CAI Rehab & Treatment Tips

You need to assess joint range, laxity, strength & swelling

AND

 Neuromuscular deficits


Neuromuscular deficits may be manifested as:
Impaired balance
Reduced joint position sense (JPS)
Strength deficits (any mm group)
Decreased ROM (esp DF)
Slower firing of peroneals to inversion perturbation
Slowed nerve conduction velocity
Impaired cutaneous sensation


Treatment & rehabilitation must not only address mechanical stability

but ALSO

Restoration of neuromuscular function



Good evidence for:

1. Both MAI & FAI contribute to CAI.

2. Often still deficits in  Dynamic Postural Control (DPC) at 6 months - they need long term rehab! Patients can benefit from the Ankle Rehab App to increase compliance.
Journal of Orthopaedic & Sports Physical Therapy, Ahead of Print : pp. 1-29
(doi: 10.2519/jospt.2015.5653)


3. CAI patients have a more ‘laterally based foot’ in gait & Functional activities. Try to retrain normal foot placement/position and feedback to land jumps and hops with a flat foot.

4. Delayed peroneal reaction time (feedforward system disrupted, ie, not just the feedback systems) – activation & timing issues – not just strength.

Simon, J. and Docherty, C. (2014) Slower Nerve ConductionVelocity in Individuals with Functional Ankle Instability. Int Jou Sports Med, 35 (9): 731-736.


6.Train the whole functional range – not just around neutral position – as the JPS & proprioception is especially poor in the inverted position...their area of danger where they need the best recovery of all.

7. Ax & Rehab multi-directional (not uni-planar). Specificity to the activities they need to return to. Variety of movements and challenges.

8. Postural control is definitely reduced at the ankle - central deficits theorised.
Riemann, B.L., and Lephart, S.M(2002) The Sensorimotor System, Part I: The Physiologic Basis of Functional Joint Stability, J AthlTrain. 37(1), p71-79.
Riemann, B.L., and Lephart, S.M(2002) The Sensorimotor System, Part II: The Role of Proprioception in Motor Control and Functional JointStability, J Athl Train. 37(1), p80-84.

9. Maximise ankle input & output by minimising hip & knee compensatory movements.

11. Challenge all variables when training proprioception
The main situations when CAI get giving way are:
1. When they are distracted, eg looking up at a sign, crossing the road, etc. Their eyes (which are usually compensating heavily for the poor proprioception) are looking elsewhere.
2. Over uneven surfaces such as a field, or over cobblestones.
3. In unmet challenges.

Thus, in rehabilitation:
- look all different directions, not just straight ahead - changes in head position will also change vestibular input.
- train at various body positions (eg, knee bent at different angles, or in lunges/tackle positions, etc).
- incorporate dynamic not just static training,
- various surfaces (eg, mini tramploline, air balance cushion or x2 cushions)
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