The Ankle: An Anterior Talofibular Ligament Rehab


Project: Rehabilitation of ATF Reconstruction

Class: ATHT 4960

Professor: Jason Bennett

By: Lerone Major

Date: April 18, 2002

Introduction

            The injury most common to any sport, in any area, and at any playing level is known as “ I sprained my ankle”.  An ankle sprain is assessed to be on the lateral side of the ankle complex, where the anterior talofibular ligament (ATF) is located.  “Ankle injuries, especially those to the lateral ankle complex, are the most common acute sports-related injuries presenting to sports medicine clinics and emergency rooms around the world”(#7, p.39). The effects of an ankle sprain can be a hindrance to performance if not taken care of properly.  “A 150-lb man running a mile subjects each foot to a load of approximately 220 tons,” in order to handle this type of pressure a person’s ankle must be in good and running condition (#11, p.729).  “A sprain involves damage to a ligament that provides support to a joint” (#8, p.8).  A sprain can be classified in degrees of severity: 1st degree, some stretching of the ligamentous fibers, with little to no joint stiffness, swelling, and pain. 2nd degree, some tearing and separation of the ligamentous fibers, with moderate instability, swelling, joint stiffness, and pain. 3rd degree, total rupture of the ligamentous fibers and severe pain, swelling, and joint stiffness (#8, p. 8-9).  Assessment of a lateral ankle sprain first comes by understanding the anatomy of the entire ankle, the biomechanics of the ankle mortise, and the mechanism of injury. 

Anatomy

            The anatomy of the ankle consists of more than just the ligaments; there is also bone and muscle involved.

Bony Anatomy (#9, p. 87-8)

·        Tibia (medial malleolus)

·        Fibula  (lateral malleolus)           

·        Talus      

* These three bones make up, at the articulations, the ankle mortise also known as the talocrural joint

·        Calcaneus

Muscular Anatomy (#9, p.94-5)

·        Anterior Tibialis (dorsiflexion)

·        Peroneus Longus and Brevis (plantarflexion and eversion)

·        Triceps Surae (gastrocnemius, soleus, plantaris)

·        Achilles Tendon (comes off the gastrocnemius attaching to the calcaneus)

·        Tibialis Posterior

Ligamentous Anatomy (#9, p.89)

·        Anterior Talofibular (ATF)

·        Calcaneofibular (CF)

·        Posterior Talofibular (PTF)

Biomechanics

The ankle joint goes through four main ranges of motion: inversion, eversion, plantarflexion, and dorsiflexion.  To understand why the mechanism of injury would cause the injury we must first understand the biomechanics of the ankle joint.   “The anterior talofibular ligament is the weakest of the three lateral ligaments” (#7, p. 331).  “The anterior talofibular ligament is the smallest” (#7, p. 40).  “Its major function is to stop forward subluxation of the talus” (#8, p. 331).  When standing, the ankle joint is not in the neutral position. “Normally, an external torsion exists in the tibia, so that the ankle mortise faces approximately 15 degrees outward.  With dorsiflexion it moves up and slightly laterally; with plantarflexion, the foot moves down and medially” (#6, p. 389).  “ When the ankle joint is in the neutral position, the anterior talofibular ligament has a medial and anterior-inferior inclination, lying approximately 75 degrees to the long axis of the fibula.  It allows for a few millimeters of anteroposterior translation and medial rotation (inversion). That is why it is the only ligament restraining anteroposterior drawer and medial rotation” (#7, p. 40).           

During plantarflexion there are functional changes in the ATF.  There is tension on the ligament due to the separation of the fibula from the talus, and then the ATF assumes the alignment closer to the axis of the fibula. (#7, p. 40). “These two factors are of the greatest importance in understanding the primary role of the ATF in resisting both inversion and talar tilt… of the ankle mortise” (#7, p. 40). “Dorsiflexion is the closed-pack, stable position of the talocrural. Plantarflexion is the loose-pack position.” The joint is more vulnerable during plantarflexion (#6, p. 389). So this helps understand the mechanism of injury.

