Sensory-Targeted Ankle Rehabilitation Strategies for Chronic Ankle Instability
McKeon PO & Wikstrom EA. Med Sci Sports Exerc. Published Online First: December 10, 2015; DOI: 10.1249/MSS.0000000000000859
Take Home Message: Sensory-targeted rehabilitation strategies (STARS) result in improvements in patient-reported and clinical outcomes. Certain deficits may be specifically targeted by different techniques.
Chronic ankle instability (CAI) with recurrent episodes of giving way and functional limitations can cause long-term complications. Sensorimotor deficits may play a significant role in those with CAI. Therefore, the authors of this randomized control study compared the effects of 3 sensory-targeted ankle rehabilitation strategies (STARS; i.e., ankle joint mobilization, plantar massage, or triceps surae stretching) on improvements in clinician- and patient-reported outcomes among individuals with CAI. The authors randomized 80 participants to 4 groups (3 STARS interventions and a control group). 75 participants completed the entire duration of the study at the 1-month follow-up. STARS programs consisted of six total treatment sessions over the course of 2 weeks. Joint mobilization participants received 2 two-minute sets of grade III (one-second large amplitude) oscillations. Participants within the plantar massage group received 2 two-minute sets of effleurage and petrissage on the plantar aspect of the foot. Trcieps surae stretching participants performed 2 sets of three 30-second stretches with their knee flexed. Control participants received no treatments. Participants were assessed at baseline, within 72 hours of their last treatment, and at a 1-month follow-up. Patient reported outcomes included self-reported disability (Foot and Ankle Ability Measure; FAAM) and self-reported physical activities levels (NASA Physical activity status scale). Clinician measures of interest were dorsiflexion range of motion (weight-bearing lunge test) and single-limb balance. Overall, the plantar massage and calf stretching groups had the best improvements in patient and clinician reported outcomes. After 2 weeks, all 3 STARS programs had improvements compared with the control group. The plantar massage and calf stretching groups had the largest improvements in patient-reported disability and number of episodes of giving way. The calf stretching and joint mobilization groups had improvements in range of motion, while all 3 groups had improvements in single leg balance. The plantar massage group had the most pronounced improvement in balance after two weeks.
Each STARS group had unique improvements. For example, joint mobilization offered the most meaningful benefit for improving dorsiflexion, plantar massage led to the most meaningful change in balance, and stretching offered benefits in various outcomes. Amazingly, these benefits were achieved with just six 5-minute treatment sessions during a 2-week period. Clinicians could carefully add a specific treatment to their rehabilitation protocol based on deficits found during assessment. It would have been interesting to see if any of the clinical findings (i.e., single limb balance & range of motion) had lasting effects at the 1-month follow-up. It would also be interesting to see if a combination of these techniques resulted in better short and long-term outcomes. For example, the joint mobilizations showed the best outcomes immediately post-treatments, while plantar massage showed better outcomes at the 1-month follow-up. The findings of this study help to confirm that clinicians should consider STARS to target improvements in certain areas for patients with CAI.
Questions for Discussion: Are there any other therapy decisions that you have used with individuals with CAI? What has your experience been with trying to improve patient and clinical outcomes in patients with CAI?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
PNF Stretching Increases Ankle Dorsiflexion Range of Motion and Decreases Tendon Stiffness Following a 6 Week Program