Lateral Ligaments, Instability and Rehabilitation
With the FIFA World Cup about to kick off in just a couple of hours and Australia once again managing to be drawn in to a group of beautiful game powerhouses, we can only hope that our
underdog status will once again work to our advantage in progressing to the second round. Ange Postecoglou has just made his final cuts to the team and we have seen the disposal of Tom Rogic; once compared to a young Harry Kewell and Josh Kennedy who in Postecoglou’s defence has had on-going form drop in recent months.
But let’s separate ourselves for a second from the patriotic bandwagon of the Socceroos and take a narrowed look past group rounds, Qatar’s alleged bribery controversy and who the Oscar will go to for best dive; to the actual injuries which are sustained in such a high quality competition, more precisely lateral ankle sprains and the rehabilitation necessary for the swiftest return to sport.
The expression lateral ankle sprain is used loosely and in lemans terms commonly refers to a lateral ligament injury; where during play the foot is found in a inverted and plantarflexed position placing pressures on ATFL and CFL beyond that which they can tolerate resulting in tear or rupture of the structures( Brukner, P.,2013).
Please note a new grading system is soon to be published in 2014 for tendon/ligament damage we will review this at a later date.
Lateral ankle sprains have been identified as the most common structural injury amongst athletes outside of non-specific bruising ( Beynnon, B. D., Murphy, D. F., & Alosa, D. M. 2002). There have been a number of predictive factors flagged throughout the research identifying both intrinsic and extrinsic influences which have potential to cause lateral ankle sprains. One of the most positively linked intrinsic factor associated with lateral ankle sprains, is in fact previous history of a sprain. The initial injury is believed to cause a partial differentiation of the ankle, rendering it unstable biomechanically as a result of ligament compromise. Additionally, muscle reaction time, more specifically closed-loop efferent reflex response, was shown to be slower in previously injured athletes reducing the stabilizing effect of the gastrocnemius and tibialis anterior, suggesting a neuromuscular deficit (Beynnon, B. D., et al.2002)
Postural sway has also been shown to influence an athlete’s risk of ankle sprain. Taking into consideration that an athlete changes their centre of gravity multiple times within seconds of play, this is a key finding when it comes to rehabilitation as it is influenced by both the central and peripheral nervous system. Other intrinsic predictive influences which have been flagged but to date have not been individually proven include; gender, height, weight, limb dominance, anatomical foot type, foot size, hypermobility and muscle strength although clinically these finding may help in developing an overall reasoning for the injury.
Extrinsic risk factors influencing ankle sprains have primarily been observed through prospective studies inclusive of bracing, taping, shoe type and the duration and intensity of competition.
There have been a number of studies looking at the use of ankle braces and rigid taping in the prevention of ankle sprains, many of which have shown nil association in the prevention of an initial ligamentous injury; however consensus amongst researchers appears to be that the use of n ankle brace or taping has a positive influence in reducing a re-occurrence of injury. Given these findings contradict each other from a biomechanical standing, it is reasonable to deduct that the presence of a compressive force such as that previously mentioned provides proprioceptive feedback to the athlete.
Shoe Type has been found to have nil association with the incidence of ankle sprain injury. In two well-controlled studies comparing high top basketball shoes to light weight infantry boots and high top basketball shoes vs low top basketball shoes during military training exercises it was shown there was no difference in the incidence of ankle sprains. Additionally, when addressing duration of time played on field, field position and intensity of competition, no difference was found over one thousands hours of basketball game play. However, it should be noted that injury was more likely to take place during officiated game play rather than practice.
So how do we prevent such an injury which can leave an athlete out of game play anywhere from seven days to twelve weeks? The answer unfortunately is not a straight forward one, in fact, in terms of developing a prevention program for ankle sprains it is suggested clubs establish more specific technical training based on landing, take off and lateral cutting movements (Stasinopoulos, D. 2002). As mentioned previously, tape has only been found to have a positive preventative effect on athletes who have already sustained an injury, the same can be said for the use of custom orthoses which are recommended for at least twelve months following a serious ankle sprain due to duration it takes for ligaments to reach full repair and regain proprioceptive ability.
In short, research shows the preventative strategies were most effective in participants who had previously suffered an ankle sprain and not necessarily in limiting the possibility of initial instance.
So what are our treatment options once the injury has taken place?
It is suggested by that in the period 0-48 hours that basic soft tissue injury protocol takes place with the addition of protected mobilization as follows;
- Protected Mobilization (open chain, controlled movements with nil resistance)
Ideally, for best healing in times such as sleep where an athlete has little to no control over foot position it is suggested that a night splint sock be used to hold the foot in a dorsiflexed position where the talus remains in a stable position and the Achilles is under tension which enhances the concept of joint compression. Many people relax their bodies during sleep, plantarflexing the foot and elongating the peroneals, which opposes the strengthening management program which we will talk about soon.
