Paradigm Shift- Ankle Rehabilitation Progression

Original Editor - Ewa Jaraczewska based on the course by Helene Simpson

Top Contributors - Ewa Jaraczewska, Jess Bell and Kim Jackson  

Introduction

In part two of the Paradigm Shift in the Rehabilitation of the Ankle course, Helene Simpson presents a progressive exercise programme for ankle rehabilitation.

General Progressions and Principles

A patient must understand their weight-bearing status and how to transfer and mobilise effectively with crutches, from standing to walking, getting in and out of showers or cars, etc.

It's important to assess the patient's footwear. The patient should wear steady shoes for mobility. If a patient is still in a moonboot, the shoe height on the other side should be adjusted to ensure equal heights.

Cardiovascular fitness should be incorporated into the exercise routine. It's important to avoid cardiovascular activities that involve too many shear forces or compressive forces.

Patients should be provided with a home exercise programme that includes three levels of difficulty and three types of exercises. Exercises should be layered. A person should achieve level one exercises before moving on to the next level.

Levels of difficulty:

• easy to medium exercises that the patient feels encouraged to do
• moderate to hard exercises
• challenging exercises

Type of exercises:

• proprioception or balance exercises

• strengthening exercises
• range of motion exercises

Guide to the Exercises

Beginning Exercises

Start by standing on two feet with and without crutches before progressing to a weight shift from the injured to the uninjured side.

Progressions include: squats to deep squats with the body weight equally distributed on both feet, and then adding in upper body rotation and/or upper limb exercises.

Balance Error Scoring System (BESS)

The patient should stand close to a wall or a chair. Initially, they can rest two fingertips on the wall and progress to having no fingertips on the wall. The progressions are as follows:

• standing with feet next to each other, eyes closed
• standing with the injured foot in front, with the weight spread equally between the two feet
• standing with the injured foot behind, with the weight spread equally between the two feet

Tandem Stance

The patient stands in a tandem stance with the injured leg in front, both feet flat on the floor. The following progressions can be introduced:

• bilateral knee flexion
• bilateral knee flexion with trunk rotation
• bilateral knee flexion with weighted upper limb exercises (e.g., using dumbbells, medicine balls or kettlebells)

They can then progress to standing in a tandem stance with the injured leg in front, with heels lifted off the ground. The following progressions can then be introduced:

• trunk rotation
• trunk rotation with weighted upper limb exercises (e.g., using dumbbells, medicine balls or kettlebells)

Theraband Exercises

Theraband exercises include:

• trunk rotation
• straight lunges
• lunges with rotation
• altered terrain: balance mat, Bosu ball
• exercises using the elements of the Star Excursion Balance Test (SEBT):
  • single-leg exercises on the uninjured leg and reaching forward, backwards, sideways, and down
  • single-leg exercises on the injured leg and reaching forward, backwards, sideways, and down
  • exercise ball under the foot: stretching the foot out and coming back, rolling the ball in a circle around
• foot arch exercises:
  • tandem standing, heels off the floor, maintaining body alignment
  • stepping forwards, stepping backwards
• alignment control progression: place the theraband below the knee

Tibialis Posterior Strengthening

The following exercises can be useful for tibialis posterior:

• windscreen wiper exercise
• modified calf raise exercise with a soft ball between the ankles:
  • squeeze and hold
  • squeeze, hold, lift to mid-range, and hold this position for 30 seconds
• modified calf raises (no ball):
  • raise up onto the toes (double leg calf raise) and then lift the uninjured leg off the ground, maintaining the raised position on the injured leg; hold this position for 15 to 20 seconds before lowering the uninjured foot to the ground and lowering back to the floor ("two up, one hold, two down")
  • progression: "one up, one hold, two down"

Intrinsics Strengthening

The following exercises are performed in sitting, before progressing to standing.

• The patient presses their foot and toes down, trying to keep their toes as long or as extended as possible. They should maintain this position while gently drawing their toes back and trying to lift their foot arch.
• Place a TheraBand underneath the front part of the patient's foot. Instruct the patient to add tension to the band by pulling it up with their hand. They then press their toes down while maintaining tension on the Theraband.
• Combined activities for intrinsic and flexors: the patient places a Theraband under their foot. The patient presses down through their intrinsic foot muscles, and the therapist pulls on the band while the flexors are activated to keep the tips of the toes down on the ground. Next, the therapist pulls the band up, so the patient has to push into flexion, aiming to push their toes into the floor.
• Flexor hallucis longus exercise: the patient turns their feet slightly out and brings their big toe towards the midline, increasing the gap between the big toe and the second toe. The patient brings their foot back behind and tries to maintain the gap between the big and second toes.