Return-to-Play Guidelines

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1 What are the Current Trends for Management and of Ankle Sprains Among Athletes? This Guy s Pretty Experienced at What He Does! (but has been plagued by ankle issues throughout his career!) Mid-Atlantic Athletic Trainers Association (MAATA) 2018 Annual Symposium EBP Workshop May 20, 2018 Ocean City, MD Thomas W. Kaminski, PhD, ATC, FNATA, FACSM, RFSA Professor Director of Athletic Training Education University of Delaware Basic Components of Therapeutic Exercise Flexibility and range-of-motion Strength and muscular endurance Re-establishment of proprioception and neuromuscular control Return-to-Play Guidelines No pain, swelling or atrophy Full ROM Normal flexibility Appropriate strength Adequate muscular endurance Perform sport skills and coordination tasks at an appropriate level Clinical assessment of acute lateral ankle sprain injuries: consensus statement and recommendations of the International Ankle Consortium Calcaneofibular Ligament (CF) Authors: Delahunt E 1,2, Bleakley CM 3, Bossard DS 1,2, Caulfield BM 1,4, Docherty CL 5, Doherty C 4, Fourchet F 6, Fong DT 7, Hertel J 8, Hiller CE 9, Kaminski TW 10, McKeon PO 11, Refshauge KM 9, Remus A 4, Verhagen EA 12, Vicenzino BT 13, Wikstrom EA 14, Gribble PA 15 Article in press 1

2 Assessing Dynamic Ankle Stability: Isotonic Strength PrimUs System Isotonic activities re dynamic and involve both ECC and CON muscle actions 1 RM is commonly used a measure of strength in larger muscle groups, however rarely used in the ankle. Some examples of isotonic exercises are shown here. Assessing Dynamic Ankle Stability: Isokinetic Strength Isokinetic Dynamometry objective quantifiable quasi-ckc assessment reliable Capable of measuring both ECC and CON muscle actions Kin Com 125 AP Isokinetic Dynamometer Concept introduced in 1967 by Hislop & Perrine (Hislop, HJ, Perrine, JJ (1967). Phys Ther. 47, ) Contemporary dynamometers enable the researcher to gather both CON and ECC data Allows for the examination of reciprocal muscle group ratios (knee, shoulder, ankle) Y-Balance Testing Developed & described by: Functional Movement Systems Plisky et al. Reliable dynamic balance assessment tool Cut-off = 89.6% for the composite score, relative to limb length Sensitivity of 100% and specificity of 71.7% Males < 89.6% are 3.5X more likely to obtain a noncontact lower extremity injury Female Shall < 94% we are try 6.5 times as likely to sustain a musculoskeletal injury it ourselves? In the ANT reach, a difference > 4 cm between the limbs is associated with an elevated risk of injury Let s Re-visit the NATA Position Statement 14. Cryotherapy should be applied to acute ankle sprains to reduce pain, diminish swelling formation and reduce secondary 15. Compression should be applied to acute ankle sprains to minimize swelling formation. 2

3 Thoughts on Overnight Taping Following Acute Ankle Sprains? Thoughts on the Footbeat? Shall we try it ourselves? 16. Acute ankle sprains should be elevated to curb swelling formation. 17. Non-steroidal antiinflammatory drugs, administered orally or topically reduce pain, swelling and improve short-term function following ankle sprains. 18. Early mobilization and functional rehabilitation is more effective over immobilization in the management of Grade I and II ankle sprains. 19. Electrical stimulation can be used as an adjunct to diminish swelling formation during the acute phase of atch?v=rmusbxtu_wm watch?v=fp9sxr5i1au Thoughts on Talar Mobilizations in Acute Ankle Sprain Management? 20. Clinicians should refrain from thermotherapy during the acute and sub-acute phase of injury due to lack of evidence and potential to exacerbate the 21. Cryokinetics can be used to reduce pain and thereby allow early rehabilitative exercises. 3

