Orthopedic Rehabilitation for Patients Status Post Ankle Fracture Brian Wolfe SPT Thursday, December 10, 2009 Objectives • Review ankle anatomy • Review effects of immobilization s/p ankle fx’s • Research pertaining to early mobilization of ankle fractures compared to immobilization • Conclusions drawn from accumulation of research Anatomy Review • Hinge Joint • Fibula, Tibia, Talus and Calcaneus • Ligaments – 3 Lateral-Ant. Talofibular, Post. Talofibular, and Post. Calcaneofibular – 3 Medial-Deltoid Ligaments • Ligaments help to make up the joint capsule Anatomy Continued • Muscles – Peroneals: Eversion and PF – Tibialis Posterior: Inversion and Arch support – Tibialis Anterior: DF – Gastroc and Soleus: PF – Plantaris associated with PF is disappearing in humans • Nerves – Tibial S1-S2 – Deep Peroneal (Fibular) – Superficial Peroneal (Fibular) Muscle Fiber Review Fiber Type Type I fibers Type II a fibers Type II b fibers Contraction time Slow Moderately Fast Very fast Size of motor neuron Small Medium Very large Resistance to fatigue High Fairly high Low Activity Used for Aerobic Long-term anaerobic Short-term anaerobic Maximum duration of Hours <30 minutes <1 minute use Power produced Low Medium Very high Mitochondrial density High High Low Capillary density High Intermediate Low Oxidative capacity High High Low Glycolytic capacity Low High High Levels of Evidence • Systematic Review-Retrospective look at studies on a single question and summarizes the research • RCT-Controls for known and unknown confounding factors, Treatment & Control groups • Cohort Study-Performed from happenstance, unknown factors not controlled, Tx & Control grps • Outcomes Studies-Dx & Tx occur as they would normally in a clinic or hospital • Case Control-Retrospective, How a Tx worked • Case Series-Manipulation without a control grp determined by the researcher • Case Reports-Reports of results of individual cases Muscle adaptations with immobilization and rehabilitation after ankle fracture. Medicine & Science in Sports & Exercise. 2004; 1695-1701. • 20 individuals participated in 10 week rehab program after 7 weeks of immobilization • Measurements taken at baseline, 2 weeks, and 7 weeks of immobilization • Measurements after immobilization taken at 5 and 10 weeks of rehabilitation • Isometric plantarflexor muscle strength testing was performed at 0, 5, and 10 weeks of rehab • Cohort Study Rehabilitation Protocol • Focused on both strength and endurance of the plantarflexors • First week pts received moist heat, joint mobilization and passive stretching • Endurance training consisted of uphill treadmill walking, using UE assist as needed • Strength training was based on a progressive resistance training principle with the knee extended and flexed to emphasize both gastroc and the soleus Results • DF’s and PF’s atrophied significantly with immobilization • Majority occurred during the first 2 weeks of immobilization • More than 50% of hypertrophy occurred in first 5 weeks of rehab in both PF’s and DF’s Length and circumference measurements in one-joint and multijoint muscles in rabbits after immobilization. Physical Therapy. 1986;66:516-520. • Rabbits were assigned to nonimmobilized control, shortened-position and lengthened-position groups • Muscles were dissected, and length and circumference measurements being taken • Soleus and Plantaris muscles were measured in each rabbit • RCT Considerations of the Study • Muscle characteristics, such as fiber type predominance, number of joints crossed, joint position during immobilization, and potential adaptations of other muscles • It is important to recognize that the extent of atrophy in the immobilized limb may be due to: – Selective involvement of specific muscle fiber types – Involvement of single-joint or multi-joint muscles – The position in which the joint is immobilized Results • In both experimental conditions, the immobilized soleus muscles were shorter than their contralateral extremity (p<.05) • Length of plantaris mm. remained unchanged • Immobilized muscles had decreased circumference values regardless of angle • Shortened soleus mm. had a greater decrease in circumference than the plantaris mm. • Increased connective tissue was observed in m. bellies of the soleus after immobilization than was observed in the plantaris mm. Results continued • Circumference and connective tissue changes were significantly noted in the plantaris muslces, just not as much as with the soleus muscles • The study believed these findings suggest that when a WB limb is immobilized, adaptations in gross muscle length and circumference are to be expected in the involved and uninvolved limbs • Prior studies reported that type II (fast-twitch) muslces atrophied more than type I (slow-twitch) • This study showed that putting the muscles in a lengthened position helps decrease atrophy Functional bracing and rehabilitation of ankle fractures. Clinical Orthopaedics and Related Research. 