Performance Based Ankle Rehabilitation Shane S. Schulthies PhD, ATC, PT Brigham Young University

Mechanism of Injury

Two types of sprains The ones that happen (forces to high, to fast, that require a force bypass to prevent.) The ones that don’t (significant preactivation, less force, applied more slowly, that rehabilitation can prevent.)

Premises Weight bearing increases the stability of the non-fractured ankle. Ankle sprains occur during the flight/stance transition. Therefore, patient is progressed from weight bearing activities to activities involving non-weight bearing.

Weight bearing increases ankle stability. Stormount et al., in weight bearing bony stability = 100% of resistance to inversion, and 28% to 50% of the resistance to internal rotation.

Premises Weight bearing increases the stability of the non-fractured ankle. Ankle sprains occur during the flight/stance transition. Therefore, patient is progressed from weight bearing activities to activities involving non-weight bearing.

Premises Athletes are routinely returned to competition before ankle ligaments are fully “healed”. Therefore, function rather than time is used for patient progression.

Complicating Factors Fractures Chondral Damage Gross laxity with associated instability Excessive inflammation (pain, loss of function, swelling, redness, and heat).

Phase 1 Begins with the sprain. Ends with patient walking full weight- bearing with normal gait pattern.

Goals Abate the inflammatory process. Protect integrity of injured tissue Improve ROM to allow normal gait for non- strenuous ADLs. Patient walk full weight-bearing with normal gait pattern. Patent descend 4 inch step without compensation.

Phase 1 Activities Weight shift and bear weight on effected ankle. Squat with heal fixed to floor. Step forward, back, side to side with ankle fixed to floor. Walk normal. Walk normal on incline.

Notes on Pain (most acceptable) Pain during passive exercises Pain during active exercises Pain after passive exercises Pain after active exercises (least acceptable)

Phase 1 Activities ROM on KAT or BAPS etc. Forward and retro step-ups, foot stationary. Mobilizations if necessary. Modalities as indicated. Compression stocking. Instruct in home program.

Stage 2 Begins when patient can walk full weight- bearing and descend a four inch step with normal gait. Ends, when patient can perform all functional exercises and descend an 8 inch step without compensation.

Stage 2 Goals Perform flex-cord 4 directionals without compensation. Descend 8 inch step without compensation. Perform all gym exercises without compensation.

Stage 2 Activities Flex-cord 4 directionals Any activity where the foot remains in contact with surface at all times Balance and perturbation Pro-fitter, skiers edge, slide board Home program

Stage 3 Begins when patient can descend a 4 inch step and perform 4 directionals without compensation. Ends when patient can pass crossover hop test and is discharged.

Stage 3 Activities Four directional runs Foot agility drills Cariocas Practice crossover hop test Sport specific drills

Stage 3 goals Normal control of all functional activities. Perform with 15% injured vs.. non-injured on the “timed crossover hop test”.

Timed Crossover Hop Test

Timed crossover hop test Intratester reliability = (Kappa) Intertester reliability =.66 (Kappa) Specificity =.88 Sensitivity =.93

Timed crossover hop test 12% chance of restricting participation when the athlete should be playing 7% chance of allowing participation when the athlete should not be playing. These percentages should increase if additional patient data is used, i.e.. swelling, pain, history etc.