Advanced Ankle Rehab

Clinical Edge video by Russell Wright (www.clinicaledge.com.au)


ROM

Once the inflammatory stage has passed, soft tissue release techniques can be used, especially targeting the peroneals.  Slow, firm pressure is more comfortable for the patient.  The patient can self release the tension with a foam roller.  A good peroneal stretch is standing either side of a rolled up towel and going into a small squat position, keeping knees pointing forwards.  Hold 30 secs x 3.

Mulligans MWM with the seatbelt can help improve DF range - ask the patient to put their foot on a chair, have the seatbelt around the back of their calf (mid-distal region) and the seatbelt around your hips as you kneel on the ground.  Apply an AP pressure to the talus as the patient dorsiflexes and you pull back on the seatbelt with your hips.  3x 6-10 reps.

If there is still restricted mobility, look to the deeper compartments e.g. tibialis anterior or further up the kinetic chain e.g. sacroiliac joint or hip.

STRENGTHENING

Bilateral heel raises with theraband around the injured lower leg (distal segment) - this will allow them to focus on maintaining a neutral foot position, not inverting.  The theraband will be attached to their right hand side if working on their right leg, and their left hand side if working on their left leg.  Progress accordingly into single heel raises, once again using the theraband.  Aim for 10-15 reps x 2 sets.

BALANCE

This can be started with SLS in the first week post-injury.  The wobble board can be used in the interim period between single leg stance and step to land activities, usually about 1 week.  Current evidence by Refshauge shows that the wobble board is only effect for improving proprioception at lower velocities; it does not address the prevention of ankle sprain at higher velocities/during sport specific activities.

Once the patient has mastered single leg stance, balance can be challenged further with wobble board with someone throwing a ball.  Then onto hop on the spot, hop to the spot, hop in/out of box as fast as the patient is able x 5 (each set is timed - this adds fatigue component and is a validated test for balance) and figure of 8 hopping to start power training (strength at speed).  Skipping can also be added.

ENDURANCE

Return to running as soon as the patient feels able.  Check with 50 repetition hop test.  Start with 10-15 minutes on the flat.  Heel inserts or Mulligan's fibular taping can be effective with return to running, if dorsiflexion range is still restricted.

POWER

Once the patient is able to manage 3 minutes of skipping comfortably, then progress to plyometric vertical jump.  Each jump should have a rest in-between as the patient is aiming for maximal velocity with each jump.  Then progress to lateral jumps and forwards/backwards jumps (also zig zag jumps if applicable).  If the sports demands it, progress then to single leg jump.  Can jump up to a box if more comfortable.

RETURN TO SPORT

Pass the agilities test:
1. 90% ROM compared with non-injured side or <2cm difference on dorsiflexion lunge test
2. Single leg heel raise test with theraband peroneal bias compared with non-injured side
3. Balance testing - timed figure of 8 hop test x 3 or square run x 3
4. Single leg vertical jump, using chalk as a marker
5. Motor control - SKB
6. Assessment of running gait

On returning to sport, start with slow warm up drills and ball drills and gradually progress from there.

POOR RECOVERY?

If not improving, check for:

Soft tissue impingement with meniscoid lesion at the antero-lateral joint line (MRI/referral to see if arthroscope is appropriate)

Fracture ( do not trust A&E x-ray! re-xray or CT scan then onward referral to specialist if fracture found)

Syndesmosis (high ankle sprain) which could involve the AITFL/PITFL and would lead to a longer recovery period, with possible stabilisation surgery required at the 12 week mark if there is little improvement

If a talar dome lesion is suspected with pain on weigh bearing and catching along the joint line, refer patient for MRI and seek specialist opinion after 3 months to see if an arthroscope is required.

Deltoid ligament sprain is suspected if there is more pain antero-medially.  This should be supported with taping.