Introduction
- Annunziato Amendola, MD
- Sebastiano Vasta, MD
- Biagio Zampogna, MD
- Sebastiano Vasta, MD
Epidemiology
Age
- •
Under the age of 35 with a peak of incidence of 15 to 19 years of age.
Sex
- •
Slightly higher incidence of ankle sprain in males (1.04).
Sport
- •
Ankle sprains are the most common injury in all sports involving running and pivoting; basketball is the most common sport in the United States associated with ankle sprain but other include football, soccer, running, volleyball, softball, baseball, and gymnastics. Ice and water sports are less likely to cause an ankle sprain.
Position
- •
Among soccer players, defenders and attackers have a higher risk of ankle injury as a result of contact with opponents.
Pathophysiology
Intrinsic Factors
- •
Muscle strength imbalance: increased eversion-to-inversion ratio and plantarflexion-to-dorsiflexion
- •
Increased BMI
- •
Higher risk for dominant ankle in soccer
- •
History of previous ankle sprains
- •
Pes cavus or calcaneovarus alignment ( Figure 39-1 )
FIGURE 39-1
Assessing foot alignment: varus hindfoot alignment may predispose to recurrent ankle sprains.
Extrinsic Factors
- •
Certain shoewear may predispose to ankle injury: air heels, poor fit
- •
Inadequate warmup with poor flexibility
- •
Artificial turf increases the risk of ankle injury
Traumatic Factors
- •
Pronation-external rotation, pronation-abduction, and infrequently the supination external rotation mechanism are responsible for tibiofibular syndesmotic injuries and high fibular fractures.
- •
Supination and adduction (inversion) of the plantarflexed foot for lateral ligament injury and fibular avulsion fractures; same as a lateral ankle sprain.
- •
Rarely, eversion, external rotation, or abduction mechanism cause an isolated injury of the deltoid ligament, otherwise it is injured together with the other ligaments through the same pathway. Type B fracture (Weber classification) or Lauge-Hansen (supination-external rotation) could also be caused by these patterns of trauma.
- •
Osteochondral injuries occur most commonly in association with sprains and fractures. Direct axial loading with shear to the ankle with or without sprain could be responsible for osteochondral lesions, but is less common ( Figure 39-2 ).
FIGURE 39-2
Anterior-posterior view of the ankle following an ankle sprain: lateral osteochondral lesion flake shaped acute.
Classic Pathological Findings
- •
Ankle sprains are usually lateral and involve the anterior tibiofibular ligament (ATFL) 100% of the time (grade I), whereas the calcaneofibular ligament (CFL) is involved in 50% to 75% of more severe sprains (grade II and III).
- •
Syndesmosis sprains usually occur with external rotation and have a spectrum of severity: from a few fibers of the distal antero-inferior tibiofibular ligament (AITFL) (stable) to complete AITFL injury and interosseus membrane (unstable) with or without deltoid involvement ( Figure 39-3 A-C ).
FIGURE 39-3
A, Anterior-posterior and mortise view: eversion external rotation ankle sprain, unable to weight bear. B, External rotation stress test; view confirms an unstable injury. C, Fixation of unstable syndesmosis (grade III) injury.
- •
OCLs occur in the medial (50%) and lateral (50%) talar dome: medial lesions are cup-shaped, usually posteromedial, and often related to chronic inversion trauma; lateral lesions are flat and anterolateral, usually following an acute sprain ( Figure 39-4 A,B ).
FIGURE 39-4
A, Magnetic resonance imaging (MRI) sagittal view: cup-shaped osteochondral lesion of the medial talar dome. B, MRI, Coronal view showing a cup-shaped osteochondral lesion of the talar dome.
- •
Ankle fractures have been classified by many authors. The most commonly used are the Denis-Weber and the Lauge-Hansen classifications. The Denis-Weber classification is based on the location of the fibular fracture. Lauge-Hansen classifies the fractures according to the foot position and the direction of the force determining the trauma.
Clinical Presentation
History
- •
For an ankle sprain, patients usually describe an inversion-type twist of the foot and ankle, or less frequently, eversion, followed by pain and swelling.
- •
Swelling, ecchymosis, and tenderness laterally for lateral sprains and lateral malleolar fractures ( Figure 39-5 ).
FIGURE 39-5
Swelling and ecchymosis following a severe sprain of the left ankle.
- •
Differentiate between ligamentous tenderness (ATFL, CFL, syndesmosis, deltoid) versus bony tenderness on examination.
- •
Decreased range of motion (ROM) with all injuries, more with fractures.
- •
Deformity may be present with displaced fractures.
