1. Range of motion after a Lateral Ankle Reconstruction
Sam DeAlto
September 26th 2016
Clinical Problem Solving II
From each article, write out patient characteristics

2. Objectives Describe patient management of the demographic of interest
To examine the evidence on ankle mobilizations as an effective intervention for patients status post lateral ankle reconstruction in an orthopedic setting
To evaluate the implementation of ankle mobilizations in an orthopedic setting

3. Patient X: 38-year old Caucasian male
PMH:
Premorbid Status:
Bilateral chronic ankle instability/sprains since (L > R)
Full time in Air-force
Recreational soccer
L lateral ankle reconstruction April 2016
Current Status:
Lives alone in apartment
MOI: traumatic fall while working in the Air-force
Not working
Unable to play recreational soccer
PT Diagnosis:
Pain in L ankle and joints of foot (5/10 at worst)
Plans to go to school in Spain
ADLs: standing, squatting, walking, climbing stairs

4. Lateral Ankle Reconstruction
Anterior talofibular ligament (ATFL), calcaneal fibular ligament (CFL), and Posterior talofibular ligament (PTFL)
Review joints of the ankle?  subtalar, talocrural

5. PT Examination Integument Balance Functional Test: squat Gait ROM
Strength
FAAM ADL and Sport
Foot ankle ability measure = FAAM

6. Initial Examination: Day 1
Objective Measure:
Results:
Integument
Both scars on L ankle slightly raised
Balance (SLS EO)
R = average
L = poor
Functional Squat Test
*Minimal weight shift to right leg
*Felt minimal pain and stiffness in L ankle
Gait
*Slow step-to pattern
*Antalgic
*Poor eccentric PF control during contact phase and increased great toe extension
FAAM (score for ADL and Sports)
ADL = 23.7%
Sports = 0%

7. Initial Examination: Day 1
STRENGTH
Left
Right
Hip Flexion 5 4
Knee Extension
Knee Flexion
Ankle DF 4+
Ankle PF
Ankle Eversion NT
Ankle Inversion
Normal values for ankle AROM:
DF = 20
PF = 50
Eversion = 20
Inversion = 30
AROM
Left
Right DF 5 PF 48 45
Eversion 18
Inversion 20 30

8. PT Plan of Care
Assessment: Patient is a 38-year-old male presenting with L ankle pain s/p lateral ankle reconstruction in April 2016 requires PT for the following: decreased L ankle dorsiflexion AROM; decreased balance and proprioception; abnormal gait pattern. Plan of Care: AROM, manual therapy, proprioceptive activities, stretching/flexibility activities, HEP, balance training, therapeutic exercise, neuromuscular re-education Frequency/Duration: 3 times per week for 4 weeks
----- Meeting Notes (9/22/16 09:26) -----
highlight important information from this slide, include information about what you did ankle ROM wise

9. PT Goals Within 4 weeks, patient will be able to:
Increase L ankle dorsiflexion AROM to 15 degrees to allow patient to walk with a normal gait pattern
Improve FAAM ADL to 28% and Sport to 10.20% to exceed MDC of 6.3% points and 10.20% points and show efficacy of therapy
Increase gross bilateral LE strength to 5/5 in order to safely ascend/descend a flight of stairs
Increase SLS on left leg to 15 seconds in order to decrease maximum fall risk
Improve gait to normal gait pattern in order to safely walk 5 minutes without pain.
Why 15??  explain if questioned

10. Clinical Question
For a 38-year-old male status-post lateral ankle reconstruction, is weight-bearing mobilization with movement an effective intervention for increasing ankle dorsiflexion range of motion?