1985;199:39-45. • Fractures treated surgically may start weight-bearing and exercise within five to seven days, provided all fx components have been stabilized • The functional brace was designed to allow DF and PF via a rigid hinge and reduces rotational stresses acting on the fractured ankle • Fibular motion in all ankle mvmts should increase mortise joint width by 1mm. • Clinical application of this is that fx’d ankles immobilized in neutral position will heal with adequate mortise joint width Continued • Functional bracing is applied when the patient is ready to bear weight, which is usually within 3 to 5 days following surgery • Screws inserted in the syndesmoses will yield different outcomes in studies, because when a screw is inserted vertically in the fibula, the forces acting are minimal and the screw will remain intact and no bone absorption will occur • To regain DF, WBing exercises are preferable to passive stretching exercise Effects of immobilization on plantar-flexion torque, fatigue resistance, and functional ability following an ankle fracture. Physical Therapy. 2000;80:769-780. • Purpose was to study the recovery of ankle plantar- flexor peak torque, fatigue resistance, and functional ability (stair climbing, walking) • PF torque and fatigue resistance were measured at 1, 5, and 10 weeks of rehabilitation using an isokinetic dynamometer • Ankle PF peak torque and fatigue resistance were correlated to timed ambulation, timed stair climbing, and unilateral heel raises Results • PF peak torque was decreased at all angular speeds and positions • Decrease in peak torque was associated with an increase in fatigue resistance • With rehab, ankle PF torque and fatigue resistance normalized • This study also demonstrated that ankle PF torque is a good predictor of stair-climbing and walking performance in pts with ankle fx’s • Effects of 8 weeks of immobilization were reversed with 10 weeks of rehabilitation Results continued • The strongest correlation existed btw descending stairs with any technique and weak isometric torque of PF • Weakest correl. was amb. at a max safe speed • Later studies by Snyder-Mackler et al postulated that the increase in fatigue resistance with disuse may be due to the selective recruitment of more fatigue-resistant motor units. Effects of long-term immobilization and recovery on human triceps surae and collagen turnover in the Achilles tendon in patients with healing ankle fracture. Journal of Applied Physiology. 2008;105:420-427. • Purpose of the study was to analyze how human tendon connective tissue responds to ~7 wk period of immobilization and a remobilization period of a similar length in pts with unilateral ankle fx • Pts were allowed partial WBing using the ROM walker halfway through the immobilization Results • Calf muscle cross-sectional area (CSA) decreased by 15% and strength by 54% in the immobilized leg after 7 weeks • During the 7 week remobilization, the CSA increased by 9% and strength by 37% • Immobilization increased both collagen synthesis and degradation in tendon near tissue • Remobilization increased muscle size and strength and tendon synthesis and degradation decreased to baseline levels Results continued • It cannot be excluded that the fracture of the ankle in close proximity could have affected this data • Achilles tendon CSA did not change significantly during either immobilization or remobilization • Muscle fibers will not decrease in volume they will just atrophy Comparison of passive stiffness variables and range of motion in uninvolved and involved ankle joints of patients following ankle fractures. Physical Therapy. 1995;75:253-261. • Purpose of this study was to quantify several variables of ankle stiffness and DF ROM in the casted and noncasted ankles of humans after cast removal • 30 subjects will malleolar ankle fx’s were tested within 4 days of cast removal but before they began physical therapy • All subjects were tested at 90 degrees of knee flexion • Case Series Results • Only 7 subjects were capable of reaching beyond 5 degrees of passive DF without evoking any calf EMG activity • Maximum passive DF ROM had a large difference btw the fx’d ankles and the matched noncasted ankles • Only a small difference in passive elastic stiffness btw the involved & uninvolved ankles was found Results continued • The graph illustrates passive torque into DF at 5 degree intervals for the casted and noncasted ankles • The only significant difference was found at maximal DF ROM • This study shows that the toughest motion to get back after immobilization is DF The lower extremity functional scale has good clinimetric properties in people with ankle fracture. Physical Therapy. 