- •
With sprains and osteochondral lesions (OCLs) it may be difficult to weight bear on the injured limb because of pain, but it is usually still possible to walk on the foot. Inability to weight bear on the injured foot usually indicates the presence of a fracture (Ottawa Ankle Rules).
- •
An osteochondral lesion or a loose body should be considered when persistent pain is present together with intermittent locking, stiffness, and limping ( Figure 39-6 ).
FIGURE 39-6
Arthroscopic view: chondral lesion following a severe ankle sprain.
Physical Examination
Abnormal Findings
- •
Knowledge of anatomy for palpation is essential. Pain and tenderness at the area of injury: ATFL and CFL in lateral sprains, bony tenderness and/or deformity and crepitus with fractures; AITFL, interosseus membrane and deltoid tenderness with syndesmosis injury.
- •
Positive anterior drawer test and talar tilt test in the setting of a lateral ankle injury; these are usually best in the subacute stage, a few days after injury.
- •
Positive squeeze test, external rotation stress test, cotton test, fibula translation test, and crossed-leg test for an acute syndesmotic injury. In the setting of a chronic injury, the stabilization test will be positive ( Figure 39-7 A,B ).
FIGURE 39-7
A, External rotation stress test. B, Stabilization test after taping technique just above the ankle joint; perform provocative activity to test syndesmotic stability.
- •
Osteochondral lesions usually determine tenderness in their common location site and joint line with the ankle in plantarflexion, anterolateral lesions will cause pain when palpating the anterolateral talar dome, whereas a posteromedial lesion will be tender behind the medial malleolus when palpating the posteromedial talus with the ankle in dorsiflexion.
- •
Possible deformity and\or skin laceration in the presence of a fracture.
Pertinent Normal Findings
- •
Normal neurovascular status
- •
In the setting of an ankle sprain, the patient should be able to walk even if painful. If not, a fracture should be investigated.
Imaging
- •
Routine plain radiographs with weightbearing anterior-posterior (AP), lateral, and mortise view to assess the presence of a concomitant fracture; the lateral view should include the base of the fifth metatarsal.
- •
External rotation stress views may be performed to assess the severity of syndesmotic or deltoid injury ( Figure 39-3 B ).
- •
Magnetic resonance imaging (MRI) may be used to assess the extent of ligament injury (deltoid and syndesmosis) and the presence of nondisplaced fractures, bony edema from stress fractures, or osteochondral injury. It is indicated if the diagnosis is not clear, or if the athlete has persistent pain and loss of function ( Figure 39-4 A,B ).
- •
Computed tomography (CT) scanning is useful to assess the extent of bone injury: intraarticular fractures, OCLs, or to evaluate bone healing in a fractured ankle.
- •
Triple-phase bone scintigraphy (bone scan) has been supplanted by MRI in the diagnosis of stress fracture, but may be useful for the investigation of diffuse bone or joint pain.
Differential Diagnosis
- •
Tendinopathy: peroneal tendons most commonly, tibialis posterior, flexor halluces longus (FHL) impingement, midportion and insertional achilles Achilles tendon ruptures.
- •
Stress fractures
Treatment
Nonoperative Management
- •
Lateral ankle and mild syndesmotic sprains are usually treated with rest, ice, compression, and elevation (RICE): nonsteroidal antiinflammatory drugs may be used for pain and swelling; a short period (1 to 2 weeks) of immobilization or comparable rigid support for grade I and II ankle sprains.
- •
Use of short leg cast or removable brace period for nondisplaced ankle fracture.
- •
Physical therapy aiming to regain ROM, strength, and proprioceptive function when appropriate for healing.
Guidelines for Choosing among Nonoperative Treatments
- •
All lateral ankle sprains, nonoperative treatment is preferred
- •
Grade I and grade II syndesmotic ligamentous injuries with a competent deltoid and posterior inferior tibiofibular ligament (PITFL) are generally treated using conservative measures.
- •
Stable and nondisplaced fractures
- •
Stable and nondisplaced osteochondral injuries
- •
In the setting of displaced osteochondral injuries, conservative measures are often unsuccessful, and surgical treatment (arthroscopy) may be more effective.
