Summer Session – 20th and 27th July 2020 for 6 hours

This reflection incorporates part 1 and 2 of the military series. In part one the presenter Pete Scott placed us in groups and assigned us with a case study which related to an injury which is common in the military. We then had to go away and design a programme for the end stage of rehab for the case study and present our findings in the next session (part 2).

Reflective Summary 

The case study that my group got given was a royal marine assaulter who is at the end stage of an ankle inversion injury. Pete informed us that a royal marine assaulter would be someone who climbs ladders, changes direction at speed and moves short and fast distances, therefore will have limited body weight. It was important to learn about the job role of our case study so the rehab programme could include exercises that are specific to what they have to do within their job. We also needed to consider how we would test them to ensure they are safe to return to work.

In part 2 of the military series each group presented their finding based off of the research that they had conducted for the case study. It was interesting to hear the different clinical tests and exercises that were includes in other groups programmes as some of these could be used in future programmes that I produce which I may not of heard of before.

During our discussion we informed the rest of the group of the tests we would use for an end stage ankle inversion injury including the Cumberland ankle instability tool and balance error scoring system, which is very specific to our case study because when climbing ladders and changing directions at speed one foot is planted therefore stability in the ankle and strength of the muscles in the foot and leg are important to support these movements which are required in a royal marine assaulters job. We also used clinical reasoning to decide whether the star excursion balance test (SEBT) or YBT was more specific to our case study. We concluded that the YBT may be better as it can help us to identify the risk of reinjury.

In order to produce the programme, we considered the common risk factors for lateral ankle sprains so exercises for strength have been included as well as proprioception, stability, neuromuscular control and mobility.

Areas for further improvement 

My first area for improvement would be to consider how each population who I work with differ. For example, within the military there clothing including footwear, body armour and helmet means they have a lot of functional differences. Therefore, in the later stages of rehab it would be vital to ensure they are completing the exercises with their equipment on so it is comparable to when they would get back to work. This will really help to see whether they are ready to return to work.

Also, in our rehab programme we needed to emphasise that at the end stage of not just an ankle inversion injury but any pathology they need to get back to doing the job roles that thy would usually do to show they are capable as this is the only way to find out.

Things to Remember:

  1. Consider the risk factors for the specific injury as this can help you to prevent the injury in the first place
  2. The stages of rehab are the same for every individual; reduce pain levels, protect the injury, active rest, ice, compress, elevate, move, regain ROM, regain strength, regain function, role specific rehab
  3. Use outcome measures at every stage of rehab as it can help you but more importantly the patient to see progress

Programme for case study and resources 

Case study = A Royal Marine Assaulter who is at the end stage of an ankle inversion injury. Design a programme for the end stage of rehab (pain free). 

A Royal Marine Assaulter: 

  • Climbs ladders
  • Changes directions at speed 
  • Moves short and fast distances 
  • Will carry limited body weight 

Consider:

  • How will we test them to ensure they are safe to return to work?
  • Include exercises that are specific to what they have to do within their job

Testing:

  • Would establish a baseline before beginning the programme 

Subjective Ax = Cumberland Ankle Instability Tool (CAIT)

  • The CAIT is a valid and reliable method for assessing ankle instability; it only tests the state of the ankle, rather than determining the risk of re-injury

Example of CAIT = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5847203/pdf/167_2016_Article_4350.pdf

Objective Ax:

  • Resisted ROM in PF, DF, INV, EV to test muscle strength… should be 5/5 on oxford strength scale 
  • No pain on palpation 
  • Establish if they can do a simple heel raise without pain or weakness (plantarflexion is important for going up and down ladders)
  • Single-leg balance.

Static balance = Balance Error Scoring System (BESS)

Example of BESS test = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445164/pdf/10.1177_1941738111403122.pdf

The BESS test, especially the single leg stance is specific to our case study. This is because when climbing ladders and changing directions at speed one foot is planted therefore stability in the ankle and strength of the muscles in the foot and leg are important to support these movements which are required in a royal marine assaulters job. 

Dynamic balance = Star Excursion Balance Test (SEBT) or Y Balance Test (YBT)

SEBT = The stance requires adequate strength, proprioception and neuromuscular control (Mohammadi et al., 2017). 

YBT = The reliability of the test is shown to be high where poor performance of the YBT is associated with an elevated risk of lower extremity injury (Mohammadi et al., 2017). 

