Wobble board

The main aim of using a balance board is to improve proprioception. .

What is proprioception?

Proprioception is our sense and awareness of the position of our body parts and is closely linked to balance. Having good proprioception helps to reduce the risk of injury
 
Following an injury, whether it be acute or an overuse injury, damage to the nerve endings of the associated structure occurs. This results in an impaired transmission of information from the proprioceptors, to the brain, meaning corrections to the body's positioning are either less effective or not made at all. Using the most common example of an ankle sprain, this means the ankle is more likely to be injured again.

Proprioception can be improved through certain exercises. These exercises should begin as soon as possible after an injury. Generally in lower limb injuries, this is as soon as full weight bearing is possible. This kind of exercise can start very simply, without the need for equipment using single leg balance exercises.
To further challenge this sense, a device such as a balance board (wobble board), wobble cushion or rocker board can be used. Balance board exercises are quite simple and can be gradually progressed to make them harder as you improve.

Lateral Ligament Reconstruction-Post operative Physiotherapy protocol

Physiotherapy is extremely important in recovery and follows the below rehabilation protocol


                                 Phase 1: Recovery (0-2 weeks)
 General  :                                                          :
- Plaster backslab or CamBoot
- Non weight bearing

Goals:
- Prevent complications eg: DVT,
- Maintain movement and strength in unaffected joints

Exercises
- Hip and knee range of motion exercises
- Quadriceps, hamstrings and gluteal strengthening
- Deep breathing exercises

                                                       2-4 Weeks
General
- Transfer to camwalker boot or ankle brace (ASO or equivalent)
- Commence weight bearing, PWB or WBAT depending on surgeon’s instructions

Goals:
  Control pain
- Control swelling
- Regain active movements

Exercises:
- Free active plantarflexion, dorsiflexion, eversion
- NO active inversion until 6 weeks post op.
- Towel stretch into dorsiflexion (gentle)
- Swimming (no kicking), when wound healing appropriate

                                                    4-6 Weeks

General
- Weight bearing as comfortable (WBAT)
- Continue bracing (ASO or Boot) for majority of ‘up’ time

Goals:
- Control swelling
- Avoid impingement (in any direction)
- Avoid synovitis
- Commence strengthening

Exercises:
- Continue active ROM
- Commence PF, DF, EV Theraband strengthening
- Seated calf raises
- Static balance drills
- Swimming (no kicking)
- Exercise/Stationary bike


           Phase 2 : Strengthening/Neuromuscular training
                                                 (6 weeks +)

General:
- Normal gait
- Commence inversion movements
- Progress to general strength, proprioception, balance
- Ankle brace only for "high risk activities" or uneven surfaces

Goals:
- Minimal swelling
- +4cm lunge or better (knee to wall)
- Single leg balance 1 minute (eyes open)
- Double leg calf raises 3 x 30
- Eversion strength 4/5

Exercises:
- Theraband strengthening all directions
- Double leg calf raises, progress to single leg calf raises
- Advanced balance/proprioception, ie: wobble board, foam etc.
- Calf stretching
- Swimming with gentle kick
- Cycling as comfortable

                                                   Phase 3: Return to sport
Goals:
- Single leg balance, 1 minute, eyes open
- Single leg calf raises 3 x 30
- Single leg squat to 900
- Lunge +6cm
- Hopping on the spot
- Normal lower limb mechanics (including pelvis/hip/knee control)
- Direction change tests within 10% of other side
- Wean off brace

Exercises:
- Single leg heel raises
- Calf stretching ++
- Theraband strengthening, focus on dorsiflexion and eversion
- Hop and land
- Ladder hopping
- Lateral hopping
- Running, cycling, swimming


                                       Phase 4: Prevention of Recurrence
Goals:
- Normal mechanics
- High level balance
- Landing strategies
- Direction change strategies

Exercises:
- Advanced landing drills, +/- external factors ie: catching/marking
- "Feedforward" training
- Advanced balance integration ie: strength work on BOSU ball
- Plyometric training

Treatment of Ankle Instability- A Surgical Approach

According to Martin J. O’Malley, MD, Associate Attending Orthopaedic Surgeon at the Hospital for Special Surgery (HSS), surgical intervention falls into two main categories.