Surgical Indications
- •
Grade III injuries and fractures with syndesmotic instability (absolute indication)
- •
Weber A/supination-adduction (SA) 2 with associated vertical medial malleolar fracture
- •
Unstable Weber B/supination-external rotation (SER) 4 or Weber C/all pronation-external rotation (PER) 1–4 fractures
- •
Osteochondral lesion (relative indication)
- •
Failure of conservative measures resulting in chronic instability
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
- •
Stability of the injury pattern in fractures and syndesmotic injuries
- •
Level of competition and desire to return to sport
- •
Time point of the injury relatively to the season
Aspects of Clinical Decision Making When Surgery is Indicated
- •
Likelihood of success with nonoperative versus operative treatment
- •
Failure of rehabilitative programs
- •
Grade III injuries or fractures with syndesmotic instability
- •
Symptoms preventing ability to participate: i.e., complaints of ankle stiffness or catching with osteochondral injuries; recurrent sprains despite optimal rehabilitation
- •
Fracture displacement and joint instability/incongruity
Evidence
Multiple-Choice Questions
- QUESTION 1.
Which of the factors below increase the risk for ankle sprain?
- A.
High-top shoes
- B.
Pes planus
- C.
Previous history of ankle sprain
- D.
Shoes with a heel counter
- E.
None of the above
- A.
- QUESTION 2.
A 20-year-old male basketball player suffered an inversion ankle sprain 4 weeks ago. He continues to have ankle pain and swelling despite optimal physical therapy. X-rays were normal. What would be the next step in management?
- A.
Nonsteroidal antiinflammatory drugs (NSAIDs) medication
- B.
Corticosteroid injection
- C.
Immobilize in a boot for 4 weeks
- D.
Magnetic resonance imaging (MRI) of the ankle
- E.
Arthroscopic surgery
- A.
- QUESTION 3.
Among the following findings, which one is strongly suggestive for an ankle fracture ?
- A.
Pain
- B.
Swelling
- C.
Inability to bear any weight on the injured foot
- D.
Hematoma
- E.
Decreased ankle range of motion
- A.
- QUESTION 4.
Which are the most important parameters that guide the type of treatment in an ankle fracture?
- A.
Mechanism of trauma
- B.
Type of sport activity level
- C.
Displacement and stability of the joint
- D.
Type of fracture
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Pathophysiology )
- QUESTION 2.
Correct answer: D (see Clinical Presentation )
- QUESTION 3.
Correct answer: C (see Clinical Presentation )
- QUESTION 4.
Correct answer: C (see Treatment )
Nonoperative Rehabilitation of Lateral and Syndesmotic Sprains
- Paul J. Pursley, PT, SCS, CSCS
- Annunziato Amendola, MD
- •
Protection of injured structures/prevent reinjury
- •
Reduction of effusion/edema/pain control/regain normal joint motion
- •
Normalization of gait/joint control
- •
Return to preinjury activity levels
Phase I (week 0 to 1)
Protection
- •
Protected weightbearing with crutches (see Box 39-1 : Ottawa Rules), immobilization boot for pain control.
Box 39-1
Ottawa Rules Classification
X-rays are only required if there is pain in the malleolar zone and if there is:
- •
bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR
- •
bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR
- •
an inability to bear weight both immediately, and in the emergency department for four steps
- •
| PHASE I (days 0 to 5) | PHASE II (days 6 to 12) | PHASE III (days 13 to 21) | PHASE IV (weeks 3 to 6) |
|---|---|---|---|
|
|
|
|
Management of Pain and Swelling
- •
PRICE principles: Protection, Rest, Ice, Compression, Elevation
- •
See Figure 39-8 : Lateral sprain
FIGURE 39-8
Day 2 status post (s/p) lateral ankle sprain.
- •
See Figure 39-9 : Syndesmotic sprain
FIGURE 39-9
Day 2 s/p lateral and syndesmotic sprain. Note: ecchymosis more proximal and anterior.
- •
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Anterior to posterior fibular mobilization (lateral sprains)
Soft Tissue Techniques
- •
Distal to proximal soft tissue mobilization/edema massage
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
OKC ankle motion for all planes
- •
Nonweightbearing dorsiflexion stretch with UE assist, for syndesmotic sprains, axial traction to hindfoot during stretch to improve comfort.
Other Therapeutic Exercises
- •
TBS, core stability, contralateral TLS
- •
Initiate isometrics progressing to isotonics with elastic band resist for inversion/eversion/DF/PF as tolerated by pain.
