don’t just recover. conquer. charlene challenger-smith, mpt, scs, atc

DON’T JUST RECOVER. CONQUER.DON’T JUST RECOVER. CONQUER.

Charlene Challenger-Smith, MPT, SCS, ATC


Pre-operative RehabBasic Healing ConceptsPost-operative RehabGoals and Criteria to Progress During Rehab Phases


PurposePt education on entirety of rehab plan pre/post operatively

GoalsEliminate effusion, normalize ROM, normalize strength, andimprove proprioception to maximize post-operative outcomes

HEP Gait/Crutch Training ADL education Clear expectations for rehab plan post-operatively


ROM Precautions Weight bearing restrictions Timeline in Regards to Healing Process


http://www.worldwidewounds.com/2004/august/Enoch/images/enochfig1.jpg


Microfracture: “Super Clot” provides enriched environment for tissue regeneration• Emphasize healing by protection from Wbing, Gentle A/PROM

and joint mobilization to nourish the clot with synovial fluid Brostrum: Reconstruction of ATF and/or CF ligament to

provide return of passive stabilizers to the ankle


Weeks 0-4Emphasis

Protection and acute healing

Goals Control pain and swelling

• Arthrogenic muscle inhibition is a reflex inhibition of joint musculature after distention or damage to a joint and can become a consequence of increased swelling

Splint x 2 weeks, cast x 2 wks NWBing x 6 weeks-Crutch Training Hip and Core Ex-Prevent Associated Disuse Atrophy Cryotherapy and Elevation


DF insufficiency persists through the acute and subacute healing phases– Yang et al., J of Sci and Med in Sport 2002

Reduction in posterior glide of the talus in the ankle mortise up to 6 months post-injury– Denegar et al., J Orthop Sports Phys Ther 2002

DON’T JUST RECOVER. CONQUER.

Joint Mobilizations (n = 41) acute ankle

sprains (<72 hrs) Anterior-posterior force

• 3 sets of 60 sec with 10 sec. rest between sets

Greater improvements in DF ROM than RICE application alone– Green et al., Physical Therapy, 2001


Vincinzo et al., JOSPT 2006 (N =16) Hx of ankle sprain (<6 mo) 3 groups

• weight-bearing MWM• non–weight-bearing MWM• no-treatment control group

Both MWM groups showed sig. increases in weight bearing DF and posterior talar glide when compared to control group


Weeks 2-6Emphasis:

Repair and regeneration

Goals A/P Dorsiflexion, Plantarflexion-to resting posture 500-1000

cycles/day Gentle Eversion allowed NWB Ankle Isometrics OKC LE ex and Core Ex


Weeks 6-10Emphasis:

Remodeling

Goals Normalize Gait-progressive WBing Progress to full ROM Progressive strengthening Advance NRE/Proprioceptive activities


6 weeks to 12 months Tissue changes from cellular to almost

collagenous by the end Tissue becomes contracted and demonstrates

greater tensile strength Activity level within physiological limits for best

healing


Lace-up ankle support effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape– Kerkhoffs et al. 2009; Cochrane Review


Weeks 10-16Emphasis:

Proprioceptive control

Goals Develop strength and stability in all planes of motion and under

various conditions• Stable vs. unstable • Predictable vs. unpredictable

Strength & endurance• Fatigue-mediated alteration in proprioception possible contributor to

injury– Hiemstra, J Orthop Sports Phys Ther. 2001


Postural control impairments present in patients with acute and chronic lateral ankle sprains– Wikstrom et al., Med. Sci. Sports Exerc, 2009

Significantly delayed onset times for ankle, hip, and hamstring muscles in CAI– Van Deun 2007


8 subjects w/ lateral ankle sprains (6-16 mos) 8 wks, 15 min/day of ankle disk training Significant decrease in onset latency of

anterior tibialis– Osborne et al., Am. J Sports Med., 2001


6 weeks of balance training program improves postural sway in patients w/ unstable ankles

Balance training on trampoline just as effective as ankle disc– Kidgell et al., J Strength & Cond., 2007



Prep for return to sport

Goals Progressive jogging program Sport cord test Dynamic Balance/Proprioceptive activity



Return to sport

Goals Unilateral Agility Multidirectional Agility Side hop test (Docherty 2005, Journal of Athletic Training) Figure 8 test


Clinical Bottom Line:• Rest, Ice, Compression, Elevation still important• Protection during healing phase: NWB• Early Gentle Active/Passive ROM and Joint mobilization• Early isometric activity for peroneal activation and proprioceptive Re-ed• Lace-up ankle support for swelling and support while initiating WBing• Progressive Proprioceptive program• SEBT, Y-balance, Side-hop, Figure 8, observation of functional movement

for return to sport

don’t just recover. conquer. charlene challenger-smith, mpt, scs, atc

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