CHRONIC ANKLE INSTABILITY
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1 CHRONIC ANKLE INSTABILITY Eric M Magrum DPT OCS FAAOMPT Orthopaedic Manual Physical Therapy Series Charlottesville ** Subjective Asterisks Signs/Symptoms ** 34 yo real estate agent; 5 months s/p misstep at construction site with ankle PF/INV injury. Goals: return to softball, coach kids soccer, walk uneven terrain work C/o: Anterolateral ankle pain, stiffness, feels vulnerable ; intermittent sharp pain laterally with lateral mvts, rotation. Intermittent effusion anterior TC, posterior to lateral malleolus. Denies mechanical, Neurovascular sxs. PMHx: Ankle sprain 5+; HS tear. Chronic Ankle Instability Development of repetitive ankle sprain Persistent post injury symptoms Giving Way Recurrent Inversion injury Differential List Peroneal Brevis Tearing - Longitudinal Peroneal Tenosynovitis Peroneal Tendon Subluxation OCD Lesion Talar Dome Ankle Impingement/Synovitis Retinacular Attenuation Syndesmosis Injury Medial/Deltoid Injury Lis Franc/Mid Foot Injury Reproduction Without Consent 1
2 ** Physical Exam Asterisks Signs/Symptoms ** Effusion anterior aspect TC Medial>lateral aspect Rearfoot Varus Limited DF ROM TC post glide; STJ EVR hypo mobility Functional Screen: Poor Single leg stance Increased sway, lateral LOB. Bilateral Squat: Limited TC DF with lateral ankle pain. Lateral Hop: Pain, loss of balance lateral (+) Talar Tilt Chronic Ankle Instability Arthrokinematic Restrictions Mechanical Insufficiencies Degenerative Changes Pathological Laxity Synovial Changes Recurrent Ankle Sprain Impaired Proprioception Impaired Neuromuscular Functional Insufficiencies Impaired Postural Control Control Strength Deficits Hertel, J Athletic Training, 2002 Reproduction Without Consent 2
3 Functional and/or Mechanical Deficits Functional Subjective report frequent giving way with normal activity Neuromuscular deficits Proprioceptive deficits Strength deficits Postural control deficits Mechanical Movement > physiological limit Pathologic laxity Arthrokinematic restrictions DJD Synovial changes Predictive of CAI 2 Weeks Inability to complete single drop landing and drop 6 months Lower FAAM ADLs Decreased SEBT (post reach directions) CAI Comprehensive Rehab Exercise Specificity Manual Therapy Proprioception - Specific Joint Neuromuscular control restrictions Strength Education Postural control Feedback Outcome Assessment Proprioception Neural input to the CNS Mechanoreceptors Articular Myofascial *Muscle afferents * Cutaneous Kinesthesia Joint Position Sense Reproduction Without Consent 3
4 Proprioception Deficits Decreased DF/EVR Clearance in swing Terminal Swing Increased PF/INV Bilateral Treatment Improve Joint Position Sense Multi station Balance Exercises Strengthening EVR/INV Frontal plane > Sagittal plane JPS deficits Reproduction Without Consent 4
5 Intrinsic Foot Muscle activation Short Foot - Drag Ball of big toe toward heel without toe flexion/clawing Activation - Lift 5 toes (passive tension arch muscles) relax toes maintain active tone in arch muscles Dissociation - Plant 1 st Ray, lift 4 lateral toes alternate <-> Lift 1 st Ray, keep 4 lateral toes stable CAI: Increased PF/INV at terminal swing Reproduction Without Consent 5
6 Results: Significant improvement in joint position sense and postural sway as well as significant changes in muscle reaction times Med Sci Sports Exerc Reproduction Without Consent 6
7 Neuromuscular Deficits Unconscious activation of dynamic restraints occurring in preparation for and in response to joint motion and loading for the purpose of maintaining and restoring functional stability Riemann BL J Athl Train 2002? Feed forward > Feed back Ligament mechanoreceptors do not facilitate a muscle reaction fast enough to protect from an inversion sprain Central Motor programming deficit Arthrogenic Muscular Inhibition Previous Ankle Sprain Impaired Peroneal Reaction Time Chronic Ankle Instability Delayed Peroneal Reaction time compared to uninvolved side Reproduction Without Consent 7
8 Neuromuscular Re-Education Unconscious Incompetence Conscious Incompetence Conscious Competence Unconscious Competence Neuromuscular Control Delayed/Inadequate Response Exercise Prescription Unexpected perturbations Landing mechanics Unstable surfaces Feedback Reproduction Without Consent 8