Activation of Primary Muscles Involved
- •
Peroneus longus/brevis (lateral and syndesmotic)
- •
Tibialis anterior (syndesmotic)
- •
FHL/tibialis posterior/EHL
- •
Gastrosoleus
Sensorimotor Exercises
- •
Intrinsic foot motion (toe extension with ankle PF/toe flexion with ankle DF)
- •
Seated circle board progressing to bilateral limb stance balance progression (as tolerated by pain, generally will be initiated earlier for lateral vs. syndesmotic)
Open and Closed Kinetic Chain Exercises
- •
Isometric ankle inversion/eversion
- •
Band-resisted inversion/eversion/PF/DF
- •
Manual-resisted ankle motions with variable speed/pressure
- •
CKC wall sits, partial squats
- •
OKC ipsilateral hip/knee exercise
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Biking
- •
Swimming with limited kicking
- •
Pool exercises in the deep end to limit weightbearing; focus on hip knee and ankle active ROM
Neuromuscular Dynamic Stability Exercises
- •
Static hold to manual perturbation in open kinetic chain
- •
Seated BAPS/circle board
Functional Exercises
- •
Functional stepping as tolerated by pain
Milestones for Progression to the Next Phase
- •
Symmetrical and pain-free gait at self-selected pace on even surfaces
- •
Full AROM, minimal pain with passive overpressure
- •
Dorsiflexion/eversion (syndesmotic)
- •
Plantarflexion/inversion (lateral)
- •
- •
Full and symmetrical unilateral heel raise
Phase II (Lateral sprains: weeks 1 to 3; Syndesmotic sprains: weeks 2 to 4)
Protection
- •
Protective bracing (lace up or Velcro strapping)
Management of Pain and Swelling
- •
Continued compression and icing/cooling as needed
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Anterior to posterior talocrural mobilization to improve dorsiflexion
Soft Tissue Techniques
- •
Distal to proximal soft tissue mobilization/edema massage; advance tissue mobilization depth as needed.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Standing gastroc-soleus (G-s) stretching for lateral sprains
- •
Manual G-s stretching while maintaining traction on the ankle joint to prevent impingement pain with syndesmotic sprains.
Other Therapeutic Exercises
- •
Isotonics for involved ankle (band, cords, manual resistance by ATC/PT
- •
Bilateral standing toe raises through full range (angle board, stairs)
- •
Nonimpact TLS for involved side
- •
Leg press, machine based hips/quads/hamstrings
- •
Activation of Primary Muscles Involved
- •
Peroneus longus/brevis (lateral and syndesmotic)
- •
Tibialis anterior (syndesmotic)
- •
FHL/tibialis posterior/EHL
- •
Gastrosoleus
Sensorimotor Exercises
- •
Progression for bilateral to unilateral stance with sport-specific perturbation (chest pass/overhead pass, volleyball passing, hand fighting for football/wrestling)
- •
Bilateral stance on unstable surfaces, adding modifications such as active ankle motion, squats, or perturbations as tolerated
- •
Light intensity ladder drills, starting with A/P motion, progressing to diagonals and laterals and tolerated by pain and movement patterns
- •
Star Excursion Balance Test (SEBT). Initiate with posterior reaching to reduce pain associated with dorsiflexion.
Open and Closed Kinetic Chain Exercises
- •
Progress OKC isotonics w/band or manual resist
- •
CKC squats, lunges, lateral lunges, step-ups
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Elliptical
- •
Walk to jog on treadmill or level surfaces
- •
Lateral slide board
- •
Swimming with full kicking
- •
Pool-based running
Neuromuscular Dynamic Stability Exercises
- •
Static hold to manual perturbation in closed kinetic chain
Plyometrics
- •
Bilateral partial anterior jumping
- •
Pool-based jumping bilateral to unilateral as tolerated by pain
Functional Exercises
- •
Step-ups/step-downs with free weight resistance
Sport-Specific Exercises
- •
Ball-based activity (passing/catching/fielding)
- •
Ground-based stick work (field and ice hockey)
Milestones for Progression to the Next Phase
- •
Minimal to no effusion/edema
- •
Symmetrical running gait
- •
No reports of pain or instability with bilateral anterior hopping
- •
Full, pain-free AROM. Full PROM with minimal pain (<2/10 per VAS)
Phase III (Lateral sprains: weeks 3 to 6; Syndesmotic sprains: weeks 4 to 6)
Protection
- •
Soft bracing as needed for stability and injury prevention
Management of Pain and Swelling
- •
Icing as needed
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Continued AP talocrural mobilization for dorsiflexion
Soft Tissue Techniques
- •
Deep soft tissue mobilization at peroneus longus/brevis as needed for tissue release
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Generalized ankle stretching in closed chain
Other Therapeutic Exercises
- •
Return to previous global strengthening program
- •
Modify foot position as needed per reports of pain for dynamic lifts where involved leg is trail leg. This will be most problematic for syndesmotic sprains (split position).
