ankle instability - iaom-us...bracing kinesiotape transverse friction pacing program protection of...

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Ankle InstabilityKasey Miller, DPT, COMT, Fellow-in-Training

January 2021

About Me

IAOM-US

• Live in Kansas City, MO and work at Modern Physical Therapy• Went to KU Med for PT School and graduated in 2016• Introduced to IAOM during school and have been assistant faculty since

January 2018• Will complete my fellowship this summer

Objectives

� Understand the prevelance and complication of ankle instability

� Identify common types of ankle instability and mechanisms of injury

� Assess for ankle instability

� Organize a plan of care for ankle instability using evidence based approach

� Acknowledge preventative measures to avoid developing ankle instability

IAOM-US

� 50-70% of the people who sustain a lateral ankle sprain (LAS) develop chronic ankle instability

� Symptoms of chronic ankle instability demonstrate an onset as early as 6 to 12 months after initial injury

� Continuation of post-injury symptoms more than 6 months following the initial injury

Chronic Ankle Instability

Hiller CE, Kilbreath SL, Refshauge KM. Chronic ankle instability: evolution of the model. Journal of

athletic training. 2011 Mar;46(2):133-41

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Chronic Ankle Instability: Symptoms

Lingering Pain

Instability

Injury Recurrence

Balance Deficits

Persistent functional disability

Swelling

Giving Way

Impaired strength

Chronic Ankle Instability: Consequences

� Increased ligamentous laxity

� Proprioceptive deficits

� Activity limitations� Up to 72% of people are unable to return to prior level of function

� 85% of people develop problems in the contralateral ankle

Löfvenberg R, Kärrholm J, Lund B. The outcome of nonoperated patients with chronic lateral instability of

the ankle: a 20-year follow-up study. Foot & ankle international. 1994 Apr;15(4):165-9.

Type of Instabilities

Functional Instability

Mechanical Instability

Functional Instability

� Recurrent ankle sprains and frequent sensation of instability

� Examination Findings:� Normal motion

� (-) Ligament laxity testing

� Self-reported symptoms such as weakness and pain

� Injured ankle “feels different”

� Feeling of instability could be attributed to:� Muscle weakness

� Altered muscle recruitment patterns

� Decreased ROM

� Balance deficits

� Impaired proprioception and joint position sense

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Functional Instability Continued

� Those who performed coordination exercises during recovery demonstrated lower incidence of functional instability

� Potential Causes of CAI:� Changes in the motor component of sensorimotor control

� Impaired postural control

� Diminished ankle-eversion strength

� Alterations in motor control of proximal muscles

Functional instability represents the sensorimotor cause of persistent injury

Mechanical Instability

� Pathologic ligamentous laxity around the ankle-joint complex

� (+) Ligamentous laxity testing� Occurs in 30% of patients following the initial ankle sprain

Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Locomotive biomechanics in persons with

chronic ankle instability and lateral ankle sprain copers. Journal of science and medicine in sport. 2016 Jul

Mixture of instabilities

Mechanical Functional

Updated Model of Chronic Ankle Instability

8 Primary components 1. Primary Tissue Injury 2. Pathomechanical Impairments3. Sensory-Perceptual impairments4. Motor-behavioral impairments5. Personal Factors 6. Environmental factors7. Component interactions8. Spectrum of clinical Outcomes

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IAOM-USHertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. J Athl

Train. 2019;54(6):572-588. doi:10.4085/1062-6050-344-18

Primary Tissue Injury

� For CAI to develop, patient must sustain an injury

� Lateral ankle sprains are most common pathology� Anterior talofibular ligament is most commonly injured ligament

� Calcaneofibular ligament is present in more severe ankle sprains

� Other potential injuries from inversion-internal-rotation mechanism of injury

� Fibular fracture

� Fifth metatarsal fracture

� Osteochondral lesion of talus

� High ankle sprain (Anterior inferior tibiofibular ligament and tibiofibular syndesmosis)*

� Subtalar joint instability*

Hertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. J Athl Train.

2019;54(6):572-588. doi:10.4085/1062-6050-344-18

Considerations of the Subtalar Joint

• Subtalar joint instability appears to be more frequent than is generally assumed.• About 25% of the cases presenting with

combined injuries of the lateral ankle and the subtalar joint.

• In particular, the calcaneofibular ligament (CFL) bridges the subtalar joint and contributes essentially to subtalar joint stability

• Current imaging options do not reliably predict subtalar joint instability.

• Distinction between chronic lateral ankle instability and subtalar joint instability remains challenging.

