Transcript Slide 1

R. Kent Kurfman, PT, DPT, OCS, MTC
Proaxis Therapy
Greenville, South Carolina
Don’t Just Recover. Conquer.
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Most common athletic / sports injury
Highest percentage (15%) of any regional
injuries in NCAA study (Hootman JM J Athl Train
2007)
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Most common injury in several sports, such
as soccer (Ekstrand/Tropp – Foot/Ankle – 1990)
10-15% of all football injuries (Garrick JG. J Sports
Med 1977)
75% of all ankle injury = ligamentous sprain,
85% of these = lateral ligaments (Garrick JG Clin
Sports Med 1988)
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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20-70% lead to chronic pain/instability - CAI
(Barrett/Bilisko – Sports Med 1995, Gerber JP Foot Ankle Int 1998, McKay GD
et al BR J Sports Med 2001, Verhagen RA et al Arch Orthop Trauma Surg
1995)
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Reinjury rates = up to 70-80%
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Landings
◦ Unexpected surface (on another athletes foot,
sloped surface).
◦ Improper foot positioning prior to landing
(excessively inverted and plantarflexed) whether
walking, running or landing from jumps
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Sudden stops and cutting movements
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Greatest: history of previous sprain
◦ 4-5x more likely to re-injury
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Distribution by gender: essentially the same
(Beynnon)
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Structural – limited information linking foot
structural characteristics (Morrison, J Athl Train 2007)
◦ High medial longitudinal arch/pes cavus
◦ Greater than normal foot width
◦ High 1st MTP dorsiflexion ROM
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Technical skill –
Body mass – higher BMI = suspected
greater risk for ankle injury
Footwear selection
◦ Inappropriate choices made , particularly during
training –
 Running footwear use for court activities
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Proprioceptive deficits: Impairment in
feedback
◦ Aberrant ankle position sense is primary problem
in landing-related injuries – foot too inverted,
due to diminished position sense
◦ Primary sensory input comes from cutaneous
pressure receptors and muscle spindles – less
from joint capsule receptors
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Long term disruption of sensory-motor
control: Central changes in sensorimotor
system function
◦ Diminished motoneuron pool excitability
◦ Mismatch of reaction time of peroneals,
compared to rapidity of ankle inversion
stress/stretch during aberrant landing.
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Bottom line: deficits in those with CAI are not
only peripheral but are also central –
maladaptive changes to movement.
◦ We need to train global coordination to gain more
complete recovery (Hass CJ AJSM 2010).
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Differ, based on history of the athlete
◦ Previously uninjured – no definitive approach!
 No evidence that use of preventative
bracing/taping/neuromuscular training will prevent
an ankle sprain
 Need to emphasize what we can encourage
 Appropriate footwear selection
 Proper practice /skill acquisition – role of coach
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Previously injured and CAI: a great deal of
evidence that we can affect future injury
occurrence!
◦ Remainder of presentation will emphasize
preventative measures in those previously
injured/CAI.
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Most commonly used supports.
◦ Both are effective, shown via multiple studies.
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Bracing:2010 study – preventative.
Expense: bracing cheaper
Taping:
◦ Support loss from taping:
◦ Don’t underestimate proprioceptive effect.
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Kinesiotaping
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Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Recommendation: Continue taping/bracing after
LAS for at least 6 months
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Purposes :
◦ Traction, protect feet from abrasion/contact
◦ Shock absorption – less certain
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Shoes act as a filter to our proprioception
We adjust the stiffness of our legs based on
cushioning (footwear and surface).
◦ Hard surfaces: more hip/knees/ankle flexion.
◦ Softer surfaces – less hip/knee/ankle flexion
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Shoes can confound this - too much
cushioning on a hard surface = increased
lower leg stiffness, greater force
transmission .
◦ No midsole material available yet that
compensates /adjusts for this
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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High top vs. Low top
◦ Mixed findings in the literature
◦ In general, high tops can have a combined effect
with bracing /taping in prevention of re-injury
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Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Athlete should choose the shoe with the least
amount of midsole that they are able to
properly/comfortably train/compete in.
Less stack height = less chance of injury
◦ More plantarflexion (heel height) = more chance of
injury.
◦ High tops = matter of preference.
