WEEK 4: Screening Tools

Mobility:
Stretching = thought to increase ROM about a given joint
- attributed to changes in the stretch re ex (traditionally)
- Protective mechanism -> muscle contracts in response to being stretched €“
- Ruled out as a 'potential mechanism' - mechanisms include changes in:
1. ability to tolerate stretch
2. Viscoelastic properties of muscle
Techniques:
- Dynamic (ballistic) = repetitive bouncing (oldest)
- Static = stretch to point of discomfort & hold for an extended time (3-4 x 15-30s) - PNF =
alternating contractions, relaxations +stretches - 10s push +10s relax
- Neural tissue = stretching of nerve tissue or surrounding tissue impeding nerve.
'No clear evidence about which technique is most e ective for improving ROM'
Static + PNF = clinically & Ballistic = healthy athletes
Alternative Techniques:
1. Pilates: develop self-image via increased posture + coordination + exibility.
- Concentrates on body alignment + muscle lengthening endurance + strength without stress on
the lungs and heart.
- Basic principles =
1- increase awareness of bodies as single integrated units
2- increase body alignment & breathing e ciency of movement.
3- increase e ciency of movement
2. Yoga: reduce stress - combined mental + physical approaches
- uniting body + mind
- Caution = needed - positions can be dangerous (for inexperienced individuals)
- Slow + deep + diaphragmatic breathing = important to calm body & produce endorphins

Massage = Rhythmically applied pressure to mechanically stimulate tissue

- Many claimed bene ts - few = evidence-based.
- Attempts to:
1- increase exibility + mobility + coordination + pain level + circulation + healing
2- decrease neuromuscular excitability + lactic acid
- Theoretical e ects = either re exive or mechanical.
Re ex mechanism = Slow/gentle/rhythmical/super cial skim to induce sedation
- thought to relieve tension, rendering muscles more relaxed.
- Aims = e ect sensory & motor nerves locally & some CNS response.
Mechanical mechanism: make mechanical/histologic changes in myofascial structures through
direct force application

Triggers: Used to relieve soft tissue from the abnormal grip of tight fascia
Fascia = CT surrounds muscles + tendons + nerves + bones + organs.
- Composed: collagen + elastic bres.
- During mvt = must stretch + move freely.
- Damaged/in amed fascia impairs movement
- can soften & release with gentle pressure (over a long period of time).
Acute cases = resolve in just a few treatments. Occasionally single treatment
Longer cases = take longer to resolve.
- Typical treatment is 3 x /wk - done manually using a foam roller/ball.

Dry needles + Other Techniques:

Dry needling/Acupuncture: insertion of needles into skin - trigger points pain vs broader area of
muscles and nerves
Strain-counterstrain: decrease muscle tension + guarding.
- passive technique places body positions of greatest comfort to relieve pain.
Positional release: based on straincounterstrain.
- Includes addition of a compression to enhance e ect.
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STM: muscle is elongated from a shortened position while static pressure is applied to the tender
point.
Graston Technique: uses handheld stainless steel instruments to locate + then separate
restrictions within a muscle

Improving Muscle Performance and Functional Capacity:

Contraction types: Isometric + Concentric + Eccentric + Isokinetic
Isometric (no change in length): stabilises body during functional movements
- increases strength, but speci c to joint angle trained
- Increase in 'systolic BP' - Valsalva maneuver increase intrathoracic pressure
- widely used in rehab settings help overcome €˜sticking points€™ later in rehab
- can be tolerated before full ROM exercises
- Begin in mid-range - proceed to inner/outer range
ExRx: 10 reps x 10 seconds
Concentric & Eccentric:
Eccentric compared to concentric contractions:
- Passive + active components resist lengthening (eg titin):
- Greater force production resulting DOMS + mechanical e ciency
- Lower motor unit activity for a given force & Lower VO2 for a given force
- Higher mechanical e ciency
- Concentric: Eccentric ratio of a lift should be approximately 1:2
- Physiologically, concentric induces fatigue > eccentric
Isokinetic: Constant velocity contractions with changes in muscle length
- €˜Maximal€™ resistance = given throughout ROM by a machine at a set speed
- Devices = $$$ ($50K) - limited in movement plane & immovable
- Often used in research (diagnostic testing) - quanti es strength v.well
- Work at a range of speeds; allows speed-speci c training
- Easy to cheat, and not obtain full e ort (requires external motivation)
€“ When done properly with maximal e ort, theoretically possible that maximal strength gains
made with this method
No conclusive evidence for this claim