Mittlmeier T, Rammelt S. Update on Subtalar Joint Instability. Foot Ankle Clin. 2018; 23(3):397-413. Krähenbühl N, et al. Currently used imaging options cannot accurately predict subtalar joint instability. Knee Surg Sports Traumatol Arthrosc. 201; 27(9):2818-2830.

Medial talocalaneal

Cervical

Interosseous

Pathomechanical Impairments� Structural abnormalities to the ankle joint and surrounding

tissues that contribute to ankle dysfunction and CAI

� Pathologic Laxity (Mechanical Instability)� Loss of structural integrity of lateral ankle ligaments

� Talocrural joint laxity� Potential subtalar joint laxity

� (+) Ligament Laxity Tests

� Anterior drawer for ATFL � Inversion Stress Test (10 degrees PF + ADD+ inversion) for CFL

� Squeeze Test: Syndesmosis

� Arthrokinematic Restrictions� Restricted anterior-to-posterior glide of talus on tibia

� Anterior displacement of the talus on the distal tibia

� Osteokinematic Restrictions� Restricted DF

Hertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. J Athl Train . 2019;54(6):572-588. doi:10.4085/1062-6050-344-18

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Clinical Tip: Anterior Drawer

� Acute LAS: Pull talus anterior via calcaneus

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� Recurrent LAS: Push tibia posteriorly � ATFL: 10 degrees PF

� CFL: Neutral

Sensory-Perceptual Impairments� Conditions that the patient senses or feels about

the body, the injury, or the self

� Diminished Somatosensation� Damage to proprioceptors, ligaments and

possible nerve injury

� Increased proprioceptive errors

� Increased recurring ankle sprains

� Decreased cutaneous sensation

� Poor plantar sensation

� Pain

� Perceived Instability� May be perceived instability

� Cumberland Ankle Instability Tool

� Identification of Functional Ankle Instability

� Fear of movement

Screening Tools

Cumberland Ankle Instability Tool

• Self report frequency and circumstances of perceived instability episodes

• 9 Questions• 1 pain• 8 perceived instability

• Score of < 24/30 considered diagnosis criterion for functional ankle instability

Identification of Functional Ankle Instability

• 10 questions about history and perceived instability• >11/37 for diagnosis criterion

IAOM-US

Foot and Ankle Ability Measure (FAAM)

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Motor-Behavior Impairments � Deficiencies and alterations in muscle

contractility, motion patterns, and physical activities

� Motor aspect of sensorimotor function

� Altered reflexes� Delayed reaction time of peroneal muscles

� Neuromuscular inhibition� Proximal muscles inhibited such as hamstrings

and quads

� Muscle Weakness� Hip abduction

� Eversion

� Plantar flexion/Dorsiflexion

� Balance Deficits

IAOM-US

Personal Factors

Demographics

Age

BMI

Sex

Medical History

Comorbid factors

Structural deficits due to previous injury

Physical Attributes

Strength and conditioning

Flexiblity

Foot morphotype

Psychological Profile

Self efficacy

Anxiety

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Environment Factors

Societal expectations

and home life

Sports Participation

Access to health care

facilities

Social support

networks

Work Environment

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Spectrum of Clinical Outcomes

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Chronic Ankle Instability

• 12 months removed from initial sprain

• Propensity for recurrent ankle sprains

• Frequency giving way episodesPersistent pain, swelling, weakness

• Pain• Swelling• Weakness

• Feeling unstable

• Changes the type of sport or physical activity they participate in

Coper

• 12 months removed from initial sprain and no recurrent ankle sprains

• minimal symptoms

• minimal deficits in self-reported function

• Full recovery

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IAOM-US

The Development of CAI

IAOM-US

• Advanced age• Neuromuscular control• Previous hx of trauma• Proximal stability• Etc.

Intrinsic Factors

• Court conditions• Opposing players• Uncontrollable environment

Extrinsic Factors

The Development of CAI

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Sensorimotor Deficits Associated with CAI

� Ligamentous structural damage has more effects than anatomical restrictions

� Disrupt afferent-efferent communication

� Central control issues that manifest peripherally

� Doherty et al performed several tests at acute stage following LAS injury to analyze kinematics and kinetics

1. Star Excursion Balance Test (SEBT)

2. Maximum Hip-knee-ankle flexion-extension moments

3. Reach test (Anterior, PL, PM)

4. Landing and drop vertical

5. Gait analysis

6. Self-reported measures (Cumberland Ankle Instability Tool and

Foot and Ankle Ability Measure)

Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Sweeney K, Delahunt E. Inter-joint coordination strategies

during unilateral stance 6-months following first-time lateral ankle sprain. Clinical Biomechanics. 2015 Feb 1;30(2):129-35.

