Step By Step

May 22, 2019

Cutting, sprinting, jumping, landing—athletes rely on their ankles for a lot. In this three-part article, athletic trainers share how they managed a trio of different ankle injuries.  

The following article ran in the July/August 2015 issue of Training & Conditioning.

By Vincent Scavo and Dr. Luis Feigenbaum

Vincent Scavo, ATC, LAT, is Associate AD/Athletic Training, and Luis Feigenbaum, PT, DPT, SCS, CSCS, ATC, LAT, is Senior Associate AD/Performance, Health and Wellness at the University of Miami.

When University of Miami running back Randy “Duke” Johnson suffered a fractured and dislocated ankle in November 2013, some wondered whether he’d be able to come back to the football field. Others doubted if he could ever possess the same speed and agility he was known for. However, thanks to a rehab spent as much in the weightroom as the athletic training room, he not only returned for the 2014 season, he came back with 10 pounds of added muscle, was one of the top rushers in the Atlantic Coast Conference (ACC), and became a third-round pick in the 2015 NFL Draft.

Duke’s rehab began three days after his injury occurred and less than 24 hours after his ankle was surgically repaired with screws and plates, by team physician Lee Kaplan, MD. Factoring in the severity of the injury and the knowledge that Duke wanted to come back bigger, stronger, and faster, we knew we had a long road ahead of us.

To make the rehab more manageable, we broke it into four phases: protection, functional progression, sport-specific, and supervised sport activities. Each stage included both therapeutic and strength components. We also followed the team physician’s guidelines to achieve a careful balance between overloading but not overtraining.

Protection: Duke was non-weight bearing for the first month post-op to allow for proper fixation and soft-tissue healing. Then, he transitioned to toe-touch weight bearing.

Our rehabilitative goals during this phase were to protect Duke’s postoperative ankle, eliminate effusion, restore adequate range of motion, and mitigate weakness caused by arthrogenic muscle inhibition. We achieved these by controlling the amount of time Duke’s leg was in a dependent position, performing ankle isometric contractions, and completing manual resistance of his hip. To specifically target range of motion, we had him do ankle pumps and write the alphabet in the air with his foot.

To get a jump on his performance plan, Duke returned to the weightroom right away. While non-weight bearing, he started an aggressive upper-body lifting regimen, which consisted of a variety of seated or supine presses, curls, and flys.

Duke also partnered with team sports nutrition specialist and exercise physiologist Anthony Musto, PhD, to adjust his nutritional plan to account for his reduced activity level. Dr. Musto recommended Duke cut out the sugary beverages he was fond of, such as fruit punch and sweet tea, to maintain his body composition.

Functional progression: From February to March, our rehab goals were to achieve full active ankle range of motion; improved core, hip, and ankle strength and endurance; symmetrical gait; single-limb balance and postural stability; and pain-free and uncompensated mobility. To achieve these, we completed manual resistance for Duke’s foot, ankle, knee, and hip; multi-planar gait drills; and progressions for heel raises, supine bridges, planks, single-limb stances, squats, and lunges.

Duke continued his upper-quarter lifting program during this second phase. He was able to gradually progress back to a normal stance for all exercises.

Sport-specific: Once Duke’s rehab shifted to football-specific activities from April to June, treatments focused on normalizing his running pattern and building stability in his ankle. At this point, we began incorporating multi-planar speed drills that emphasized acceleration and deceleration, multi-planar agility drills that worked change of direction, ladder drills, and cone drills. At first, Duke completed these movements in the pool, but switched to level surfaces as he improved. We also implemented a jogging to running progression during this phase.

In the weightroom, Duke was able to introduce Olympic lifting to his regimen. In addition, he added a lower-
body program to complement his upper-body lifts, incorporating squats, box jumps, cleans, lunges, leg extensions, leg curls, and bridges.

Supervised sport activities: By the six-month mark, Duke was cleared to return to play, so our rehab goal from July to August was progressing him to supervised sport-specific activities. To test his agility and mobility, we utilized the Comprehensive High-Level Activity Mobility Predictor-Sport. We found movement insufficiencies in his sagittal plane mobility and his frontal and transverse planes, so we adjusted his treatment program.

To improve Duke’s deficits in sagittal plane mobility, we used acceleration/deceleration exercises and strengthened his thigh and trunk muscles. His frontal plane deficits were addressed with lateral agility drills and by strengthening his lumbo-pelvic hip complex. Lastly, we used rotational agility drills and strengthened Duke’s hip rotators to tackle his transverse plane deficits.

