Ankle Injuries in Sport:
• Common
• Debilitating
• Poorly Rehabilitated
• Reocurring
• Functional Instability

Chronic instability is not limited to injuries:
Genetic and neuromuscular disorders result in instability without trauma.
Hereditary Disorders of Connective Tissue (HDCT)
• Ehlers-Danlos Syndrome
• Marfan’s Syndrome
• Osteogenesis Imperfecta
• Benign Hypermobility Syndrome (Mild EDS
Hypermobility – Type III)

Hereditary Disorders of Connective Tissue:
•Result of defective collagen (glue)
•Elastin and collagen are weak
•Tissue is frail and lax
•Fibrillins are weak and tear

Up to 70% show the same symptoms as those with frequent ankle sprains.

“Hypermobility is defined as an abnormally increased range of joint motion due to excessive laxity of the constraining soft tissues” (Everman, 1998).
Clinical Maneuver
Apposition of Thumb to Forearm
Right
Left
Extension of fifth finger beyond 90 degrees
Right
Left
Extension of elbow beyond 10 degrees
Right
Left
Extension of knee beyond 10 degrees
Right
Left
Forward flexion of trunk, legs straight, palms touching the floor
Total Beighton Score (0-9)
Unable to perform
(0 points)
Able to Perform
(1 Point)
0
0
0
0
1
1
1
1
0
0
0
0
0
1
1
1
1
1

Inability to use the ankle for daily activity:
• Walking
• Standing
• Bathing
• Getting out of a chair
• Basic balancing
Functional instability of the ankle is the most common residual disabilities after an acute ankle sprain.

• Strengthening (pronation)
• Balance
• Proprioception
• Caused by nerve-fiber damage
• Traditionally low in hypermobile subjects
“Recent studies have demonstrated reduced proprioceptive sensation in the joints of subjects who have hypermobility syndrome. Such findings have led to speculation that impaired sensory feedback contributes to excessive joint trauma in effected individuals” (Everman, 1998).

Most common trauma:
•Talofibular Joint
•Calcaneofibular Joint
Other trauma – often seen in hypermobile subjects:
• Talocrural Joint
• Talocalcaneal Joint
• Talocaneonavicular Joint
• Calcaneocuboid Joint

Traditional rehabilitation therapies:
• Balance Boards
• Theraband resistance
• Open and Closed Kinetic Chain
• Peroneal reaction treatment
• Joint proprioception treatment

Traditional means of rehabilitaion:
• Resistance training
• Reactive Neuromuscular training
• Proprioceptive training

Study purpose was to determine the effects of exercise on nonaccident-related chronic ankle instability, particularly in subjects who have Ehlers-Danlos Syndrome or Benign Hypermobility Syndrome.
The study looked at multi-range stability in the talocrural, talocalcaneal, talocaneonavicular and calcaneocuboid joints .

Hindfoot
Talocrural
Tibiofibular
Talocalcanear (Subtalar)
Midfoot
Talocalcaneonavicular
Cuneonavicular
Cuboideonavicular
Intercuneiform
Cuneocuboid
Calcaneocuboid

Participants:
• Direct Observation
• Volunteers
• Hypermobility Syndrome
• Five or higher on Beighton’s Scale
• 18-older
• No recent ankle trauma
• No severe ankle trauma

Procedures:
• Eight-Week Exercise Program
• Three days of exercise per week
• Traditional Rehabilitation Therapies
• Resistance Training
• Reactive Neuromuscular
• Proprioception/Balance
• Active stabilization exercises

Measures:
•Range of Motion
•Functional Strength
•Stability
•Proprioception
•Neurological Reflex
•Study start, after four weeks, study end (total of three measures)

Range of Motion:
• Standard Goniometer
• Anatomical Neutral
• Dorsiflexion – 20 0
• Plantar Flexion – 50 0
• Inversion – 5 0
• Eversion - 5 0

