SHCC Post Operative Ankle Rehabilitation An Evidence-Based Approach

1. SHCCPost Operative AnkleRehabilitation An Evidence-Based Approach Charlene Challenger-Smith, MPT, SCS, ATC

2. Outline • Pre-operative Rehab • Basic Healing Concepts • Post-operative Rehab • Goals and Criteria to Progress During Rehab Phases

3. Pre-Hab Purpose Pt education on entirety of rehab plan pre/post operatively Goals Eliminate effusion, normalize ROM, normalize strength, and improve proprioception to maximize post-operative outcomes • HEP • Gait/Crutch Training • ADL education • Clear expectations for rehab plan post-operatively

4. Key Rehab Consideration • ROM Precautions • Weight bearing restrictions • Timeline in Regards to Healing Process

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

6. MFx vs. Ligament Reconstruction Healing Considerations • 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

7. Rehabilitation: Phase I Maximum Protection Phase Weeks 0-4 Emphasis • 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

8. Rehabilitation: Range of Motion • 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

9. Rehabilitation: Range of Motion 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

10. Rehabilitation: Range of Motion 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

11. Rehabilitation: Phase II Early ROM and Joint Protection Weeks 2-6 Emphasis: • 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

12. Weeks 6-10 Emphasis: Remodeling Goals Normalize Gait-progressive WBing Progress to full ROM Progressive strengthening Advance NRE/Proprioceptive activities Rehabilitation: Phase III Strengthening

13. Basic Science Healing Concepts • 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

14. Rehabilitation: External Support • 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

15. Phase III Strength/Endurance Continued Weeks 10-16 Emphasis: 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

16. Rehabilitation: Balance/Proprioception • 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

17. 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 Rehabilitation: Balance/Proprioception

18. Rehabilitation: Balance/Proprioception • 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

19. Phase IV Advanced Strengthening Weeks 16-20 Emphasis: • Prep for return to sport Goals • Progressive jogging program • Sport cord test • Dynamic Balance/Proprioceptive activity

20. Phase V Return to Sport Weeks 20-24 Emphasis: • Return to sport Goals • Unilateral Agility • Multidirectional Agility • Side hop test (Docherty 2005, Journal of Athletic Training) • Figure 8 test

21. Rehabilitation Wrap Up • 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