Anatomic reconstruction

The preferred is an anatomic reconstruction, in which the stretched or torn ligaments is repaired and allowed to heal in a shorten position. This reconstruction can be accomplished by using the patient’s own tissue, also known as a Broström procedure, or utilize a cadaver tendon, also called an allograft, if the patient’s own tissue is too stretched out or different. For added stability and to help prevent re-injury, the surgeon may also tighten the retinaculum, a band of fibrous tissue that helps hold the ankle in proper alignment.

In almost all cases, anatomic reconstruction is possible and preferable. This procedure offers the advantages of maintaining full mobility of the joint, a smaller incision, and a more rapid recovery. The primary drawback of this procedure is that ligaments may become loose a second time and require additional repairs, but this is rare. Results of the Broström procedure performed are excellent. In a case series of seventy-three patients, all but one was satisfied with the procedure and would have the procedure again.

Peroneal substitution

The second type of surgery is peroneal substitution ligament reconstruction, a procedure in which the ligament is replaced entirely with another piece of tendon from the patient’s ankle. This procedure is less ideal as the main dynamic stabilizer of the ankle, the peroneal tendon, is used.

Peroneal substitution ligament reconstruction requires a larger incision than anatomic reconstruction, has a somewhat longer recovery period, and carries a risk of nerve irritation, which can lead to chronic pain.Non-anatomic personal substitution ligament reconstruction is rarely used because it sacrifices a good tendon, has higher instances of post-operative stiffness and pain.

Arthroscopic Procedures

Arthroscopy is a less invasive sports surgery procedure, utilizing a camera and small tools to work inside of a joint. It usually involves 3-4 small portal incisions into the joint, rather than one large incision. The actual joint is not exposed to the outside world.

Utilizing the arthroscope and small tools, your surgeon performs the procedure inside the joint while looking through a camera or view screen. Arthroscopic procedures have become very common, and are often done as an outpatient procedure.

Advantages

• Smaller incisiions and smaller scars
• less chance for infection
• less pain after surgery
• quicker initial recovery

Disadvantages:

• Weaker repair (depending on the tissues)
• Requires greater surgical skill
• Possible nerve damage due to use of tourniquet

The most common arthroscopic sports injury surgery procedures include meniscus repairs and meniscectomies, articular cartilage surgery, patella lateral release, labral repairs, and some rotator cuff repairs.

Whether your injury requires an open or arthroscopic procedure is dependent upon:

• Type of injury
• Amount of damage
• Location of the injured tissues
• Surgeons skill level
• Type of procedure

Based on the type of injury you have, clinical and diagnostic testing, and your surgeons preference will determine if you require an open or arthroscopic procedure.

Some procedures cannot be performed arthroscopically, such as ligament reconstructions and fracture repairs. Other injuries can be treated with either arthroscopy or open procedures, and will depend on your surgeon's preference and experience as to which is used.

Rehabilation Exercises

How to do rehabilitation exercises for an ankle sprain?

Start each exercise slowly and use your pain level to guide you in performing these exercises. Ease off the exercise if you have more than mild pain. Following are some examples of typical rehabilitation exercises.
Keep in mind that the timing and type of rehabilitation exercises recommended for you may vary according to your doctor's or physical therapist's preferences.

Range-of-motion exercises

Range-of-motion exercises begin right after your injury while you have ice on your ankle. Perform a set of exercises by repeating them 10 to 30 times. Do each set 3 to 5 times a day.

• Trace the alphabet with your toe, which encourages ankle movement in all directions.
• Sit in a chair with your foot flat on the floor. Slowly move your knee side to side while keeping your foot pressed flat.

Towel curls . While sitting, place a hand towel on a smooth floor, such as wood or tile. While keeping your heel on the ground, curl your toes and grab the towel with your toes to scrunch the towel. Let go, and continue scrunching up the entire length of the towel. When you reach the end of the towel, reverse the action by grabbing the towel with your toes, scrunching it, and pushing it away from you. Repeat, until you have pushed the entire length of the towel away from you.

Stretching exercises

Start exercises to stretch your Achilles tendon as soon as you can do so without pain. The Achilles tendon connects the calf muscles on the back of the lower leg to the bone at the base of the heel.


Towel stretch



• Towel stretch . If you cannot stand, sit with your knee straight and a towel looped around the ball of your foot. Gently slowly pull back on the towel for about 15 seconds until you feel your calf stretch. In moderate to severe ankle sprains, it may be too painful at first to pull your toes far enough to feel a stretch in your calf. Use caution and let pain be your guide. A little pain is normal, but you should not feel moderate to severe pain. Do 15 to 20 repetitions of this exercise, 3 to 6 times a day.

