Erin Reeves

Sasser

IR 1/Period 3/11 AP

03/07/2017

Man Downand Down Again:

The Efficiency of a Proprioceptive Training Program for Sprained Ankles to Decrease Risk of

Re-injury in High School Athletes

An average of 23,000 ankle sprains happen every single day (Hayman 32). When the

number is presented solitarily, it may be hard to believe. However, when compared to the fact

that only 4,000 more vehicular accidents occur each day (How Many 1), the importance of

ankle injuries becomes more striking. Teenage athletes who are recovering from ankle injuries

should recognize the impact of the injury, the importance of rehabilitation, and the risk of

ongoing conditions. One measure that is extremely important to ankle injury patients is the usage

of a physical therapy program for neuromuscular strength training. An ankle sprain is very

common for teenagersathletes and non-athletes alike. The most common cause of an ankle

sprain occurrence is extreme inversion and plantar flexion, usually affecting the lateral ankle

complex. The lateral ankle complex is composed of three ligaments: the anterior talofibular, the

posterior talofibular, and the calcaneofibular (Chinn 158).

Ankle sprains have a range of severity, and can be classified under Grade I, II, or III. The

severity of the sprain is determined by the amount of damage done to the ligaments and tendons

in the ankle joint. A first grade or first degree sprain is when the tendons and ligaments in the

ankle joint have been stretched to the point of uncomfort but not torn. Symptoms includes mild

pain, some swelling, mild joint stiffness, and some difficulty jogging or running (Choo). Second
degree sprains are the most common among not only teenage patients but adult patients as well.

In a second degree sprain, the ligaments are stretched and partially torn. There is significant

swelling on the ankle, as well as significant bruising. There is a moderate amount of pain when

pressure is applied to the affected foot, and the patient has trouble walking (Choo). A third

degree sprain is the most severe of the three degrees. In a third degree sprain, the ligament has

been severed completely. Common symptoms of this level of sprain include severe swelling,

severe pain, instability of the joint, extreme loss of motion, and walking can be very painful

(Choo).

The patient will receive an initial diagnosis by a doctor following the initial sprain, which

includes a general mobility test, and sometimes an x-ray or MRI, if the doctor has reason to

believe that a higher degree sprain has occurred. The patient will be prescribed a brace and a

physical therapy regimen. The grade, or degree, that the ankle sprain was classified under will

determine the intensity of the treatment program. If more damage was incurred, the intensity will

increase. While the intensity may fluctuate, it is important to note that the nature of the

rehabilitation program is not altered. The neuromuscular training program for the rehabilitation

of ankle sprains is used concurrently for the prevention of a recurring ankle sprain. This training

program is recommended by a multidisciplinary clinical practice guideline, developed with the

aim to prevent further health impairment of patients with acute lateral ankle injuries and meant

for all care providers who are involved in the treatment and guidance of patients with ankle

injuries (Mailuhu et al. 2). The effects of acute ankle injuries do not stop after the athlete returns

to play. If the ankle had not healed properly, there are a few repercussions that the athlete should

keep in mind. However, these repercussions may be prevented or at least lessened if the athlete

keeps up with their physical therapy as prescribed by their doctor, and the exercises they should
complete on their own. In a study conducted at the School of Public Health in Ireland by Doherty

et al., it was found that 40% of patients studied reported chronic ankle instability a year

following the study (Doherty 5). Furthermore, every subsequent ankle injury further increased

the athletes risk of a re-injury to that extremity.

Figure 1.1

Ankle injuries are one of the leading injuries in all ages alike, including teenage athletes,

adult athletes, and non-athletes. Ankle injuries are the most common sports injury in high school

athletes, accounting for roughly 22.6% of all high school sports-related injuries (Nelson et al.

383). The patterns of sports-related injury vary slightly by sport, age, and type of athletic

exposure, but one fact remains consistent: Nearly 20,00,000 injuries occur yearly in organized

high school athletics, and the ankle is the most commonly reported site of injury (Nelson 381).

Figure 1.1 (Nelson) presents the breakdown of the occurrence of injury in 7 different sports and
two genders Overall, girls had an ankle injury rate that was similar to boys. It is already known

that ankle injuries are the leading type of injuries for the general population. This knowledge can

be applied to warn athletes and non-athletes to take special precaution when dealing with ankle

injuries. Before an injury even happens, the patient should be thinking of preventative measures.