As much as rehab and strength and conditioning were instrumental in getting Duke back on the field, taking care of his mental health played just as important a role. Shortly after his surgery, we evaluated him using the Tampa Scale for Kinesiophobia-Shortened Version, a questionnaire that assesses an athlete’s fear of reinjury, fear of pain, and ability to perceive and report symptoms. Duke’s score was low, which suggested he was mentally prepared to handle the rigors of recovery.

When we got into the meat of Duke’s rehab, we used several strategies to keep him upbeat. For example, small victories built his confidence, which translated to even more success. Therefore, we took advantage of every opportunity to showcase his progress, from immediately implementing upper-body weightroom work to incorporating position-specific drills in the athletic training room.

Duke also fed off of the medical staff’s opinion on his progress. Each favorable follow-up visit with the team physician seemed to serve as a confidence booster.

One of the final stages of any recovery is helping the athlete overcome the fear of reinjury. With Duke, we embraced the concept of “causative cures” to ensure the physical and mental aspects of his rehab were intact. This meant replicating the position of how his injury occurred using balance and proprioceptive exercises. In addition to being physically capable, Duke had to consciously trust his ankle to complete the exercises correctly.

By the end of August, Duke’s rehab was complete, and he could begin to enjoy the results. For starters, his focus on improving his nutrition paid off. He was able to bulk up from 195 to 205 pounds and increased his lean body mass by more than seven pounds. Meanwhile, his body fat percentage decreased from 13.3 to 11.9.

In the weightroom, improving his body composition translated to strength gains. When Duke returned to the team, he was able to complete 19 bench press reps at 225 pounds, up from his previous personal best of four when tested as a freshman.

Building strength also had a direct impact on Duke’s performance on the field. The added muscle meant he could tolerate more contact over the course of the season, and he was able to expand his repertoire of plays to include more inside runs. In addition, Duke’s trademark stiff-arm became stronger and more effective.

By the time the 2014 season started, Duke was firing on all cylinders, mentally and physically. On the field, that translated to 1,652 rushing yards, 421 receiving yards, and 13 total touchdowns. Those numbers propelled him to become Miami’s all-time record holder in all-purpose yards, rushing yards, and yards per carry. To cap off the year, he was named first-team all ACC and won the Brian Piccolo Award, annually given to the “most courageous” football player in the league.

After Duke’s monstrous season, he was a third-round pick of the Cleveland Browns in the 2015 NFL Draft. His aggressive approach to rehab not only helped him come back at a high level in college, but will also propel him to new heights in the NFL.

 

Playing Through Pain

By Beth Tenore

Beth Tenore, MS, ATC, served as Assistant Athletic Trainer for the State University of New York at Buffalo at the time of this article.

Coming back from lateral ankle reconstruction surgery would be daunting for any athlete. Having to undergo the procedure a second time less than two years later would lead a lot of players to call it quits. And few would even consider returning to play if the surgery failed again. Yet for Mackenzie Loesing, this sums up a three-yeaar priod. as a women’s basketball player at the State University of New York at Buffalo (UB).

When Mackenzie arrived as a freshman in July 2012, she was four months out from her first reconstruction surgery on her right ankle. We spent the next 12 weeks advancing her recovery with dynamic stabilization and running and jumping progressions. By seven months post-op, she had returned to sport. She competed braced and taped while continuing her rehab to maintain strength.

As Mackenzie’s freshman season progressed and she became a consistent starter, she reported occasional discomfort and pain in her right ankle. The following summer, she said the joint felt unstable, despite no specific mechanism of reinjury. A visit to an ankle specialist revealed that the reconstruction surgery had failed. Mackenzie had partially torn both her anterior talofibular ligament (ATFL) and calcaneo-fibular ligament. Not wanting to go under the knife again so soon, she decided to play through the pain and put off surgery until after her sophomore season.

Since Mackenzie was missing the ACL equivalent in her ankle, we needed to implement a comprehensive stabilization and strengthening program to keep her on the court. I put her through the Functional Movement Screen and designed a plan that took a full kinetic chain approach to managing her injury.

To treat Mackenzie’s pain and edema, I employed a variety of modalities, such as Kinesiotape, ultrasound, intermittent compression, and e-stim. I also utilized Graston to address the trigger points that had developed in her lower leg from compensating for her torn ankle ligaments.

Working closely with Nate Harvey, MS, SCCC, UB’s Head Strength and Conditioning Coach for Olympic Sports, our main goal in the weightroom was to strengthen the muscles that crossed Mackenzie’s ankle, as well as the larger lower-extremity muscles that attenuated the forces through her ankle. To do this, we used clamshells, hip-hikes, pistol squats, donkey kicks, lateral band walks, and monster walks. In addition, we utilized the pool, bike, and elliptical for conditioning and implemented core exercises to build her neuromuscular control.

