Guideline. Drugs & Therapeutics Committee

Transcription

1 Physiotherapy Rehabilitation Guidelines for patients undergoing Lateral Ligament Reconstruction of the Ankle Document Type Date Approved Ratifying Body Related Documents Guideline 13/11/2017 Drugs & Therapeutics Committee Physiotherapy rehabilitation guidelines Pes Cavus Correction Physiotherapy rehabilitation guidelines Anterior ankle arthroscopy Physiotherapy rehabilitation guidelines Total Ankle Replacement Physiotherapy rehabilitation guidelines Subtalar and Hindfoot fusion Physiotherapy rehabilitation guidelines Hallux valgus deformity- Scarf Osteotomy Physiotherapy rehabilitation guidelines Tibialis Posterior Reconstruction Physiotherapy rehabilitation guidelines ACI of the ankle Author Owner (Executive Director) Directorate Superseded Documents Subject Review Date Joanna Benfield, Foot & Ankle Specialist Physiotherapist, RNOH Lucy Davies Operations Rehab Guidelines for Lateral Ligament Reconstruction of the Ankle (2008) Clinical, Clinical Units, Communication, Inpatient & Outpatient Services 13/11/2022 Ankle Page 1

2 Keywords and Phrases Consultation Group/Approving Bodies/Subject Matter Expert Rehabilitation, foot and ankle surgery, lateral ligament, anterior talofibular ligament, ATFL, calcaneofibular ligament, CFL, posterior talofibular ligament, PTFL, ankle sprain, instability, chronic ankle instability, CAI, mechanical instability, functional instability, Brostrum, Crisman-Snook, physiotherapy, complications, outcomes, milestones, function, treatment, exercise, pain relief, restrictions, limitations, sport, fitness, postural awareness, pain education, mobility, goals, precautions, compliance, ankle pain, leg pain, foot pain. Members of Foot and Ankle Unit Team (4 consultants, & Clinical Nurse Specialist) Members of Outpatient Musculoskeletal Physiotherapy Team (Band 5, 6, 7 and 8a staff members at Stanmore and Bolsover Street) Members of Inpatient Orthopaedic Physiotherapy Team (Band 7 and 8a staff members) Readership All staff (inc. Clinical) Ankle Page 2

3 Table of Contents 1. Equality Impact Assessment (EIA) Disclosure Statement Privacy Impact Assessment (PIA) Disclosure Statement Introduction and aims Definitions Duties and Responsibilities Body of Policy Monitoring and the effectiveness of this policy... 7 Appendix 1: Appendix 2: Appendix 3: Glossary of Terms Other linked trust policies and guidelines Extra sources of information and support Ankle Page 3

4 Equality Impact Assessment (EIA) Disclosure Statement Equality Impact Assessment (EIA) Disclosure Statement This policy was assessed on the 1st day of June 2017 for its impact on equality. The assessment determined that the policy will not have a significant negative impact on equality in relation to each of the protected staff/patient groups below: i.) Age; ii.) Sex (Male and Female); iii.) Disability (Learning Difficulties/Physical or Sensory Disability); iv.) Race or Ethnicity; v.) Religion and Belief; vi) Sexual Orientation (gay, lesbian or heterosexual); vii) Pregnancy and Maternity; vii) Gender Reassignment (The process of transitioning from one gender to another); viii) Marriage and Civil Partnership. Ankle Page 4

5 1. Privacy Impact Assessment (PIA) Disclosure Statement Privacy Impact Assessment (PIA) Disclosure Statement This policy was assessed on the 1 st day of June 2017 for its impact on privacy. The assessment determined that the policy will not have a significant negative impact on privacy of members of staff/patients. Ankle Page 5

6 2. Introduction and aims Please note that this is advisory information only. Individual / your experiences may differ from those described. All exercises must be demonstrated to a patient by a fully qualified physiotherapist. We cannot be held liable for the outcome of you undertaking any of the exercises / interventions shown here independently of direct supervision from the RNOH. As a specialist orthopaedic hospital we recognise that our broad and often complex patient group needs an individualised rehabilitation approach. Our emphasis is on patient-specific rehabilitation, which encourages recognition of those patients who may progress slower than others. These rehabilitation guidelines are therefore milestone driven and designed to provide an equitable rehabilitation service to all our patients. They will also limit unnecessary visits to the outpatient clinic at RNOHT by helping the patient and therapist to identify when specialist review is required. 3. Definitions See section Duties and Responsibilities Not applicable for this guideline. Ankle Page 6