It is important to care for the ankles because there are many facets of the additional benefits to

the remainder of the body and well-being of the athlete. One facet is improved balance. Since

balance and joint stability mutually depend on sensory input from peripheral receptors, balance

can be interpreted as a function of joint stability. Being a joint of the lower extremity in close

proximity to the body's base of support, the ankle plays an integral role in maintaining balance.

Thus, the stability of the ankle joint is paramount when considering regulation of balance

(Blackburn et al. 316).

A neuromuscular training program is a medically accredited format to present to an ankle

sprain patient. The completion of such a program can have many additional benefits to the

patient, aside from the standard goal of healing the ankle, so that he or she may return to normal

activity.

Foremost, a neuromuscular training program will allow the patient to train their ankle

back to normal abilities in a shorter period of time then if the patient were to simply wait out the

injury until it felt functional to them. Manual therapy, such as the exercises presented in a

neuromuscular training program, have been proven to have beneficial effects following acute and

subacute ankle injuries involving the complete gradient of sprain severity. A study by Lin et al.

proved that manual therapy also increased ankle function up to 1 month following the

treatment (Lin et al. 23). This study corroborates multiple others in that they all prove

neuromuscular training programs to hasten the recovery time of an acute ankle injury, much to
the athletes benefit. A neuromuscular training program, in addition to the immediate healing of

the ankle, has numerous short-term and long-term effects on the patients ankle and their general

health.

A short-term facet that a neuromuscular training program would remedy is the patients

balance. Balance and the stability of joints depends on the input created by peripheral receptors.

Thus, balance can be interpreted as a result of joint stability. As the ankle is a joint in the lower

extremity of the body and very proximal to the bodys base of support, it likely plays a pivotal

role in the ability of a patient to balance themselves (Blackburn et al. 316). Thus, the health of

the ankle may be directly correlational to the bodys overall ability to balance. In a study by

Karakaya et al., it was found that proprioceptive training for the ankle, including stretching,

strengthening, and balance board exercises during two weeks, causedsignificant improvements

than no intervention (3301). Evidently, the usage of a proprioceptive training program has more

benefits to the athlete than just the ankles health and wellbeing.

Furthermore, the usage of a neuromuscular training program has long term benefits on

the ankle sprain patient. The primary facet that patients want to avoid is chronic ankle instability.

It was found that 32-74 percent of individuals with a previous lateral ankle sprain history suffer

from chronic symptoms, such as chronic ankle instability (Evidence review 5). The majority of

patients with a lateral ankle sprain history will sustain at least one additional sprain, with many

developing physical and subjective functional limitations, with ongoing giving-way in the

affected ankle, resulting in the defined condition of chronic ankle instability (2016 consensus

1). It is crucial that the athlete takes certain preventative measures in an attempt to decrease their

risk of concurrent lateral ankle sprains, which will require a higher expenditure of time and

money on their part.

 A neuromuscular training program is pertinent to the well-being of the athlete and their

injured ankle. A training program will decrease the risk of re-injury by lessening chronic ankle

instability, and will maintain the athletes balance abilities post-sprain. Additionally, the training

program will allow the sprained ankle to heal more properly and faster than if the patient were to

heal the ankle on its own. While a training program should be properly implemented, it is up for

debate over which means it should be implemented.

While examining the patterns and trends of society and teenage athletes, the means over

which the training program is presented would be most effective when presented as an

application. Applications are more readily available and more whole-heartedly embraced by the

general population, teenagers in specific.

Some may advocate for the old-fashioned method of implementing this training program,

a hard-copy pamphlet or packet, given out by a physical therapist of caregivers digression.