Functional training (FT)

Traditional focuses on:
- Isolated focusing on single plane of speci c muscle
- Low neuromuscular demand - no interaction b/w segments in kinetic chain
Most ADL€™s require: multi-joint + multi-muscle + multi-planar movement
- High neuromuscular demand (proprioceptive input & integration)
- Good interaction b/w segments in kinetic chain
FT uses integrated exercises to improve:
1. Strength
2. Neuromuscular control
3. Stabilisation
4. Dynamic exibility
Exercise variables include:
1- plane of motion
2- body position
3- base of support
4- type of balance modality
5- type of external resistance.

Plyometric exercise: used in later stages of rehab -

Involves rapid eccentric stretch prior to immediate rapid concentric contraction
- forceful explosive mvt over a short period of time
- NB: rate of stretch is more critical than the magnitude of the stretch.
- Eg: hops, bounds & depth jumps = lower & medicine balls throws = upper
- Places stress on MSK.
- Execution must be technically correct.
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Strength Tx:
Equipment: Machines + Free Weights + Theraband + BW
Machines: safe/easy to: use + increase weight + constrains to single plane & $$$
Free Weights: no mvt restriction + < safe, di cult + requires neuromuscular
Theraband: multiple plane, cheap, portable, low max resistance
BW: free & can beprogressed by eliminating/introducing gravity - limited selection

Types of Volume/Programming in RT (SETS):

Single: 1 set x 8-12 reps performed at slow speed.
Tri-: 3 exercises (same muscle group) x 2-4 sets without rest.
Multiple: 2-3 warm-up sets with increasing resistance followed by several sets at the same
resistance.
Supersets: 2 exercises in single set targetting agonist & antagonist.
Pyramids: 1 set x 8-12 reps with light resistance, resistance increase over 4-6 sets until only 1-2
reps can be performed. The pyramid can also be reversed from heavy to light resistance.
Split routine: Workouts exercise di erent muscle groups on successive days €“ Eg) Upper body
Mon/Wed/Fri; Lower Body Tues/Thurs/Sat
Circuit training: Rapid movement between a series of stations including: weight training, exibility,
calisthenics, or brief aerobic exercises. Eg) 8-12 stations repeated 3 times.
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WEEK 5: Kinetic Chain
Posture Analysis:
Assessment:
Observations =
1. Body type
2. Asymmetries and alignments
3. Observe from all perspectives
4. Assess height di erences b/w anatomical landmarks

Normal Curvatures of the Spine:

Lumbar: normally curves slightly forward -> €˜lordosis€™
- Helps spine carry weight of trunk, arms, & head in a balanced
- well-aligned nature
Thoracic: normally curves slightly backward -> €˜kyphosis€™
Kyphosis & Lordosis helps balance the loads that are carried by spine.