In the case of recurrent lateral ankle sprains or chronic instability of the ankle as a result of a previous moderate to severe ankle sprain there is an indicated need for the development of strength and proprioception rehabilitation. It is hypothesized by (Willems, T., Witvrouw, E., Verstuyft, J., Vaes, P., & Clercq, D. D. 2002), that when the inverted foot makes contact with a surface due to the structures diminished proprioception, it may result in a varus thrust from an inversion lever through the subtalar axis. In many cases everter muscles are not strong enough to reduce the velocity of this motion and the strength of the lateral ligaments are tested beyond its limits resulting in injury.
Developing a functional exercises program for the rehabilitation of an athlete with a lateral ankle sprain should be primarily sport specific or aimed towards reaching a players SMART Goals, however given we do not have a specific client at our grasp, I will provide an example of a progressive program, staying in the blogs opening theme of soccer.
|1||-Double Support heel raise from flat surface – controlled motion, hold for 2sec at top.
2×6-8 twice daily- Theraband (yellow) looped around both feet, straight legs, abducting the feet. 2×8-10 twice daily
|Barefoot standing on pillow, moving feet up and down.(progress to closing eyes)||Walking/slow pace forward, backwards, lateral stepping.
|2||Single Support heel raise from flat surface – controlled motion, hold for 2sec at top.
2×6-8 twice daily
– Theraband (yellow) looped around both feet, straight legs, abducting the feet. 3×8-10 twice daily
|Barefoot change through multiple different surface, grass, concrete, pillow, rubber matting ect(progress to stepping over objects ie boxes, hurdles)||Walking/slow pace forward, backwards, lateral steps and vine.
figure 8 patterns
|3||– Double stance heel raise with single stance eccentric phase on step, below level ground..- Theraband (Green) looped around both feet, straight legs, abducting the feet. 3×8-10 twice daily||Wobble board stabilization
5x 45-60sec twice daily
|Ladder step exercises
small ball skills
object avoidance movement
|4||– Single stance heel raise on step, both eccentric and concentric phase below level ground..- Theraband (Green) looped around both feet, straight legs, abducting the feet. 3×8-10 twice daily||Wobble board circles
8-10 clockwise + 8-10 counter clockwise
3 sets each way twice daily
|Advance ladder step exercises
ball movement skills
ie: drag backs, light dribbling, light passingCutting movements slowly
|5||– Single stance heel raise on step, weighted back pack, below level ground..- Theraband (blue) looped around both feet, straight legs, abducting the feet. 3×8-10 twice daily||Single stance balance
20sec each leg
|Cutting movements faster
jump and land
increase kicking intensity
|6||RETURN TO SPORT/regular training||RETURN TO SPORT/regular training||RETURN TO SPORT/regular training|
* Weekly progression is only viable if the patient feels little to no pain and is able to complete current exercises to the satisfaction of clinician.
** The example has not been tested and aims to show a combination of different rehabilitation modalities which can be progressed.
In conclusion, rehabilitation of an athlete whether; weekend warrior or Olympic representative requires the inclusion of more than just a “stretch and strengthen” approach which was once looked upon favourably by many allied health clinicians. Taking in to consideration the structures involved, their mechanism of action and the supporting influences associated is imperative, as well as the need for neuromuscular retraining for proprioceptive sense enhancement.
I hope you enjoyed the second blog published by FootNotes and please stay tuned for our up coming sports events and podiatric interventions including; Tour De France and the US OPEN.
Director /Chief Editor
Beynnon, B. D., Murphy, D. F., & Alosa, D. M. (2002). Predictive Factors for Lateral Ankle Sprains: A Literature Review. Journal of Athletic Training, 4, 376 -380.
Brukner, P. (2013). Brukner and Khan’s Clinical Sports Medicine (4thth ed.). Australia: McGraw-Hill Education. (Original work published 2007).
Douglas H. Richie Jr. D.P.M. (n.d.). Chronic Ankle Instability. Retrieved June 2, 2014, from http://www.aolabs.com/wp-content/uploads/2011/11/lecture-Richie-Lat-Ankle-Instab-2011.pdf
Stasinopoulos, D. (2002). Comparison of three preventive methods in order to reduce the incidence of ankle inversion sprains among female volleyball players. Br J Sports Med, 182 -185.
Willems, T., Witvrouw, E., Verstuyft, J., Vaes, P., & Clercq, D. D. (2002). Proprioception and Muscle Strength in Subjects With a History of Ankle Sprains and Chronic Instability. Journal of Athletic Training, 4, 487 – 493.