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Ankle Ligaments: The ATFL part 2

In the last post I discussed how lateral ankle ligament sprains are the most common injury to affect both the general and the athletic populations,[1-7] with the anterior talofibular ligament (ATFL) is injured most frequently.[1-2] The available research suggest that an injury to the ATFL responds well to the Protection, Optimal Loading, Ice, Compression, and Elevation (P.O.L.I.C.E) principle[1,3-5,8] and early mobilisation, providing the basis for functional training i.e. strength and Neuromuscular Control (NMC).[1,3-5]

Initially, pain and swelling are the major limiting factors to any treatment, and therefore the range of motion (ROM) available at the ankle. This is managed in the early stages through the use of P.O.L.I.C.E, and early mobilisation; which takes the form of ROM exercises e.g. plantar flexion, dorsiflexion, inversion, and eversion.[1,3-5] Early mobilisation provides controlled stresses to the ankle joint and has been shown to speed up the recovery of acute ankle injuries.[1] To maintain cardiovascular fitness and to help work the ankle functionally, although in a controlled manner, one can use of the stationary bike or elliptical. Due to the importance of restoring NMC,[3,5] NMC exercises should be afforded their own time slot; as insufficient NMC is a contributing factor to both initial and secondary injuries.[9]

Rehabilitation exercises, no matter their guise; be it strength, flexibility, or NMC, are always commenced on a stable surface. During a NMC session, the goal is to provide greater kinesthesia through better communication between the neural and muscular systems. Therefore to progress NMC exercises from a stable base, the exercise could include external perturbations (catching/throwing an object), be conducted on an unstable surface (foam pad/mat/beam), having a flight phase included,[10-11] and finally by combining progressions. An example here would be a single leg stand; this can be progressed by: throwing and catching a ball (reaching out of the base of support), standing on an unstable surface, standing on an unstable surface whilst throwing and catching a ball.

This months rehab exercise for the ATFL is the Step-up, whilst this may primarily be used for strength, it can have a great NMC adage. Once the patient is fully weight bearing, able to take their full weight on a single leg, and is confident in stepping up through their injured side; then step-ups can be introduced. Initially the step-up can be conducted onto a shallow box, which can be made higher as the patient progresses.

I hope part 2 has given you some practical advice that you can take into your rehab or own practice.

Thanks for reading!

Jamie

PT Sports Med

Stages

  1. To start, the patient will stand facing the box, before stepping onto it leading with the injured side. The patient will stand up achieving full extension, before stepping back down in a controlled manner
  2. Adding a foam pad/mat onto the top of the box to create an unstable surface, then continuing as in 1.
  3. Stable box; upon stepping up onto the box, adding in a hip/knee drive of the contralateral leg
  4. Foam pad/mat on box; stepping up onto the box with a hip/knee drive of the contralateral leg
  5. Stable box, hip/knee drive of the contralateral leg: achieving flight phase
  6. Foam pad/mat on box, hip/knee drive of the contralateral leg: achieving flight phase

In addition to the foam pad/mat to progress the exercise the therapist can add in perturbations, these could be visual or physical perturbations. Visual perturbations could be advantageous for athletes, as they have to take in a lot of external information whilst remaining focussed for their task at hand. The step-up is a very versatile exercise; in that it can be altered to conduct a side step-up, a step-up with an eccentric step down, a weighted step-up +/- an eccentric step down

References

  1. Lynch, S.A. and Renström, P.A.F.H., 1999. Treatment of acute lateral ankle ligament rupture in the athlete: conservative versus surgical treatment. Sports Medicine, 27(1), pp. 61-71.
  2. Tohyama, H., Yasuda, K., Ohkoshi, Y., Beynnon, B.D. and Renström, P.A.F.H., 2003. Anterior drawer test for acute anterior talofibular ligament injuries of the ankle: how much load should be applied during the test? The American Journal of Sports medicine, 31(2), pp. 226-232.
  3. Gutierrez, G.M., Kaminski, T.W. and Douex, A.T., 2009. Neuromuscular control and ankle instability. PM & R: The Journal of Injury, Function, and Rehabilitation, 1(4), pp. 359-365.
  4. Kerkhoffs, G., Van Den Bekerom, M., Elders, L.A.M., Van Beek, P.A., Hullegie, W.A.M, Bloemers, G.M.F.M., De Heus, E.M., Loogman, M.C.M, Rosenbrand, K.C.J.G.M., Kuipers, T., Hoogstraten, J.W.A.P., Dekker, R., Ten Duis, H.J., Van Dijk, C.N., Van Tulder, M.W., Van der Wees, P.J. and De Bie, R.A., 2012. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British Journal of Sports Medicine, 46(12), pp. 854-860.
  5. Brukner, P. and Khan, K. 2013. Clinical sports medicine. 4th Australia: McGraw-Hill Education.
  6. Gribble, P.A., Bleakley, C.M., Caulfield, B.M., Docherty, C.L., Fourchet, F., Fong, D.T.P., Hertel, J., Hiller, C.E., Kaminski, T.W., McKeon, P.O., Refshauge, K.M., Verhagen, E.A., Vicenzino, B.T., Wikstrom, E.A. and Delahunt, E., 2016a. A 2016 consensus statement of the International Ankle Consortium: Prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine, 50(24), pp.1493-1495.
  7. Gribble, P.A., Bleakley, C.M., Caulfield, B.M., Docherty, C.L., Fourchet, F., Fong, D.T.P., Hertel, J., Hiller, C.E., Kaminski, T.W., McKeon, P.O., Refshauge, K.M., Verhagen, E.A., Vicenzino, B.T., Wikstrom, E.A. and Delahunt, E., 2016b. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine, 50(24), pp. 1496-1505.
  8. Hossain, M. and Thomas, R., 2015. Ankle instability: presentation and management. Orthopadeics and Trauma, 29(2), pp. 145-151.
  9. Herrington, L., Myer, G. and Horsley, I. 2013. Task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: a clinical commentary. Physical Therapy in Sport, 14(4), 188-198.
  10. Paterno, M.V., Myer, G.D., Ford, K.R. and Hewett, T.E., 2004. Neuromuscular Training Improves Single-Limb Stability in Young Female Athletes. Journal of Orthopaedic and Sports Physical Therapy, 34(6), pp.305-316.
  11. Coughlan, G. and Caulfield, B., 2007. A 4-week neuromuscular training program and gait patterns at the ankle joint. Journal of Athletic Training, 42(1), pp. 51-59.

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