Kyphosis: Increased backward curve of thoracic spine

- Posterior pelvic tilt (PPT)
- Tight = pectorals, ant. deltoids, hamstrings ۼ
- Weakens scapula adductors = rhomboids, trapezius, levator scapulae
- Weakens horizontal arm abductor = post. deltoid
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Forward Head: Increased = exion (lower cervical) + extension (upper cervical)
- Shortens ant. neck muscles
- Weakens = lower cervical + upper thoracic erector spinae & ant. neck muscles
- Tightness: levator scapulae, SCM, scalenes, suboccipitals, upper trapeziius
- Associated with €œsway back€ posture
Caused by = computer work (Associated with osteoporosis + Dowager€™s Hump)

Flat Back: Loss of normal = lordotic curvature, OR kyphotic curve of = straight

- appears stooped forward and it is di cult for them to stand up
Results = degenerative arthritis or spinal fusion
Associated with chronic pain and loss of stability
Stooping forward shifts CoG outside of BoS (requires stick/walker to prevent falls)
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Sway Back: Pelvis has no APT or PPT - it shunts forward
Looks like an exaggerated lumbar forward curve
- Stress in lower thoracic and lumbar region
- Disc herniation* or sciatic pain
- Weak + lengthened spine exors =
1- Rectus abdominis
2- obliques
3- transverse abdominis + psoas major
- Tight spine extensors = erector spinae
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Lordosis: Abnormal/excessive forward curve of the lumbar spine
- APT
- Stress in lumbar region
- Weak/lengthened = hamstrings, rectus abdominis/obliques, transverse abdominis
- Tight = psoas major and erector spinae

Scoliosis = (Functional or structural) - Lateral curve in thoracic or lumbar spine

- C-curve: right or left according to direction of convexity
- S-curve: C-curve with compensatory secondary curve
- Leg length discrepancy: pelvic landmarks may not be level
Shoulders not level

Common causes = congenital, leg length di OR long term unilateral activities

Test = forward bend test or anterior/posterior observation
- Associated with spinal fatigue pain as paravertebral & erector spinae are under constant strain
to keep person upright
Tight on = concave side of curve
Weak on = convex side of curve
Symmetrically 'strengthen' and stretch back muscles (Erector spinae, lats, rhomboids and
trapezius)
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 Open vs Closed Kinetic Chain:
Kinetic Chain:
Functional Strength = Ability of neuromuscular system to reduce & produce force, & dynamically
stabilise the kinetic chain during functional movements in a coordinated fashion
Neuromuscular e ciency: Ability of CNS to allow agonists, antagonists, synergists, stabilisers &
neutralisers to work e ciently & interdependently during dynamic kinetic chain activities

Injury:
When structure = damaged - normal function is compromised
- Adaptive/compensatory changes occur, changing force distribution + movement
- Leads = tissue overload, decreases performance & predictable injury patterns
-E.g. di erent force distribution, activation patterns, length changes etc

Open vs Closed Kinetic Chain:

Closed (CKC) = Distal segment is xed/immovable (or against resistance)
- More predictable movement pattern
- Insertion is xed and the muscle acts to move origin
- characterised by €˜concurrent shifts€™ or €˜ecoconcentric contractions =
- concentric + eccentric contractions at opposite ends of muscle
Open (OKC) = Distal segment moves freely
- Less predictable movement pattern
- Origin is xed and muscle contraction produces movement at insertion

Advantages & disadvantages of open vs closed kinetic chain:

OKC Knee Extension: foot is not xed or not in contact with a surface
- allows lower leg move independently - creates shear + compression on joint.
- Modifying exercise reduces these forces + manage pain while still targeting quadriceps
strength.
Incorporating additional external resistance (Thera bands):
- placing resistance bands, you alter forces acting on joint and alleviate pain.
- if shear force causes discomfort, add an extra thera band to reduce shear force by changing
direction or magnitude of resistance.
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 CKC Knee Extension: foot is xed or in contact with a surface
- Terminal knee extension exercise in a CKC provides bene ts:
- as you extend your knee
- involves hip extension + activates hamstrings along with the quadriceps.
- This co-contraction of the quads and hams enhances joint stability at knee & hip
- Engaging hams = counterbalance anterior pull on tibia caused by the quads.
- Bene cial for reducing shear forces + minimising discomfort in knee joint.
- Additionally adding trunk exion, you can activate posterior chain, including the hamstrings,
which can assist in maintaining an upright posture and engaging more muscle groups.

