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March 2005

By Jennifer Swanson, DPT

Proprioceptive training can help prevent ankle injuries

The ankle must absorb forces equaling up to three times the body weight during sport-related activities such as running, jumping, cutting, and pivoting—exposing the joint to a variety of injuries. Specifically, sports such as football, basketball, hockey, and soccer increase the risk of an injury to the foot and ankle because of the potential for direct trauma, compression, shear stresses, and excessive rotational forces. The resultant injuries can range from fractures and dislocations to ligament tears and muscle strains.

However, the ankle joint can be just as easily injured during activities of daily living such as walking on an uneven surface, stepping off a curb, or landing in an awkward position. Therefore, it is not surprising that the ankle is the most common site of injury in the body, with an incidence of 1 per 10,000 people a day, accounting for approximately 20% of all sports-related injuries.¹

Traditional rehabilitation programs for the ankle have emphasized range-of-motion and flexibility exercises, progressive muscle strengthening and endurance exercises, and activity-specific training. Taping and/or braces are frequently used as well, particularly during sport activities. With proper functional treatment, the individual can often return to work or sport within a few days or weeks, and most injuries resolve without difficulty. However, up to 50% of people who incur an ankle sprain develop some form of chronic symptoms,² including persistent pain, stiffness, recurrent swelling, and functional or mechanical (anatomic) instability.³ It has been proposed that during the initial rehabilitation of these individuals, proprioception exercises may have been neglected or inadequately performed.⁴

ANATOMY OF PROPRIOCEPTION
What exactly is proprioception and how does it influence joint stability? Proprioception is defined as the ability to sense the position, location, orientation, and movement of the body and its parts.⁵ Proprioceptors are sensory receptors located in joints, muscles, tendons, and ligaments. These specialized receptors enable the body to process information from a variety of stimuli and, in turn, relay information regarding both the quality of movement and the position of the body in space. There have been multiple studies that have shown that the level of proprioception can be adversely affected by injury and/or fatigue. Therefore, individuals with decreased proprioception may be at a greater risk for sustaining an injury.

Figure 1. Double Leg Stance on a Wobble Board

Impairments in the ability of an individual to sense joint position following injury are often overlooked in rehabilitation programs. Consequently, it is often considered to be a major risk factor in the development of recurrent injuries, despite restoration of the integrity of the affected muscles, ligaments, and tendons.⁶ Proprioception, however, may play a key role in preventing chronic ankle injuries. In a prospective controlled study by Verhagen et al, it was shown that the use of a proprioceptive balance program was effective for the prevention of ankle sprain recurrences among individuals with a history of previous ankle injuries.⁷

Restoring proprioception after an injury is critical to allow the body to maintain stability and orientation during both static and dynamic activities related to sports and daily living. Specific exercises must be incorporated in order to reestablish normal proprioception. The goal of these proprioceptive exercises should be to increase the reaction time and improve the awareness of the injured joint during functional and sport activities.

CLINICAL APPLICATION
Rehabilitation programs should be designed to challenge, enhance, and improve this system in order to improve both static and dynamic joint stability. Static stability refers to the ability to maintain the body’s center of mass above the base of support while in a stationary position, whereas dynamic stability refers to the ability to maintain one’s balance under changing conditions of body movement. Ankle joint stability is a prerequisite to both functional and sports-related activities and is controlled by the interaction between static stabilizers and dynamic muscle restraints. Proprioception training has been an effective intervention for improving functional stability at the ankle joint, as well as the knee and shoulder.

Figure 2. Progression to Single Leg Stance on a Balance Disc

The inclusion of proprioceptive retraining exercises can begin early in rehabilitation and should incorporate activities that require balance, coordination, agility, and power, as well as movements that challenge the normal range of motion. In the injured individual, proprioception is purposeful and occurs at the conscious level of processing. However, it can be enhanced with training, and as the skill is perfected, the movement will become automatic and under subconscious control.

The proprioceptive exercises should initially be performed with the eyes open, as it allows the individual to develop visual cues regarding their position in space. Repeating these skills with the eyes closed further challenges the proprioceptive receptors, as they must respond with decreased environmental input and instead focus on the sensation of joint position. These activities should progress from simple, static skills to complex, dynamic skills. As the individual’s kinesthetic awareness improves, the application of unstable surfaces and external forces should serve to increase the demands on the proprioceptive receptors as well. During the latter stages of rehabilitation, it is important to practice these skills when fatigued, as this is the time in which injuries are most likely to occur.