Mechanism of Injury

            Injury occurs in an inverted, plantar-flexed, and internally rotated position (#8, p. 331).  80-90% of ankle sprains occur as a result of this mechanism (#2, p. 295).  “The great majority of lateral ankle sprains occur at the moment when the foot makes contact either landing from a jump or at the termination of the swing phase in running or walking.  At foot strike, the ankle joint is in plantar flexion, while the foot is supinated.  In this position support is mainly muscular and ligamentous.  Bony stability is lessened mainly because the medial malleolus extends more distal than the lateral malleolus, allowing an accentuation of inversion; in this way, the medial malleolus may act as a fulcrum for an inversion sprain.   As inversion proceeds, the strength of the peroneal muscle may be overcome and force falls upon the lateral ankle ligaments, particularly the ATF” (#7, p. 41-2).  This is why during your rehab protocol it is important to strengthen the lateral compartment for muscular strength and endurance.  The more inversion force applied causes complete tearing of the ATF and the stress is passed on to the CF, and after the CF is the PTF and the possibility of surgery arises.    The Rehabilitation Protocol for an athlete who has sustained a lateral ankle injury that requires immobilization or surgery resulting in the use of an immobilization boot or cast.

Phase I

Goals/Objectives

  • Teach proper crutch walking technique
  • Progress to walking without the crutches
  • To minimize loss of muscular strength
  • To maintain pain-free ROM
  • To decrease signs of inflammation
  • To maintain overall physical fitness

Exercises/Treatment to Meet Goals/Objectives( 5days a week)

1.      Crutch Walking (#1, p. 160)

-         Non-weight Bearing

·        Stand on uninjured leg and place the crutches and injured leg out in front

·        Lean on the crutches placing the weight in hands

·        Take a step forward with uninjured leg

·        Repeat until walking

-         Up and Down Stairs

·        Up with the good

·        Down with the bad

2.      Muscle loss

·        Electrical Muscle Stimulation (E-stim)

·        Russian Current 10minutes

·        Isometric muscle contractions (dorsiflexion & plantarflexion)  2 to 3 sets until tired

3.      Walking

·        Proper gait, no toeing out

·        Heel-to-toe walking

·        Walking in straight line

4.      Pain-free ROM

·        Pain-free Achilles stretching

·        Grade1 joint mobilization

 #8, p.335

·        Limit ROM to dorsiflexion and plantarflexion

5.      Maintain Overall Fitness

·        Stationary Bicycle 20minutes 2 to 3x a day (#3)

·        Push Ups 4 sets of 10

·        Crunches 5 sets of 20 (obliques and rectus abdominus)

Criteria to Proceed to Phase II

  1. Removal of walking boot/cast
  2. Reduction of swelling and pain
  3. Reduction of signs of inflammation to allow therapeutic exercise
    1. Heat
    2. Redness
    3. Pain
    4. Swelling
    5. Loss of function

Phase II

Goals/Objectives

  • Regain full-weight bearing
  • Restore normal gait patterns
  • Increase ROM 95% (compared to uninjured)
  • Increase flexibility 95% (compared to uninjured)
  • Increase muscular strength 85% (compared to uninjured)
  • Increase muscular endurance 75% (compared to uninjured
  • Increase proprioception 90% (compared to uninjured)
  • Reduce swelling
  • Reduce pain
  • To maintain overall physical fitness

Exercises/Treatment to Meet Goals/Objectives (5 days a week)

1.    Regain full weight bearing/ Return to normal Gait

·        Proper gait mechanics

·        Heel-to-toe walking

2.      ROM 95%

·        PNF Stretches (inversion, eversion, dorsiflexion, plantarflexion)

·        ABC in whirlpool 10minutes

·        Towel pumps (dorsiflexion, plantarflexion) 3 sets of 20

#8, p.335

·        Achilles stretch on slant board

#8, p.335

3.      Muscular Strength 85%

·        Toe walks 2 laps up and down the gym floor

·        Toe raises 2 sets of 20

·        Heel walks 2 laps up and down the gym floor

·        Heel raises 2 sets of 20

·        Theraband pain-free 3 sets of 15 ( Progress according to athlete) all 4 direction

·        Towel crunches

 #8, p.335

4.      Flexbility 95%

·        Same as ROM

·        Passive ROM

5.      Muscular Endurance 75%

·        Light Theraband as fast as they can go, until they get tired

6.      Proprioception 90%

·        Seated slanted wedge board two leg balance progressing to one leg

#8, p.335

·        Standing on injured leg 3 sets 30sec.