Step ups: Lateral, forward & backward step-ups = widely used CKC exercises
- Lateral step-ups = used more clinically
- Step height can be adjusted to patient capabilities (up to 20cm)
- > 20 cm create a large exion moment at knee, increasing anterior shear force and lowering
hams cocontraction.
- can produce increased join tshear forces compared to stepping exercise.
- Hams contraction appears to be insu cient to neutralise shear force produced by quads.

Surgical Tubing:
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- Have created a means of safely strengthening terminal knee extension
- NB:OKC shear greatest between 0-30 degrees exion
- Ant. resistance at femur produces ant. shear of femur & eliminates ant. tibial translation
- Performed in 0-30 degrees also lowers knee exion moment, further lowering ant. tibial shear
- Rubber tubing produces an eccentric quad contraction when moving to knee exion
- Weightbearing terminal knee ext. with tubing increase the quads EMG activity

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 WEEK 6: Hip
Adductor-Related Groin Strains:
- Pain on palpation of tendons/insertion
- Groin pain during resisted adduction
1st deg: pain but minimal loss of strength and
minimal restriction of motion
2nd Deg: tissue damage that compromises the
strength of the muscle, but not including complete loss
of strength and function
3rd Deg: complete disruption of tendon (complete loss of function of muscle)
- Incidence = known - Athletes play --> minor groin pain.
- common = ice-hockey + soccer (often adductor/iliopsoas)

Signs/Symptoms:
- Gait = Antalgic (€˜against pain€™) gait + Uneven stride cadence/length
- Muscle spasm + tenderness + swelling
- Stress to muscle = determines which muscle is injured
Pain responses in one of the following movements:
1. hip ex. + knee ext. (iliopsoas)
2. hip ex. + knee ex. (rectus femoris)
3. hip ex. + lateral rot. + abd. + resisted knee ex. (sartorius)
4. hip add (adductors)

Potential Mechanisms:
- Extended beyond limit OR rapid forceful contraction
- Falls, direct blow to muscle, overstretching OR overuse

Risk Factors:
1. Muscle => tightness/weakness/imbalances/prior injury/poor WU/workload spike.
2. Association btw strength, exibility & MSK strains
- low abd ROM among injured soccer players
- low add muscle strength
'Adductor : Abductor' strength ratio in NHL players
- 95% = asymptomatic
- 78% = symptomatic

Assessment:
ROM:
- Flex/Ext
- Add/Abd
- IR/ER

Strength (HHD):
- Hip Abd =
- Squeeze Test = sphygmomanometer cu placed b/e knees and squeeze hard
- highest pressure displayed and site of pain experienced was recorded
- IR/ER = assessed in supine position - dynamometer placed on medial malleous

HHD Considerations:
1. Long vs Short Lever:
- lever positioned = 5 cm proximal to joint center for knee/ankle joint assessments
- placement helps that force exerted by subject is captured by the HHD.
2. Learning E ect:
- No. of trials required before reaching a plateau varies among individuals.
- Some achieve consistently within a few trials - others require more practice.
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 - Speci c no. of trials needed reach a plateau depend son factors such as:
- complexity of the task
- subject's familiarity with HHD + their motor skill level.
3. Subject Stabilisation:
- minimise extraneous movements that a ects accuracy of the measurements. - some
require to stabilise themselves (holding a bench),
- others require external stabilisation provided by the tester.
- choice of subject stabilisation method depends speci c protocol being used.
4. Intra-inter tester reliability:
Intra-tester reliability = Single tester should be able to obtain consistent values.
Inter-tester reliability = Di erent testers should be able to obtain consistent values
5. HHD Reliability
in uenced by various factors:
- technique
- calibration
- subject cooperation
- positioning of HHD relative to the joint being assessed.
To have reliable measurements = protocols, training, calibration should be followed.

