UW HEALTH SPORTS REHABILITATION Rehabilitation Guidelines for Lateral Ankle Reconstruction The ankle is a very complex joint. The muscles of the lower leg, ankle ankle sprains or even progress to the There are actually three joints that and foot also help to stabilize the ankle ankle giving way with routine daily make up the ankle complex: the joint dynamically. When the ankle activities. Aggressive rehabilitation, tibiotalar joint, the subtalar joint and complex starts to move excessively in bracing, taping and orthotics are all the distal tibiofibular joint. Stability one direction, reactive corrective firing non-surgical options that may be of a joint is maintained by connective of the opposite muscle groups can help appropriate to prevent instability. tissue structures and the dynamic stabilize the joint. The muscles that are If these measures fail to control the support of the surrounding muscles. primarily responsible for preventing instability it may be necessary to The primary stabilizing connective lateral ankle sprains are the peroneus restore the anatomy of the lateral tissues are ligaments. A ligament longus and brevis (Figure 2). The ankle with surgical reconstruction. connects bone to bone to limit excessive ability for these muscles to react quickly The preferred surgical method is to movement. The outside (lateral) ankle is not only related to their strength but perform an anatomic repair of the complex is stabilized at each of the more importantly by proprioception, anterior talofibular and calcaneofibular three joints by three major ligaments. which is the body’s ability to sense the ligaments via a technique called The tibiotalar joint is stabilized by the position of the joint and subsequently the Brostrom repair, which involves anterior talofibular (ATFL) ligament. correct it as necessary by sending nerve shortening the attenuated ligaments The subtalar joint is stabilized by the impulses to the appropriate muscles. and a direct repair with suture calcaneofibular (CF) ligament and the Proprioception can be enhanced or fixation. When the anatomical repair tibiofibular joint is stabilized by the trained with the use of balance exercises is reinforced with the advancement of anterior and posterior tibiofibular so these are commonly used in ankle the inferior extensor retinaculum, it (ATFL and PTFL) ligaments (Figure 1). sprain prevention and rehabilitation is called the modified Brostrom repair. programs. When the repair is further augmented Lateral ankle sprains are very with a slip of the peroneus brevis tendon Intraosseus Membrane Tibia common, especially in sports such as through a drill hole in the fibula it is ATFL (tibiofibular) basketball and volleyball. Generally referred to as a modified Brostrom- Fibula ATFL (talofibular) athletes recover well from this type Evans technique. The peroneus brevis of injury with physical therapy and tendon then acts as a check to inversion PTFL Talus rehabilitation. However, up to 20% stresses and provides reinforcement to of lateral ankle sprains can lead to the anatomical repair without limiting CFL chronic pain and instability. This long-term inversion/eversion motion or Calcaneus instability may occur via repetitive strength. For revision surgeries or in the (continued) Figure 1 The health care team for the UW Badgers and proud sponsor of UW Athletics 621 SCIENCE DRIVE • MADISON, WI 53711 • UWSPORTSMEDICINE.ORG Rehabilitation Guidelines for Lateral Ankle Reconstruction case of excessive instability, an allograft strength, proprioception, movement reference to the average individual, (cadaver tissue, usually a tendon) control and guide the athlete’s return but individual patients will progress may be needed to reconstruct both the to sport. The rehabilitation guidelines at different rates depending on their anterior talofibular and calcaneofibular are presented in a criterion based age, associated injuries, pre-injury ligaments. progression. Specific time frames, health status, rehabilitation compliance After surgery, rehabilitation with a restrictions and precautions are and injury severity. The technique physical therapist or athletic trainer given to protect healing tissues and used for reconstruction may alter the is needed to restore range of motion, the surgical repair/reconstruction. rehabilitation as well. General time frames are also given for Lateral View Soleus muscle Extensor digitorum longus muscle Fibularis (peroneus) longus muscle Superior extensor retinaculum Tendinous sheath of tibialis anterior Fibularis (peroneus) brevis muscle Lateral malleoulus and subcutaneous bursa Calcaneal (Achilles) tendon Inferior extensor retinaculum Tendinous sheath of extensor digitorum Common tendinous sheath longus and peroneus tertius of fibularis (peroneus) longus and brevis Tendinous sheath of extensor hallucis longus Subcutaneous calcaneal bursa (Subtendinous) bursa of calcaneal tendon Superior and Inferior fibular (peroneal) retinacula Calcaneus Extensor digitorum brevis muscle Fibularis (peroneus) tertius tendon Fibularis Fibularis Abductor digiti minimi muscle (peroneus) (peroneus) Tuberosity of 5th metatarsal bone longus brevis tendon tendon Figure 2 2 621 SCIENCE DRIVE • MADISON, WI 53711 • UWSPORTSMEDICINE.ORG Rehabilitation Guidelines for Lateral Ankle Reconstruction PHASE I (Surgery to 6 weeks after surgery) Appointments • 2 weeks after surgery, the patient is seen by the surgeon; within 2-5 days of this first visit with the surgeon following surgery, the patient should have the first rehabilitation appointment Rehabilitation Goals • Protection of the post-surgical ankle Precautions • Non-weight bearing until the first visit following surgery with the surgeon, then touchdown weight bearing (TDWB) in a boot or cast Range of Motion (ROM) • No range of motion at this time, unless specified by surgeon, depending on Exercises technique (Please do not exceed the ROM specified for each exercise and time period) Suggested Therapeutic • 4-way straight leg raises Exercise • Full arc quad sets • Abdominal isometrics • Planks from knees Cardiovascular Fitness • Upper Body Ergometer per patient PHASE II (begin 6 weeks after surgery) Appointments • Rehabilitation appointments are one time a week for ~4 weeks Rehabilitation Goals • Continued protection of the repair • 75% of full active range of motion • Total leg strength to permit transition to weight bearing • Wean out of boot to an ankle stabilizing orthoses (ASO) Precautions • No inversion or eversion range of motion to protect the repair • Progressive and graduated return to weight bearing Range of Motion (ROM) • Active and Active Assistive range of motion for ankle plantarflexion and dorsifexion Exercises • Active and Active Assistive range of motion for forefoot and toe mobility (Please do not exceed the ROM specified for each exercise and time period) 3 621 SCIENCE DRIVE • MADISON, WI 53711 • UWSPORTSMEDICINE.ORG Rehabilitation Guidelines for Lateral Ankle Reconstruction Suggested Therapeutic • Ankle isometric strengthening in neutral Exercise • Double leg balance exercises - starting in neutral with very short range of motion excursions • Standing 4-way straight leg raises • Planks from feet—forward and lateral Cardiovascular Fitness • Upper Body Ergometer, gentle stationary biking PHASE III (begin after meeting Phase II criteria, usually 10 to 12 weeks after surgery) Appointments • Rehabilitation appointments are one to two times per week Rehabilitation Goals • Full active range of motion in weight bearing and non-weightbearing positions • 5/5 (full strength) peroneal strength in neutral and plantarflexed positions • 5/5 hip strength • Normal gait mechanics Precautions • No jumping, hopping or sports • ASO to protect repair outside of therapy appointments Suggested Therapeutic • Ankle strengthening exercise progression: progressing from short arc isotonics to Exercise full arc isotonics to eccentric strengthening • Balance progression: Double leg unstable surface to single leg stable surface • Gait Drills: forward march, backward march, side stepping, backward stepping, hip circle walk • Gentle stretching as needed to regain full range of motion Cardiovascular Fitness • Walking, biking, Stairmaster and elliptical (if Phase II criteria is met) • No swimming Progression Criteria • Full ankle strength on manual muscle testing and single leg balance equal to the other side 4 621 SCIENCE DRIVE • MADISON, WI 53711 • UWSPORTSMEDICINE.ORG Rehabilitation Guidelines for Lateral Ankle Reconstruction PHASE IV (begin after meeting Phase III criteria, usually 14-16 weeks after surgery) Appointments • Rehabilitation appointments are once every 2 to 3 weeks Rehabilitation Goals • Patient to demonstrate stability with higher velocity movements and change of direction movements that replicate sport specific patterns • No apprehension or instability with high velocity change of direction movements • Improve core and hip strength as well as mobility to eliminate any compensatory stresses to the ankle • Cardiovascular endurance for specific sport or work demands Precautions • Progress gradually into provocative exercises by increasing velocity and progressing from known to unanticipated movement patterns Suggested Therapeutic • Impact control exercises beginning 2 feet to 2 feet, progressing from 1 foot to Exercise • the other and then 1 foot to the same foot • Movement control exercises beginning with low velocity, single plane activities and progressing to higher velocity, multi-plane activities • Return to running drills