7 5. Body of Policy Team Contact Details: Foot & Ankle Unit Consultants: Mr Singh, Mr Cullen, Mr Goldberg & Mr Welck Foot and Ankle Unit: Tel: (Please note that if ing from an address external to RNOH that this address is not secure so please do not include patient identifiable data) Physiotherapy Department: Tel: Ankle Page 7

8 Indications for surgery: Generally for Chronic Lateral Ankle Instability in patients who have failed to respond to conservative treatment. Possible complications: Infection Bleeding Nerve damage Deep Vein Thrombosis Pulmonary Embolism Scarring Persistent / Recurrent pain Recurrent instability Talo-crural and sub-talar joint stiffness Numbness/Pin s & Needles in the foot post-operatively Surgical techniques The technique(s) used will depend on the severity of the ankle instability and the quality of the lateral ligament complex. Surgery tends to include one of the following: Primary Anatomical (non-augmented) repair. Carried out by reattaching torn ligaments in order to regain lateral ankle stability. A Brostrom repair is the common technique used in an anatomical repair. Secondary Extrinsic (augmented) repair. The surgeon may use the peronei and re-route them, commonly through the lateral malleolus in order to gain greater stability. A Chrisman-Snook stabilisation is the commonly used technique at RNOH. Expected outcome: Improved function / mobility Improved pain relief, with decreased analgesic requirements Improved ankle-hindfoot complex stability Decreased requirement for orthotics Return to full sporting activity Full recovery may take up to twelve months Ankle Page 8

9 Pre-operatively The patient will be seen pre-operatively where able and with consent, the following will be assessed or discussed: Current functional levels General Health Social history and home set up Ability to mobilise, plus the provision of appropriate walking aids to be used post operatively Post-operative expectations Post-operative management explained, including the provision of bed exercises. Post-operatively Always check the operation notes, and the post-operative instructions. Discuss any deviation from routine guidelines with the team concerned. This is very important as the patient may have had a combination of techniques which may affect weightbearing status and progressions. Ankle Page 9

10 INITIAL REHABILITATION PHASE: 0-4 Weeks Goals: To be safely and independently mobile with appropriate walking aid, adhering to weight bearing status To be independent with home exercise programme as appropriate To understand self-management / monitoring, e.g. skin sensation, colour, swelling, temperature, circulation, elevation Restrictions: Ensure that weight bearing restrictions are adhered to: Primary Anatomical Repair and Secondary Anatomical Repair: o Back slab with foot in neutral dorsiflexion and maximum eversion for 2 weeks Non Weight Bearing (NWB). o Below Knee Plaster of Paris (BK POP) at 2 weeks. Full Weight Bearing (FWB). o POP removed at 4 weeks. Into ankle brace. FWB. No Range of Movement into Inversion for 6 weeks and care on Plantarflexion for 6 weeks to avoid stretching / stressing / damaging the repair site. Elevation If sedentary employment, may be able to return to work from 4 weeks postoperatively, as long as provisions to elevate leg, and no complications Treatment: Likely to be in Walker Boot or POP Pain-relief: Ensure adequate analgesia Elevation Exercises: teach circulatory exercises Education: teach how to monitor sensation, colour, circulation, temperature, swelling, and advise what to do if concerned Mobility: ensure patient independent with transfers and mobility, including stairs if necessary On discharge from ward: Independent and safe mobilising, including stairs if appropriate Independent with transfers Independent and safe with home exercise programme / monitoring Milestones to progress to next phase: Out of POP. Team to refer to physiotherapy at 4 weeks from clinic. Progression from NWB to FWB phase. Team to refer to physiotherapy if required to review safety of mobility / use of walking aids Adequate analgesia Ankle Page 10

11 RECOVERY REHABILITATION PHASE: 4 weeks- 12 weeks Goals: To be independently mobile unaided To achieve full range of movement Muscle strength: eversion grade 4 or 5 on Oxford scale Optimise normal movement Restrictions: No Range of Movement into Inversion until week 6, and care on Plantarflexion, to avoid stretching / stressing / damaging the repair site. Care on inversion and plantarflexion until week 12 Do not formally stretch ligament reconstruction into inversion or plantarflexion. It will naturally lengthen over a 6 month period Ensure adherence to weight bearing status To wear ankle brace until week 12, and longer if needed, until good stability and proprioceptive control No balance exercises until eversion grade 4 or 5 on Oxford scale achieved No impact exercise; i.e. jogging, aerobics Treatment: Pain relief Advice / Education Posture advice / education Mobility: ensure safely and independently mobile. Progress off walking aids once able. Gait Re-education Exercises: o Passive range of movement (PROM) / Active assisted range of movement (AAROM) / Active range of movement (AROM) (See restrictions above) o Strengthening exercises as appropriate o Core stability work o Balance / proprioception work once appropriate o Stretches of tight structures as appropriate (e.g. Achilles Tendon), not of ligament reconstruction o Review lower limb biomechanics and kinetic chain. Address issues as appropriate Swelling Management Manual Therapy: o Soft tissue techniques as appropriate o Joint mobilisations as appropriate Monitor sensation, swelling, colour, temperature, circulation Orthotics if required via surgical team Ankle Page 11