Special Test = Trendelenburg Sign Test

- stands with feet together -> examiner stands behind patient -> Patient exes knee on one side
to stand on one leg

Rehab: -> Steps = in ammation/Pain -> ROM -> Stability -> Functional Training

Hamstring Strain Injuries (HSI):

Factors for HSI:

- Previous posterior thigh injury
- Low eccentric hamstring strength
- Overstride

Type I etiology:
- caused during high speed running/mvts such as kicking/twisting/jumping/hurdling
- common = long head of biceps femoris at proximal junction
- Swing phase (sprinting) - hamstrings eccentrically decelerate tibia before foot strike

Type II etiology:
- Generally caused during stretch related movements and ballistic limb actions
- Commonly seen in dancing and gymnastics
- Cause of injury is often an excessive stretch into hip exion
- Proximal free tendon of semimembranosus (near the ischial tuberosity)

Prognosis:
Time (days) to jog pain free is the greatest predictor of time to return to play (RTP) post HSI:
- 1-2 days -> <2 weeks to RTP
- 3-5 days -> >2 weeks to RTP
- >5 days -> >4 weeks to RTP
- More proximal the injury in type I HSI = > time to return to pre-injury level
- Length of the hamstring tear correlates with time to RTP

Type I and II clinical features and diagnosis (acute):

Features:
- Sudden onset of pain and usually the inability to continue activity
- Reduced contractive strength
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 - Hematoma, bruising
- Tenderness
Diagnosis:
- Mechanism of injury and site speci c palpation is the primary form of assessment
- Negative result €˜Slump Test€™: neural tension, rules out radicular pain
- MRI = recommended form of imaging (accuracy in identifying location of injury)

Rehab:

Phase I acute =
First 48 hours
1. Minimising scar tissue formation (may reduce changes of re-injury
2. Simple analgesics
3. Light, frequent pain-free muscle contractions (prior to RICE)
4. RICE
Before moving into sub-acute phase:
1) Pain free walking
2) Adequate force with resisted muscle contraction

Phase II sub-acute/conditioning =
- Stretching surrounding structures
- Soft tissue treatment
- Myofascial release
- Neural mobilisation (hamstring stretch position w/knee exed + gentle cervical
ex)

- Hamstring strengthening exercises Nordic Protocol: 60-85% reduction in HSI rates

- Progressive running program: commence when comfortable running at ~50%.

- Jogging warm-up followed by = footwork + agility drills + interval running

Phase RTP =
- Completion of progressive running program
- Full ROM L = R: PROM + AROM straight leg raises
- Pain free maximal iso contraction
- 90-95% of ecc strength of contralateral limb
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WEEK 7: Knee
ACL Rupture:
- Mechanism = hyperext., valgus, ant. tibial translation, rot.
- Clinical = Lachman, pivot shift
- Conservative Tx for older pop. with low demands who do not have instability
- Surgery: allograft, autograft (patellar tendon, hamstrings)
- Traditional vs. accelerated protocol
- Outcomes: very good short-term, knee OA in long-term

PCL Rupture:
- Dx = Posterior draw of up to 25mm, €˜sag€™ sign
- Lax capsule posterior + collateral ligaments ‰ provide posterior displacement resistance
- Mechanism = blow to ant. tibia (dashboard injury) or hyper ex.
- Other ligaments commonly torn
- If isolated injury €“ conservative tx
- Surgical repair technically di cult

Collateral Ligaments:
- MCL: strong at band from medial epicondyle of femur -> medial condyle of tibia and medial
side of tibial shaft
- LCL: rounded cord from lateral epicondyle of femur to lateral head of bula
- MCL tear: valgus stress
- Conservative treatment
- 98% return to sport
- May have instability afterwards
- LCL tear: v.rare