BALANCE TRAINING
One of the major categories of proprioceptive training involves balance exercises. These exercises help to train the proprioceptive system with an early emphasis on static activity. One of the most basic proprioceptive exercises involves single leg balance on a stable surface. An element of instability is provided by progressing from a hard surface to a soft surface such as a foam pad, wobble board, rocker board, or mini-trampoline, thus requiring more control to maintain stability (see Figures 1 and 2). Ultimately, these exercises should include the incorporation of functional and sport activities, increasing the difficulty of the proprioceptive skills, and facilitate the athlete’s progress toward return to sport (see Figure 3).

Figure 3. Incorporation of Sport-Specific Activities

The use of perturbations can be applied while on a wobble board or tilt board to further expose the ankle to destabilizing forces and possibly induce compensatory alterations in the activation patterns of the muscles crossing the joint. These movements place the individual in a relatively protected, yet unstable situation that replicates the patterns of movement known to cause injury. If effective, this training will promote the development of adaptation strategies that can be applied to unexpected situations on the playing field.⁸ Perturbations can be applied in anterior and posterior, medial and lateral, and rotary directions in random order and of varying magnitude. The timing and speed of the applied perturbations should be varied as well. As the individual’s ability to maintain their balance with double limb support improves, the treatment should be progressed to single limb stance. Eventually, the task can be functionally progressed even further by having the individual perform a sport-specific task, such as catching and throwing a ball during the perturbation exercise.

A comprehensive rehabilitation program for the ankle should incorporate not only the traditional interventions such as strength, flexibility, and range of motion, but also include activities designed to enhance agility, proprioception, and neuromuscular control. Agility and proprioceptive training should be built in to the treatment plan to better enable the individual to return to preinjury levels of activity and reduce the risk of reinjury upon return to sport. In addition, proprioceptive training can play an important role in primary injury prevention, as uninjured athletes and other active individuals may benefit from a proactive approach by incorporating these techniques into their training programs.

Jennifer Swanson, DPT, is a staff physical therapist and sports physical therapy fellow with Centers for Rehabilitative Services at the UPMC Center for Sports Medicine, Pittsburgh.

REFERENCES

Trevino SG, Davis P, Hecht PJ. Management of acute and chronic lateral ligament injuries of the ankle. Orthop Clin North Am. 1994;25:1-16.
Sander E. Ligamentous injuries to the ankle. Am Fam Physician. 1980;22:132-138.
Bassewitz HL, Shapiro MS. Persistent pain after ankle sprain: targeting the causes. Physician Sportsmed. 1997;25(12):58-69.
Khan K, Bruker P. Ankle acute injuries. In: Fahey TD, ed. Encyclopedia of Sports Medicine and Science. Internet Society for Sport Science. Available at: sportsci.org. March 7, 1998.
Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. 1997;25:130-137.
Bunton EE, Pitney WA, Kane AW, et al. The role of torque, muscle action and proprioception during closed kinetic chain rehabilitation of the lower extremity. J Ath Training. 1993;28(1):10-20.
Verhagen E, van der Beek A, Twisk J, Bouter L, Bahr R, van Mechelen W. The effect of a proprioceptive training program for the prevention of ankle sprains—a prospective controlled trial. Amer J Sports Med. 2004;32:1385-1393.
Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy of perturbation training in non-operative anterior cruciate ligament rehabilitation programs for physically active individuals. Phys Ther. 2000; 80:128-140.

RESOURCES

Bernier JN, Perrin DH. Effect of coordination training on proprioception of the functionally unstable ankle. J Orthop Sports Phys Ther. 1998;27:264-275.
Laskowski ER, Newcomer-Aney K, Smith J. Refining rehabilitation with proprioception training: expediting return to play. Physician Sportsmed. 1997;25(10):89-98.
Sheth P, Yu B, Laskowski E, An KN. Ankle disk training influences reaction times of selected muscles in a simulated ankle sprain. Am J Sports Med. 1997;25:538-543.

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