APPLIED REHABILITATION Figure 5: Heel raise

the transverse and longitudinal arches, maintenance of a concave foot in push-off and tip-toeing and the maintenance of planti- grade contact during dynamic functional movements.

Furthermore, the combined action of peroneus longus and tibialis posterior help to support the arches of the foot and maintain the metatarsal heads in contact with the floor during dynamic functional movements (fig- ure 5). Consequently peroneal dysfunction can result in a less rigid arch during the support phase of gait and reduced stability of the foot and ankle (figure 6). A useful functional strengthening exercise to address this issue (which also has a significant sensorimotor challenge) is to place some tubing around the midfoot while maintaining single leg balance on the forefoot or during single leg heel raises (figure 7).

Figure 7: Use of tubing in heel raise

Sensorimotor training can be further progressed by the manipulation of variables such as single/double leg support, ankle position, eyes open/closed, relative instability of surface and the performance of a skill. Once the athlete is able to comfortably balance on labile surfaces of moderate difficulty, more dynamic sensorimotor training should commence. In order to ensure specificity of training it is necessary at this stage to incorporate challenges and movement patterns that reflect those performed in the athlete's sport.

During this phase it is possible to use rehabilitation exercises which simultaneously challenge strength, endurance, stability and sensorimotor control throughout the full functional joint range of motion. In order to achieve this, the relative importance of various factors must be assessed. The specific flexibility, strength, power, balance and fitness demands of the sport should be assessed as well as the specific stresses on the ankle complex.

The relative dominance of closed and open skills should also be considered as should equipment and surfaces involved. In order to facilitate rehabilitation planning it may be helpful to compile a list of key sport-specific skills and stresses. Once completed, this list may then be used to help identify key variables that should be included in functional rehabilitation drills. Table 1 summarises some of the key sport-specific skills involved in high jumping and rugby and based on this information, table 2 identifies the relative impor- tance of rehabilitation variables using simple ticks.

sportEX medicine 2007;32(Apr):17-22 Figure 6: Loss of rigid arch

TABLE 1: KEY SPORT-SPECIFIC SKILLS AND STRESSES Rugby outside-half ■ Open skills ■ Passing ■ Kicking ■ Catching ■ Timing ■ Positioning ■ Ball retention ■ Tactical appreciation ■ Decision making ■ Rucking ■ Mauling ■ Tackling ■ Staying upright in contact ■ Going to ground ■ Support play ■ Surface-grass

High jumper ■ Closed skill ■ Curved run ■ Explosive power

■ Vertical speed generated through transformation of horizontal speed by lever action of takeoff leg

■ During takeoff, ankle moves from dorsiflexion and eversion into plan- tarflexion and inversion

■ High load training drills ■ Surface-track

As can be seen from tables 1 and 2, one key difference between the rehabilitation of a high jumper and rugby outside-half with an ankle injury is that high jump is a closed skill while rugby almost entirely consists of open skills (with the exception of kicking at set- pieces). Consequently, greater emphasis is placed on the restora- tion of perfect form and technique of a specific task during the rehabilitation of the high jumper, whereas greater emphasis is placed during the rehabilitation of the rugby player on the ability to respond appropriately to varying environmental stresses. As a result, the rehabilitation of the rugby player will include the com- pletion of considerably more high-speed reactive skills, while the rehabilitation of the high jumper may concentrate on the restora- tion of dynamic explosive power.

TABLE 2: RELATIVE IMPORTANCE OF REHABILITATION VARIABLES

Rehabilitation variable Importance (tick as appropriate) Rugby

High Jump

Flexibility Strength

Speed

Endurance Power

Decision making Direct contact

Directional change Skill challenge Space limitation

Unanticipated movements Opposition

Equipment Distraction

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