Meniscus:
- Mechanism = loading + rotation
- Types = bucket-handle, posterior horn, anterior horn, horizontal (degenerative)
- Medial tears = common than lateral
- Lat. = common with ACL tears as the lat. tibia plateau subluxates anteriorly
Goal: preserve as much of the healthy meniscus as possible
- Vascular regions may heal themselves
- Surgery:
- Arthroscopic meniscectomy
- Repair
- Transplantation

Unhappy Triad: Common injury

- Combination of = ACL + MCL + meniscus
- Consider mechanism of injury
- Meniscus tear = longitudinal, if instability continues --> bucket handle tear
- MCL tear as a result of the valgus moment about the knee joint because foot is planted on the
ground and body CoG is taken laterally

Considerations:
1. Mechanism of injury
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2. Structures damaged
3. Client€™s physical activity prior to injury
4. Stairs in home?
5. Return to work/sport
6. Co-morbidities
7. Long-term outcomes/goals
- Incidence of graft failure 3-6%
- Re-injury most likely within 12 months post surgery
- Risk of ACL tear ipsilateral or contralateral knee 5-10x higher than uninjured
- Post ACL-recon kinematics of gait ‰ˆ ruptured ACL than intact ACL

Case Study Example:

€“ 36 y/o male. Truck driver/crane and forklift operator/ repairs and installation. Recreational
Brazilian Jiu Jitsu.
€“ Hx: Jiu jitsu take down - Immediate onset of sharp pain R knee, limping. 2 weeks performing
motorcycle stunts, continual sharp pain inside knee. Walking at home, sudden loss of pain and
feeling of knee giving way.
€“ Ice, NSAID€™s and knee support
€“ Sought physio treatment (ice, massage, ExRx)
€“ Physio goals: reduce swelling, increase ROM
€“ Physio referral: MRI

Results:
- Right knee full ACL rupture, MCL Grade 2 tear and bucket handle tear of meniscus
- GP => referral for orthopaedic surgeon
- Orthopaedic surgeon orders MRI for left knee => Full ACL rupture (old injury)
- 2 weeks o work to reduce swelling, minimal use of motorcycle as transport
Prehab + ExRx:
- Surgical outcomes are improved with the knee in as good condition as possible.
- Goal: similar strength and ROM as uninjured leg
- Recovery time is reduced
- Exercise prescription similar to that of rehabilitation

ExRx:
1. Increasing ROM
2. Increasing Strength

Prehabilitation:
- Aims: minimise swelling, increase ROM/ exibility, increase strength & balance
Initial exercises:
- Heel slides
- Isometric quad contractions
- Single leg raise - supine
Progression:
- Single leg raise standing with then w/out support
- Mini squats
- Heel raises
- Hamstring stretches

- Crab walk €“ add theraband for resistance

- Squats €“ progress to single leg squats
- Leg abduction
- Standing leg circles
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- Heel/toe taps
- Stationary cycle
- Seated hamstring curls €“ add theraband for resistance

Surgery:
- Options:
1. No surgery, just rehabilitation exercise
2. Partial meniscectomy
3. ACL reconstruction and meniscectomy
- Client chose meniscectomy
- Home based exercises is all that is necessary, no requirement for physio treatment.

Conservative Rehab:
- Goals: Restore full ROM/strength & Control in ammation

Week 1:
- Isometric quads, hamstring and calf muscles
- SLR
- Heel slides

Week 2:
- SLR all planes
- CKC up to 90°
- Start resisted lower extremity ex
- Balance and proprioception supported progress to unsupported bilateral
- Cycling no tension increase time gradually
- Once full weight bearing start treadmill
- Flexibility/stretching ex€™s

Week 3:
- Flexibility/stretching (avoid crouch and full squats)
- Weight bearing CKC
- Lower extremity resisted ex€™s
- Mini squats up to 90° exion
- Balance txn bilateral progress to unilateral
- Stairs
Avoid: running, jumping, twisting , if swimming no breaststroke