• Calf stretch . If you are able to stand, you can do this exercise by facing a wall with hands at shoulder level on the wall. Place your injured foot behind the other foot with the toes pointing forward. Keep your heels down and your back leg straight. Slowly bend your front knee until you feel the calf stretch in the back leg. Hold this position for at least 20 seconds and repeat. Try to do this stretch 3 to 6 times a day.

Muscle-strengthening exercises

Talk to your doctor or physical therapist about the timing of strengthening exercises for the ankle . Generally, you can start them once you are able to stand without increased pain or swelling.

These exercises should be held for 3 to 5 seconds. Do 15 to 20 repetitions once or twice daily for 2 to 4 weeks, depending on the severity of your injury.





Eversion Exercises


• Start by sitting with your foot flat on the floor and pushing it outward against an immovable object such as the wall or heavy furniture. After you feel comfortable with this, try using rubber tubing looped around the outside of your feet for resistance.
• While still sitting, put your feet together flat on the floor. Press your injured foot inward against your other foot.
• Next, place the heel of your other foot on top of the injured one. Push down with the top heel while trying to push up with your injured foot.

 

Balance and control exercises

You can usually start balance and control exercises  when you are able to stand without pain. But talk to your doctor or physical therapist about the exact timing. Also, don't try these exercises if you could not have done them easily before your injury. If you think you would have felt unsteady doing these exercises when your ankle was healthy, you are at risk of falling when you try them with an injured ankle.
Do these exercises 6 times for 60 seconds at least once a day.

• Stand on just your injured foot while holding your arms out to your sides with your eyes open. When you can do this for 60 seconds, try adding the advanced moves in the next level.
• Stand on your injured foot only and:
  • Hold your arms across your chest with your eyes open.
  • Hold your arms out to the sides and close your eyes.
  • Hold your arms across your chest and close your eyes.

Stretching exercises should be continued on a daily basis and especially before and after physical activities to prevent reinjury. Even after your ankle feels better, continue with muscle-strengthening exercises and balance and control exercises several times a week to keep your ankles strong

RICE Treatment

Ankle sprian Treatment Protocol:

R = Rest. Stay off the injured ankle. This helps it heal and also helps prevent further injury. Your doctor might have you use crutches if walking is too painful. Stay off your feet most of the time until you can walk without pain.

I = Ice.Apply ice as soon as possible. Ice decreases pain immediately by numbing the skin and reduces swelling by constricting blood vessels. Much of the pain from an injury is caused by swelling from torn blood vessels. Controlling the swelling helps you make a speedier recovery.

It's best to use crushed ice in a watertight bag covered with a thin cloth so it's not too cold against the skin. Apply it for 15 minutes directly over the area of swelling. Longer applications may cause a rebound dilation of the blood vessels and may actually increase swelling.

Apply the ice every four to eight hours as long as the swelling continues (even as long as a week).

.

C = Compression. Compression (wrapping the ankle with a strip of elastic cloth) will help decrease swelling and support your ankle. You can use an elastic wrap from the drug store or get an air splint from your doctor. (Your doctor will show you how to use it.) Be careful not to wrap the ankle too tightly. This would slow the blood flow to your foot. Use the elastic bandage for 1 to 2 days.

E=Elevation .Elevate the injured ankle as much as possible, particularly while applying ice; this allows gravity to drain some of the swelling. Place the ankle higher than the knee, the knee higher than the hip and the hip higher than the heart. Use books, a suitcase or a box under the mattress at night; this works better than a pillow.

Who is podiatrist?

A podiatrist, also called a doctor of podiatric medicine, is a specialist who provides medical diagnosis and treatment of foot and ankle problems, including, but not limited to sprains and fractures, bunions, heel pain/spurs, hammertoes, neuromas, ingrown toenails, warts, corns and calluses. A podiatrist also renders care of sprains, fractures, infections, and injuries of the foot, ankle and heel. In addition to undergraduate medical school training, podiatrists also attend graduate school for a doctorate degree in podiatry. Podiatrists are required to take state and national exams, as well as be licensed by the state in which they practice.

According to the American Podiatric Medical Association, there are more than 17,800 practicing podiatrists in the United States. Podiatrists are in demand more than ever today because of a rapidly aging population. In addition, according to the association, foot disorders are among the most widespread and neglected health problems affecting people in this country.