12 Hydrotherapy if appropriate Pacing advice as appropriate Milestones to progress to next phase: Muscle strength: eversion grade 4 or 5 on Oxford scale Full range of movement Neutral foot position when weight bearing / mobilising Failure to meet milestones: Refer back to team / Discuss with team Continue with outpatient physiotherapy if still progressing Ankle Page 12

13 INTERMEDIATE REHABILITATION PHASE: 12 weeks 6 months Goals: Independently mobile unaided out of brace Grade 4 or 5 muscle strength around ankle Optimise normal movement Return to low impact activity / sports Restrictions: Do not formally stretch ligament reconstruction into inversion or plantarflexion. It will naturally lengthen over a 6 month period To wear ankle brace until week 12, and longer if needed, until good stability and proprioceptive control No balance exercises until eversion grade 4 or 5 on Oxford scale achieved Treatment: Further progression of the above treatment: Pain relief Advice / Education Posture advice / education Mobility: Progression of mobility and function Wean from Brace: Once appropriate when has good stability and proprioceptive control Gait Re-education Exercises: o Range of movement o Progression of strengthening exercises as appropriate including of evertors. o Core stability work o Balance / proprioception work including progression to use of wobble boards, trampet, gym ball, dyna-cushion as appropriate o Stretches of tight structures as appropriate (e.g. Achilles Tendon), not of ligament reconstruction o Review lower limb biomechanics and kinetic chain. Address issues as appropriate. o Sports specific rehabilitation Swelling Management Manual Therapy: o Soft tissue techniques as appropriate o Joint mobilisations as appropriate ensuring awareness of those which may be fused and therefore not appropriate to mobilise Monitor sensation, swelling, colour, temperature, circulation Orthotics if required via surgical team Ankle Page 13

14 Hydrotherapy if appropriate Pacing advice as appropriate Milestones to progress to next phase: Independently mobile unaided out of brace Muscle strength: eversion grade 5 on Oxford scale Returned to low-impact activity / sports Failure to meet milestones: Refer back to team / Discuss with team Continue with outpatient physiotherapy if still progressing Ankle Page 14

15 FINAL REHABILITATION PHASE: 6 months 1 year Goals: Return to high impact sports if set as patient goal Normal evertor activity Single leg stand 10 seconds, eyes open and closed To be able to do multiple single leg heel raise Establish long term maintenance programme Treatment: Mobility / function: Progression of mobility and function, increasing dynamic control with specific training to functional goals Gait Re-education Exercises: o Progression of exercises including strengthening, balance and proprioception, core stability o Sports specific / functional exercises Swelling Management Manual therapy o Soft tissue techniques as appropriate o Joint mobilisations as appropriate ensuring awareness of those which may be fused and therefore not appropriate to mobilise Pacing advice Milestones for discharge: Independently mobile unaided Return to normal functional level Grade 5 eversion strength on Oxford scale Good proprioceptive control on single leg stand on operated limb Appropriate patient-specific functional goals achieved Return to sports if set as patient goal Ankle Page 15

16 FAILURE TO PROGRESS If a patient is failing to progress, then consider the following: POSSIBLE PROBLEM Swelling Pain Breakdown of wound e.g. inflammation, bleeding, infection Recurrent instability Numbness/altered sensation ACTION Ensure elevating leg regularly Use ice as appropriate if normal skin sensation and no contraindications Decrease amount of time on feet Pacing Use walking aids Circulatory exercises If decreases overnight, monitor closely If does not decrease overnight, refer back to surgical team or to GP Decrease activity Ensure adequate analgesia Elevate regularly Decrease weight bearing and use walking aids as appropriate Pacing Modify exercise programme as appropriate If persists, refer back to surgical team or to GP Refer to surgical team or to GP Refer back to surgical team Ensure exercises not too advanced for patient Address core stability Liaise with podiatrist/orthotics re: footwear Review immediate post-operative status if possible Ensure swelling under control If new onset or increasing refer back to surgical team or GP If static, monitor closely, but inform surgical team and refer back if deteriorates or if concerned 6. Monitoring and the effectiveness of this policy This guideline will be reviewed 5 yearly. Ankle Page 16