Monthly Training Regimen
Exercise
Resistance Training
Reactive Neuromuscular Training
Proprioception Exercises
Active Stabilization Exercises
Mon.
Tue.
Wed.
Thur.
Friday Sat.
Sun.
X X X
X
X
X
X
X

• Leg Press
• Calf Raise
• Knee Extensor
• Knee Flexor
• Two sets of 12 repetitions at 60% max.
• Resistance increased by 10% at week four
• Third set added at week seven

Used resistance tubing:
• Uniplanar Anterior Weight Shift
• Uniplanar Posterior Weight Shift
• Uniplanar Medial Weight Shift
• Uniplanar Lateral Weight Shift

One-foot standing balance
One-foot standing balance with hip flexion
One-foot standing balance using weights in diagonal pattern
One-foot standing balance while playing catch
Exercises on balance board

Used a step-stool measuring 16” x 16” x 8” (40.6cm x 40.6cm x 20.3cm
• Forward step-up on stool
• Lateral step-up on stool
• Two-foot hop-up on stool
• Two-foot lateral hop-up on stool
• One-foot hop-up on stool
• One-foot lateral hop-up on stool
• Two-foot jump-over stool
• Two-foot lateral jump-over stool
• One-foot jump-over stool
• One-foot lateral jump-over stool

Plantar Flexion
Dorsiflexion
Inversion
Eversion
Measured on a scale 0-15:
• 0 Non functional
• 0-4 Functionally Poor
• 5-9 Functionally Fair
• 10-15 Functional


 Overall increase in functional strength
 Decrease in pain
 Decrease in joint popping

 All participants fully functional in all tests
 Virtual elimination of pain
 Elimination of joint popping

Less = lower exercise = atrophy = less functionality
More = more exercise = hypertrophy = more functionality =
Independence= Higher Quality of Life

More = depression = unwillingness to exercise = atrophy = more pain
Less = Better outlook = social activities = social exercise = Less medication = Higher Quality of Life

Less = Poor balance = unwillingness to exercise = Higher risk of injury =
Nerve fiber damage = Decreased proprioception
More = Better balance = feeling of ability = exercise adherence = lower risk of injury = Increased independence = Higher quality of life

-20
-30
-40
-50
-60
-70
20
10
0
-10
-1
R Plnt
R Dors
R Invert
R Evert
L Plnt
L Dorsa
L Invert
L Evert
-2 -3 -4 -5

10
0
-10
-20
-30
-40
-50
-60
-70
R Plnt P
R Dors P
R Invert P
R Evert P
L Plnt P
L Dorsa P
L Invert P
L Evert P

-15
-20
-25
-30
0
-5
-10
Part. 1 Part. 2 Part. 3 Part. 4 Part. 5 1-5 Mean

Overall decrease in both passive and active indicates:
Hypermobile joints can be strengthened and stabilized before laxity leads to injury.
Proper, supervised exercise is of benefit to this population

Inversion injuries:
• Common
• Reoccur
• Difficult to rehabilitate

Participants showed:
Decreased Range of Motion
Decreased Pain and Joint Popping
Increased Balance and Proprioception
Increased Daily Functioning

Rehabilitation of other joints for this special population
Shoulder Capsule
Hip Socket
Interphalangeal Joints
Metacarpophalangeal Joints

EDS patients, and possibly patients with other hypermobility syndromes, could be treated in multiple joints prior to disruptive injuries or the need for surgery due to joint hyperlaxity.
Injury and surgery is more damaging and dangerous for this population than the average person.

Study participants showed primary gains during the initial four weeks of study intervention
Primary increases in range of motion occurred during the final four weeks of study intervention
Therefore, it is possible that a four-week intervention followed by maintenance would be as, if not more, successful

Studies involving a larger population and studies involving multiple-joint treatments
Long-term effects of exercise on children with Hereditary
Disorders of Connective Tissue
Four-week versus Eight-week programs
Animal studies involving muscle, tendon and ligament tensile strength, elasticity and plasticity