9 Strengthening -? Controversy Evertors (increased PF/INV terminal swing) Concentric Invertors = Improved JPS Co Contraction Closed Kinetic Chain Proximal Hip/Gluteals Foot Intrinsics Eccentric Invertors Displace COM laterally Functional Sport Specific Reproduction Without Consent 9
10 Reproduction Without Consent 10
11 Star Excursion (Y) Balance Test Postural Control Involves Somatosensory, Visual, and Vestibular systems to remain upright Eyes Closed Unstable surfaces Progressive Dynamic Sport Specific CAI patients have altered sensory organization strategies Increased reliance on visual information (Up regulation) Decreased somatosensory information from ankle (Down regulation) Resultant motor control deficit Progressive Balance Program Dynamic stabilization Perturbations Unpredictable changes in direction Landing from Hop Dynamic reaching - SEBT Improved static stabilization: TTB eyes closed Improved dynamic stabilization : SEBT Improved self reported functional status : (FADI) Reproduction Without Consent 11
12 Single-Limb Stance Activities Participants performed three repetitions of single-limb stance activities. Each activity (eyes open and eyes closed) had seven levels of difficulty. 1. Arms out on hard floor for 30 s 2. Arms across chest on hard floor for 30 s 3. Arms across chest on hard floor for 60 s 4. Arms out on foam pad for 30 s 5. Arms across chest for 30 s on foam pad 6. Arms across chest for 60 s on foam pad 7. Arms across chest for 90 s on foam pad Single-Limb Hops to Stabilization 10 hops in each direction Hop from the starting position to the target position (18, 27, or 36 inches). After stabilizing balance in a single-limb stance, participants hopped in the exact opposite direction back to the starting position and stabilized in the single-limb stance. Four directions of hops: Anterior/Posterior Medial/Lateral Antero lateral/posterio medial Antero medial/posterio lateral Hop to Stabilization and Reach Hop After stabilization in the single-limb stance, participants had to reach back to the starting position Then they hopped back to the starting position and reached to the target position. Unanticipated Hop to Stabilization Numbers displayed to participants. Corresponding to a target position to which they would hop. Hop to stabilization - participants were allowed to use any combination of hops (AP, ML, AM/PL, or AL/PM) they desired to accomplish the goal of getting through the sequence error-free. Reproduction Without Consent 12
13 Arthrokinematic Restrictions Degenerative Changes Chronic Ankle Instability Pathological Laxity Mechanical Insufficiencies Synovial Changes Recurrent Ankle Sprain Impaired Proprioception Functional Insufficiencies Impaired Postural Control Impaired Neuromuscular Control Strength Deficits Changes at the Joint Increased laxity Altered joint alignment TC, Distal tib fib Impaired arthrokinematics Sensorimotor changes Increased load on the joint ARTHROKINEMATIC IMPAIRMENTS Hypo mobility Distal Tibia fibular Joint Positional Fault Talar Positional Fault Limited Posterior Talar Glide Reproduction Without Consent 13
14 Anterior positional fault of the Talus may be present in individuals with CAI Reproduction Without Consent 14
15 Limited ankle dorsiflexion ROM during midstance Limited dorsiflexion ROM during gait among individuals with CAI may be a risk factor for recurrent ankle sprains Joint mobilization was associated with: - Greater DF ROM* -TTB anterior posterior direction* -Posterior Talar displacement -Mean of TTB medial-lateral This indicates that joint mobilization treatment has mechanical and functional benefits for addressing impairments in sensorimotor function and arthrokinematic restrictions commonly experienced by individuals with CAI Development of CPR to predict success with Manual Therapy + Exercise ¾ Variables predicted 95% likelihood for success Worse with standing Worse in the evening Navicular drop > 5mm Hypo mobile Distal Tib-Fib Reproduction Without Consent 15
16 Proximal Tibiofibular Joint Anterior Mob/Manipulation Grasp posterior aspect of fibular head with 2 nd MCP ER tibia, Flex knee to barrier with opposite hand on distal tibia High velocity, low amplitude thrust direction of force toward ipsilateral buttock Proximal TibFib Posterior Mobilization/Manipulation Decreased Post Medial glide Stabilize medially to prevent valgus Stabilize tibia medially Pisiform on fibular head Mob/Thrust down to table (Post Med) Reproduction Without Consent 16