2009;89:580-588. • LEFS is an activity limitation questionnaire such as donning/doffing socks and shoes, household chores, ambulation, etc. • This was a measurement study using data collected from 2 previous RCT’s and 1 inception cohort study • 307 pts were measured within 7 days after cast removal after immobilization • Data was collected at baseline and at short and long term follow-up • Systematic Review Results • The Lower Extremity Functional Scale demonstrated high internal consistency • The variance in activity limitation explained by the items on the survey was high (98.4%) • Each item had a positive correlation with the overall scale, and most items supported the unidimensionality of the scale • These findings suggest that the scale has high internal consistency and construct validity with short-term follow up (4 weeks) Results continued • The LEFS scale did not show significant correlation with long-term follow up (24 weeks), however it did show similarity • The researchers believed this may be related to a lack of difficult items that could reflect changes in activity limitation for participants of high ability during this period Early postoperative ankle exercise. Clinical Orthopaedics and Related Research. 1994;300:193-196. • 53 pts with dislocated lateral malleolar fractures were randomly selected after operation for either active ankle mvmt and WBing in an orthosis or no ankle mvmt but WBing in a walking cast • Follow-up examinations were performed after 3, 6, and 18 months • After operation, pts were randomly placed into an orthosis or walking cast group • RCT Results • No differences were found btw the grps except for a better linear analogue scale result at 3 months for the orthosis group • Ankle AROM do not improve the rehabilitation of surgically treated lateral malleolar fractures • Superficial wound infection occurred in 3 pts, 2 in the orthosis group and 1 in the cast group • Only at 6 weeks did the exercise group show better ankle mobility Results continued Use of a cast compared with a functional ankle brace after operative treatment of an ankle fracture. Journal of Bone and Joint Surgery. 2003;85:205-211. • 100 patients with an unstable and/or displaced ankle fracture • Randomly allocated into two groups: immobilization in a below-the-knee-cast or early mobilization in a functional ankle brace • Follow-up examination were performed at 2, 6, 12, 52 weeks and at 2 years postoperatively • Excluded ankle fractures requiring screw placement across the syndesmosis • RCT Methods • Pts who wore a below-the-knee cast used crutches for the first two weeks, PWB was then allowed in a fiberglass short leg walking cast for the next four weeks. • Full WB was allowed at 4 weeks and the cast was removed at 6 weeks post-op • The other group was in a functional Air-Stirrup ankle brace that was applied immediately after surgery • Daily Active and PROM exercise of the ankle and subtalar jt was encouraged until normal gait was obtained Results • Overall complication rates btw the grp treated with a cast (16%) and the grp treated with a brace (66%) was significant • Return to work did not show a sig. difference • Higher functional outcome scores for the ankle brace group were only found to be significant at 6 weeks Results continued • Researchers concluded that long-term functional outcomes after postoperative treatment of an ankle fracture with a cast and that after use of a functional brace are similar • In the grp treated with a brace, 33 pts had a post- operative complication • Our patients must be educated on the risks of infection when they are placed in the functional brace Early mobilization in a removable cast compared with immobilization in a cast after operative treatment of ankle fractures: a prospective randomized study. Foot & Ankle International. 2007;28:13-19. • Both groups were NWB for the first 6 weeks • Separated into 2 groups of nonremovable fiberglass cast for 6 weeks and the other into a removable fiberglass cast • The removable fiberglass brace group exercised the affected ankle 3 times a day, for 10 min, consisting of AROM and PROM • Pts were evaluated at 3, 6, 9, 12, and 24 weeks post- operatively • RCT Results • Pts who had early mobilization in a removable cast had higher functional scores a 9 and 12 weeks postoperatively. • The early mobilization group also returned to work earlier (67 days) compared to the below the knee cast group (95 days) • There was no significant difference in Quality of Life at 6 months btw the two groups • ~10% postoperative infection trend (1 superficial, 2 deep) in the early mobilization group Results Charted Conclusions • When treating patients s/p ankle fx’s we always need to consider the immobilization effects it will have on or patients and design a rehab program appropriately • Patients should be aware of the higher risk of wound complications with bracing treatment • Younger and more active patients should be considered for bracing techniques • Research has found that immobilization will return to similar function as early mobilization after rehabilitation and should not affect the patients overall quality of life Questions?
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