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Determining return to play is one of my struggles, especially for my competitive athletes. I have a 16 year old male soccer player who is recruited to play D1. I saw him earlier this year for left ankle impingement and now I’m currently treating him for a sprained right ATFL. I had to educate him the difference between joint mechanics versus a sprained ligament. Sprained ligaments take 4-6 weeks to heal while his ankle impingement issue was cleared in 2 weeks post talocrual distraction, talor posterior glides, and gastroc stretches. Current injury: someone tripping him and he landed on his foot inverted and he walked off the field. Reports some minor swelling and iced it that night. He has been playing for 5 weeks before he came to see me (direct access) and has not gotten better. Aggravating Factors: playing soccer, cutting, agility workouts, sprinting. Relieving Factors: resting. His dad understands the different pathologies but he still wants his son to return to the field ASAP because his final soccer games are coming up this month.
Objective:
Functional movement: no issues with SL squat, balance, stair-step down
Ankle AROM: end range inversion with over pressure is painful, all others cleared, R ankle DF 5 degrees
Joint mobility: limited posterior glide of talus, subtalor mobility no pain or different compared to L
MMT: Gross ankle 5/5 no pain
Special test: + anterior drawer, + tender to R ATFL
Functional Test: Able to do the following activities no pain: karyoky, ski-hops, side shuffle, jog, B hop, SL hopTreatment:
Manual: Talo-crual distraction, talar posterior glide
TherEx: standing star balance, balance on bosu (EO/ EC), ½ kneel dorsiflexionQuestions:
1) Should I wait for full tissue healing? He wants to return but he’s afraid of re-injury. Should we yellow-flag this fear as a potential biopsychosocial factor or is this reasonable given the fact that it takes awhile for a ligament to heal? Is there anything else to consider?2)“Being a slave to external evidence—waiting a year for ankle ligament healing without tempering it with the best individual clinical experience and accounting for the patient’s preferences may not be an effective approach to return to play. This does not mean evidence should be ignored, rather that its use must be judicious.” What does “being judicious” mean to you as a clinician?
3) Arden proposes a return-to-play decision model. Have you used a similar decision making model? What are the main things you consider before return to play?
4) What other special test or objective measure would you do for my patient? Is there anything else you would do differently?
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Hey Oksana
What do you mean by + anterior drawer?
Have you been able to reproduce his symptoms with any functional eval or treatment techniques in the clinic?
How quickly do his symptoms occur with the aggs you listed? -
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What is his distal tib-fib mobility like? Sometimes this can help differentiate ATFL vs synovial tissue as the structure at fault. If he has pain with inversion, push his distal TF posteriorly: an ATFL sprain would not like this and would increase pain, non-ligamentous structures, such as his capsule/synovial tissue, etc. might actually like this and decrease pain and increase ROM ability into inversion. You can use this as a mobilization with movement technique as per Mulligan and follow it up with tape if effective. Distal TF dysfunction also may be relevant to his DF loss as well.
Just a thought. -
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Something similar to this. Tension starts A to P on distal fib with a superior inclination and spirals around posterior fib and posterior-medial tibia.
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Aaron – thanks so much for offering up the thoughts on differentiation between ATFL vs. other structures, and also for the taping technique. However, I think I am a little confused. Mechanically, it makes sense to me that a posterior fibular glide would IRRITATE an ATFL sprain. However, many authors (e.g., E. Magrum) recommend a such a posterior glide in the presence of an ATFL injury. Also, it has been shown that the position of the fibula is anterior in patients with CAI. With ATFL disruption, it seems that the talus would be anterior (which it has been shown to be) and that the fibula would be posterior (in opposition to what is placed). Perhaps I am not understanding the frame of reference for anterior/posterior.
I hope to have made my lack of understanding clear. Would posterior glide of the fibula assist in treating an ATFL injury (as is recommended by many) or incriminate an ATFL injury (as makes sense mechanically)?
Okana – the article you raised certainly seems to raise more questions than propose answers (as it manifestly attempted to do). “Return to play is complex and influenced by a range of factors.” That is certainly accurate and what makes life as a PT challenging in this regard.
As the article pointed out, waiting for full tissue healing might be a little excessive, but his fears certainly are a concern and indicate that he MIGHT not yet be ready for full return to activity.
Judicious use of the evidence means that the evidence is indeed considered, but is not the sole determining factor in making decisions. Judicious use of evidence means not discounting all of the other components of decision making shown in the Venn diagram (Figure 2). As the diagram shows, there is A LOT of components that go into that decision, which again, why the issue is complex.
I have yet to read the article, however if you are hungering for more pessimism and how we can’t use a simple special test or two to make the decision simple and easy, see the attached article.
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Nick – You are correct in that an anteriorly displaced/translated distal fibula occurs with a typical inversion sprain and is a common dysfunction found in CAI, no doubt. My comment to Oksana is that if his symptoms have been there for 5+ weeks that whatever ligamentous disruption there was may be not be the limiting factor now and causing his lack of DF and/or Inversion ROM loss. In an acute sprain a posterior glide on the distal fib does increase length/tension on the ATFL. However, much like many of the other Mulligan techniques (which sometimes work in an opposite way from what would mechanically make sense, such as a lateral tibial glide with knee flexion in WB), ROM into inversion, even with an ATFL injury does improve with the MWM technique in a posterior/superior direction. I think in an acute ATFL injury, a posterior glide to the distal fibula is typically painful, as is palpation in the area generally. However, limitation in inversion ROM is often improved with a posterior glide (if this is tolerated). Since this situation is not acute, I would suspect that the posterior glide would not hurt and likely be needed and also, likely improve his inversion ROM loss. Hope this makes some kind of sense.
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Back to the return to sport issue.
I had trouble with this as well for LE athletes.After reading Phil Pliskys blog I felt more confident and began to use this mind set.
Check it out and maybe Eric can tell me if this is a wrong thought process but I have felt more confident when I clear someone with this idea.
http://philplisky.com/category/return-to-sport-and-discharge-testing/
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Great discussion!
And thanks for sharing that post Kyle. I really like that mind set and I’ll def try incorporating that.Regarding the inversion sprain… we had a guest speaker in PT school on Mulligan techniques and he was talking about using posterior distal fib glides in acute ankle sprains if tolerated. We had a kid in class who had sprained his ankle 2 days before and despite the technique not being too pleasant, he reported significant decrease in pain generally and with ambulation. Obviously anecdotal, but the point is, I think based on pt presentation and tolerance, it might be worth trying. Thoughts?
Also, that specific technique was a sustained posterior glide with repeated active inversion.
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Thanks so much to Aaron and others for posting regarding the experience and rationale behind the posterior talar glide in the presence of ankle sprain/ATFL injury. Results > biomechanical rationale.
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