Overview. 20% of lateral ankle sprains can lead to chronic pain and instability (UW Sports Medicine, 2014)

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1 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)

2 Anatomy of the Ankle Anterior Talofibular Ligament (ATFL) Calcaneofibular Ligament (CFL) Posterior Talofibular Ligament (PTFL) Chronic ankle instability: o Mechanical insufficiencies o Functional insufficiencies o Combination of both (Brigham and Women s Hospital, 2010; Hertel, 2002; Kraemer, 2014)

3 Surgical Procedures Nonaugmented (Anatomic) Lateral Ankle Repair Brostrom, modified Brostrom techniques 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)

4 Surgical Procedures Augmented (Tenodesis) Lateral Ankle Reconstruction Evans, Watson-Jones, Elmslie-Trillat, Chrisman-Snook o A portion of the peroneus brevis tendon is used to reconstruct the lateral ligaments o Used with more severe cases (greater extent of ligament damage) o Satisfactory stabilization in > 90% of patients after 10 years (Stapp et al., 1996)! Poor long term results (persistent pain, degenerative changes, restricted subtalar motion) (Baumhauer & O Brien, 2002; OrthopedicsOne, 2014; Starkey, 2013; William Beaumont Army Medical Center, 2005)

5 Surgical Procedures Nonaugmented Repair (Starkey, 2013) Augmented Reconstruction

6 Timeline Initial Rehabilitation (0-6 weeks) o Phase I: Weeks 1-2! Pain management o Phase II: Weeks 3-6! Reconst.: Minimize quad atrophy and deconditioning! (Repair: early mob. " ankle ROM, no PF or inv.) Beginning Strengthening (6-12 wks) o Phase III: Weeks 6-10! Ankle rehab (WB in boot) o Phase IV: Weeks 11-12! Full ROM (WB in shoe) Advanced Strengthening (12-16 weeks) o Phase V: Weeks 12-16! Strength, proprioception o Phase VI: Weeks 16+! Endurance, specificity Return to Sport (Minnesota Orthopedic Sports Medicine Institute, 2014; Workers Compensation Board, 2005)

7 Initial Rehabilitation Phase I: Weeks 1-2 Goals: o Rest and recovery from surgery o Control swelling and pain o Increase ADL Interventions: o Rest and elevation to control swelling o Physician prescribed medications for pain o Hip and knee AROM o Patient education! Sutures removed at days, back in cast for another 4 weeks (Minnesota Orthopedic Sports Medicine Institute, 2014)

8 Treatment (orthoinfo.aaos.org, 2014) (madclouds.com, 2014) *Avoid all strenuous physical activity keep foot elevated!

9 Initial Rehabilitation Phase II: Weeks 3-6 Goals: 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)

10 Initial Rehab Exercises 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) 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)

11 Initial Rehab Exercises Hip Clam Shells (durablehealth.net, 2014) Single Leg Raise (emi2hips.com, 2014) Upper Body Lift *Repairs: avoid plantarflexion and inversion exercises (Starkey, 2013) (sprouthealthlifestyle.com, 2014)

12 Beginning Strengthening 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) 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)

13 Exercises T-Ball Squat (learning.summitrehab.ca, 2014) *Avoid: Ankle ABC s (scoutingmagazine.org, 2014) -vigorous plantarflexion and inversion exercises -anterior joint mobilizations (Stapp et al., 1996) Cardiovascular Exercise (sw.org, 2014)

14 Beginning Strengthening Phase IV: Weeks 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) 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)

15 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

16 Advanced Strengthening Phase V: Weeks Goals: o Prevent re-injury o Gait Training o Proprioception o Full strength o Power (Minnesota Orthopedic Sports Medicine Institute, 2014; Royal National Orthopeadic Hospital, 2009) 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) Cardiovascular Exercise: Running on Treadmill Swimming Cycling

17 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

18 Advanced Strengthening Phase VI: Weeks 16+ Goals: o Return to Play o Endurance o Sport specificity o Prevent re-injury Example Exercises: Weighted 90 Squats Single Leg Stance - Body Blade Side Lunges Box Jumps T-test agility Sport specific drills Stretching (gastroc and soleus) Cardiovascular Exercise: Sprint Intervals Swimming Running on Treadmill (Minnesota Orthopedic Sports Medicine Institute, 2014)

19 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

20 Conclusion Rehab Program Goals Stretching / ROM exercises o Weeks Strengthening o Weeks Cardiovascular endurance o Week 3 Week 12+ Proprioception o Week 12+ Speed o Week 12+ Power o Week 12+ Agility o Week 12+ (Minnesota Orthopedic Sports Medicine Institute, 2014; Tymms & Bedi, 2011)

21 References 1. Ankle OCD surgery rehabilitation guidelines. Tripler Army Medical Center Web site May% doc+&cd=2&hl=en&ct=clnk&gl=us Updated May Accessed September 19, Ankle reconstruction / modified Brostrom repair / peroneal tendon repair. William Beaumont Army Medical Center Web site. Updated August Accessed September 19, Baumhauer JF, O Brien T. Surgical considerations in the treatment of ankle instability. J Athl Train. 2002; 37(4): Coetzee JC, Ebeling PB. Ankle ligament reconstruction rehabilitation protocol. Minnesota Orthopedic Sports Medicine Institute Web site. Accessed September 19, de Vries JS, Krips R, Sierevelt IN, Blankevoort L, van Dijk CN. Interventions for treating chronic ankle instability (review). The Cochrane Library. 2011; 8: Godges J, Klingman R. Ankle- Lateral ligament reconstruction and rehabilitation. Loma Linda U DPT Program Web site. Accessed September 19, Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002; 37(4): Karlsson J, Lundin O, Lind K, Styf J. Early mobilization versus immobilization after ankle ligament stabilization. Scand J Med Sci Sports. 1999; 9: Kraemer M. Lateral ankle reconstruction case study. AlterG Web site. Accessed September 19, Lateral ankle ligament reconstruction, post-operative recovery guidelines. Chelsea and Westminster Hospital, NHS Trust Web site. Published January Accessed September 19, 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):

22 References 12. Modified Brostrom-Gould repair for chronic lateral ankle instability. Brigham and Women s Hospital Web site. 20protocols/ankle-brostrom%2520gould%2520repair%2520for%2520lateral%2520ankle%2520instablility.pdf+&cd=2&hl=en&ct=clnk&gl=us Published Accessed September 19, Procedure: ankle ligament reconstruction. Workers Compensation Board Web site. Published January Accessed September 19, Rehabilitation guidelines for lateral ankle reconstruction. University of Wisconsin Sports Medicine Web site. Updated June Accessed September 19, Rehabilitation guidelines for patients undergoing surgery for lateral ligament reconstruction of the ankle. Royal National Orthopaedic Hospital, NHS Trust Web site. Updated Accessed September 19, Sandor, R. Ankle exercises. Camino Medical Group Web site. Updated January Accessed September 19, Starkey C. Athletic training and sports medicine. Burlington, MA: Jones & Bartlett Learning; 2013: Stapp MD, Smith TF, Challa SF. Chronic lateral ankle instability: repair versus reconstruction. Podiatry Institute Web site. Updated Accessed September 29, Tymms G, Bedi H. Post operative physiotherapy protocol for lateral ligament reconstruction. Orthosport Victoria Web site. Published Accessed September 19, 2014.

23 Questions?