Return to Sport Progressions for the Ankle Sprain

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Return to Sport Progressions for the Ankle
Sprain
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Stages of Healing
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Stage I immediately after injury
Rehabilitation Steps Treatment Aims

• Careful evaluation of injury severity
• Decide need for x-ray
• Application of compression
• Ice in elevation
• Gentle dorsi- and plantar flexion
• Light partial weight-bearing
• Supply crutches
• NSAIDs
• Teach home ice and ROM program
• Warn of danger of tight wrap

Establish accurate diagnosis Protect from further
injury Minimize hemorrhage
Reid 1992
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Stage II acute inflammation
Rehabilitation Steps Treatment Aims

• Continue partial weight-bearing
• Continue home ice program
• Compression and elevation
• ROM - no inversion
• Isometric resisted when
• 50 weight-bearing
• Set up cardiovascular program

Protect from further injury Minimize
edema Maintain ROM Maintain fitness
Reid 1992
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Stage III subacute phase
Rehabilitation Steps Treatment Aims

• Cryokinetic program
• Consider adding other modalities
• Program weight-bearing
• Increase ROM avoid inversion
• Isometric progressed to isotonic work
• Increased cardiovascular exercises
• Use ankle wedge and resisted exercises
• Supply with ankle orthosis

Restore ROM except inversion Control
edema Resolve effusion Progress
strengthening Gain full weight-bearing
Reid 1992
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Stage IV rapid progression
Rehabilitation Steps Treatment Aims
Gain full ROM and strength Restore "spring" in
gait Maintain fitness

• Add more resistance exercises
• Skipping and hopping
• Attempt to restore full ROM
• Commence proprioceptive work
• Running on rebounder

Reid 1992
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Stage Vfinal rehabilitation
Rehabilitation Steps Treatment Aims

• Modalities to resolve chronic effusion
• Mobilization to restore joint play
• Increase strengthening
• Add running forward and backward
• Starts and stops
• Figure-of-eights and wind sprints
• Functional assessment
• Establish home program

Restore full strength and ROM Restore
proprioception Return to activity safely
Reid 1992
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STAGES OF REHAB
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Four Components of Rehabilitation

• Range of motion
• Progressive muscle-strengthening exercises
• Proprioceptive/balance training
• Activity specific training

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Restoration of Motion

• Begin as soon as swelling has stabilized or
  immobilization discontinued
• Active first (DF and PF 1st and progress to INV
  and EV when tenderness over the ligaments
  decrease then circumduction)
• Passive second (hold 20 sec every 2 hrs)
• - moderate pull but no pain
• Cardinal planes first ? Alphabet writing
• Ensure full Active and Passive ROM
• - may need joint mobilizations

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Range of Motion

• Range of motion must be regained before
  functional rehabilitation is initiated.
• Achilles tendon stretching regardless of WB
  capacity.

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Muscle-strengthening

• Once ROM is achieved and swelling and pain are
  controlled
• Essential to rapid recovery and is a preventative
  measure against reinjury
• Peroneal muscle focus (insufficient strength
  associated with CAI and reinjuryBrJSports Med,
  1999)

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Muscle-Strengthening

• All muscles should be targeted
• Performed bilaterally expect gains in both
  extremeties while the cross-over effect of
  training only 1 limg may equal only 1.5 TO 3.5
  (AM J Sport Med, 2000)

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Muscle Endurance

• Early on in the rehab the emphasis should be on
  endurance
• Working towards 3-4 sets x 30 reps
• DF, PF, INV, EV and finally circumduction

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Muscle-strengthening

• Advanced manual resistance
• Athlete maximally resists randomly applied
  perturbations

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Muscle-Strengthening Exercises

• Isometrics 4 directions
• Progress to isotonic (with and without resistance
  in pain free motion)
• 1. Clinician-assisted manual
• resistance 3-5 sec for 10-12 reps
• in each cardinal plane
• 2. Weights or tubing

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Muscle-strengthening DAPRE

• Progressive resistance program DAPRE (Daily
  Adjustable Progressive Resistance Exercise-
  Knight, Perrin and Gieck)
• 4 sets x 10 reps while increasing the applied
  weight/load for each set
• Athlete can advance to the next level when he/she
  can complete with correct form the 4th set of 10

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Strength Training Progression Table
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Muscle-strengthening

• Eccentric focus
• 1C-1P-4E Pause 1 sec between the concentric and
  eccentric phases and perform the eccentric
  component over a 4 sec period
• 2-3 sets x 10-12 reps in all 4 directions
• 2x/day

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Additional Strength Exercises

• Toe raises
• Heel walks
• Toe walks
• Toe curls
• Marble pick ups

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Summary ROM and Strength in Early Rehabilitation
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Restoration of Proprioception

• Eliminate visual input ASAP
• Single Leg Stance Drills (star drill, 3 or 5
  point balance work into ADL)
• Toe balancing or wobble board once achieve 75 of
  normal ROM

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Proprioceptive and Balance Training