As a result of our efforts, Mackenzie was able to suit up for her entire sophomore season, starting all but one game and averaging more than 16 points per contest. Once the season concluded, she had her second reconstruction surgery. This time, though, we were a bit more conservative with her return-to-play progression. We didn’t start rehab until six weeks post-op and began with range-of-motion exercises and light strengthening. Gradually, we moved to moderate resistance exercises and incorporated proprioceptive activities.

Knowing that undergoing two post-op ankle rehabs in two years would be mentally taxing, we kept a close eye on Mackenzie’s outlook. To keep her motivated and engaged, Nate and I came up with a weightroom plan that would allow her to participate in team lifts. Doing a lot of seated upper-body work and single-leg exercises, Mackenzie was able to spend valuable time with her teammates, who cheered her on and spotted her when she needed it.

In the athletic training room, I tried to help Mackenzie stay positive by keeping things light and upbeat. Sometimes, we’d poke fun at her situation by joking about how swollen her ankle was (e.g., “Oh, today is a good day—only the size of a golf ball, not an orange!”). Even saying things like, “Bikini season is coming, and all this biking is going to have you ready in no time!” would get her laughing during yet another session on the recumbent bike.

At times, injury-related discussions were too heavy, so we tried to bring her focus back to basketball. While she was observing practices, her teammates would ask her what she was seeing on the court, and I often asked her about the techniques, plays, and strategies of the game so she could stay in touch with her ballplayer side.

Mackenzie returned to play without any restrictions in time for the 2014-15 season, and it started off well. However, during a Thanksgiving tournament, she began to have sharp, shooting pains in her foot and up her leg and reported a clicking, pinching sensation in her anterior ankle. She went to the ankle specialist and got an MRI, which revealed she had ruptured her ATFL for the third time. Again, there was no specific mechanism of injury.

Considering Mackenzie’s history of two failed reconstructions, the doctor felt it was in her best interest to end her basketball career. This was devastating news for her. Mackenzie and I spent a lot of time discussing her options going forward, which were extremely difficult conversations.

When she asked for my input, I stuck to the facts. I went over the short- and long-term risks of continuing to play (dislocation and fracture acutely, arthritis and a reduced quality of life in the future), clarified what the doctors said, and tried to lay out all her options. Throughout her entire deliberation process, I gave Mackenzie as much information as I could without inserting my opinion, and I never tried to convince her to retire. There is a time and a place to be emotional as an athletic trainer, but it’s not when your athlete is deciding whether or not to end their career. After also consulting with her family and coaches, Mackenzie opted to play as long as she was able, with the goal of finishing her junior season.

Managing Mackenzie’s third ATFL tear while she continued to play was our most trying endeavor yet. I employed every pain management tool I could think of, including Hivamat, H-Wave therapy, neural flossing, corticosteroid injections, and trigger point release, but few provided lasting relief.

No idea was off limits if we thought it would keep Mackenzie’s pain levels down. I even tried convincing her to wear sneakers every day to support her ankle—good luck getting a 20-something with fashion sense to do this for any amount of time—and we put limits on how long she stood throughout the day. Wearing sneakers seemed to be the most effective modality, but it became a crapshoot as the season went on—what helped on Monday didn’t always work on Tuesday.

Nate and the women’s basketball coaches got involved, as well. To limit the stress on Mackenzie’s ankle, she only practiced the day before games. This helped rest her ankle, but it proved frustrating for Mackenzie. She would expect her ankle to feel better at practice after several days’ rest, but this usually wasn’t the case.

In addition, any conditioning work was done in the pool or on a bike. Initially, this plan was effective, but as the season progressed, even biking and swimming caused Mackenzie pain.

Despite the physical and mental struggles, Mackenzie made it through her junior year successfully. She scored her 1,000th career point, becoming only the fifth junior in program history to do so. She was also named Mid-American Conference Sixth Player of the Year and led the team to the Women’s National Invitational Tournament for the first time in school history.

Unfortunately, the 2014-15 season was Mackenzie’s last on the court. She underwent her third ankle reconstruction over the summer and will not attempt to play again, opting to take a medical disqualification for her senior year and serve the team as a student coach.

All things considered, I don’t think Mackenzie regrets playing against her doctor’s advice, and I don’t regret my decision to support her. As athletic trainers, it is our job to consider an athlete’s future health, but sometimes, all we can do is arm them with the knowledge of what could happen and let them decide how to proceed. In Mackenzie’s case, she was not ready to give up the game, even after her second failed surgery. So when she committed to finishing her junior season, I committed to giving her that chance.