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Associated Deficits with CAI

Static Postural Control Deficits

Dynamic Postural Control Deficits

Gait Deficits

Deficits in Jumping and Landing Tasks


� Lose ankle strategy to maintain static balance

� Utilize hip strategy

� Increase in ROM at the hip joint but decreased ankle ROM

� Difficult for individual to utilize different components of the

kinetic chain individually and they became ”locked”

� Decreased stability with single leg stance

Static Postural Control

Deficits

Dynamic Postural

Control Deficits

Gait Deficits

Deficits in Jumping

and Landing Tasks

Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Sweeney K, Patterson MR, Delahunt E. Lower limb interjoint

postural coordination one year after first-time ankle sprain. Med Sci Sports Exerc. 2015 Mar 31;47(11):2398-405.


� Reduced hip-knee flexion moment and ankle dorsiflexion during star excursion balance test (SEBT)

� Reach distances were reduced in PL and PM directions

� SEBT deficits manifested bilateraly

� Highlight LAS and CAI is not exclusive to peripheral symptoms but

have central manifestations

Static Postural Control

Deficits

Dynamic Postural

Control Deficits

Gait Deficits

Deficits in Jumping

and Landing Tasks




� Reduction of push-off tendencies

� Decreased hip extension

� increased ankle displacement in the frontal plane



Gait Deficits




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� Increase in hip flexion before initial contact (preparation for landing)

� Reduction in hip flexor activity after initial contact

� Hip stiffness and bilateral increased extension moments during landing

� Inter-limb asymmetries� Tendency to off-load injured limb and shift load to non-injured side

� Contralateral injury



Gait Deficits


Doherty C, Bleakley C, Hertel J, Sweeney K, Caulfield B, Ryan J, Delahunt E. Lower extremity coordination and

symmetry patterns during a drop vertical jump task following acute ankle sprain. Human movement science. 2014 Dec 1;38:34-46. IAOM-US

Predicting Chronic Ankle Instability

Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Recovery from a first-time lateral ankle sprain and the predictors of

chronic ankle instability: a prospective cohort analysis. The American journal of sports medicine. 2016 Apr;44(4):995-1003.

W ill your patient develop

CAI after Lateral Ankle

Sprain?

Jumping and Landing

Unable to perform within

2 weeks following injury

Star Excursion Balance

Test

Poor dynamic control in

PL and PM directions

the Foot and Ankle Ability

Measure

Poorer self reported

function

IAOM-US

Four Pillars of Prevention After Initial Sprain

Protection of healing

structures

Evaluate all Joints

Affected by Injury

Correction of Hypomobility

Strategies to correct

hypermobility

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Protection of Healing Structures

Bracing

Kinesiotape

Transverse Friction

Pacing Program

Protection of Healing Structures: Bracing

� Bracing elicited more synchronous motion throughout gait

� Coordination variability decreased with bracing

� Greater pattern stability

� Bracing increases coordination patterns

� May work to guard against malalignment

� Push Brace is our favorite

� Care: Recurring

� Med: Acute or Secondary

Jagodinsky AE, W ilburn C, Moore N, Fox JW, Weimar W H. Ankle Bracing Alters Coordination and Coordination

Variability in Individuals W ith and W ithout Chronic Ankle Instability. J Sport Rehabil. 2020 Mar 4:1-8.

Protection of Healing Structures: Kinesiotape

� Swelling� Lymphatics

� Bruising

� Tenosynovitis

� Weaning off a brace

Jagodinsky AE, W ilburn C, Moore N, Fox JW, Weimar W H. Ankle Bracing Alters Coordination and Coordination

Variability in Individuals W ith and W ithout Chronic Ankle Instability. J Sport Rehabil. 2020 Mar 4:1-8.

Protection of Healing Structures: Transverse Friction

� Fibroblast proliferation

� Collagen Re-alignment

� Analgesic

� Micro lymphatic Drainage

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Transverse Friction Review

Ligament

• Start with 2/10 and progress once pain free• One direction

Tendinitis

• Start 2/10 and progress once pain free• One direction

Tenosynovitis

• Start extremely light and stay light• Tendon on slack• Perform tendon glides after tenderness is reduced

Tendinosis

• Start aggressive and stay aggressive• Both directions• Stimulate blood flow or jumpstart inflammatory response

Protection of Healing Structures: Pacing Program

▪ Acute/Inflammatory Pain increases for hours to 3-4 days▪ Proliferation After 4 days, pain levels off▪ Early remodeling 11 to 21 days▪ Late remodeling 3 to 6 weeks▪ Back to sports 8 to 12 weeks (with supportive device

for up to one year)

Hubbard T and Hicks-Little C. Ankle ligament healing after an acute ankle spring: An evidence-based approack. J Athletic Training. 2008; 43:523-529.