Week 4:
- Continue strength, functional proprioceptive and endurance txn
- Start jumping, light running

Rehab:
Post-ACL Surgery Rehab:
- 2x recovery time
- If ACL = repaired using hamstring tendon - avoid hamstring curls/stretches 2 wks
- If patella tendon = used in ACL reconstruction then consider knee pain during exercises up to
6-12mths postop when kneeling or in full knee ex.
Week 6-9:
- Full pain free ROM
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- Gait training
- Lower limb Strength
- Proprioception
- CV
Week 9-12:
- Continue ROM
- Lower limb Strength
- Commence ecc hamstring exercise
- Progress glutes and calves
- Progress exercises focus on dynamic strength and eccentric quad control
- Proprioception progress to dynamic
- CV
- progress bike time and distance
- Treadmill incline walking (avoid jogging)
- Commence jogging in pool -> by end week 12 post-op light jogging on land

Late Stage Rehab and RTS:

Goal to return to full activity:
- Client-speci c based on their progression
- Sport-speci c strengthening, proprio, CV
- Dynamic exercises e.g. agility training
- High level balance exercises
- Explosive strength e.g. squat jumps
- Jog -> run
RTS 6-12 months:
- High level sport speci c strengthening
- Progressive RTS: restricted -> unrestricted -> match play (MP) -> competitive MP
- 65%-88% RTS rate within 1 st yr post op
- 72% returned to pre-injury activity level 2 yrs post op

Post-ACL Reconstruction:
- Return to sport
- Single leg hop for distance
- Co-contraction
- Carioca
- Shuttle run

Preventative Measures:
Control of the limb in pivoting and landing and reducing functional valgus
- Increase exion of knee and hip
- Eccentric knee control
Balance of power + recruitment of quads&hamstrings crucial for knee stability
- Hamstring activation to dynamically stabilise jknee and prevent ant. tibial displacement
- Balance training
- Prevention programs demonstrated an ovrall +ve e ect in reduced ACL injuries
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 WEEK 9: Ankle

Ankle Stability:
Ankle laxity dependant on joint position
- DF position has the least ankle joint laxity
- Talar geometry
- Show a strong degree of symmetry when comparing limbs but they have been shown to have up
to 7.5% di erence in surface area and volume
Talar positioning €“ how to palpate for the talus?
What e ect maytalar positioning have on ligaments of the ankle?

All ligaments contribute to overall ankle stability

- Anterior talo bular ligament primary stabiliser
- Resists varus tilt throughout all positions of exion

Ankle Injuries:
Lateral Ankle Injury (Inversion Sprain): most common during sport
- Mechanism: athlete's COG = shifted over the lat. border of weight-bearing leg, causing the ankle
to roll inward at a high velocity
- Dx: mechanism of injury, oedema, site of pain/discomfort
- Anterior talo bular ligament most likely involved
- Being the primary stabiliser, contributes to ongoing instability

Management =
Acute:
- gait support = use of an Aircast ankle brace for Tx lat. ligament ankle sprains
- produces signi cant improvement in ankle joint function at both 10 days
- and 1 month compared with standard management with elastic support bandage
Rehab Progression: AROM, stretching, strengthening and proprioception/balance

Syndesmosis (High Ankle Sprain):

- Mechanism: excess ER force on bula with the tibia leads =
- disruption in syndesmotic ligaments, in particular the AITFL
- occurs in high energy contact sports (rugby)
Rehab = 4x longer than lateral ankle injuries.
Management =
Acute:
- Protecting the joint, minimising pain, oedema and loss of ROM
- Immobilisation
- Weight bearing restriction if required (based on severity)
Sub acute:
- Normalising ROM
- Strengthening
- Stretching (plantar exors)
- Daily functional tasks
- Progressive mobilisation
Neuromuscular training:
- Proprioception,
- Plyometrics
- Sport-speci c training
- High level balance

