1. Alberto Friedmann, MS American College of Sport Medicine
Exercise Treatment of Non-Accident Related Chronic Ankle Instability in Ehlers-Danlos Syndrome
Alberto Friedmann, MS
American College of Sport Medicine

2. Ankle Injuries in Sport:
Common
Debilitating
Poorly Rehabilitated
Reocurring
Functional Instability

3. Chronic instability is not limited to injuries:
Genetic and neuromuscular disorders result in instability without trauma.
Hereditary Disorders of Connective Tissue (HDCT)
Ehlers-Danlos Syndrome
Marfan’s Syndrome
Osteogenesis Imperfecta
Benign Hypermobility Syndrome (Mild EDS Hypermobility – Type III)

4. Hereditary Disorders of Connective Tissue:
Result of defective collagen (glue)
Elastin and collagen are weak
Tissue is frail and lax
Fibrillins are weak and tear

5. Up to 70% show the same symptoms as those with frequent ankle sprains.

6. Unable to perform (0 points) Able to Perform (1 Point)
“Hypermobility is defined as an abnormally increased range of joint motion due to excessive laxity of the constraining soft tissues” (Everman, 1998).
Clinical Maneuver
Unable to perform (0 points)
Able to Perform (1 Point)
Apposition of Thumb to Forearm
Right
Left 1
Extension of fifth finger beyond 90 degrees
Extension of elbow beyond 10 degrees
Extension of knee beyond 10 degrees
Forward flexion of trunk, legs straight, palms touching the floor
Total Beighton Score (0-9)

7. Functional Ankle Instability
Inability to use the ankle for daily activity:
Walking
Standing
Bathing
Getting out of a chair
Basic balancing
Functional instability of the ankle is the most common residual disabilities after an acute ankle sprain.

8. Ankle Rehabilitative Therapies
Strengthening (pronation)
Balance
Proprioception
Caused by nerve-fiber damage
Traditionally low in hypermobile subjects
“Recent studies have demonstrated reduced proprioceptive sensation in the joints of subjects who have hypermobility syndrome. Such findings have led to speculation that impaired sensory feedback contributes to excessive joint trauma in effected individuals” (Everman, 1998).

9. Most common trauma:
Talofibular Joint
Calcaneofibular Joint
Other trauma – often seen in hypermobile subjects:
Talocrural Joint
Talocalcaneal Joint
Talocaneonavicular Joint
Calcaneocuboid Joint

10. Traditional rehabilitation therapies:
Balance Boards
Theraband resistance
Open and Closed Kinetic Chain
Peroneal reaction treatment
Joint proprioception treatment

11. Traditional means of rehabilitaion:
Resistance training
Reactive Neuromuscular training
Proprioceptive training

12. Study purpose was to determine the effects of exercise on non-accident-related chronic ankle instability, particularly in subjects who have Ehlers-Danlos Syndrome or Benign Hypermobility Syndrome. The study looked at multi-range stability in the talocrural, talocalcaneal, talocaneonavicular and calcaneocuboid joints .

13. Hindfoot
Talocrural
Tibiofibular
Talocalcanear (Subtalar)
Midfoot
Talocalcaneonavicular
Cuneonavicular
Cuboideonavicular
Intercuneiform
Cuneocuboid
Calcaneocuboid

14. Participants: Direct Observation Volunteers Hypermobility Syndrome
Five or higher on Beighton’s Scale
18-older
No recent ankle trauma
No severe ankle trauma

15. Procedures: Eight-Week Exercise Program
Three days of exercise per week
Traditional Rehabilitation Therapies
Resistance Training
Reactive Neuromuscular
Proprioception/Balance
Active stabilization exercises

16. Measures: Range of Motion Functional Strength Stability Proprioception
Neurological Reflex
Study start, after four weeks, study end (total of three measures)

17. Range of Motion: Standard Goniometer Anatomical Neutral
Dorsiflexion – 200
Plantar Flexion – 500
Inversion – 50
Eversion - 50

