Chronic Ankle Instability:

Transcription

1 Chronic Ankle Instability: The Spectrum of Care from Intake to Discharge Ashley Marshall, PhD, ATC A.T. Still University Postdoctoral Research Fellow Practice-Based Research

2 Objectives Describe the progression of an acute lateral ankle sprain (LAS) to chronic ankle instability (CAI) Compare and contrast the evidence regarding the treatment of LAS and CAI Evaluate recommendations for incorporating patientreported outcome measures, clinician-rated outcome measures and treatments at the point-of-care into lateral ankle sprain rehabilitation 2

3 Progression from LAS to CAI 3

4 Just an Ankle Sprain? LAS are the most common injuries associated with physical activity and athletic participation. ~625,000 LAS are seen in U.S. emergency departments annually. (Waterman 2010) 60% of all injuries in HS and College sports are LAS. (Hootman 2007, Fernandez 2015, Powell 1999, Fong 2007) 4

5 Mild Injury First-time LAS: - Up to 70% of individuals will suffer a recurrent sprain (Gerber 1998) - Up to 75% will eventually develop CAI (Anandacoomarasamy 2005) A single LAS can result in degenerative joint changes and increase injury risk (Golditz 2014; Kramer 2007) Large financial burden: up to $4 billion annually (Soboroff 1984) 5

6 Post-Acute Deficits Following LAS Lingering, disabling symptoms, including pain and decreased function (Gerber 1998, Anandacoomarasamy 2005, Konradsen 2002, Braun 1999, Hiller 2011) Over 50% of individuals who sustained a LAS report symptoms 10+ years after injury (Hiller 2011) Short-term recovery > Long-term consequences

7 Post-Acute Deficits Following LAS 7 Hertel 2008

8 Post-Acute Deficits Following LAS McKeon & Wikstrom 2015

9 Chronic Ankle Instability 9 McKeon & Wikstrom 2015

10 Development of CAI 10

11 CAI Criteria History of at least 1 significant ankle sprain - At least 1 interrupted day of desired physical activity History of the previously injured ankle joint giving way and/or recurrent sprain and/or feelings of instability Ankle Instability Instrument (AII): yes to 5+ questions Cumberland Ankle Instability Tool (CAIT): <24 Identification of Functional Ankle Instability (IdFAI): >11 Self-reported foot and ankle questionnaire Foot and Ankle Ability Measure (FAAM): ADL <90%, Sport <80% Foot and Ankle Outcome Score (FAOS): <75% in 3+ categories Gribble 2014

12 Treatment of LAS and CAI 12

13 NATA Position Statement 13

14 NATA Position Statement 14. Cryotherapy should be applied to acute ankle sprains to reduce pain, minimize swelling formation, and decrease secondary injury. Evidence Category: C 15. Compression should be applied to acute ankle sprains to minimize swelling. Evidence Category: C 16. The limb with the acute ankle sprain should be elevated to minimize swelling. Evidence Category: C 17. Nonsteroidal anti-inflammatory drugs, administered orally or topically, reduce pain and swelling and improve short-term function after ankle sprains. Evidence Category: A 18. Functional rehabilitation is more effective than immobilization in managing grade I and II ankle sprains. Evidence Category: A 19. Grade III sprains should be immobilized for at least 10 days with a rigid stirrup brace or below-knee cast and then controlled therapeutic exercise instituted. Evidence Category: B 20. Electrical stimulation can be used as an adjunct to minimize swelling during the acute phase of injury. Evidence Category: C 21. Clinicians should refrain from thermotherapy during acute and subacute phase of injury due to lack of evidence and the potential to exacerbate injury. Evidence Category: C 22. Cryokinetics can be used to reduce pain and thereby allow early rehabilitative exercises. Evidence Category: C 23. Rehabilitation should include comprehensive ROM, flexibility, and strengthening of the surrounding musculature. Evidence Category: B 24. Balance training should be performed throughout rehabilitation and follow-up management of ankle sprains to reduce re-in jury rates. Evidence Category: A 25. Passive joint mobilizations and mobilizations with movement should be used to increase ankle dorsiflexion and improve function. Evidence Category: B 14 Kaminski 2013

15 Balance Training Wikstrom 2009

16 Impairment-Based Rehab Assess ROM Treat ROM Re-assess ROM Assess Strength Treat Strength Re-assess Strength Assess Balance Treat Balance Re-assess Balance Assess Functional Treat Functional Re-assess Functional Donovan 2012

17 Impairment-Based Rehab Mobilizations & Stretching Assess ROM Arthrokinematic Deficit Yes No Re-assess ROM Osteokinematic Deficit Yes Stretching Donovan 2012

18 Donovan 2012

19 The Foot Core

20 Core Stability Concepts Motor Control Coordination of local stabilizer and global mover muscles Motor Capacity Strength Muscle Endurance Lumbopelvic core: - Abdominal draw-in maneuver Foot Core - Short foot maneuver? Hertel 2017

21 The Foot Core The Foot Core McKeon 2015

22 Short Foot Exercise

23 Toe Spread-Out Exercise

24 Isolated Greater Toe Extension

25 Isolated Lesser Toe Extension

26 Foot Core Rehab Paradigm McKeon 2015

27 Outcome Measures 27

28 Patient-Centered Care 28

29 Patient-Reported Outcome Measures 29

30 Patient-Reported Outcome Measures 30

31 Patient-Reported Outcome Measures 31

32 Clinician-Rated Outcome Measures Weight-Bearing Lunge Test 32 Single Leg Balance

33 Clinician-Rated Outcome Measures Star-Excursion Balance Test 33

34 Clinician-Rated Outcome Measures Drop Vertical Jump 34