Paradigm Shift- Ankle Rehabilitation Progression

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

Top Contributors - Ewa Jaraczewska and Kim Jackson  

Introduction

In part two of the course, the instructor presents a progressive exercise program for ankle rehabilitation. This program incorporates the instructor's experience working with all patients' age groups and various ankle injuries. This program aims to "make sure our patients are functional and that they will be ready when they hit stage three when they have to do things for sport-specific rehabilitation"

General Principles

• Teach the patient to transition from a sitting to a standing position
• Instruct the patient to stand with their crutches and rest the foot on the floor
• Teach the patient basic and advanced Activities of Daily Living (ADL), including getting in and out of the shower, in and out of the car
• Assess the patient's footwear: shoes should be steady, if the patient is in the boot, the shoe height on the other side should be adjusted
• Instruct the patient how to walk properly
• Incorporate cardio fitness into the exercise routine. Avoid cardio activities that involve too many shear forces or compressive forces
• Layered the exercises: achieve one level and move to the next level
• Provide the patient with a home exercise program that includes three levels of difficulties and three types of exercises:

Level of difficulty

1. easy to medium exercise that the patient feels encouraged to do
2. moderate to hard exercise
3. challenging exercise

Type of exercises

• Proprioception or balance exercises

• Strengthening exercises
• Range of motion exercises

Guide to Exercises

Beginners

• Standing on two feet with and without crutches
• Weight shift from the injured to the uninjured side
• Squatting and deep squatting with body weight equally distributed on both feet
• Twisting movement to the upper body and/or arm exercises during squatting

Balance Error Scoring System (BESS) Principles

The patient is standing close to a wall or a chair, or resting two fingertips on the wall with progression to no fingertips on the wall:

• Standing with feet next to each other, eyes closed
• Standing with the injured foot in front, weight equal between the two feet
• Standing with the injured foot behind, weight equal between the two feet

Tandem Stance

The patient is standing in a tandem stance with the injured leg in front, both feet flat on the floor:

• Bilateral knee flexion
• Bilateral knee flexion with trunk rotation
• Bilateral knee flexion with dumbbells, medicine balls or kettlebells held in hands and upper extremities moving up, down, sideways

The patient is standing in a tandem stance with the injured leg in front, with heels lifted off the ground:

• Trunk rotation
• Trunk rotation with dumbbells, medicine balls or kettlebells held in hands

Progression: Patient is standing in tandem stance with the injured leg in front, with both heels lifted off the ground

Therabands

Theraband tied with one end to a stable surface and with another end around the injured leg:

• Trunk rotation
• Straight lunges
• Lunges with rotation
• Altered terrain: balance mat, Bosu ball
• Exercises using principles of the Star Excursion Balance Test (SEBT):
  • Single-leg exercises on uninjured leg and reaching forward, backwards, sideways, down
  • Single-leg exercises on the injured leg and reaching forward, backwards, sideways, down
  • Exercise ball under the foot: stretching out and coming back, coming backwards, 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: placing theraband below the knee

Tibialis Posterior Strengthening

• Windscreen wiper exercise
• Modified calf raise exercise with a soft ball between the ankles:
  • Squeeze and hold
  • Squeeze, hold, lift mid-range and hold the position for 30 seconds
• Calf raises without the ball
  • Two feet up followed by lifting the uninjured side, maintain for 15 to 20 seconds, return to standing on both feet ("two up, one hold, two down")
  • Progression: "one up, one hold, two down"

Intrinsics Strengthening

The patient is sitting on the chair:

• The foot and toes are pressed down: the patient tries and maintains the toes as long or as extended as possible. The position is kept while the patient gently draws the toes back and tries to lift that arch
• TheraBand is placed underneath the front part of their foot. The patient pulls the theraband to add tension to that band. Next, the patient draws it by pressing the toes down and pulling the TheraBand back
• Combined activities for intrinsic and flexors: theraband is placed underneath the foot. The patient presses down the intrinsics, and the therapist pulls up that band while the flexors are activated to keep the tips of the toes down on the ground. Next, the therapist pulls it up, so the patient gets an extension. The patient works into that band, pushing the toes down towards the floor.
• Exercise for flexor hallucis longus: the patient turns the feet slightly out and brings the big toe towards the midline, so the gap between the big toe and second toe is open. The patient brings the foot behind and tries and maintain that gap.

Progression: changing the position to standing