11. Initial Changes in Posterior Talar Glide and Dorsiflexion of the Ankle after Mobilization with Movement in Individuals with Recurrent Ankle Sprain (Vicenzino, et al. 2006)

12. Vicenzino, et al. 2006 Study Design: Purpose:
Double blind, randomized crossover experimental study with repeated measures, including control group
Purpose:
Evaluate the initial effect of mobilization with movement (MWM) in weight-bearing and non-weight bearing on posterior talar glide and talocrural dorsiflexion in individuals with recurrent lateral ankle sprain

13. Vicenzino, et al. 2006 16 individuals: Inclusion Criteria:
8 female, 8 male
Age: 18 to 27
Inclusion Criteria:
History of recurrent lateral ankle sprains (2-6)
> 20 mm asymmetry on the Weight-bearing Lunge Test
No history of lateral ankle sprain on the contralateral side
Exclusion criteria:
Acute ankle sprain within the past 6 months
Previous injury or surgery to the back, hip, or knee or major injury or fracture to the ankle or distal leg
What is Wbing lunge test?
State 2 most important
Put stars around points to talk about

14. Outcome Variables
1. Talocrural dorsiflexion Posterior glide of talus
Talcrural DF – Wbing Lunge
Performed in standing in standardized position (2nd toe, center of heel and knee were kept in a plane perpendicular to the wall and heel firmly in contact with the ground)
Subject then leans FW until anterior knee contacted the wall and max DF was obtained
Tape measure was used to measure distance b/t the great toe and the wall
Heel contact is maintained throughout the test
2. Posterior talar glide
Performed using assessment of tibial inclination during DF of the ankle with the thigh and foot in a standardized position (thigh fully stabilized on a firm table, subtalar jt maintained in neutral, and foot parallel to the floor)
Performed in sitting on edge of examination table with inclinometer distal to the tibial tub. Examiner then placed subjects foot in subtalar neutral with foot parallel to the floor, applied a glide to the talus posteriorly by using direct manual contact (contact point was distal palmar surface of thumb) over the anterior talus.
End point of test was a firm end-feel in which case the examiner recorded the angle of tibial inclination
Both measurements were taken on the affected and unaffected side and were repeated and recorded 3 times both pre-treatment and post-treatment.

15. Treatment Groups
Treatment sessions: 4 sets of 4 glides held for 10 seconds with 20 seconds rest period
Weight-Bearing MWM (MWM_WB)
Non-Weight-Bearing MWM (MWM_NWB)
No Treatment (control)
State repetitions/duration for groups

16. Treatment (MWM_WB)
Belt applies a P/A force to the distal tibia (therapist leans backwards) while the talus and foot remain stationary on the table and the patient actively goes to end of pain-free range DF

17. Treatment (MWM_NWB)
Therapist glides the talus A/P against a tibia that is fixed by the treatment table, while the patient actively dorsiflexes the ankle to end of available pain-free DF

18. Conclusions
Both MWM groups improved posterior talar glide and DF ROM immediately after application greater than that of the control group
There is little difference in treatment effect between both MWM groups
MWM_WB may improve coupling at the talocrural joint
MWM_WB (close to ankle function) may improve coupling at the talocrural joint rather than provide greater improvements in posterior talar glide and weight-bearing dorsiflexion

19. Limitations Small sample size (16 subjects)
Only looked at immediate effects
Measurement reliability
Validity of the assessment of the posterior talar glide
Relevance to Patient X

20. Effects of Joint Mobilization on Chronic Ankle Instability: a Randomized Controlled Trial (Cruz-Diaz, et al. 2015)

21. Cruz-Diaz, et al. 2015 Study Design:
Randomized clinical trial with control group
Purpose:
Evaluate short- and long-term effects of mobilization with movement in weight bearing on ankle dorsiflexion range of motion, dynamic postural control and self reported instability in individuals with chronic ankle instability

22. Subject Characteristics
81 subjects:
47 male, 34 female
Age: 20 to 34
Inclusion criteria:
History of ankle sprains on the same side in the last 2 years
Asymmetry > 2cm on weight-bearing lunge test
Self-reported instability of “giving-way”
Not receiving any other PT treatment during the study
Exclusion criteria:
Acute ankle sprain within 6 months
History of bilateral ankle sprains
Bony injury associated with ankle sprain
Previous injury or surgery to back, hip or knee