Sensorimotor Exercises
- •
Unilateral stance on unstable surfaces (See Figure 39-10 A,B )
FIGURE 39-10
Single limb stance on disk for proprioception with progression of dorsiflexion and sport-specific positioning. Upright position ( A ); flexed position ( B ).
- •
Unilateral stance with perturbation on stable/unstable surfaces
- •
Full speed planned movement drills
- •
Ladder drills
- •
Cone drills
- •
- •
Unilateral jumps to unstable surfaces (foam pad/BOSU)
Open and Closed Kinetic Chain Exercises
- •
Weighted squats/lunges/lateral lunges/step-ups
- •
Olympic lifts with cuing for good technique
- •
Standing-resisted hip movement without UE assist
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Treadmill running levels and inclines
- •
Sport cord resisted sprint intervals anterior/posterior/lateral
- •
Cord resisted lateral slide board
- •
Cord resisted skate sprints (as applicable per sport and facilities)
Plyometrics
- •
Box jumps
- •
Bounding
- •
Hurdle drills bilateral to unilateral
- •
Split jumps
- •
Directional jumping
- •
Planned
- •
Reaction based on command
- •
Sport-Specific Exercises
- •
Sport-specific multidirectional movement progressing from planned to reactive drills
Milestones for Progression to the Next Phase
- •
Symmetrical and pain-free sprints
- •
Unilateral hopping <90% of contralateral LE
- •
Full passive range without pain
- •
SEBT <95% contralateral LE
Phase IV (weeks 6 to 18)
Protection
- •
Prophylactic soft bracing
Techniques for Progressive Increase in Range of Motion
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Stretch program/ maintenance
Other Therapeutic Exercises
- •
Maintain global strengthening program
Activation of Primary Muscles Involved
- •
Peroneus longus/brevis (lateral and syndesmotic)
- •
Tibialis anterior (syndesmotic)
- •
FHL/tibialis posterior/EHL
- •
Gastrosoleus
Sensorimotor Exercises
- •
Unilateral balance activities for injury prevention
Sport-Specific Exercises
- •
Return to full competitive sport/ prophylactic soft bracing or taping
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Able to function maximally for activity
- •
No swelling, little or no pain with activity, able to perform near previous levels
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Instability during sport-based activity
- •
Giving way episodes consistent with inversion instability for lateral ankle sprains; continuing pain with dorsiflexion and external rotation loading of the ankle
- •
Intractable pain due to impingement or instability or osteochondral injury
- •
Limited ROM due to scarring or impingement.
Tips and Guidelines for Transitioning to Performance Enhancement
- •
Be cautious with transition to resisted or plyometric exercise as the involved LE is the trail leg. The foot/ankle complex will be forced into dorsiflexion, which can be more painful, especially following a syndesmotic sprain.
- •
No exercise should be advanced or progressed until the exercise can be performed with good technique.
- •
With high demand activity and sport-specific exercises, prophylactic bracing is recommended
Performance Enhancement and Beyond Rehabilitation: Training/Trainer and Optimization of Athletic Performance
- •
Ankle sprains, both high and low (lateral) predispose athletes to recurrent injury.
- •
Prophylactic maintenance of balance, neuromuscular control, strength and flexibility is important to minimize re-injury
- •
Prophylactic bracing is recommended
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
No reported instability while braced during high level practice situations
- •
Symmetrical gait for maximum speed sprints and shuffles
- •
Unilateral hopping/jumping < 90% of contralateral side
Evidence
Multiple-Choice Questions
- QUESTION 1.
Which of the following is important in preventing a recurrent ankle sprain?
- A.
Prophylactic bracing
- B.
Decreased range of motion
- C.
Hop test less than 50% the opposite side
- D.
Presence of joint swelling
- A.
- QUESTION 2.
Which of the following indicates that it is safe to return to sport?
- A.
Pain during jumping activity
- B.
No pain or swelling of the ankle after a heavy workout with sport-specific exercises
- C.
Daily antiinflammatory medication is still required for pain control after sport-specific exercises
- D.
A mild limp with sport-specific exercises
- A.
- QUESTION 3.
Which of the following is the most significant difference between a high ankle sprain and a lateral ankle sprain?
- A.
Rehab protocol
- B.
Likelihood of recurrent injury
- C.
Expected time to return to sport
- D.
Likelihood of surgery
- A.
- QUESTION 4.
Which of the following modalities is not recommended following an ankle sprain?
- A.
Immobilization
- B.
Heat therapy
- C.
Cold therapy
- D.
Antiinflammatory medication
- A.
- QUESTION 5.
Which of the following is an indication for surgical management of a lateral ankle sprain?