17 Ankle Page 17

18 Appendix 1: Glossary of Terms Not applicable. Ankle Page 18

19 Appendix 2: Other linked trust policies and guidelines Physiotherapy rehabilitation guidelines Pes cavus correction Physiotherapy rehabilitation guidelines Anterior ankle arthroscopy Physiotherapy rehabilitation guidelines Total Ankle Replacement Physiotherapy rehabilitation guidelines Subtalar and hindfoot fusion Physiotherapy rehabilitation guidelines Hallux valgus deformity- Scarf Osteotomy Physiotherapy rehabilitation guidelines Tibialis Posterior Reconstruction Physiotherapy rehabilitation guidelines ACI of the ankle All other RNOH Physiotherapy Rehabilitation Orthopaedic Post-operative Guidelines (Knee, Sarcoma Unit, Peripheral Nerve Injuries, Shoulder & Upper Limb, Spinal Surgery Unit) Ankle Page 19

20 Appendix 3: Extra sources of information and support Summary of evidence for physiotherapy guidelines A comprehensive literature search was carried out to identify research relating to rehabilitation for ankle instability and surgery for recurrent ankle instability and subsequent rehabilitation. After reviewing the articles and information, the physiotherapy guidelines were produced on the best available evidence. Baumhauer J, O Brien T (2002) Surgical Considerations in the Treatment of Ankle Instability. Journal of Athletic Training 37 (4) Burrus, M., Werner, B., Hadeed, M., Walker, J., Perumal, V. and Park, J. (2014). Predictors of Peroneal Pathology in Broström Gould Ankle Ligament Reconstruction for Lateral Ankle Instability. Foot & Ankle International, 36(3), pp Cheng M, Tho K (2002) Chrisman-Snook Ankle Ligament Reconstruction Outcomes A Local Experience. Singapore Med J 2002 Vol 43(12) : De Vries J, Krips R, Sierevelt I, Blankevoort L, Van Dijk C (2007) Interventions for treating chronic ankle stability. A Cochrane Review. Cochrane Database of Systematic Reviews. Issue 1 Fujii T, Kitaoka H, Watanabe K, Luo Z, An K (2006) Comparison of Modified Brostrom and Evans Procedure in Simulated Lateral Ankle Injury. Medicine & Science in Sports & Exercise 38 (6): Gribble et al (2016) Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine (50) Hennrikus, W., Mapes, R., Lyons, P. and Lapoint, J. (1996). Outcomes of the Chrisman-Snook and Modified-Broström Procedures for Chronic Lateral Ankle Instability. The American Journal of Sports Medicine, 24(4), pp Hsu, A., Ardoin, G., Davis, W. and Anderson, R. (2015). Intermediate and Long-Term Outcomes of the Modified Brostrom-Evans Procedure for Lateral Ankle Ligament Reconstruction. Foot & Ankle Specialist, 9(2), pp Karlsson J, Lundin O, Lind K, Styf J (1999) Early mobilization vesus immobilization after ankle ligament stabilization. Scandinavian Journal of Medicine & Science in Sports 9: Karlsson J, Rudholm O, Bergsten T, Faxen E, Styf J (1995) Early range of motion training after ligament reconstruction of the ankle joint. Knee Surgery Sports Traumatology Arthroscopy 3: Kramer, D., Solomon, R., Curtis, C., Zurakowski, D. and Micheli, L. (2010). Clinical Results and Functional Evaluation of the Chrisman-Snook Procedure for Lateral Ankle Instability in Athletes. Foot & Ankle Specialist, 4(1), pp Ankle Page 20