Evaluation of All Joints Affected by Injury

Talocrural Joint Syndesmosis

Subtalar Joint Hip

Knee Proximal Tib-Fib


� Can lead to adjacent instability by altering the kinetic chain� Talocrural joint hypmobility may lead to subtalar instability

� Assess� Talocrural joint

� Subtalar joint

� Distal tibiofibular joint

� Proximal tibiofibular joint

� 1st MTP

� Limited Dorsiflexion is common� Anterior translation of talus on tibia

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IAOM-US

Talocrural Traction

Talocrural Posterior glide

STJ Medial Glide

Correction of HypermobilityNeuromuscular

Control

Somatosensory Activation

• Proprioception• Balance

Fundamental Performance

Advanced Performance

Functional Advancement

SenmocorTM

Correction of HypermobilityNeuromuscular

Control


• Proprioception• Balance




Correction of Hypermobility: Neuromuscular Control

IAOM-US

Neuromuscular Control





� Unconscious efferent response to an afferent signal concerning joint stability

� Preparatory (anticipatory) and Reactive (reflexive) activation

� Pre-activating muscles � Short foot

� Pronation control

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Correction of Hypermobility: Somatosensory Activation

IAOM-US





Functional Advancement � Reflex modulation

� Proprioception

� Balance management

� Postural Control

Correction of Hypermobility: Fundamental Performance

IAOM-US






� Sagittal Plane Control� Flexion/Extension Correctives

� Frontal Plane Control� Abd/Add Correctives

� Transverse Plane Control � Rotational Correctives

Correction of Hypermobility: Advanced Performance

IAOM-US






� Fundamental Movements with ankle stability

� Hinge

� Squat

� Lunge

� Push

� Pull

� Twist

� Ambulation

Correction of Hypermobility: Functional Advancement

IAOM-US






� Agility Strategies

� Performance Training

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IAOM-US IAOM-US

Tests for Ankle Instability

TalocruralStress Test

Anterior Drawer

Syndesmosis

Squeeze Test

External Rotation Test

�Max PF + Inversion = ATFL

� 10 deg PF + Inversion = CFL

�DF + Inversion = PTFL

Tests for Ankle Instability: Stress Test

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▪ Anterior Drawer▪ 10 degrees PF: ATFL ▪ Neutral: CFL ▪ 15 degrees DF + Neutral: CFL

▪ DF Laxity < Neutral laxity = ATFL ▪ DF Laxity = Neutral laxity = CFL

JM Hollis, et al. Simulated Lateral Ankle Ligamentous Injury - Change in Ankle Stability. American Journal of Sports Medicine. 1995;23:672-677.

Tests for Ankle Instability: Anterior Drawer Tests for Anterior Instability: Squeeze Test

IAOM-US

IAOM-US

Tests for Ankle Instability: External Rotation Test

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Case Review

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Ankle-Foot Case: WHO

WHO:• 64-year-old female, retired high school teacher. • Daily activities include housework and volunteering

at the local senior center. • She generally enjoys traveling both within the

United States and internationally. • She notes that she has been able to ride her

stationary bicycle with minimal discomfort, and it actually seems to help her symptoms.

Photo by BBH Singapore on Unsplash

Ankle-Foot Case: WHAT & WHERE

WHAT:• Dull aching at the right ankle,

with warmth and swelling; burning pain at the distal foot.

WHERE:

• Patient places her hand at the anterolateral aspect of the ankle to indicate her aching pain, where it also feels swollen and warm.

• Pain in her foot is located at the dorsum and plantar aspect of the distal foot between the 2nd and 3rd metatarsal and refers proximally along the sole of the foot.

How does this apply to Instability?

• A previous history of ankle sprain may have led to• Laxity of the tibiofibular syndesmosis leading to increase

loads on the TCJ• Leading to early osteoarthritis of the TCJ

• Potential insufficiency of the anterior talofibular ligament leading to flat foot• Leading to Morton’s neuroma

• This is further complicated by the slight knee valgus due to early osteoarthrosis, promoting the hyperpronation, which can lead to a hypermobile 1st ray• And that can lead to increased load on the metatarsals,

and perpetuate the Morton’s neuroma

Treatment Ideas

IAOM-US

• TCJ• STJ• Midfoot• Knee • Hip

Joint Dysfunction

• Tib Post• Foot intrinsics

Muscle Dysfuncion

• Balance• Proprioception• Reflexes • Anticipatory

Sensorimotor Control

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Questions

IAOM-US

Thank you

IAOM-US [email protected]

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