Pott€™s Fracture:
- Mechanism: Foot forcibly moved laterally - violent abduction mvt
- Fracture of lateral malleolus OR/AND medial malleolus
- Lateral talus knocks against lateral malleolus
- Inferior tibio bular ligaments ruptured
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 - Deltoid ligament sprain -> talus rotate about long axis -> potential for fracturing posterior
margin of tibia
- Reduction if bones are not aligned, pins/plate and screws
- Plaster cast 8-12 weeks
- If bony and soft tissue damage excessive -> fusion of joint

Achilles Injuries: Gastrocnemius works during propulsion

- Soleus = used more for postural stability
- Mechanism of Injury:
- Tendinitis: acute overuse
- Tendinosis: overuse can develop into chronic tendinitis
- Rupture: acute
- Healing time:
- Tendinitis: several days-6wks
- Tendinosis: 6-10wks -> 3-6mths (chronic cases)
- Rupture: 6-12 months depending on surgery or not

Management =
Tendinopathy
- Eccentric Ex: 3x 15 reps 2xdaily 12 weeks
- Decreased pain
- Improved function
- E ects last up to 1yr
- Stretching
- Rupture
- Surgery
- Post physio tx -> same treatment as for tendinopathy

Surgical interventions: Joint Replacement:

- Only used for severe arthritis cases
- Current developments in prostheses brings gait kinematics closer to normal gait, usually
spatiotemporal di erences remain
- Joint fusion preferred (arthrodesis)

Chronic Ankle Instability (CAI):

- Giving way of the ankle, mechanical instability, pain/swelling, strength loss, recurrent sprain, and
functional instability
- Prevalence
- Rate of re-sprain after an acute sprain 3-54%
- Up to 53% reported feeling of instability up to 3 years later
- Persistent pain at 1 yr follow up: 33%, and 3 yr follow up: 25%
- 65.8% collegiate and high school athletes reported history of ankle sprain; 30.9% of these
developed CAI

- Residual problems persist for decades - 72% of unable to return to previous level of activity
- Fear of ankle giving way - been reported to worsen over time rather than improve
- Likely development of impairment + activity limitation is independent of severity of initial injury
- Not con ned to injured limb - problems reported in contralateral ankle of 85% of people who
develop CAI after unilateral sprain.

Person with CAI may t into one of these groups

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 Proprioception:
- Active or passive repositioning of inversion and eversion most commonly tested
- no sig di in passive eversion + passive inversion/eversion mixed for joint position
- De cits in one plane cannot be generalised to all planes of movement
- Impaired movement detection sense inversion/eversion

Gait:
- More inverted before during and immediately after initial contact
- Decreased toe clearance during terminal swing phase
- Poor dorsi exion ROM in gait among individuals with CAI = risk factor for sprains

CAIT (Cumberland Ankle Instability Tool):

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 CAI Management:
1. Balance training: Static and dynamic, i.e Wobble board
2. Ankle muscle strength training Strengthening peroneal muscles = accepted
3. Ankle supports/bracing/taping

Insu cient Ankle ROM:

- Increased plantar- exor extensibility and dorsi exion ROM = important for ACL injury-prevention
programs (landing patterns)
- Relationship = b/w ankle ROM + performance on balance tests in elderly women with no health
problems
- Ankle exercises aimed increasing ROM increases e ectiveness of clinical + community designed
for improving balance and reducing falls in elderly
women

RTP for ankle injury = multifactorial process

Functional testing = objective measures to gauges progression through rehab
- Tests: Balance/Proprioception/Strength/Range of motion/Agility
Example Illinois Agility Test

Innovation:
- Unstable ankles associated with:
1. Lower inversion proprioception
2. Higher concentric plantar exion strength at faster speeds
3. Lower eccentric eversion strength at slower speeds
- Muscle actions important for protection against ankle sprains
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