23. Methods
Outcomes Assessed: measured pre-treatment, after first session, 3 weeks and 6 months
Weight Bearing Lunge Test to measure ankle DF
Cumberland Ankle Instability Tool (CAIT) to measure self-reported ankle instability
Star Excursion Balance Test (SEBT) to measure dynamic postural control
3 Groups Tested: received 2 sessions/week for 3 weeks
Weight-bearing mobilization with movement (MWM_WB)
2 sets of 10 repetitions with 2 minutes rest
Sham treatment for placebo group
Same as MWM_WB
Control group
No treatment received
How the groups treatments were performed:
1. MWM_WB – similar to previous study…patient in high kneeling position with affected ankle in a weight-bearing neutral position and one upper extremity support for stability. A rigid belt was passed around the inferior margin of the medial malleolus and the waist of the therapist while manually fixing the talus and calcaneus with both hands. The therapist draws the tibia forward on the talus resulting in a posterior talar glide of the talus in the ankle mortise. Holding the glide, patients were told to perform a slow dorsiflxion movement until the first onset of pain or until the end of their range.
Sham treatment – fixed the talocrural joint by placing a semi-rigid orthesis to limited ankle DF. With the patient in supine, the therapist passively flexed and extended the knee for 2 sets of 10 following the same protocol as in the MWM_WB group
SEBT – measured 3 trials in anterior, posterolateral and posteromedial direction. Took sum of each of those 3 trials and divided it by 3 x LL and multiplied by 100 to get percentage

24. Dorsiflexion ROM Results
On average, the ROM changes between the 3 groups are stated below:
Post  MWM_WB increased ROM by 6.71 degrees compared to sham group and 7.13 degrees compared to control
3-weeks  WMW_WB increased ROM by 6.84 degrees compared to sham and 7.30 compared to control
6-months  MWM_ increased ROM by 6.96 degrees compared to sham and 7.27 degrees compared to control
Significant change immediately after post-treatment and while the gains in DF were minor prior to initial treatment, the gains remained constant proving that continued MWM_WB is effective to initially change DF and maintain it.
Figure out AXIS – figure out how many degrees were significant

25. CAIT and SEBT Results
CAIT  MWM_WB group showed a significant improvement in self-reported feeling of “giving way” after 3-weeks while the sham and control maintained similar scores from baseline
SEBT  MWM_WB group showed greater significant improvements after 3-weeks in all reach distances compared to the sham and control groups

26. Conclusion and Limitations
Conclusions:
MWM_WB can increase DF ROM, dynamic postural control and self-reported feelings of instability for people with ankle sprains and ankle instability
The treatment effects of MWM_WB endure over time (up to 6 months)
Limitations:
Small sample size
Only 6 mo long-term
Relevance to Patient X

27. Significance to Patient X
Patient X received 12 visits of PT over 4 weeks
Therapy included:
Therapeutic exercise  bicycle ergometer, gastroc/soleus stretch, heel raises, step-ups on bosu, mini wall squats, 4-way ankle exercises with t-band, FW lunge, intrinsic marble pick-ups, towel scrunches
Manual Therapy ankle PROM, posterior talar glide mobilization grade I-IV, hawksgrips gastroc/soleus, strumming front of ankle, scar tissue mobilization
Balance/Proprioception  SLS, BAPS, balance board, cone taps, SLS with ball toss

28. Patient Progress Initial Evaluation: Week 1 Re-Evaluation: Week 4
Balance (SLS EO)
R = average
L = poor
R = excellent
L = excellent
Gait
*Slow step-to pattern
*Antalgic
*Poor eccentric PF control during contact phase and increased great toe extension
*Step through pattern with c/o sharp pain in the front of his ankle during contact and through heel-off stance phase
*no observable abnormalities
Functional Squat Test
*Minimal weight shift to right leg
*Felt minimal pain and stiffness in L ankle
*felt minimal pain and stiffness in L ankle
FAAM (score for ADL and Sports)
ADL = 23.7%
Sports = 0%
ADL = 58.33%
Sports = 18.75%
State MDC for FAAM – ADL (28.0) and sport (10.2)
State MDC for ankle ROM – 6 to 8 degrees

