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Ankle Injury Prevention

Ankle Injury Prevention . R. Kent Kurfman, PT, DPT, OCS, MTC Proaxis Therapy Greenville, South Carolina. Incidence/scope of the problem:. 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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Ankle Injury Prevention

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  1. Ankle Injury Prevention R. Kent Kurfman, PT, DPT, OCS, MTC Proaxis Therapy Greenville, South Carolina

  2. Incidence/scope of the problem: • Most common athletic / sports injury • Highest percentage (15%) of any regional injuries in NCAA study (Hootman JM J Athl Train 2007) • 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)

  3. Incidence/scope of the problem: • 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) • Reinjury rates = up to 70-80%

  4. Mechanisms of injury: • 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 • Sudden stops and cutting movements

  5. Risk factors: • Greatest: history of previous sprain • 4-5x more likely to re-injury • Distribution by gender: essentially the same (Beynnon) • 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

  6. Risk factors: • 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

  7. Underlying factors: • 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

  8. Underlying factors: • 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.

  9. Underlying factors: • 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).

  10. Preventative strategies: • 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

  11. Preventative strategies: • 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.

  12. Taping/Bracing: • Most commonly used supports. • Both are effective, shown via multiple studies. • Bracing:2010 study – preventative. • Expense: bracing cheaper • Taping: • Support loss from taping: • Don’t underestimate proprioceptive effect. • Kinesiotaping

  13. Taping/Bracing • Recommendation: Continue taping/bracing after LAS for at least 6 months

  14. Footwear: • Purposes : • Traction, protect feet from abrasion/contact • Shock absorption – less certain • 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

  15. Footwear • 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

  16. Footwear • 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

  17. Recommendations: • 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.

  18. Neuromuscular Retraining • 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 • Consideration of study problems

  19. Neuromuscular Retraining • 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

  20. Neuromuscular Retraining • 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

  21. Neuromuscular Retraining • 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

  22. Neuromuscular Retraining • 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.

  23. Neuromuscular Retraining • Typical tools used: • Simple tools work well • Wobble board • Half-rolls • AIREX • BOSU

  24. O’Driscoll et al. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2011, 3:13. http://www.smarttjournal.com/content/3/1/13

  25. Bottom Line: • 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

  26. Thank you

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