values of the percentage of posterior load on foot (P=0.015) and percentage of bilateral anterior load (p=0.02)
– Palcebo group – no change in any variable (loads, pressures etc)
– Manipulation exerts proprioceptive effects
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Evidence-Based Treatment - MT
• Yeo (MT, 2011) - Hypoalgesic Effect of Mobilisation
• 13 Subjects post lateral ankle sprain (sub-acute)
• Assessed: – DF ROM using ankle lunge test– Pain Pressure Threshold (PPT) using
electronic digital algometer• DF ROM increase by 9.6mm for the
treatment group – Significant difference between
treatment and manual control group (p=.000)
– Significant difference between treatment and no manual group (p=.002)
• PPT increased by 17.76% after treatment– Significant difference between
treatment and manual control group (p=.000)
– Significant difference between treatment and no manual group (p=.002)
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Evidence-Based Treatment – Ther Ex
• Collado (Scand J Med Sci Sports, 2010) RCT of 18 athletes following first-time ankle sprain, matched with 10 healthy controls– When active eversion pnfree and passive inv stretch
pnfree, added peroneal strengthening to PT – 2 groups - ecc or concentric manual resistance– 3X/week for 6 session, 5 sets of 10 reps with 2 min
rest between sets (300 total reps)– Results:
• Initial evers strength improved compared to healthy controls• Ecc bias ex restored normal peroneal strength• Concentric bias ex did not restore normal peroneal strength
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Chronic Ankle Instability
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Ankle Instability
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Evidence-Based Treatment - Chronic
• Manual Therapy:– Vicenzino (2006):
Mobilization with Movement
– RCT: 16 patients with recurrent sprains and decreased post talarglide• 3 groups: No TX, WB
MWM or NWB MWM– MWM treatment
techniques improved posterior talar glide and DF ROM for both mob groups
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Evidence-Based Treatment - MT
• Gomez et al, 2015 -Outcomes– 52 pts CAI randomized
to WB MWM, HVLA, or placebo
– Both WB MWM and HVLA significantly improved with WB dorsiflexion ROM (effects lasted 48 hours), although WB MWM had larger effect sizes
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Evidence-Based Treatment - MT
• Gomez et al - Outcomes– 52 pts CAI randomized
to WB MWM, HVLA, or placebo
– Both WB MWM and HVLA significantly improved with WB dorsiflexion ROM (effects lasted 48 hours), although WB MWM had larger effect sizes
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Evidence-Based Treatment - Chronic
• Hoch (J Orthop Res, 2011) results:
– Significantly greater DF ROM and time to boundary (TTB) in AP direction with EO
– No significant differences in SEBT
– Conclusion:
• Single joint mobilization tx has mechanical and functional benefits in CAI pts
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Evidence-Based Treatment - Chronic
• Balance:
– Webster (J Sport Rehab, 2010), SR of functional training for people with CAI
• Functional training defined as dynamic, closed-kinetic-chain activity other than quiet standing
• Significant improvements in dynamic postural control
• Significant improvements in self-reported outcomes
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Outcomes
N: LLR= 75 LLR+OCD= 42
Ave LOS: LLR – 60 days (5 visits)
Ave LOS: LLR+OCD – 57 days (5 visits)
0
10
20
30
40
50
60
70
LEFS Admit Score LEFS D/C Score LEFS Change Score
Outcomes for LLR and LLR+OCD
LLR LLR +OCD
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LLR with or without OCD - RehabTimeframe Goals Treatment
Weeks 0-6 post-op 1. Minimize Swelling2. No inversion/PF3. Maintain WB compliance4. Good communication with
surgeon!!!! (Op-note)
1. Monitor for signs of infection2. Pt education re: precautions3. Elevation/compression
stocking4. Proximal hip strengthening
Weeks 6-12 post-op 1. Initiate chondral training2. Normalize gait3. Balance and proprioception4. Improve ROM – stability
priority over mobility
1. Start chondral training program (low load/high rep)
2. Manual therapy as needed to improve ROM (DF/MTP etc)
3. Progress balance and proprioception (bilat)
4. Gait training5. Functional strengthening6. Continue chondral training
Weeks 12-16 post-op 1. Progress functional strengthening
2. Balance and proprio equalside-to-side
3. Start gradual return to sport as appropriate – in line activities 3 months, full return closer to 4.5 months
1. Continued emphasis on balance and proprio (uneven surfaces)
2. Sport specific training if strength, balance good
3. Continued functional strengthening
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LLR with or without OCD - Outcomes
• Muscle reaction time in patients with mechanical instability after LLR (Li,2015)– Pre-op
• delays of tibialis ant and peroneus longus activation compared to age-gender matched controls
– 6 months post-op• Significantly improved AOFAS hindfoot
scores • Negative ant drawer test• No change in muscle reaction time
compared to pre-op values for tib ant and PL
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LLR Post-Op Outcomes• LLR (modified Brostrom) with or without OCD
– Outcomes after surgery:• 1.2% revision rate at 8.4 yr fu period (So, J Foot Ank Surg, 2017)
• Improved joint position sense (Halasi, Br J Sports Med, 2005)
• Self-reported outcomes at 13yr f/u were excellent (48%), good (33%), and fair (19%) (Muijs, BJBS, 2008)
• Early functional rehabilitation was superior to 6 weeks immobilization for RTW and RTS times (deVries, CR, 2006)
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Questions?