Orthopedic Rehabilitation for Patients Status Post Ankle Fracture by qhm84862


									  Orthopedic Rehabilitation for
Patients Status Post Ankle Fracture
           Brian Wolfe SPT
     Thursday, December 10, 2009
• Review ankle anatomy
• Review effects of immobilization s/p ankle
• Research pertaining to early mobilization of
  ankle fractures compared to immobilization
• Conclusions drawn from accumulation of
                  Anatomy Review
• Hinge Joint
• Fibula, Tibia, Talus and
• Ligaments
   – 3 Lateral-Ant. Talofibular,
     Post. Talofibular, and Post.
   – 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

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
• 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
• DF’s and PF’s atrophied significantly with
• Majority occurred during the first 2 weeks of
• 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
• Muscles were dissected, and length and
  circumference measurements being taken
• Soleus and Plantaris muscles were measured in
  each rabbit
     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
• 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.
• 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
• 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
 • Ankle PF peak torque and fatigue resistance were
   correlated to timed ambulation, timed stair climbing,
   and unilateral heel raises
• 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
• 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
• 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
• 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
• 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
• 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
• 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.
• 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
• 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
• 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
• 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
• 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
• 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
• 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
      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.
 • 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-
 • RCT
• Pts who had early mobilization in a removable cast
  had higher functional scores a 9 and 12 weeks
• 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
• 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

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