Yudu - sportEX medicine - 1999-2010

REHABILITATION ANKLE INJURY The cervical and interosseous ligaments

around the lateral aspect of the subtalar joint are often forgotten in ankle injuries. These two ligaments control the amount of rear foot eversion/inversion of the subtalar joint. Classically, in severe inversion injuries, the subtalar complex can also be damaged. The use of orthotic cups to prevent unwanted stretching to these ligaments, and thus to restrict over-pronation, has been of benefit in the early to mid stages of rehabilitation (9).

REHABILITATION The key to any successful rehabilitation programme (Fig. 3) is understanding the mechanism of injury, the correct diagnosis, and the grade and severity of the injury. The initial 72 hours is vital, as the reduction of oedema around the ankle joint allows better early function, which has been shown to return an athlete back to fitness more quickly (10). Compression is far more important than ice. It is important to maintain compression at all times, especially within the first 48 hours. Leaving on a compression garment and introducing ice immersion while letting the compression drip-dry is of far more benefit than applying ice alone (11). The use of intermittent compression garments such as Flowtron or newer products such as Game

ReadyTM , which allow ice to be applied using

various pressures through a compressive sleeve, are of great benefit, especially as longer treatment times can occur without the hazard of an ice burn. Myers and colleagues injected the lateral ligament complex of patients who were blindfolded and tested on a 30° inversion drop-down door at a speed of 440°/second (12). They found no difference in the reaction times of tibialis anterior and peroneal brevis and longus between the placebo group (saline) and the tested group (lidocaine). However, compared with the control group, both injected groups (lidocaine and saline) experience suppressed muscle activity during perturbation tests and dynamic activity (walking). The authors concluded that any oedema within the joint causes a reduction in dynamic stability. Once the swelling has subsided, the next step is to gain range of movement, passively and actively. Weight-bearing is advocated as early as possible, whether assisted or not, depending on the severity and tolerance of the patient (13). It is important at this stage not to overload the injured ligament and joint. Protection via bracing and taping is vital (14,15). “Little and often” is a good guide in the early stages when dealing with weight-bearing and exercises to increase range. This allows for

Anterior tibiofibular ligament (Syn. anterior inferior tibiofibular ligament)

Capsule of the ankle (talocrural) joint

Sports-specific

Lateral collateral ligament (ankle joint): anterior talofibular part

Drills incorporating both functional strength and proprioception

Straight line. Lateral movement rotation cutting jumping

Inflammation

Reduction of swelling/pain relief/ protection of joint via tape-orthotic/ constant compression post 72 hours/heel cups in suspected subtalar ligament damage

Joint range of movement Physiological and accessory Dorsiflexion range most important

Proprioception Non-weight-bearing Weight-bearing

Strength Concentric>isometric>eccentric

Functional strength/reaction (perturbation)/isokentic

Return to training

Modified: continuous review of joint and tissue reaction Prevention programme

Lateral collateral ligament (ankle joint): calcaneofibular part

Lateral talocalcaneal ligament

Figure 2: The ligaments of the ankle www.sportEX.net

A programme incorporating all the elemets of the rehabilitation programme that becomes a daily part of the athlete’s routine

Figure 3: Gradual progressions of a rehabilitation programme