- A.
Pain at 3 weeks following the sprain
- B.
Decreased ROM at 3 weeks following a sprain
- C.
Recurrent ankle sprains after optimal rehabilitation
- D.
Presence of a small avulsion fracture off the distal fibula
- A.
Answer Key
- QUESTION 1.
Correct answer: A (see Protection )
- QUESTION 2.
Correct answer: B (see Milestones for Progression to Advanced Sport-Specific Training and Conditioning )
- QUESTION 3.
Correct answer: C
- QUESTION 4.
Correct answer: B
- QUESTION 5.
Correct answer: C (see Criteria For Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention )
Postoperative Rehabilitation after Lateral Ankle Ligament Repair/Reconstruction
- Scot A. Youngblood, MD, CDR, MC, USN
- William E. Burns, DPT, OCS, SCS
Indications for Surgical Treatment
- •
Recurrent lateral ankle instability despite an appropriate course of nonoperative care: rehabilitative exercises and ankle supportive (lace-up) bracing.
Brief Summary of Surgical Treatment
Major Surgical Steps
- •
Examination under anesthesia—anterior drawer and talar tilt testing for confirmation of excessive laxity
- •
Open surgical approach to anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL)
- •
Inspection of peroneal tendons as appropriate
- •
Shortening and repair of native tissue to anatomic attachment points on the fibula of both the ATFL and CFL
- •
Imbrication of the repair with the inferior extensor retinaculum (Gould modification)
Factors That May Affect Rehabilitation
Anesthetic
- •
For the vast majority of cases, rehabilitation is delayed until at least the 2-week mark. Barring any anesthetic complication, there should by this time be no persistent impact of the choice of anesthetic at the first rehabilitation session.
Surgical
- •
Arthroscopy of ankle: Some experts recommend a routine diagnostic arthroscopy of the ankle before the ligament repair. Intraarticular lesions encountered are treated as appropriate: osteochondral lesion of the talus microfracture, synovectomy, or postinjury scar debridement.
- •
Tissue augmentation: In the setting of atrophic native tissues, the surgeon may opt to perform a reconstruction with tendon autograft or allograft (most commonly a gracilis or semitendinosus hamstring tendon). Most experts recommend a slower progression of activities after implantation of grafted tissue, especially allograft (donated tissue).
- •
Peroneal tendon repair or tenodesis: Peroneal tendinopathy (tendinitis and tears) can occur with inversion injuries to the ankle. Chronic pain or swelling in the area of the tendons and preoperative imaging may demand exploration of the tendons at the time of the surgery. Indicated treatment can include a tenosynovectomy, tendon repair, or tenodesis (removal of the diseased tendon and suturing of the remaining tendon ends to the other peroneal tendon).
- •
Hindfoot or forefoot realignment: Some patients with ankle instability have a predisposing architecture to their foot: cavovarus (inverted heel and a high arch). Realignment osteotomies of the heel and/or the forefoot may be indicated to protect the repair and prevent additional inversion injuries. Typically these osteotomies are kept nonweightbearing for 6 weeks before progression of weightbearing.
Other Surgical Techniques and Options
- •
It has been said that many foot and ankle surgeons perform a “Brostrom”, but every one of them performs it slightly differently. Choices available to the operative surgeon beyond those listed in the section above include repairing only the anterior talofibular ligament (and not the calcaneofibular ligament), performing a midsubstance repair versus reattaching the ligaments to bone, using suture anchors versus drill holes in the bone to accomplish the repair, choosing not to incorporate the inferior extensor retinaculum, sacrificing a portion of a peroneal tendon in order to reinforce the repair, and choice of suture (absorbable suture versus second generation high tensile strength polyethylene braided suture). These multiple variables underscore the importance of communicating with the operative surgeon regarding the planned rehabilitation protocol to ensure it is neither too aggressive nor too restrictive for the specific repair that was performed.
Before Surgery: Overview of Goals, Milestones, and Guidelines 1
1 Prehabilitation, if appropriate, is described in the Nonoperative Rehabilitation section of this chapter.
- •
Resolution of any residual swelling in the involved ankle
- •
Restoration of full active range of motion in all directions
- •
Normalize gait pattern
- •
Maximize static and dynamic single-limb standing balance in the involved ankle
- •
Maximize strength of the peroneals, gastrocnemius/soleus complex, and tibialis anterior and posterior muscles
- •
Understand the anatomical basis of the surgical repair performed
- •
Understand any additional procedures performed and their implications for the patient’s specific postoperative rehabilitation
- •
Know the positions and activities that will stress the repaired structures, and avoid these until the appropriate timeframe
- •
Progressive advancement of activities with adequate protection of healing structures
Phase I : Immediate Postoperative Period (days 0 to 14)
- •
Patients should be encouraged to keep their operative extremity elevated in their nonweightbearing splint, especially for the first 3 to 5 days after their surgery, during which swelling peaks.
