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Don’t Just Recover. Conquer. R. Kent Kurfman, PT, DPT, OCS, MTC Proaxis Therapy Greenville, South Carolina.

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Presentation on theme: "Don’t Just Recover. Conquer. R. Kent Kurfman, PT, DPT, OCS, MTC Proaxis Therapy Greenville, South Carolina."— Presentation transcript:

1 Don’t Just Recover. Conquer. R. Kent Kurfman, PT, DPT, OCS, MTC Proaxis Therapy Greenville, South Carolina

2 Don’t Just Recover. Conquer.  Most common athletic / sports injury  Highest percentage (15%) of any regional injuries in NCAA study (Hootman JM J Athl Train 2007)  Most common injury in several sports, such as soccer (Ekstrand/Tropp – Foot/Ankle – 1990)  10-15% of all football injuries ( Garrick JG. J Sports Med 1977)  75% of all ankle injury = ligamentous sprain, 85% of these = lateral ligaments (Garrick JG Clin Sports Med 1988)

3 Don’t Just Recover. Conquer.  20-70% lead to chronic pain/instability - CAI ( Barrett/Bilisko – Sports Med 1995, Gerber JP Foot Ankle Int 1998, McKay GD et al BR J Sports Med 2001, Verhagen RA et al Arch Orthop Trauma Surg 1995)  Reinjury rates = up to 70-80%

4 Don’t Just Recover. Conquer.  Landings ◦ Unexpected surface (on another athletes foot, sloped surface). ◦ Improper foot positioning prior to landing (excessively inverted and plantarflexed) whether walking, running or landing from jumps  Sudden stops and cutting movements

5 Don’t Just Recover. Conquer.  Greatest: history of previous sprain ◦ 4-5x more likely to re-injury  Distribution by gender: essentially the same (Beynnon)  Structural – limited information linking foot structural characteristics (Morrison, J Athl Train 2007) ◦ High medial longitudinal arch/pes cavus ◦ Greater than normal foot width ◦ High 1 st MTP dorsiflexion ROM

6 Don’t Just Recover. Conquer.  Technical skill –  Body mass – higher BMI = suspected greater risk for ankle injury  Footwear selection ◦ Inappropriate choices made, particularly during training –  Running footwear use for court activities

7 Don’t Just Recover. Conquer.  Proprioceptive deficits: Impairment in feedback ◦ Aberrant ankle position sense is primary problem in landing-related injuries – foot too inverted, due to diminished position sense ◦ Primary sensory input comes from cutaneous pressure receptors and muscle spindles – less from joint capsule receptors

8 Don’t Just Recover. Conquer.  Long term disruption of sensory-motor control: Central changes in sensorimotor system function ◦ Diminished motoneuron pool excitability ◦ Mismatch of reaction time of peroneals, compared to rapidity of ankle inversion stress/stretch during aberrant landing.

9 Don’t Just Recover. Conquer.  Bottom line: deficits in those with CAI are not only peripheral but are also central – maladaptive changes to movement. ◦ We need to train global coordination to gain more complete recovery (Hass CJ AJSM 2010).

10 Don’t Just Recover. Conquer.  Differ, based on history of the athlete ◦ Previously uninjured – no definitive approach!  No evidence that use of preventative bracing/taping/neuromuscular training will prevent an ankle sprain  Need to emphasize what we can encourage  Appropriate footwear selection  Proper practice /skill acquisition – role of coach

11 Don’t Just Recover. Conquer.  Previously injured and CAI: a great deal of evidence that we can affect future injury occurrence! ◦ Remainder of presentation will emphasize preventative measures in those previously injured/CAI.

12 Don’t Just Recover. Conquer.  Most commonly used supports. ◦ Both are effective, shown via multiple studies.  Bracing:2010 study – preventative.  Expense: bracing cheaper  Taping: ◦ Support loss from taping: ◦ Don’t underestimate proprioceptive effect.  Kinesiotaping

13 Don’t Just Recover. Conquer.  Recommendation: Continue taping/bracing after LAS for at least 6 months

14 Don’t Just Recover. Conquer.  Purposes : ◦ Traction, protect feet from abrasion/contact ◦ Shock absorption – less certain  Shoes act as a filter to our proprioception  We adjust the stiffness of our legs based on cushioning (footwear and surface). ◦ Hard surfaces: more hip/knees/ankle flexion. ◦ Softer surfaces – less hip/knee/ankle flexion

15 Don’t Just Recover. Conquer.  Shoes can confound this - too much cushioning on a hard surface = increased lower leg stiffness, greater force transmission. ◦ No midsole material available yet that compensates /adjusts for this

16 Don’t Just Recover. Conquer.  High top vs. Low top ◦ Mixed findings in the literature ◦ In general, high tops can have a combined effect with bracing /taping in prevention of re-injury

17 Don’t Just Recover. Conquer.  Athlete should choose the shoe with the least amount of midsole that they are able to properly/comfortably train/compete in.  Less stack height = less chance of injury ◦ More plantarflexion (heel height) = more chance of injury. ◦ High tops = matter of preference.