4 22. Rehabilitation should include comprehensive range-of-motion, flexibility, and strengthening of the surrounding musculature. Evidence Category: B Strength and Muscular Endurance: Why are they important? With any injury some strength is lost Dependent on: Area injured Extent of injury Amount of time disabled Muscular Strength Maximum force that a muscle or group of muscles can exert Muscular Endurance Muscle's ability to sustain a submaximal force in either a static or repetitive activity over a period of time. Of all the parameters, strength is probably the most obvious and frequently sought following Optimal muscle function is necessary for dynamic stabilization in the ankle Dynamic Muscular Stability in the Ankle That had to hurt! Muscle strength and endurance are two dimensions within a continuum of muscle resistance. Muscles that control movements in the ankle region must work around the changing axes of motion associated with the biomechanics of the region. Co-contraction is important, especially eccentric control Loss of this efficiency may result in an inability to dissipate forces in a coordinated manner Components of Lateral Muscular Stability Evertors Some argue that strength of the peronei is a central component in the treatment of ankle instability. Musculature: Peroneus longus Peroneus brevis Function to evert and PF the foot. Provide lateral stability and help to maintain foot stability (PL). Tropp H. Pronator weakness in functional instability of the ankle joint. Int J Sports Med 1986;7: Components of Anterior Muscular Stability Dorsiflexors Musculature: Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peroneus tertius Some recent interest in this muscle and ankle injuries (Witvrouw E. at al. The significance of the peroneus tertius muscle in ankle injuries. Am J Sports Med, 2006;34(7): ) Absent in 5% - 17% of Caucasian population DF strength has been implicated as a risk factor for ankle sprain. (Willems et al. Intrinsic risk factors for inversion ankle sprains in male subjects. Am J Sports Med, 2005;33(3): ) Components of Posterior Musculature Stability Plantar Flexors Least packed position Musculature Triceps surae Plantaris Tibialis posterior Flexor digitorum longus Flexor hallucis longus PB and PL Deficits in PF strength associated with ankle injury risk. (Baumhauer JF, et al. A prospective study of ankle injury risk factors. Am J Sports Med, 1995;23: ) 4

5 Components of Medial Muscular Stability Invertors Musculature: Tibialis anterior Tibialis posterior Provide medial stabilization for the foot and ankle. TP acts as a sling to support the arch, along with help from the PL. Reports of invertor weakness in those with ankle instability Ryan L. Mechanical stability, muscle strength, and proprioception in the functionally unstable ankle. Aus J of Physio 1994;40: Sekir U. et al. Effect of isokinetic training on strength, functionality and proprioception in athletes with functional ankle instability. Knee Surg Sports Traumatol Athrosc Rehabilitation Goals Combining OKC and CKC rehab techniques to regain normal motion, strength, and sensorimotor function. Balduini and Tetzlaff (Clin Sports Med 1982) suggest that although there is no consensus regarding ankle sprain rehab ---- the goal should be to decrease the incidence of AI! Current Strength Interventions from a Clinician s Perspective 4-way HIP t-band kicks (a nice stress on the ankle musculature) Dynamic exercises (cuff weights, surgical tubing, resistive bands) Explosive/reactive manual resistance exercises Emphasis on EV/DF beginning with the foot PF, knee flexed, and hip IR Similar to rhythmic stabilization exercises in the shoulder! Current Strength Interventions from a Clinician s Perspective Toe raises, heel walks, toe walks Standing sideways on a slant board Use of unstable surfaces too With toe raises push a quarter into the floor to isolate the foot intrinsics Emphasis on many repetitions! Isokinetic training Dynamic strengthening plyometrics Single leg hopping exercises --- laterally for distance Hip Abductor Strengthening Exercises? Monster Walks Clams 23. Balance training should be included throughout rehabilitation, and follow-up management of ankle sprains to reduce re-injury rates. =ESqPhgXuVE4 5

6 Functional Return-to-Play Insights? 24. Joint mobilizations should be utilized to increase ankle dorsiflexion and improve function. Evidence Category: B Sport-Specific Balance Alter G Reactionary Functional Movements Interesting Cost Analysis 28. Both lace-up and semirigid ankle braces and traditional ankle taping have been shown to be effective in both preventing ankle injuries and reducing the rate of reoccurrence in athletic populations. McGuine et al Cost per Ankle Sprain NNT x cost of prophylaxis Use Table 3 from Olmsted et al article Total Cost per Season Cost per Ankle Sprain x # of interventions Use Table 3 from Olmsted et al article Taping is more expensive than bracing across the course of a 13 week season 6

7 McGuine et al McGuine et al Numbers Needed to Treat Analysis Basketball Study 14.5 ( ) Translation = 1 injury prevented during a season on a basketball team with 15 players Football Study 28.3 ( ) Translation = 2-3 injuries prevented during a season on a football team with 60 players 29. Clinicians working with athletes should perform a multi-intervention prevention program, lasting at least 3 months, focused on balance and neuromuscular control to reduce the risk of ankle Athletes with a history of ankle injury may benefit more from this type of training. 30. Leg muscle (evertor, invertor, dorsiflexor, and plantar flexor) and hip extensor and abductor strength may be considered as an ankle injury prevention strategy. 31. Clinicians should consider assessing dorsiflexion range of motion in at-risk athletes. If dorsiflexion range of motion is limited, clinicians should incorporate techniques to enhance arthrokinematic and osteokinematic motion for possible prevention of ankle Thank You 7