Rehabilitation of the Athlete Following Ligamentous Injury

Stephanie Albin, DPT, OCS, FAAOMPT

12th Annual C U Sports Medicine Fall Symposium

Friday, September 22, 2017

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

Lateral/Inversion Ankle Sprain

• Repeated injury associated with:

– early traumatic arthritic changes

Mechanism of Injury

• Inversion and plantar flexion

Mechanism of Injury

• Inversion and plantar flexion

Landing on Inverted Foot from Ht

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

Treatment - Acute Inversion Ankle Sprains

Higgs, J, Jones, MA, “”Clinical Reasoning in the Health Professions”, Clin Reasoning in Health CareProfessions, 2nd ed, Oxford: Butterworth-Heinemann, 2000.

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

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)

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

Chronic Ankle Instability

Ankle Instability

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

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

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

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

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

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

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

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

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)

Questions?