21 Letts M, Davidson D, Mukhtar I (2003) Surgical Management of Chronic Lateral Ankle Instability in Adolescents. Journal of Pediatric Orthopaedics 23 (3) Li, H., Hua, Y., Li, H., Ma, K., Li, S. and Chen, S. (2017). Activity Level and Function 2 Years After Anterior Talofibular Ligament Repair: A Comparison Between Arthroscopic Repair and Open Repair Procedures. The American Journal of Sports Medicine, 45(9), pp Li, H., Zheng, J., Zhang, J., Hua, Y. and Chen, S. (2015). The Effect of Lateral Ankle Ligament Repair in Muscle Reaction Time in Patients with Mechanical Ankle Instability. International Journal of Sports Medicine, 36(12), pp Li, H., Zheng, J., Zhang, J., Cai, Y., Hua, Y. and Chen, S. (2015). The improvement of postural control in patients with mechanical ankle instability after lateral ankle ligaments reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 24(4), pp Marsh J, Daigneault J, Polzhofer G (2006) Treatment of Ankle Instability in Children and Adolescents with a Modified Chrisman-Snook Repair: A Clinical and Patient-Based Outcome Study. Journal of Pediatric Orthopaedics 26 (1) Matheny, L., Johnson, N., Liechti, D. and Clanton, T. (2016). Activity Level and Function After Lateral Ankle Ligament Repair Versus Reconstruction. The American Journal of Sports Medicine, 44(5), pp Mattacola C & Dwyer M (2002) Rehabilitation of the Ankle after Acute Sprain or Chronic Instability. Journal of Athletic Training 37 (4) Miyamoto, W., Takao, M., Yamada, K. and Matsushita, T. (2014). Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes. The American Journal of Sports Medicine, 42(6), pp Park, K., Lee, J., Suh, J., Shin, M. and Choi, W. (2016). Generalized Ligamentous Laxity Is an Independent Predictor of Poor Outcomes After the Modified Broström Procedure for Chronic Lateral Ankle Instability. The American Journal of Sports Medicine, 44(11), pp Pearce, C., Tourné, Y., Zellers, J., Terrier, R., Toschi, P. and Silbernagel, K. (2016). Rehabilitation after anatomical ankle ligament repair or reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 24(4), pp Petrera, M., Dwyer, T., Theodoropoulos, J. and Ogilvie-Harris, D. (2014). Shortto Medium-term Outcomes After a Modified Broström Repair for Lateral Ankle Instability With Immediate Postoperative Weightbearing. The American Journal of Sports Medicine, 42(7), pp Russo, A. (2016). Treatment of chronic lateral ankle instability using the Brostrom-Gould procedure in athletes: long-term results. Joints. 4,(2), pp Sammarco, V. (2001). Complications of Lateral Ankle Ligament Reconstruction. Clinical Orthopaedics and Related Research, 391, pp Ankle Page 21

22 Shakked, R., Karnovsky, S. and Drakos, M. (2017). Operative treatment of lateral ligament instability. Current Reviews in Musculoskeletal Medicine, 10(1), pp Shibuya, N., Bazán, D., Evans, A., Agarwal, M. and Jupiter, D. (2016). Efficacy and Safety of Split Peroneal Tendon Lateral Ankle Stabilization. The Journal of Foot and Ankle Surgery, 55(4), pp So, E., Preston, N. and Holmes, T. (2017). Intermediate- to Long-Term Longevity and Incidence of Revision of the Modified Broström-Gould Procedure for Lateral Ankle Ligament Repair: A Systematic Review. The Journal of Foot and Ankle Surgery, 56(5), pp Tohyama, H., Beynnon, B., Pope, M., Haugh, L. and Renström, P. (1997). Laxity and flexibility of the ankle following reconstruction with the Chrisman- Snook procedure. Journal of Orthopaedic Research, 15(5), pp Tourné, Y. and Mabit, C. (2017). Lateral ligament reconstruction procedures for the ankle. Orthopaedics & Traumatology: Surgery & Research, 103(1), pp.s171-s181. White, W., McCollum, G. and Calder, J. (2015). Return to sport following acute lateral ligament repair of the ankle in professional athletes. Knee Surgery, Sports Traumatology, Arthroscopy, 24(4), pp Xu, H. and Lee, K. (2016). Modified Broström Procedure for Chronic Lateral Ankle Instability in Patients With Generalized Joint Laxity. The American Journal of Sports Medicine, 44(12), pp Xu, H., Choi, M., Kim, M., Park, K. and Lee, K. (2015). Gender Differences in Outcome After Modified Broström Procedure for Chronic Lateral Ankle Instability. Foot & Ankle International, 37(1), pp Yoo, J. and Yang, E. (2016). Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace. Journal of Orthopaedics and Traumatology, 17(4), pp Ankle Page 22

23 This policy is available on request in large print and alternative languages. It is a manager s responsibility to ensure employees are aware of these options. * The following policies must be sent for review to the Local Counter Fraud Specialist: Fraud and Bribery Standard Financial Instructions Declaration of Interests Gifts and Hospitality Whistleblowing Disciplinary IT Anti-Money Laundering Managing Sickness Absence Secondary Employment Expenses Overpayment Financial Redress TOIL (Time off in Lieu) Code of Conduct/Standards of Business Conduct Data Protection Lone Worker Patient Transport Commercial Sponsorship Overseas Visitors Disclosure Ankle Page 23