R is for rehab - Journal 3

The following is a tracking of a collegiate female soccer player's syndesmotic ankle sprain, or more commonly known as the high ankle sprain. The date of injury was September 29. Her mechanism of injury invovled forced ankle eversion combined with dorsiflexion, while attempting to block multiple goals during a drill in practice. Her position is goalkeeper. The player presented with all the same signs and symptoms of a lateral ankle sprain, in addition to the location of pain being approximately two inches superior to lateral malleolus. Athlete was unable to support own weight, and was immediately removed from play, and remained on the sideline where ice, compression, and elevation was applied. Player was fitted with crutches, and instructed on use.

The following day, player was set up with ice and stim to aid in removing the moderate swelling that resulted. Ankle girth measurements, and goniometric measurements were taken. By day 3, which was a Thursday, the team generally holds light practices in preparation for Friday games, so player repeated ice/stim treatment to aid in reducing edema, given a compression wrap which consist of Power Flex tape wrapped distal-to-proximal without any figure 8's. Figure 8's can be done to help with angles, but I prefer not to do them when the goal is to aid in flushing edema from ankle. The upcoming Friday game was Away, so player was not scheduled to travel with the team, however unbeknownst to the Training staff, she did decide to drive herself three hours to the opposing school to watch the game. Player came in the next day (Saturday), which is when information of her travels were revealed, and was given ice/stim treatment, repeat of measurements, and a good-humored lecture! Player was given the remainder of Saturday off, as well as Sunday, and told to stay off ankle.

With the team playing on Sundays, Mondays are "off" days except for those requiring treatment, so player arrived with significantly less swelling and bruising, so we continued ice/stim treatment, and began range of motion (ROM) and mobility exercises. Although the swelling had subsided, player reported increased tenderness along anterior tibiofibular syndesmosis. Even though progress was being made, the Head Athletic Trainer scheduled her an appointment to have x-rays of her ankle the upcoming Tuesday; seven days post-injury. Player and I traveled to Dr. D's office where we waited 2 hours to be seen, and another 45 mins. to be evaluated. We recieved some good information, especially from the Physician's Assistant about taping techniques, but player was really upset over the whole "waiting" ordeal, only to be told what we already knew. But, this is when I had to explain to player the need for the x-ray; in order to diagnose/rule out any other serious problem.

The following day (8 days post-injury), we began a semi-aggressive rehab program, which I arranged in stages, that was to be combined with her continuing to practice with the team, scheduled workouts with the team, and rehab exercises with myself. By day 10, she was able to suit up and participate in most team drills, and individual position drills, with relatively little pain during activity. Most of her discomfort came after practice, where she would recieve additional treatment.

Her rehab would consist of a combination of up to 3-5 exercises under each category. Often, I would allow her to choose. The exercises with the asterisks are original ideas of mine, or alterations of existing ones.

Warm Up - 10 mins.

• Bike
• Warm whirlpool
• Light field jog
• Elevated sports massage

Manual Therapy - 10 mins.

• Lateral glides +inversion
• Medial glides +eversion
• Posterior glides +dorsiflexion
• Anterior glides +plantarflexion
• Traction
• MMT
• Achilles tendon stretch

Balance Activities - 15 mins.

• 1/2 foot balance x 30sec-1min
• Star drill
• Med-ball toss, w/o rebounder
• Body Blade
• Heel raise w/ lateral force *
• Crossover lunge

Strength & Mobility - 15 mins.

• Penny heel raises *
• Tubing
• Lateral shuffles
• Single leg heel touches
• Total gym
• Marbles

Balance/Reaction - 10mins.

• Wall ball
• Cones (plyo's)
• Hurdles (rope tied to UBE) *
• Circle Hops *
• Four square

Proprioception - 10 mins.

• X Factor *
• BAPS w/o ball
• Reach & 'round *
• Single leg body blade

Treatment - 15 mins.

• E-stim
• Sports massage

These are just a sample of the exercises we performed. There were other variations to these exercises that I would come up with, and adjustments I would make midway through the execution. Each day, we did something different, but remained within the different stages of difficulty. By the fourth week, she was at an advanced level and many of the activities were aimed at soccer-style movements.

Working with her, I learned a lot about the pysche of an injured athlete, motivation, how the body responds to different activities, the importance of clear instructions, being creative, and overall, caring and showing interest. In the beginning, I would sort of instruct her on what to do because I knew what the exercises were in my head, but I think she appreciated it when I began to write out what the planned course was for that particular day. Also, after every session, I would reassess her functionality and I think she appreciated that as well, because she would tell me what was different from yesterday, and how things have either progressed or regressed.

I really like the approach I took in regard to her rehab design. With the help from ideas we've learned in lectures, I chose to begin sessions with specific goals and give her an idea of where my expectations were aimed, and also, it gave her a chance to respond and share her goals.

Being the backup goalkeeper, there was no true measurement of her recovery; only what she reported. For instance, her returning to game form wasn't measured by her performance because she did not play. I believe she continues to have lingering discomfort, but she understands that this particular type of sprain, takes longer than usual.