17 Proximal TibFib Anterior Mobilization/Manipulation Decreased Ant Lateral glide Opposite side so manipulating hand is in line with axis of joint Stabilize with inside hand Pisiform over fibular head Mob/Manip (Anteriolateral direction) Individuals with CAI demonstrated changes in soleus H/M ratio without changes in fibularis longus activation following Distal Tibiofibular joint manipulation Proximal tibiofibular joint manipulation did not have an effect on muscle activation J Electromyogr Kinesiol Distal Tib/Fib Posterior Mobilization/Manipulation Distal LE edge of table, stabilize foot at end ROM DF Stabilize distal Tibia with inside hand Thenar eminence contact lateral malleolus Anterior to Posterior force through weight shift Distal Tibiofibular Joint Functional Posterior Mobilization Clinician stabilizes the anterior aspect of the distal tibia. Opposite hand grasps the anterior aspect of the distal fibula with the Thenar eminence As the patient translates the knee forward, the distal fibula is translated in an anterior-toposterior direction Athletic Training & Sports Health Care Vol. 1 No Reproduction Without Consent 17
18 Mulligan Distal TibFib Taping Talocrural Distraction Mobilization/Manipulation Grasp dorsum of the foot with interlaced fingers, Stabilize plantar aspect with thumbs DF, pronate to barrier Long axis distraction Mob/Manipulation - Caudal Talocrural Posterior Mobilization/Manipulation Contact anterior talus with thumbs/web space DF, pronate/supinate to barrier; Stabilize with thigh Anterior to posterior force to talus Mob/Manipulation MWM Patient actively pulls into DF Reproduction Without Consent 18
19 Posterior Talar Mobilization With Movement Clinician contacts the anterior aspect of the talus with thumbs Anterior-to-posterior directed force is maintained while patient lunges forward Adjust lunge direction (medial, lateral) and force on talus angulation to engage specific barrier Athletic Training & Sports Health Care Vol. 1 No Contact anterior aspect talus with web space 1-2 nd digits Mobilization belt around posterior distal Tib-fib and clinicians buttocks Patient lunge to engage DF barrier Anterior Posterior mobilization at talus; Posterior Anterior mobilization distal tibia through clinician weight shift Functional Talocrural Posterior Mobilization STJ Distraction Reproduction Without Consent 19
20 Medial Tilt Eversion Mobilization/Manipulation STJ Grasp calcaneus medially thumb/2 nd MCP (inside arm); Outside hand navicular (thumb, calcaneus distally 2 nd MCP Stabilize Fibula laterally with 2 nd MCP Popliteal region into clinician s iliac crest Distraction Lean back Ulnar deviation medial tilt (fulcrum with hypothenar on tibia) Lateral Tilt Inversion Mobilization/Manipulation STJ Grasp calcaneus medially thumb/2 nd MCP (inside arm); Outside hand navicular (thumb, calcaneus distally 2 nd MCP Stabilize Tibia medially with 2 nd MCP Popliteal region into clinician s iliac crest Distraction Lean back Radial deviation lateral tilt (fulcrum with hypothenar on tibia) STJ Medial/Lateral Glides Medial Column Mid foot Mobilization Navicular on Talus Medial Lateral Rotation Plantar-Dorsal Glide Reproduction Without Consent 20
21 Medial Column Mid foot Mobilization Medial Cuneiform on Navicular Medial Lateral Rotation Plantar-Dorsal Glide Medial Column Mid foot Mobilization First MT on Medial Cuneiform Medial Lateral Rotation Plantar-Dorsal Glide Plantar Mid Foot Mobilization/Manipulation Navicular Medial Cuneiform 1 st MTP Calcaneocuboid Joint Techniques Cuboid may present plantar positioned joint dysfunction and with medial rotation in inversion sprains Overactivation of PL pulling on a loose packed cuboid Cuboid dorsal glide hypomobility Less often will present dorsally positioned joint dysfunction Loss of plantar mobility and loss of Eversion Reproduction Without Consent 21
22 Plantar Cuboid Mobilization/Manipulation Dorsal Cuboid Whip Manipulation Prone Dorsiflexion Self Mobilization Summary Exercise Prescription Specificity Proprioception Multistation Balance Exercises DF/EVR at initial contact Neuromuscular Re education Feed forward > Feed back Strengthening Closed Kinetic Chain (Invertors, Evertors, Proximal) Postural Control Eyes closed, Dynamic Manual Therapy Specificity Restore TC DF Normal Arthrokinematics Reproduction Without Consent 22
23 ? Questions? Reproduction Without Consent 23
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