• Recovery of balance and postural control
• Progressions
• NWB-gtWB without pain
• Bilateral -gt unilanteral stance
• Eyes open-gteyes closed
• Firm -gtsoft surface or uneven or moveable surface

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Proprioceptive Training Components

• Circular Wobble Board
• In sitting position, rotate board clockwise and
  ocuntclockwise using 1 foot and then both feet
  in standing rotate using 1 foot and both feet
• 5-10 reps 2x/day
• Eyes open-gt eyes close-gt with resistance

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Early Proprioceptive Training Components

• Walking on different surfaces
• Walk in normal or heel-to-toe fashion over
  various surfaces hard and flat-gt uneven
• 20-50 feet 2x/day
• Eyes open-gteyes closed
• With or without resistance

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Early Proprioceptive Training Components

• Manual proprioceptive neuromuscular facilitation
  exercises
• Clinician provides degrees of resistance and
  random perturbations as athlete moves the foot
  through functional patterns
• 5-20 reps 1-2x/day
• Velocity and resistance can be varied to
  stimulate sensory feedback

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• A B with eyes open/closed
• C can be progressed to active
• movements that invoke perturbations
• while maintaining balance
• E. perturbations invoked externally

Other balance tools bosu, extreme balance
board, sit fit disc
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Advanced Balance and Functional Exercises

• Internal provoked perturbations while performing
  dynamic activities.

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Advanced Proprioceptive Training Components

• Walk-jog
• 50 walking 50 jogging in forward and backward
  direction progress to jog in a pattern (fig-8
  circle)
• Increase distance in increments of 2 km
• Increase intensity and incorporate activity
  specific training (supervised by sport physio or
  AT that is familiar with demands of the sport)

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Advanced Proprioceptive Training Components

• Jog-run
• 50 jogging and 50 running forward and backward
  run in a pattern (fig-8, circle)
• Increase distance in increments of 2 km
• Increase intensity and incorporate activity
  specific training (supervised by sport physio or
  AT that is familiar with demands of the sport)

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RUNNING PROGRESSION RULE OF THIRDS
Magee
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Other Advanced Functional Exercises

• Lunges forward, 45 degree angle, sideways
• Bound and stick
• Hopping drills start with 2 legs and progress to
  injured leg only (ie. 4 square drills)
• Step ups up and over, forward and sideways, low
  to high step
• Hop on toes
• Skipping rope

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Return to Sport

• At the court/field/playing surface
• Start with multidirectional sport specific
  movements
• The area in which this is performed could
  progressively decrease
• Use opponent (ie. Offensive player changes
  directions unannounced instantaneous change in
  direction of defensive player)
• Perform in game situations during practice
• GAME ON!!
• PROGRESS TO EACH LEVEL IF NO INDICATION OF INJURY

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A Reminder

• Individuals respond differently to exercises,
  therefore, each program needs to be modified to
  fit the individuals needs.

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A Common Mistake

• Lack of variability in speed and intensity.

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Maintenance of Fitness

• Strength Training for uninvolved leg
• Bike/elliptical/stairmaster/water
  running/swimming
• Upper body strengthening
• Core strength
• Flexibility

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Ankle Rehabilitation Checklist

• Note All items on this list should be checked
  before returning to play.
• Name ______________________________________
• Date of Injury ______________________
• Phase 1 Ready to Start Rehabilitation
• A. I am wearing the protective tape, brace, or
  wrap that my doctor prescribed.
• B. I can stand on the injured leg without pain.
• C. Pain and swelling have gone down.
• Phase 1 complete. Date ________________________
• Days after injury ________________________

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Ankle Rehabilitation Checklist

• Phase 2 Beginning Level
• A. My ankle does not feel too stiff to draw the
  letters of the alphabet with my toes.
• B. Strength in my calf and ankle muscles is back
  to normal.
• C. I know when I need to wear an ankle brace or
  taping and how to apply it.
• D. Neither low-impact aerobic exercise nor
  weight lifting causes pain or swelling.
• Phase 2 complete. Date __________________
• Days after injury ________________________

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Ankle Rehabilitation Checklist

• Phase 3 Intermediate Level
• A. Balance when standing on the injured leg is
  as good as the uninjured leg.
• B. Increasing my aerobic exercise or weight
  lifting does not cause pain or swelling.
• C. My general strength is back to preinjury
  level.
• Phase 3 complete. Date __________________
• Days after injury ________________________

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Ankle Rehabilitation Checklist

• Phase 4. Advanced Level
• A. My return-to-running program has been
  completed without pain or limitation.
• B. I can do sport-specific movements and skills
  without pain or limitation.
• C. My coach or physical education teacher knows
  about my special needs for gradual return to play
• and my long-term needs to prevent future injury.
• Phase 4 complete. Date _________________________
• Days after injury ________________________
• Cleared for full participation. Date
  _________________
• by Dr __________________________________

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Thank you
Karen Craven BSc(PT), Dip Sport (PT),
CSCS 306-220-7854 craven.sports_at_sasktel.net