- •
No study has shown an advantage to motion before the 2-week point, at which skin sutures are often removed. The desire to aggressively begin therapy in the anxious patient must be balanced by the potentially significant complications of wound dehiscence and infection. Most patients have healed their incisions adequately by 2 weeks to have their sutures removed, Steri-Strips applied, and gently begin progressive range of motion.
| PHASE I (weeks 1 to 2) | PHASE II (weeks 2 to 6) | PHASE III (weeks 6 to 12) | PHASE IV (weeks 12 to 16) | PHASE V (weeks 16 to 24) |
|---|---|---|---|---|
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Goals
- •
Allow adequate resolution of swelling and pain with appropriate soft tissue rest after the surgical procedure.
- •
Allow the incision to heal adequately before the institution of motion and aggressive advancement of range of motion exercises.
- •
Preserve full range of motion of the ipsilateral hip, knee, and digits.
Protection
- •
Nonweightbearing in a posterior splint secured with elastic bandage.
- •
Crutch ambulation
Management of Pain and Swelling
- •
Oral analgesic medication and ice
- •
Rest, ice, compression, and elevation
- •
Commercially available sequential compression cryotherapy devices may be used to control and reduce swelling
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Active range of motion activities for the ipsilateral hip, knee, and digits during the protection phase
Other Therapeutic Exercises
- •
Upper body ergometry to maintain cardiovascular fitness
Milestones for Progression to the Next Phase
- •
Healing of the surgical incision with reduction of postoperative swelling.
Phase II (weeks 2 to 6)
- •
Ensure normal mobility of the surgical incision and underlying tissues in order to prevent the development of adhesions that could impede the progression of range of motion.
- •
Neuromuscular electrical stimulation (NMES) can be used to facilitate activation of the peroneus longus and brevis as well as the tibialis anterior muscles in cases of inhibition.
- •
If available and when the surgical incision is fully healed, aquatic therapy, particularly water walking, can help facilitate lower extremity strengthening and the return to a normal walking pattern.
- •
Articulated Cam Walker Range of Motion Progression. Another option for rehabilitation in this timeframe is to utilize an articulated cam walker with adjustable range of motion stops to allow protected early motion. During the third and fourth weeks postoperatively, 10° of dorsiflexion and 20° of plantarflexion are allowed while the patient is weightbearing as tolerated. During the fifth and sixth weeks, 20° of dorsiflexion and 40° of plantarflexion are allowed. (See Evidence References, Karlsson et al.) Obviously this rehabilitative option would be dependent on the availability of an articulated cam walker and would be in addition to the therapy discussed in this section.
Goals
- •
Resolution of postoperative swelling
- •
Transition to Weight Bearing As Tolerated (WBAT) in cam walker
- •
Increase dorsiflexion in the operative ankle to at least 10°
- •
Increase plantarflexion in the operative ankle to at least 30°
- •
Increase strength in the peroneals, gastrocnemius/soleus complex and tibialis anterior and posterior muscles to at least 3+/5
Protection
- •
WBAT with the use of a cam walker
- •
A standard cam walker can be used or, if available, an articulated cam walker may be employed to allow for the progression of functional yet protected range of motion in the talocrural joint (see Clinical Pearls ).
