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Ankle Rehabilitation
ANDY DAVIS MSPT, LAT
SPORT AND SPINE CLINIC OF MOSINEE
Ankle Injuries
Ankle Injuries
Ankle Sprains
 The ankle is the second most commonly injured body
part in sports.
 Ankle Sprains are the most common (85% are lateral
ankle sprains)
 Result in alterations in postural control, ankle
proprioception and neuromuscular functions.
 Chronic ankle instability (CAI) has been documented
to develop in about 30% of ankle sprains
Sports Med (2013) 43:385-393
Ankle Sprains
 Tissue healing timeframes for ligaments range into
6-12 weeks for scar tissue to mature to full tensile
strength
 Reported timeframes for return to play have been
around 50% of ankle sprains in high school sports
return in less than one week.
Athl Train 2007;42(3);381-387
J
Mechanical vs Functional Instability
 Mechanical Ankle Instability (MAI): movement that
goes beyond its normal range. This can be caused by
pathological laxity, decreased joint mobility,
synovial inflammation, and degenerative changes.
 Functional Ankle Instability (FAI): “giving way”
episodes that are caused by proprioceptive deficits,
neuromuscular deficits, postural control deficits, and
muscle weakness.
Chronic Ankle Instability
 Chronic Ankle Instability (CAI) can affect 10-20% of
people who have an acute ankle sprain.
 CAI is made up of both FAI and MAI, with the
patient experiencing these symptoms for greater
than one year after the injury.

CAI show decreases in joint position sense, reaction time,
muscle activation (specifically peroneus longus), postural
control, muscle strength, dorsiflexion range of motion.
• FOOT AND ANKLE SPECIALIST AUG 2014 : (7) 298-326
FAI
 FAI group vs ankle sprain copers vs controls
 FAI group showed increased amount of talar tilt
laxity vs the copers.
J Athl Train. 2013 Sept-Oct; 48(5):581-589
 Talar tilt range can be 0-23 degrees , but normal
ankles have 0-5 degrees.
 When Anterior Talofibular ligament is involved, less
laxity is noted than when Calcaneo-fibular ligament
is also involved
Wheeless’ Textbook of Orthopaedics
Patient Self Reports
 Foot and Ankle Disability Index (FADI)
 Lower Extremity Function Test (LEFS)
 Foot and Ankle Ability Measure (FAAM)
 Sports Ankle Rating System
 Cumberland Ankle Instability Tool (CAIT)
Arch Phys Med Rehabil 2006;87:1235-1241
 Which is the best to use??
Patient Self Reports
 Utilize the tool that best fits the patient scenario
 CAIT is a tool to use to assess functional ankle
instability independent of reference to the other leg.
It is also able to measure the severity of the FAI.
Ankle Sprains
 Focus today on 1st and 2nd degree lateral (inversion)
ankle sprains
 Diagnosis
- History, Palpation, Special Tests, Assessment
- Ottawa Rules to help determine need of x rays
Ottawa Rules
Ankle Sprains
 Use of Temporary Immobilization
 Approximation of tissues
 Decreases capsular distention
 WBAT
 R.I.C.E.
 Cryotherapy
 Decreases metabolism to limit the secondary hypoxic injury
 Decrease effusion
 Compression
 Vasopneumatic compression
 Horseshoe/Lateral J pad
Muscle Strengthening
 Strength work can help alter the muscle
mechanorecptors, aiding in controlling joint motion.
J OF ATH TRAINING 1998; VOL 33 (4), 310-314
Muscle Strengthening
 Decreased eversion strength for CAI
Clinical Biomechanics 29(2014)439-443
 Decreased muscle activation patterns
*Decrease in peroneal nerve motor conduction
velocity.
*This decrease in reaction time can be up to 12 weeks
even with 5/5 MMT
AJSM 1996; 24: 362-9
AJSM 1998; 26: 72-8
 Decreases also seen in hip joint abduction, adduction, and
extension.

*Gluteus Medius weakness is linked to ankle inversion sprains
Physical Therapy in Sport 15(2014) 15-19
Muscle Strengthening
Ankle Strengthening
Muscle Strengthening
 The peroneal muscles can be affected by hemarthrosis,
similar to the VM inhibition with knee pain
AJSM 1998; 26 (1) 72-77
 Eccentric Muscle Actions: Can enhance joint stability by providing
an antagonsitic force that resists joint translation.
J Athl. 2013 Jul-Aug; 48(4): 528-545
 Drop Leg Test

