CAI Rehab & Treatment Tips

You need to assess joint range, laxity, strength & swelling

AND

Neuromuscular deficits

Neuromuscular deficits may be manifested as:

Impaired balance

Reduced joint position sense (JPS)

Strength deficits (any mm group)

Decreased ROM (esp DF)

Slower firing of peroneals to inversion perturbation

Slowed nerve conduction velocity

Impaired cutaneous sensation

Treatment & rehabilitation must not only address mechanical stability

but ALSO

Restoration of neuromuscular function

Good evidence for:

1. Both MAI & FAI contribute to CAI.

2. Often still deficits in Dynamic Postural Control (DPC) at 6 months - they need long term rehab! Patients can benefit from the Ankle Rehab App to increase compliance.

Dynamic Balance Deficits 6 Months Following First-Time Acute Lateral Ankle Sprain: A Laboratory Analysis

Cailbhe Doherty, Chris Bleakley, Jay Hertel, Brian Caulfield, John Ryan, Eamonn Delahunt

Journal of Orthopaedic & Sports Physical Therapy, Ahead of Print : pp. 1-29

(doi: 10.2519/jospt.2015.5653)

Wikstrom, EA, Hubbard-Turner, T and McKeon, PO (2013) Understanding and Treating Ankle Sprains and their Consequences: A ConstraintsBased Approach. Sports Med, 43(6): 385-393.

3. CAI patients have a more ‘laterally based foot’ in gait & Functional activities. Try to retrain normal foot placement/position and feedback to land jumps and hops with a flat foot.

4. Delayed peroneal reaction time (feedforward system disrupted, ie, not just the feedback systems) – activation & timing issues – not just strength.

Simon, J. and Docherty, C. (2014) Slower Nerve ConductionVelocity in Individuals with Functional Ankle Instability. Int Jou Sports Med, 35 (9): 731-736.

5. BAREFOOT REHAB HELPS TO STIMULATE FOOT SENSORY AREAS

Burcal, C.J., Hoch, M.C. and Wikstrom, E.A. (2017) Effectsof a Stocking on Plantar Sensation in Individuals with and without AnkleInstability. Muscle & Nerve, 55 (4): 513-519.

6.Train the whole functional range – not just around neutral position – as the JPS & proprioception is especially poor in the inverted position...their area of danger where they need the best recovery of all.

7. Ax & Rehab multi-directional (not uni-planar). Specificity to the activities they need to return to. Variety of movements and challenges.

8. Postural control is definitely reduced at the ankle - central deficits theorised.

Riemann, B.L., and Lephart, S.M(2002) The Sensorimotor System, Part I: The Physiologic Basis of Functional Joint Stability, J AthlTrain. 37(1), p71-79.

Riemann, B.L., and Lephart, S.M(2002) The Sensorimotor System, Part II: The Role of Proprioception in Motor Control and Functional JointStability, J Athl Train. 37(1), p80-84.

9. Maximise ankle input & output by minimising hip & knee compensatory movements.

10.Train both sides – central 'spillover'

Carroll, TJ, Herbert, RD, Munn, J, Lee, M and Gandevia, SC (2006) Contralateral Effect of Unilateral StrengthTraining: Evidence and possible mechanisms. J ApplPhysiol, 101(5): 1514-1522.

11. Challenge all variables when training proprioception

The main situations when CAI get giving way are:

1. When they are distracted, eg looking up at a sign, crossing the road, etc. Their eyes (which are usually compensating heavily for the poor proprioception) are looking elsewhere.

2. Over uneven surfaces such as a field, or over cobblestones.

3. In unmet challenges.

Thus, in rehabilitation:

- look all different directions, not just straight ahead - changes in head position will also change vestibular input.

- train at various body positions (eg, knee bent at different angles, or in lunges/tackle positions, etc).

- incorporate dynamic not just static training,

- various surfaces (eg, mini tramploline, air balance cushion or x2 cushions)