 

Little Bone, Big Issue

By Dale Blair

Dale Blair, MS, ATC, CSCS, is Head Athletic Trainer at Wenatchee (Wash.) High School. Named to the Northwest Athletic Trainers’ Hall of Fame in 2006, he was honored as a NATA Most Distinguished Athletic Trainer in 2014.

Os trigonum syndrome is often mistaken as a routine ankle sprain. Since it’s often triggered by a plantar flexion mechanism and accompanied by swelling and pain, it’s easy to see why. So when Christian Brandt-Sims, a football, basketball, and track athlete at Wenatchee (Wash.) High School, twisted his ankle while walking down a hill in December 2013, I thought it was a typical sprain. It took five months of continuous symptoms, visits to two podiatrists, and lots of trial and error before we finally discovered the tiny bone that was causing the trouble.

When Christian’s injury first occurred, it was the middle of basketball season, and he was eager not to miss any time on the court. For treatment, we started an ankle strengthening/proprioceptive rehab protocol and taped his medial longitudinal arch and ankle for practices and games.

A month later, Christian’s condition hadn’t significantly improved, so I started to think it was more than an ankle sprain. He was referred to a local podiatrist, who diagnosed him with a tibialis posterior strain. Christian then decided to end his basketball season and focus on rehabbing his ankle.

To treat the strain, we added interferential stimulation to our rehab protocol. I also had Christian do foot and medial ankle strengthening exercises, such as weighted towel toe curls.   

Once the spring track season started, we continued treatment and modified his workouts to ease the stress on his ankle. But he was still plagued by pain, immobility, and swelling.

There is a fine line between deeming a treatment “ineffective” and being patient with a rehab protocol. However, both Christian and I eventually became frustrated with his lack of progress. We tried increasing the intensity and number of exercises in the program yet backed off after we saw little improvement.  

By this point, it had been nearly five months since Christian’s initial misstep on the hill, and he had made little to no progress in his recovery. Concerned, I referred him to a sports podiatrist for a second opinion. After an X-ray, MRI, bone scan, and physical examination, we finally had the correct diagnosis for Christian’s ankle: He had os trigonum syndrome.

The os trigonum is an accessory bone that forms in the posterolateral aspect of the talus within the joint capsule. The presence of an os trigonum is congenital, and less than 10 percent of people have it. Os trigonum syndrome arises with a twisted or rolled ankle, which aggravates the accessory bone and causes inflammation, pain, and limited mobility.

Looking back, I understand why it took so long to land on the os trigonum diagnosis. For starters, since so few individuals have the accessory bone and even fewer develop the syndrome, it’s not a condition that most sports medicine practitioners are familiar with.

In addition, after the first podiatrist diagnosed the tibialis posterior strain, we found Christian also had a foot/lower-extremity biomechanical structure that could keep his tibial posterior inflamed. Therefore, the continued pain seemed like a natural byproduct and supported the physician’s diagnosis.

Once we finally identified Christian’s injury, we were able to take more effective action. There are two ways to treat os trigonum syndrome. The first method involves injecting four corticosteroid shots into the ankle over a five-week period. Often, this is enough to alleviate symptoms. If it fails, the next step is a surgical procedure to remove the bone.

Already several weeks into the track season, Christian was barely able to participate and gladly accepted the corticosteroid injections. They temporarily alleviated his symptoms and enabled him to use his ankle much more freely. For the remainder of the season, we had Christian train on an underwater treadmill or stationary bike instead of the track, minimizing the stress on his ankle while maintaining his cardiorespiratory conditioning. He was able to compete in a few meets, ultimately placing in two hurdle events at the state track competition.

Unfortunately, once the season concluded, we realized the corticosteroid injections did not completely address Christian’s pathology. He had surgery on June 11, which included a synovectomy and removal of the os trigonum from his right ankle. For three weeks post-op, Christian was on crutches and non-weight bearing, before transitioning to partial weight bearing for another three weeks and beginning a rehabilitation program that included ankle mobility, strengthening, and proprioceptive exercises.

Two months post-op, Christian returned to full activity. He participated in football and track during the 2014-15 school year and got through both seasons without any issues.

The experience of rehabbing Christian’s os trigonum syndrome has taught me to think twice when athletes present with nagging posterior ankle pain and don’t respond to treatment in a traditional timeframe. Maybe they just have an ankle sprain, but, like Christian, they could have os trigonum syndrome. If not caught early, that little bone can be a big pain.

 

 

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