·        Cross Country slide board 1min., 30sec, 15 sec.

7.      Overall Physical Fitness

·        Aquatic exercise ( laps in pool, to athlete ability)

·        Stationary bike intervals workout

·        Push ups 3 sets of 20

·        Crunches  5 sets of 20

Criteria to Proceed to Phase III

  1. Athlete regains normal gait
  2. Obtained
    1. 95% ROM
    2. 95% flexibility
    3. 85% muscular strength
    4. 75% muscular endurance
    5. 90% proprioception
  3. Athlete is mentally prepared to begin sports specific activities

Phase III

*Sports specific activities begin in this phase

*My athlete is a female cheerleader

Goals/Objectives

  • Continue to gain ROM 100% (compared to uninjured)
  • Continue to increase flexibility 100% (compared to uninjured)
  • Continue to increase muscular strength (to level of uninjured or above)
  • Continue to increase muscular endurance 100% (to level of uninjured or above)
  • Continue to increase proprioception 100% (to level of uninjured or above)
  • Establish athlete’s confidence in their ability to return to full play
  • Gain motor activity in relation to sports specific activity
  • Maintain and optimize overall physical fitness

Exercises/Treatment to Meet Goals/Objectives (3x a week)

1.     ROM 100%

·        Continue ROM exercises from Phase II

·        BAPS board seated progressing to standing

#8, p.336

2.    Flexibility 100%

·        Continue from phase II

·        Join in team stretches

3.     Muscular Endurance 100%/ Muscular Strength 100%

·        Plyometrics 4 inch box side to side and up and down until tired

#11, p.237

·        Mini tramp  Hold stunt position Liberty for 1min 2x

#11, p.241

·        Running 1mile

·        Team Conditioning as tolerated

·        Team workouts as tolerated

·        Basic Tumbling forward roll, backward roll, cartwheel, toe touch

·        Advanced Tumbling back-handspring, round-off, tumbling pass as skills allow

Criteria to Proceed to Phase IV

  1. Athlete is mentally prepared to return to full play
  2. Physician release (if necessary)
  3. Obtained
    1. 100% ROM
    2. 100% flexibility
    3. 100% muscular endurance
    4. 100% muscular strength
    5. 100% proprioception

Phase IV

 

*My athlete is a female cheerleader

Goals/Objectives

  • Maintain 100% flexibility
  • Maintain 100% muscular strength
  • Maintain 100% muscular endurance
  • Maintain 100% proprioception
  • Return to Full Participation

Exercises/Treatment to Meet Goals/Objectives (2 to 3x a week)

1. Athlete Continues Rehabilitation from phase II

2. Continue stretches before practice

3. Athlete ice 15 minutes and stretch after practice

4. These things can be done in the practice are with the team

Summary

A lateral ankle sprain was the topic of this protocol, but it does not mean that this is the only type of injury that occurs at the ankle joint.  There are other injuries that include fractures, avulsions, medial ankle sprains, syndesmosis sprains, Achilles strains, and the list goes on.  The rehabilitation techniques for these injuries may be similar, but they are not exactly the same.  To differentiate between the different injuries of the ankle is important, and can be critical in returning your athlete back to full competition.  This rehab protocol can be modified for the use in other sports as well, but the phase three exercises might be changed.  The idea of this protocol is to give a general base for use in the athletic training world, but it should be used as a guide.  Allow your athlete to help make up the protocol and activities.  With their own input they will be more likely to cooperate and recover faster.  To listen to your athlete and modify your techniques according to their needs is the mark of a good athletic trainer.

Reference Page

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10. Trotter, Dara.  (2002).  Handout: Clinical in Athletic Training ATHT 3003. 

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