29. Strength and ROM STRENGTH: Week 1: Left Week 1: Right Week 4: Left
Hip Flexion 5 4
Knee Extension
Knee Flexion
Ankle DF 4+
Ankle PF
Ankle Eversion NT
Ankle Inversion
Normal values for ankle AROM:
DF = 20
PF = 50
Eversion = 20
Inversion = 30
Left AROM:
IE: Week 1
RE: Week 4 DF 5 8 PF 48 40
Eversion 18 14
Inversion 20 24

30. Progress Toward Goals Patient X met all but 2 goals:
Increase L ankle dorsiflexion AROM to 15 degrees to allow patient to walk with a normal gait pattern
Increase gross bilateral LE strength to 5/5 in order to safely ascend/descend a flight of stairs (EXCELLENT PROGRESS)
This may be due to:
Consistent c/o pain in front of ankle
Delayed PT: 3 mo post-operative period
PMH: Contralateral ankle has impairments
Planning to get a R lateral ankle reconstruction in future

31. Research Relevance to Patient X
Hard to find studies with the following:
Lateral ankle reconstruction, bilateral ankle sprain, MWM_WB and ankle DF ROM
Patient X did not perform MWM_WB but did perform posterior talar glides in supine as well as therapeutic exercise to increase DF
Reconstruction of Lateral Ligaments: Do the anatomical procedures restore ankle kinematics?

32. What would I do differently?
After looking at the research, I would consider doing MWM_WB for patients s/p lateral ankle reconstruction based on the following:
Surgeon protocol
Patient impairments
Lateral Ankle Reconstruction procedures and ROM
Modified Brostrom Evans Procedure – no significant difference in ROM b/t surgical side and non-surgical side
Lateral Ankle Reconstruction procedures on ROM
Modified Brostrom Evans Procedure – no significant difference in ROM b/t surgical side and non-surgical side
REDUCE WORDS ON LATERAL ANKLE RECONSTRUCTION PROCEDURES

33. Overall Conclusion
MWM_WB in order to increase ankle DF ROM in individuals s/p lateral ankle reconstruction is uncertain; HOWEVER,
MWM_WB can increase ankle DF in patients with chronic ankle instability in short and long-term
MWM_WB may be more effective functionally for patients with history of chronic ankle sprains
More research needed to compare MWM_WB on bilateral chronic ankle instability and lateral ankle reconstruction
More research needed to look at therapeutic exercise in combination with MWM_WB on ankle DF

34. Questions

35. References
Cruz-Díaz, David, Rafael Lomas Vega, Maria Catalina Osuna-Pérez, Fidel Hita-Contreras, and Antonio Martínez-Amat. "Effects of Joint Mobilization on Chronic Ankle Instability: A Randomized Controlled Trial." Disability and Rehabilitation 37.7 (2014): Web.
Hsu, A. R., G. T. Ardoin, W. H. Davis, and R. B. Anderson. "Intermediate and Long-Term Outcomes of the Modified Brostrom-Evans Procedure for Lateral Ankle Ligament Reconstruction." Foot & Ankle Specialist 9.2 (2015): Web.
"Lateral Ankle Sprain." Related Keywords & Suggestions. N.p., n.d. Web. 21 Sept
Schmidt, R., E. Cordier, C. Bertsch, E. Eils, S. Neller, S. Benesch, A. Herbst, D. Rosenbaum, and L. Claes. "Reconstruction of the Lateral Ligaments: Do the Anatomical Procedures Restore Physiologic Ankle Kinematics?" Foot Ankle Int Foot & Ankle International 25.1 (2004): Web.
"Surgical Treatment of Chronic Ankle Lateral Instability: Reconstruction with Tenodesis or Tendon Graft." N.p., n.d. Web. 21 Sept
Vicenzino, Bill, Michelle Branjerdporn, Pam Teys, and Kate Jordan. "Initial Changes in Posterior Talar Glide and Dorsiflexion of the Ankle After Mobilization With Movement in Individuals with Recurrent Ankle Sprain." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 36.7 (2006): Web