The YBT may be more suitable as the SEBT can be time consuming, however it also depends on the type of equipment available (Fullam, Caulfield, Coughlan & Delahunt, 2014). The YBT may be more specific to our case study as it can help us to identify the risk of reinjury. Both tests have strong clinical value (YBT – Plisky et al., (2009), SEBT – Gribble et al., (2013)).

 Agility = The shorter Illinois Agility test 

Example of the shorter Illinois Agility test = https://www.topendsports.com/testing/tests/illinois-shorter.htm

This test is specific for our case study as they need to change direction at speed and move short and fast distances – this can help to assess if they are ready to go back to work. 

Week 4 Programme:

All exercises must be performed pain free for return to play/work.

Monday and Thursday: Tuesday and Saturday:  
inversion and eversion strength plantarflexion and dorsiflexion strength
Exercise Sets Reps Exercise Sets Reps
Towel crunches (increase resistance) 3 12 Smith machine calf raises (increase weight) 3 12
Seated banded inversion (increase  resistance) 3 12 Seated calf raise (increase weight) 3 12
Tip-toe peroneal walk out with band (increase resistance) 3 8 Tip-toe farmers walk with weights 3       60 secs
Seated banded eversion (increase resistance)  3 12 Lying toe rasies with resistance band 3 12
Single leg stance on wobble board whilst bouncing ball on wall 3           20 secs Smith machine reverse calf rasies (increase weight) 3 12
Single leg stance on wobble board whilst bouncing ball on wall 3       20 secs
Wednesday and Sunday: Thursday:
proprioception, kinetic chain and mobility Active rest
Exercise Sets Reps Exercise Sets Reps
Tripod squat  3 10 Banded talus mobilisation 3 12
Clock lunging (increase weight) 3 10 Knee to wall (3 angles) 3 9
Glute bridge walk out with resistance band 3 12 Single leg stance on wobble baord whilst bouncing ball on wall 3 20 secs
Captain morgan on exercise ball 3             30 secs Skater jumps  3              12 
Dumbell single leg RDL (increase resistance) 3 12  Plant and cut (4-5    steps)                   3             10 
Banded talus mobilisation 3 12
Knee to wall (3 angles) 3 9
Single leg stance on wobble board whilst bouncing ball on wall 3           20 secs

The common risk factors for lateral ankle sprains include:

  • Previous ankle sprains which could be due to reduced proprioception and stability (Bekerom et al., 2013)
  • Muscle weakness (David, Halimi, Mora, Doutrellot & Petitjean, 2013)

These risk factors have allowed us to produce a rehabilitation programme for a lateral ankle sprain. Exercises for strength have been included as well as proprioception, stability, neuromuscular control and mobility. 

References

Bekerom, M. P. J. Van Den, Kerkhoffs, G. M. M. J., McCollum, G. A., Calder, J. D. F., & Didk, N. van. (2013). Management of acute lateral ankle ligament injury in the athlete. Knee Surgery, Sports Traumatology, Arthroscopy, 21(6), 1390–1395. 

David, P., Halimi, M., Mora, I., Doutrellot, P., & Petitjean, M. (2013). Isokinetic testing of evertor and invertor muscles in patients with chronic ankle instability. Journal of Applied Biomechanics, 29(6), 696–704.

Fullam, K., Caulfield, B., Coughlan, G. F., & Delahunt, E. (2014). Kinematic analysis of selected reach directions of the Star Excursion Balance Test compared with the Y-Balance Test. Journal of sport rehabilitation, 23(1), 27-35

Gribble PA, Kelly SE, Refshauge KM, Hiller CE. Interrater reliability of the star excursion balance test. J Athl Train. 2013;48(5):621-626. doi:10.4085/1062-6050-48.3.03

Mohammadi, V., Hilfiker, R., Jafarnezhadgero, A. A., Jamialahmadi, S., Karimizadeh Ardakani, M., & Granacher, U. (2017). Relationship between training-induced changes in the Star Excursion Balance Test and the Y balance test in young male athletes. Annals of Applied Sport Science, 5(3), 31-38.

Plisky, P. J., Gorman, P. P., Butler, R. J., Kiesel, K. B., Underwood, F. B., & Elkins, B. (2009). The reliability of an instrumented device for measuring components of the star excursion balance test. North American journal of sports physical therapy : NAJSPT, 4(2), 92–99.

 

 

 

 

 

 

 

 

 

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