18 Don’t Just Recover. Conquer.  Effective in prevention of future injury –  Balance training alone = 36% reduction in ankle sprain  Multiple-intervention training (balance, weight, plyometric, agility/sport specific training)= 50% reduction in ankle sprain injuries  Consideration of study problems

19 Don’t Just Recover. Conquer.  Retraining guidelines: ◦ Dosage: Typical = 6 weeks, 3-5 sessions/week ◦ Wobble boards – common denominator ◦ 4 constructs: static balance, joint position sense, dynamic balance, motoneuron pool excitability (via agility and plyo work). ◦ Strength - only a component ◦ Bottom line: Since balance control is multifactorial, work on all factors during a session

20 Don’t Just Recover. Conquer.  Program components: ◦ Static single leg balance – easiest to retrain, acts as a base for all other activities.  Goal: 60” eyes open, 30” eyes closed. ◦ Position sense retraining –essential for landing control  Technique accuracy is essential

21 Don’t Just Recover. Conquer. ◦ Dynamic balance and neuromuscular control.  A progression of balance board / soft surface training.  Emphasize speed of control, range of control.  Add distractions – throwing/catching  Balance with reaching

22 Don’t Just Recover. Conquer.  Agility: progression back to “real activity” – hopping, cutting activities. ◦ Concentrate on doing these activities on very firm surfaces. ◦ Proprioceptive/kinesthetic confusion issues on soft surfaces.

23 Don’t Just Recover. Conquer.  Typical tools used: ◦ Simple tools work well  Wobble board  Half-rolls  AIREX  BOSU

24 Don’t Just Recover. Conquer. Week 1Week 2Week 3Week 4Week 5Week 6 Postural stability Single leg stance on Airex® cushion: (3 minutes) Single leg stance on tilt board: (3 minutes) Single leg stance on BOSU® ball: (3 minutes) Single leg stance on BOSU® ball with rebounding ball catches: (3 minutes) Anterior jump lands from Reebox® step: (2 sets × 10 reps with 10 second stabilization) Lateral jump lands from Reebox® step(2 sets × 10 reps with 10 second stabilization) Strength Double leg heel raises: (3 sets × 12 reps) Double leg bridge: (2 sets × 10 reps) Clam-shell gluteus medius: (2 sets × 10 reps - each side) Double leg heel raises: (3 sets × 12 reps) Double leg bridge: (2 sets × 10 reps) Clam-shell gluteus medius: (2 sets × 10 reps - each side) Single leg heel raises: (2 sets × 10 reps - each side) Single leg bridge: (3 sets × 12 repseach side) Figure-4 gluteus medius: (2 sets × 10 reps - each side) Single leg heel raises: (2 sets × 10 reps - each side) Single leg bridge: (3 sets × 12 repseach side) Figure-4 gluteus medius: (2 sets × 10 reps - each side) Single leg heel raises with weight (15 kg): (3 sets × 12 reps - each side) Double leg squats: (3 sets × 12 reps) Resisted lateral side-steps: (3 sets × 12 reps/step - each sides) Single leg heel raises with weight (20 kg): (3 sets × 12 reps - each side) Single leg squats: (3 sets × 10 reps - each side) Resisted lateral side-steps: (3 sets × 12 reps/step - each sides) Plyometics Tuck jump: (3 sets × 10 reps) Broad jumps: (3 sets × 10 reps) 180° tuck jumps: (3 sets × 5 reps in each direction) 90° hop turns: (10 reps - clockwise and anti-clockwse) Double leg lateral jumps over mini-hurdle: (3 sets × 10 reps) Single leg lateral jumps over mini-hurdle: (3 sets × 10 reps) Speed/ Agility Figure of 8 runs: (10 m course, 5 reps in each direction) Ladder: forward run through: (10 reps) Ladder: lateral run through: (10 reps - each way) Ladder: lateral hop through: (10 reps - each way) Ladder: hopping slalom drill: (10 reps) Lateral shuttle runs: (10 m course, 2 sets × 10 reps) O ’ Driscoll et al. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2011, 3:13.

25 Don’t Just Recover. Conquer.  Lateral ankle sprain = high injury rate  Highest risk = previous ankle sprain  Important to address deficits aggressively to prevent CAI  Multifaceted approach is best ◦ Bracing/taping ◦ Shoe selection ◦ Aggressive neuromuscular retraining with attention to quality of movement

26 Don’t Just Recover. Conquer. Thank you


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