18. Monthly Training Regimen
Exercise
Mon.
Tue.
Wed.
Thur.
Friday
Sat.
Sun.
Resistance Training X
Reactive Neuromuscular Training
Proprioception Exercises
Active Stabilization Exercises

19. Resistance Exercises Leg Press Calf Raise Knee Extensor Knee Flexor
Two sets of 12 repetitions at 60% max.
Resistance increased by 10% at week four
Third set added at week seven

20. Reactive Neuromuscular Training
Used resistance tubing:
Uniplanar Anterior Weight Shift
Uniplanar Posterior Weight Shift
Uniplanar Medial Weight Shift
Uniplanar Lateral Weight Shift

21. Proprioceptive Exercises
One-foot standing balance
One-foot standing balance with hip flexion
One-foot standing balance using weights in diagonal pattern
One-foot standing balance while playing catch
Exercises on balance board

22. Active Stabilization Exercises
Used a step-stool measuring 16” x 16” x 8” (40.6cm x 40.6cm x 20.3cm
Forward step-up on stool
Lateral step-up on stool
Two-foot hop-up on stool
Two-foot lateral hop-up on stool
One-foot hop-up on stool
One-foot lateral hop-up on stool
Two-foot jump-over stool
Two-foot lateral jump-over stool
One-foot jump-over stool
One-foot lateral jump-over stool

23. Functionality Plantar Flexion Dorsiflexion Inversion Eversion
Measured on a scale 0-15:
0 Non functional
0-4 Functionally Poor
5-9 Functionally Fair
10-15 Functional

24. Functionality After four weeks: After eight weeks:
Overall increase in functional strength
Decrease in pain
Decrease in joint popping
After eight weeks:
All participants fully functional in all tests
Virtual elimination of pain
Elimination of joint popping

25. Quality of Life Functional Strength
Less = lower exercise = atrophy = less functionality
More = more exercise = hypertrophy = more functionality = Independence= Higher Quality of Life

26. Quality of Life
Pain
More = depression = unwillingness to exercise = atrophy = more pain
Less = Better outlook = social activities = social exercise = Less medication = Higher Quality of Life

27. Quality of Life Proprioception
Less = Poor balance = unwillingness to exercise = Higher risk of injury = Nerve fiber damage = Decreased proprioception
More = Better balance = feeling of ability = exercise adherence = lower risk of injury = Increased independence = Higher quality of life

28. Change in Range of Motion, Active

29. Change in Range of Motion, Passive

30. Overall Change in Range of Motion

31. Reduction in ROM
Overall decrease in both passive and active indicates:
Hypertrophy in tendons and ligaments as well as muscle tissue.
Hypermobile joints can be strengthened and stabilized before laxity leads to injury.
Proper, supervised exercise is of benefit to this population

32. Inversion Changes Inversion injuries: Common Reoccur
Difficult to rehabilitate

33. Participants showed:
Decreased Range of Motion
Decreased Pain and Joint Popping
Increased Balance and Proprioception
Increased Daily Functioning

34. Implications
Rehabilitation of other joints for this special population
Shoulder Capsule
Hip Socket
Interphalangeal Joints
Metacarpophalangeal Joints

35. Implications
EDS patients, and possibly patients with other hypermobility syndromes, could be treated in multiple joints prior to disruptive injuries or the need for surgery due to joint hyperlaxity.
Injury and surgery is more damaging and dangerous for this population than the average person.

36. Implications
Study participants showed primary gains during the initial four weeks of study intervention
Primary increases in range of motion occurred during the final four weeks of study intervention
Therefore, it is possible that a four-week intervention followed by maintenance would be as, if not more, successful

37. Future Research
Studies involving a larger population and studies involving multiple-joint treatments
Long-term effects of exercise on children with Hereditary Disorders of Connective Tissue
Four-week versus Eight-week programs
Animal studies involving muscle, tendon and ligament tensile strength, elasticity and plasticity