ANKLE INJURY

activation and afferent input (7), early resolution of oedema is vital. As previously described, the application of focal compression around the injured tissues is recommended (8). Cryotherapy and more specifically, cryokinetics are also a key part of the acute man- agement of ankle injury and are invaluable in achieving early safe loading of the tissues and the restoration of full range of motion. Cryokinetics are carried out using the application of ice to the injured area, the athlete is then instructed to gently move the ankle through all available movements within the limits of pain. In the acute stages it is suggested that five slow repetitions of each movement are performed every hour. Once pain and swelling have resolved and sufficient healing has taken place, functional rehabil- itation can be progressed in line with the biological healing process.

During the early stages following injury it may be possible to address functional deficits that have been associated with ankle injury such as hip abductor weakness. In a recent study, Friel et al (9) identified the presence of ipsilateral hip abductor weakness after inversion ankle sprain. Similarly, in a prospective study exam- ining risk factors for injury, hip abductor and external rotator weak- ness have been linked to an increased incidence of lower extremity injury in females (10). Therefore it appears that hip strengthening and motor control stability training may have an important role to play in all ankle rehabilitation programmes.

During the early stages of functional rehabilitation, range of motion enhancement, sensorimotor training and strengthening are perhaps most important. Early restoration of full ankle range of motion is critical to prevent alteration in walking and running mechanics. Dorsiflexion is usually most restricted and is best treated using manual therapy. A recent systematic review of manual therapy techniques in the management of ankle injury, reported a positive effect of different modes of manual mobilisation (mobilisation with movement (MWM), physiological, chiropractic, osteopathic) on ankle dorsiflexion range of motion in the early stages following injury (11). Improvement in ankle range of motion may be maintained and further enhanced by calf stretching exercises.

The importance of sensorimotor training in the rehabilitation and prevention of ankle injuries has been highlighted by a number of authors (12,13). Indeed, several studies have demonstrated that simple balance training consisting of predominantly wobble board exercises can significantly reduce functional ankle instability and injury recurrence (14,15). In light of this it is reasonable to conclude that all rehabilitation programmes following lateral ankle injury should include sensorimotor training.

The peroneal muscles have an important role to play in joint sta- bilisation and the restoration of sensorimotor control. Following lateral ankle injury, peroneal weakness, reduced peroneal response time and reduced peroneal activation have been observed and have been linked with the development of chronic functional ankle insta- bility (16,17). Appropriate facilitation and sensorimotor training of the peroneii must therefore be included.

Techniques such as proprioceptive neuromuscular facilitation (PNF) strengthening (eg. repeated contractions and slow reversals) and basic holding and placing of various ankle positions can be partic- ularly useful in the early stages. Early sensorimotor training can

18

Figure 2: Lunge stabilisation

also be facilitated by continued use of cryokinetic exercises that involve simple kinaesthetic and proprioceptive challenges in stand- ing such as progressive heel-to-toe gait re-education. Proprioceptive exercises can be further progressed by performing gentle rhythmic stabilisations whilst standing in a lunge position on the affected side (figure 2). Due to potential injury from exces- sive talar internal rotation, it is recommended that during the early stages the ankle is maintained in a neutral position with correct foot and lower leg alignment.

As the ability of the athlete improves and appropriate tissue healing permits, strengthening and sensorimotor training should then be carried out in various joint positions. Considering that the ATFL is most vulnerable when the ankle is plantarflexed, it may be useful to progress rehabilitation by introducing balance and strengthening exercises in progressively greater degrees of plantarflexion. For example, single leg standing on a decline board (figure 3), balancing on a wedge on top of a rocker board (figure 4) and single leg heel raises.

It is important to stress that when placing the foot in increasing degrees of plantarflexion, correct foot and ankle alignment must be maintained. Particular attention should be given to ensuring that weight is distributed across all five metatarsal heads to maximise peroneus longus activation. The peroneus longus tendon is attached by two tendinous slips that pass across the sole of the foot to the lateral sides of the first metatarsal base and the lateral side of the medial cuneiform. Its primary actions include support of

Figure 3: Decline balance

Figure 4: Rocker board www.sportex.net