*Pt in sidelying, and examiner passively abducts the leg to the end
range of hip abduction, then extends the hip 20 degrees. Patient is
asked to hold this position as the examiner lets go. A drop of 2-12
inches shows weakness to the posterior fibers of the gluteus medius
Physical Therapy in Sport 15 (2014) 15-19
Ankle ROM
 Manual joint mobilization has been shown to help
decrease pain and increase DF ROM for the acute
and chronic ankle sprains.
Br J Sports Med 2014;48:365-370
JOSPT 2013(43)456
 Reduction in ankle DF during terminal stance of gait
can alter knee joint kinematics and kinetics in the
sagittal and frontal planes. The Knee 21(2014)669-675
Proprioception
 Theory of proprioception is to shorten response
times of muscles affecting joint position sense.
AJSM 1997; 25(4):538-43
 Postural control deficit first reported by Freeman et
al (J Bone Joint Surg Br. 1965;47:678-695), and since then
numerous studies have shown the importance of
proprioception and balance.
Med Sci Sports Exerc 2009;41:1510-30

J Strength Cond Res 2012;26:568-74
Gait and Posture 39(2014) 404-409
Ankle
sprains affect single
leg stance and sudden angular displacement.
Proprioception
 Assessing and rehabbing with dynamic control may
provide a better functional picture than solely testing
proprioception.
Foot Ankle Spec (2013) 346-351
Proprioception
Proprioception
 BOSU muscle activation for single leg stance (Tibialis
Anterior, Peroneus Longus, Medial Gastrocnemius), was
different on blue vs black side
J Strength Cond Res 2010; 24(1):218-22
not
Functional Testing
 When is the athlete ready for return to play?
 Star Excursion Balance Test (SEBT): looks at 3
directions: anterior, posteromedial and posterlateral,
with the posteromedial being the best predictor.
 Single leg hop, timed hop, triple hop and crossover
hop (by Noyes and colleagues)
 Lower extremity functional test (LEFT)
J Sport Rehabil. 2002;11:190-201
 Functional Lower Extremity Evaluation (FLEE)
JOSPT 2014(44)12:947-954
Functional Testing
Functional Testing
FLEE
 Control Sequence: timed lateral step down and
timed leap and catch
 Hop Sequence: Single leg hop for distance, single leg
timed hop, single leg triple hop for distance, and
crossover hop for distance.
 Endurance Sequence: Square hop test, LEFT
Taping vs Bracing
 Both have had evidence of success, especially with
the individuals with a history of ankle sprains, in
reduction of injuries.
 Ankle bracing has been shown to be a more cost
effective in the long term. Am J Sports Med. 2011;39(9):1840-1848
Achilles Tendon
Achilles Tendon Rupture
 Acute Achilles tendon rupture annual incidence of 18
per 100,000 people per year.
 Immobilization vs. early active rehabilitation and
weight bearing
 Fear of movement and physical activity
(kinesiophobia) plays a role in rehab outcome
Scand J Med Sci Sports 2014; 24:152-158
 Early WB is widely accepted but no consensus on the
preferable protocol
Injury, Int. J Care Injured 45 (2014)1782-1790
Achilles Tendon Rupture
 Immediate FWB leads to higher patient satisfaction,
earlier ambulation and earlier return to work and
pre-injury activity level.
 Early ankle mobilization (free plantar flexion with
DF restriction of 0 degrees) is superior to
immobilization, after 3 weeks
 Combined functional treatment, immediate WB &
early ankle mobilization, starting at week 3, is most
beneficial.
Injury, Int. J Care Injured 45 (2014)1782-1790
Achilles Tendon Rupture
 Early weight bearing can prevent muscle atrophy,
stiffness, adhesions, and DVT’s and has been
associated with stronger tendons due to improved
vascularization and an improved immunologic
response.
Journal of Foot and Ankle Surgery 52 (2013) 622-628
 Low rerupture rates can be achieved with
conservative management of acute AT ruptures and
no difference in rerupture rates in WB and NWB
groups.
J Bone Joint Surg Am 2014;96:1073-9
Achilles Tendon Rupture
 Achilles Tendon Total Rupture Score and heel rise
work had no difference in the early WB vs NWB of
the nonoperative achilles tendon groups.
J Bone Joint Surg Am 2014;96:1497-503
 Ability to perform a single leg heel-rise is
significantly related to patient reported outcome
after Achilles tendon rupture.
Scand J Med Sci Sports 2014; 24:152-158
Achilles Tendonosis
 Cause can be multifactorial: impaired flexibility,
overuse, overload, poor running technique, cavus
and planus foot types.
 Mistakenly interchanged with Achilles tendinitis, as
tendonosis has calcifying
degeneration/fibrocartilaginous near the Achilles
insertion on calcaneus or 3-5 cm above.
Achilles Tendonosis
 Eccentric exercise has been show to improve
symptoms and may reduce degenerative changes.
 Increasing flexibility and strength are primary goals.
 Avoidance of hills and impact activity.
Foot Ankle Clin N Am 19(2014)73-86
Thank You!