Management of Pain and Swelling
- •
Acetaminophen and/or NSAIDs as needed
- •
Ice and elevation following physical therapy and other periods of prolonged standing and/or walking
- •
Commercially available sequential compression cryotherapy devices may be used to control and reduce swelling
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
Tarsometatarsal and intermetatarsal joint mobilization in the operative foot
Soft Tissue Techniques
- •
Scar mobilization and retrograde massage to prevent adhesions at the surgical site and mobilize edema
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Active-assisted range of motion of the talocrural joint to 10° of dorsiflexion and 30° of plantarflexion
Other Therapeutic Exercises
- •
Upper body ergometry to maintain cardiovascular fitness
- •
Upper body strengthening activities as tolerated (preferably in a seated or supine position)
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
- •
Isometric activation of the peroneus longus, brevis and tertius
- •
Isotonic dorsiflexion and plantarflexion through a protected range of motion (10° of dorsiflexion and 30° of plantarflexion)
Sensorimotor Exercises
- •
Seated active plantarflexion to 30° and dorsiflexion to 10° using a rockerboard (see Figure 39-11 )
FIGURE 39-11
The rockerboard can be used in the initial stages of rehabilitation for reestablishment of dorsiflexion ( A ) and plantarflexion ( B ) in the operative ankle.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Multi-angle isometrics to 10° dorsiflexion and 30° of plantarflexion
Neuromuscular Dynamic Stability Exercises
- •
Rhythmic stabilization in all directions (dorsiflexion, plantarflexion, inversion, and eversion)
Functional Exercises
- •
Ambulation in cam walker
Milestones for Progression to the Next Phase
- •
Resolution of postoperative swelling
- •
No pain with full weightbearing and ambulation in cam walker
- •
Active range of motion to at least 10° of dorsiflexion and 30° of plantarflexion
- •
3+/5 strength in the involved peroneus longus, brevis and tertius; gastrocnemius/soleus complex and tibialis anterior and posterior
Phase III: Immediate Postoperative Period (weeks 6 to 12)
- •
The use of a treadmill for gait training can be effective in facilitating the normalization of the patient’s gait pattern and ambulatory cadence.
- •
Ensure supplementation of the patient’s outpatient treatment course with a comprehensive home exercise program of progressive range of motion and strengthening exercises.
Goals
- •
Transition to full weightbearing in lace-up figure-8 ankle brace
- •
Advance to full active range of motion in all directions
- •
Increase strength in the involved peroneus longus and brevis, gastrocnemius/soleus complex and tibialis anterior and posterior to 4/5
- •
Normalize gait pattern and ambulatory cadence
- •
Initiate single-limb activities for strength, balance and proprioception training
Protection
- •
Lace-up figure-8 ankle brace
Management of Pain and Swelling
- •
Oral analgesic medication or NSAIDs as needed.
- •
Ice and elevation following physical therapy and other periods of prolonged standing and/or walking
- •
Commercially available sequential compression cryotherapy devices may be used to further control and reduce swelling
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Tarsal, tarsometatarsal, and intermetatarsal joint mobilization as needed to address particular mobility restrictions.
Soft Tissue Techniques
- •
Scar mobilization as needed
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Active assisted range of motion exercises through the normal range of motion in all directions. Care must be taken not to advance beyond the normal ligamentous endfeel of the surgically repaired anterior talofibular and calcaneofibular ligaments in dorsiflexion, plantarflexion or inversion.
Other Therapeutic Exercises
- •
Stationary cycling
- •
Upper body strengthening activities as tolerated (preferably in a seated or supine position)
Activation of Primary Muscles Involved in Injury Area or Surgical Structures
- •
Peroneus longus, brevis and tertius
Sensorimotor Exercises
- •
Standing Biomechanical Ankle Platform System (BAPS) exercise: clockwise and counterclockwise, level 1 or 2 ( Figure 39-12 )
FIGURE 39-12
Standing Biomechanical Ankle Platform System (BAPS) board. The patient rotates the board in both clockwise and counterclockwise directions. The BAPS system incorporates an adjustable half-dome base by which the degree of motion and instability can be advanced (Levels 1 to 5). Refer to postoperative phases for appropriate advancement of levels.
- •
Single-limb static standing balance on firm surface
- •
Sagittal and coronal plane weight shifting on rocker board ( Figure 39-13 )
FIGURE 39-13
Sagittal plane weight shifting on a rockerboard isolating ankle plantarflexion ( A ) and dorsiflexion ( B ). Coronal plane weight shifting for eversion and inversion can also be incorporated utilizing the rockerboard.
Open and Closed Kinetic Chain Exercises
- •
(OKC) Multi-directional ankle strengthening with resistance band
- •
(CKC) Double-limb calf press (body weight only)
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Treadmill walking
Neuromuscular Dynamic Stability Exercises
- •
Rhythmic stabilization in all directions
- •
Single-limb standing on operative leg while pulling against resistance band with nonoperative leg (sagittal plane) ( Figure 39-14 )
FIGURE 39-14
Resisted hip flexion ( A ) and extension ( B ) while standing on single limb. These exercises can also be advanced to standing on a foam mat with the single limb.
Functional Exercises
- •
Wall squats
- •
Single-limb stepping (4″ step)
Milestones for Progression to the Next Phase
- •
Full active range of motion in all directions
- •
Strength in the involved peroneus longus, brevis and tertius; gastrocnemius/soleus complex and tibialis anterior and posterior to 4/5
- •
Normal gait pattern and ambulatory cadence
Phase IV (weeks 12 to 16)
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