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Effective in prevention of future injury –
 Balance training alone = 36% reduction in ankle
sprain
 Multiple-intervention training (balance, weight,
plyometric, agility/sport specific training)= 50%
reduction in ankle sprain injuries
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Consideration of study problems
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Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Retraining guidelines:
◦ Dosage: Typical = 6 weeks, 3-5 sessions/week
◦ Wobble boards – common denominator
◦ 4 constructs: static balance, joint position sense,
dynamic balance, motoneuron pool excitability (via
agility and plyo work).
◦ Strength - only a component
◦ Bottom line: Since balance control is multifactorial,
work on all factors during a session
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Program components:
◦ Static single leg balance – easiest to retrain, acts
as a base for all other activities.
 Goal: 60” eyes open, 30” eyes closed.
◦ Position sense retraining –essential for landing
control
 Technique accuracy is essential
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
◦ Dynamic balance and neuromuscular control.
 A progression of balance board / soft surface training.
 Emphasize speed of control, range of control .
 Add distractions – throwing/catching
 Balance with reaching
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Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Agility: progression back to “real activity” –
hopping, cutting activities.
◦ Concentrate on doing these activities on very firm
surfaces.
◦ Proprioceptive/kinesthetic confusion issues on
soft surfaces.
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Typical tools used:
◦ Simple tools work well
 Wobble board
 Half-rolls
 AIREX
 BOSU
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
O’Driscoll et al. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2011, 3:13 . http://www.smarttjournal.com/content/3/1/13
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Postural
stability
Single leg
stance on
Airex® cushion:
(3 minutes)
Single leg
stance on tilt
board: (3
minutes)
Single leg stance
on BOSU® ball:
(3 minutes)
Single leg stance on
BOSU® ball with
rebounding ball
catches: (3 minutes)
Anterior jump lands
from
Reebox® step: (2
sets × 10
reps with 10
second
stabilization)
Lateral jump lands
from
Reebox® step(2
sets × 10
reps with 10
second
stabilization)
Strength
Double leg
heel raises: (3
sets × 12 reps)
Double leg
bridge: (2 sets
× 10 reps)
Clam-shell
gluteus medius:
(2 sets × 10
reps - each side)
Double leg
heel raises:
(3 sets × 12
reps)
Double leg
bridge: (2 sets
× 10 reps)
Clam-shell
gluteus
medius:
(2 sets × 10
reps - each
side)
Single leg heel
raises: (2 sets ×
10 reps - each
side)
Single leg bridge:
(3 sets × 12
repseach
side)
Figure-4 gluteus
medius: (2 sets ×
10 reps - each
side)
Single leg heel
raises:
(2 sets × 10 reps each
side)
Single leg bridge:
(3 sets × 12
repseach
side)
Figure-4 gluteus
medius: (2 sets ×
10 reps
- each side)
Single leg heel
raises with
weight (15 kg): (3
sets × 12
reps - each side)
Double leg squats:
(3 sets ×
12 reps)
Resisted lateral
side-steps:
(3 sets × 12
reps/step - each
sides)
Single leg heel
raises with
weight (20 kg): (3
sets × 12
reps - each side)
Single leg squats:
(3 sets ×
10 reps - each side)
Resisted lateral
side-steps:
(3 sets × 12
reps/step each sides)
Plyometics
Tuck jump: (3
sets × 10 reps)
Broad jumps:
(3 sets × 10
reps)
180° tuck jumps:
(3 sets × 5 reps in
each direction)
90° hop turns:
(10 reps clockwise and
anti-clockwse)
Double leg lateral
jumps
over mini-hurdle:
(3 sets ×
10 reps)
Single leg lateral
jumps
over mini-hurdle:
(3 sets ×
10 reps)
Speed/
Agility
Figure of 8
runs: (10 m
course,
5 reps in each
direction)
Ladder:
forward run
through:
(10 reps)
Ladder: lateral
run through: (10
reps - each way)
Ladder: lateral hop
through: (10 reps each
way)
Ladder: hopping
slalom
drill: (10 reps)
Lateral shuttle runs:
(10 m
course, 2 sets × 10
reps)
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
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Lateral ankle sprain = high injury rate
Highest risk = previous ankle sprain
Important to address deficits aggressively to
prevent CAI
Multifaceted approach is best
◦ Bracing/taping
◦ Shoe selection
◦ Aggressive neuromuscular retraining with attention
to quality of movement
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t
Thank you
Don’t Just
Just Recover.
Recover. Conquer.
Conquer.
Don’t