However, this packet must be carried to the location of wherever the patient wishes to complete

their exercises. An application would be accessible on a mobile phone, a laptop, tablet, or any

other electronic device which are compatible with applications. Therefore, the training program

may be easily carried with the athlete wherever they find themselves at the time that they wish to

complete their training program. Furthermore, an application, such as the one used in a study by

Van Reijen et al., will becomprisedofinstructionalvideosandverbalinstructionswhereasa

papercopyincludedonlypicturesoftheexercisesthatneededtobeperformed(2).This

featurewouldbeahugebenefittothepatientifthepictureshappentobeconfusingornot

understandableatfirst.Inthatcase,thepatientmayquicklyaccessavideowithfurther

explanations.
 Anapplication,throughtheimplementationonadevicesuchasasmartphone,ismore

widelyaccessibletothegeneralpublicthanahardcopybookletwouldbe.Thisbookletwould

primarilybedistributedbythephysicaltherapistoffice,sothepatientmustvisitthe

establishmentonsitetoreceiveacopy.Ontheotherhand,theapplicationwouldbeeasily

downloadedfromawebsiteorapplicationstore.Therefore,itmaybeaccessedatanytimethe

patientdeemsitnecessary,withouttheabsoluteneedofvisitingaphysicaltherapisteachtime

theyneedtheexercises.

Theapplicationwouldalsohavemanycostbenefitsovertheusageofapaperbooklet.

Asidefromtheindirectcostsofpurchasingandmaintainanelectronicdevice,thedirectcostsfor

theelectronicapplicationwouldbenoneforthepatient.Ontheotherhand,apapercopywould

beexpensivetoprintoutnumerouscopiesforeachindividualpatient.Furthermore,distributinga

papercopyrequirethepatienttovisitaphysicaltherapistoffice.AstudybytheUSConsumer

ProductsSafetyCommissionestimatedthatin2003alonethedirectmedicalcostoftreating

anklesprainsinhighschoolsoccerandbasketballplayers(ages1518years)was$70million,

andtheindirectcostswere$1.1billion(McGuineetal.1103).Thepriceforemergencyroom

andphysicianvisitsforsprainedanklesisseverelyhigh,whichisamajorfactorthatworksasa

deterrenttoyoungathleteswouldwanttohaveadoctorassesstheirsuspectedsprain.An

applicationwouldridthesecosts,andwouldbeaccessibletotheathletewithoutanactual

prescription.

However,ifanathleteweretovisitadoctorandrequireaprescribedneuromuscular

trainingprogram,anapplicationwouldbearevolutionarywayforthedoctortokeepthepatient

uptodate.Afeatureofanapplicationwouldbethatitmaybeupdatedinrealtime.Thisallows
thedoctortogetmessagesacrosstopatientsinstantaneously,andadoctorcouldalsotailorthe

generaltrainingprogramtofitapatientsspecificneeds.Physicianswouldwanttheirtreatment

toseemasuptodateastheypossiblycan,asthisisafactorthatpatientsconsiderwhenchoosing

theirdoctor.ThetechnologicaladvancementsinthemedicalfieldsuchaseHealth,definedby

Verhagenetal.asthepracticeofmedicineandpublichealthsupportedbyelectronicprocesses

andcommunication(1),couldleadtoanincreaseinpatientsforphysicians,conveyingthatthe

benefitofanapplicationwouldnotonlyapplytothepatientsbuttothephysicaltherapistsas

well.

Thecompiledresultsindicatethatthecompliancyratestoasupervisedphysicaltraining

programarerelativelylow.Thismisfortunetothemedicalfieldisaccompaniedwiththefalse

perceptionthatlateralankleinjuriesareminorinjuries,andmaybehealedwithouttheproper

usageofaneuromusculartrainingprogram.Thefalseperceptionmustbecounteredwiththe

knowledgethataneuromusculartrainingprogramhasmultiplefacetsofbenefitsforthepatient.

Includedamongthesefacetsareimprovedbalance,decreasedriskofreinjuryandchronicankle

instability,andahastenedrecoverytimeandreturntotraining.Theimplementationofatraining

programpresentedonanapplicationwouldsurelybethemostbeneficialmediumofwhichto

presenttheneuromusculartrainingprogram.Theapplicationwouldbetailorabletotheneedsof

theathleteandthephysician,asitmaybeupdatedbythephysicianinstantaneously.

Furthermore,thecostbenefitsoftheapplicationaretremendous;itcouldpossiblycutoutclose

to$70millionspentonthedirectcostsofvisitinganemergencyroomforalateralanklesprain.

Applications,whencomparedtoahardcopypaperbookletofexercises,ismuchmoreaccessible
tothegeneralpublic,asmanypeoplehaselectronicdevicesandarethereforeabletoparticipate

intherevolutionizingtechnologyofeHealth.
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